A Little too Early

Extra-uterine life can be very unforgiving for the preterm neonate. It is like being taken from the shores of Lake Victoria to the heart of The Amazon without warning, without acclimatization. The fragile skin of the preterm baby loses heat to the environment so fast that it puts it at risk of dying from cold. If they are too tiny, their hearts have a hole that ensures blood goes directly to the body with only little going to the lungs. This hole usually closes within the first week of life for the term neonate. The preterm intestines are delicate; so delicate that formula milk can be deleterious to some of them. The blood vessels in their brains are weak; they can bleed without provocation. With an immature immune system, they are at great risk of getting infections, some of which can be life-threatening. The sad part of it all is that preterm neonates can forget to breathe, completely; these ones are given caffeine. Interesting, right? 

The world celebrated World Prematurity Day a few days ago. It will only be just if I share the story of one preterm baby that I took care of, Baby Rose. Baby Rose is not his real name. In the newborn unit, babies are given their mothers’ names. In the confusion and frenzy that comes immediately after giving birth, a mother can forget a new name. The one she gave her newborn. I was born Oliver Reginald Tambo. My father, under pressure to appease the spirits of his dead uncle, changed the name to Oliver Kiaye, and then I changed it to Kiaye Oliver. This confusion is what we don’t want in the nursery, and that is why all babies are called by their mothers’ names.

I am mostly a strict doctor. I am hard on myself and on everyone I work with. If you met me in the nursery then, you would be tempted to ask if it’s a matter of life and death. Yes, it is. I have become more accommodating lately because when you work in a broken system, you can only do and expect so much. Our rounds are ever so full of ‘this is a low resource setting.’ Mpaka lini?

720grams, this was the weight of Baby Rose when his mother had gone into sudden cataclysmic labor that had him come out with twelve weeks to go. Too early. His skin was pink. Pink and fragile. Tiny veins could be seen as dark lines running beneath the thin skin. His heart pounded like a distant train and his pulses were large for his age. He had a patent ductus arteriosus. Kisungu kubwa. Let this pass, I couldn’t avoid the jargon. So I saw him and wrote my notes.

The major challenge I had was putting a line in the baby’s veins so that he could receive medication. Remember at this time, I only had six weeks of experience as a medical doctor. I was not so good with those preterm lines. In my entire life, I have only had two successful cannulations in this population of patients. I called someone to do it for me as I organized other aspects of treatment. On top of antibiotics and caffeine, I did the daily fluid plan, put the baby in an incubator, and left. The next day was uneventful, I did my daily rounds as usual. Baby Rose was doing well as far as I was concerned. She was breathing in short bursts and then stops breathing briefly and then continues. It took time to sink in my head that neonates are periodic breathers.

Talking to Rose, the mother of the baby, this was a special child. She had lost several from similar circumstances before. She was the wife of an ex-army officer who had decided to start a new family after almost losing his life in battle. Battles change men. It makes some men soft and compassionate, while some become shells of their former selves. I gave her the reassurance that we will do whatever it takes to save the life of her baby and bring her joy. Childlessness can be a source of unending sadness. In the grand scheme of things, nature’s most prized characteristic of life is reproduction. She, mother nature, tricked us into mating by making sex a deeply pleasurable experience.  It was not going to be easy for Rose and her baby, I just didn’t know yet. Nobody knew.

The next day was rather uneventful. We had admitted so many babies to our unit. The March sun was blazing above with conviction. It synergized with the newborn radiant warmers to make the unit a furnace. Streams of sweat trickled from my armpit downwards making me uncomfortably wet. The newborn unit was the closest I got to the heat of hell that awaits sinners on the grande finale when the universe will empty into nothingness; when the Good Lord will come for his followers. I was tired. When I was about to leave, Rose called me across the window.

“Daktari, leo nitampea maziwa kiasi gani?”

She was a motivated woman. I told her to take care of the feeding and we would take care of the treatments. The feeding session went just fine. She had enough milk for her baby. Her tits were small though. Small and taut. Her suspensory ligaments were still strong. These ligaments loosen with age, making the breast drop and become pendulous. You would actually doubt if her baby was getting sufficient milk. The size does not matter. I have seen flat-chested mothers take care of twins. To each, their own. The oxygen levels of the baby were acceptable on low flow oxygen.

Fast forward to about ten or so days later, Baby Rose was not gaining weight. As a matter of fact, his weight had dropped significantly to just above 500grams. To put that into context, his legs were the size of an average human thumb. He was spiking fevers occasionally despite being on antibiotics. We went to second-line medication. He had episodes where he stopped breathing and that was worrying me. I was on call that night, I knew I had to make things right lest I stay awake the whole night pacing up and down trying to right every wrong. I had powerful antibiotics on board but again, no intravenous access. I tried every sort of vein that I could see or imagine without success. I called the anesthetist to give it a shot and see if we could get to something lakini wapi? From the way he held the cannula, I knew it would only take the hand of God to get intravenous access. I gave up folks. I went to gather some sleep. Sleep is hard to come by when taking care of babies. They change conditions so fast. I had not discovered my hidden cooking skills by then, so I passed by the cafeteria for some chapo beans.

The next day, we were lucky to get a small vein on the arm, the basilic vein. I cannulated it myself. I wondered where it was hiding all along. He got his meds as was scheduled. I felt like a neonatologist. A few days later, he had started gaining weight. This was promising. At least our efforts were finally yielding something. We optimized his feed and ensured he was warm and comfortable. The incubator was sanitized at least five times a day. That was part of our management plan. We were intentional about it. My consultant was particularly strict on infection prevention and control.

The weekend of Easter had proved very difficult for Rose and Baby Rose. The baby’s oxygen levels were dropping every so often. She was also getting apneic attacks more frequently. We went to the maximum oxygen levels that can be delivered by the special mask we were using. I called the consultant to discuss the state of the baby. I told him that we could be dealing with a spontaneous bleed in the brain that was threatening to reboot the system. The consultant advised me to refer the baby to KNH for more specialized care. Successfully referring a patient to KNH deserves a Grammy award. Dr. Maosa would be a celebrity if that were the case. His referrals are almost always successful. KNH had no space for Baby Rose. The care of Baby Rose belonged to me and my boss. My favorite consultant so far. I will not mention the name. Because I don’t want him or her to thump their chest saying they are Dr. Kiaye’s favorite. The consultant told me to prepare the mother for any eventuality; the chances of survival were diminishing with each passing day. Preparing a family for an impending doom is not easy folks. I have made it a habit not to give strict timelines. I tell people that life is in the balance, get ready. This is different from saying you have six months to live.

We did all we could. I kept updating his treatment and feeding. His oxygen levels were still low. Babies came in and out of the unit leaving him in the incubator in some corner in Cube C. He was proving to be resilient. He had fallen in love with his fate. When nature decides to put its faith in the feeble hands of premature neonates, you don’t give up on them. The baby was gaining weight albeit slowly. We kept our faith alive. As he was growing, we graduated from tube feeding to cup feeding. The hole in his heart was closing as expected after a course of ibuprofen.

One day Baby Rose’s oxygen levels decided to go up and stayed up. I stood by her and looked at the pulse oximeter for close to half an hour on that day. The saturations were constantly above 90%. It took me by surprise that a baby that we had ‘written off’ was starting to show signs of winning. I was happy, my consultant was happy, my nurses were happy, Rose was happy, the heavens were happy. We weaned him off oxygen a few days later. We were not off the hooks yet. We had to ensure that we consolidated our gains.

I left the pediatrics rotation before Baby Rose left the nursery. I was happy I was leaving a fairly stable child. He was at 1350 grams by then. I handed him over to my colleagues who were starting the rotation. I told them of tales and near-death experiences of that baby. And then I forgot about Baby Rose.

A few weeks ago, when we were walking with Dr. Maosa to the medical outpatient clinic, my attention was drawn to a woman who kept waving at me.     She had carried a baby in her arms. You know as a man, you could be shocked with a gift of your own baby without knowing it. You never know and you never trust yourself. Well, I don’t remember going in raw anywhere in the recent past and so I went to her. It was Rose. Rose and Baby Rose. I was happy. The baby had grown so big that I could not recognize him. He had fat cheeks and was bubbly. His mother had brought him to a routine pediatric clinic for regular check-ups. It was marvelous. He had beaten all the odds.

Author: Dr. Kiaye Oliver

I am a dreamer. I love medicine. She is generous. I am also in love with literature, she makes me see the world the way I want to and sometimes the way it is.

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