Miracles We Have Seen

by Harley Rotbart

  Acute myocarditis could have killed Michael. Sepsis could have killed him. He could have died from complications on the ECMO machine. Heart transplantation is risky and could have killed him. Yet, today, Michael survives with a normal heart and no long-term complications of any of his medical illnesses or interventions.

  Miraculous.

  Date of event: Early 2000s

  The Power of a Mother’s Touch

  Alan R. Spitzer, MD

  I am a neonatologist, a specialist in the care of newborn babies. During the course of my career, I have had the opportunity to care for many premature infants born to families who struggled to conceive a child. Years ago, in the earlier days of infertility treatment, families might go through repeated courses of in vitro fertilization (IVF) in the hope of finally conceiving a successful pregnancy. This is the story of one such family and an experience that, to this day, I have no explanation for and will never forget.

  In the early 2000s, the parents of Baby Daniel had several trials of IVF before finally giving birth to a tiny one-pound, five-ounce infant, delivered after only twenty-five to twenty-six weeks of gestation (forty weeks is full term). Amazingly, this baby initially did quite well, having only mild respiratory distress due to his very immature lungs. His breathing problems were fairly easy to manage with modest levels of support on a breathing machine, connected to a tube we placed through his nose and into his trachea (windpipe). A few days into hospitalization, Baby Daniel was sufficiently stable for us to initiate feedings through a tube into his stomach and begin to reduce the intravenous (into his vein) nutrition that had been sustaining the infant. The neonatal intensive care unit (NICU) staff was very pleased with the baby’s progress and, in my meetings with his parents, I was cautiously optimistic about Baby Daniel’s chances for survival. As always, I made sure they understood the many land mines that potentially awaited any extremely low birth weight infant during an NICU hospitalization, but I felt confident we would be able to manage this infant through those potential obstacles.

  Speaking with families about their premature infants was something I always enjoyed doing, since resolving the many questions they typically had always seemed to make the NICU stay easier for everyone. If I could instill confidence in them with respect to my judgment by responding to their concerns, it added immeasurably to the ease of making the right decisions for both the baby and the parents. So each day, I would make time in the afternoon to speak with family members. I was always very keen on incorporating the family as much as possible into the care of their child; I called it “family rounds.” Family rounds proved to be especially important in the events that were to follow with Baby Daniel.

  Not only was this child’s hospitalization one that took place in the early days of IVF, it was also early in the days of the Internet. One afternoon, when I stopped by to see Baby Daniel’s parents on family rounds, they were waiting for me with a two-inch thick sheaf of articles they had downloaded online. At first, I was a bit taken aback and didn’t quite know how to respond to the material they were showing me, much of which they did not fully understand. But then I realized that if I went over the articles with them and directed them to the information that seemed most rewarding, I could accomplish a few things. First, it seemed an ideal way to help educate them about the challenges facing their tiny infant and, at the same time, I could validate their desire to ensure nothing was being overlooked in the care of Baby Daniel, who was so precious to them. Furthermore, if this was to become the new approach for the parents of my future patients (and it certainly turned out to be so!), I could learn to direct their Internet searches to articles that would be most helpful to them. Baby Daniel’s parents were pleased with this response, and we would typically spend ten to fifteen minutes each day going through their new downloads. Over a couple weeks, we all began to look forward to these sessions, as I found myself learning some “hot-off-the-presses” news in neonatology that I was unaware of, while the family gained confidence in my responsiveness as a physician.

  Several weeks into his NICU course, however, Baby Daniel took a major unexpected turn for the worse. As was often the case, we suspected septicemia, a serious total body infection seen frequently in premature babies in intensive

  care. We obtained all the necessary tests and, while awaiting the results, started antibiotics to treat all the most common types of germs that can cause this infection. In addition, we had to increase the breathing machine support levels higher than we had ever needed for him before—an ominous sign, to be sure. Fortunately, because of our daily Internet sessions on family rounds, by this time the parents trusted my decisions and were pleased that we had reacted so quickly to the change in his condition. But over the next twenty-four hours, Baby Daniel did not respond well. His condition steadily deteriorated, forcing us to initiate a much more aggressive type of breathing support called “high frequency ventilation,” along with higher and higher oxygen supplementation and increasing amounts of pressure applied from the breathing machine to get the oxygen into his stiffening lungs.

  To our dismay, even these desperate measures failed to make a dent in his dangerously low oxygen levels. They continued to plummet, barely rising much above 75 percent saturation of his blood (94 percent saturation is considered normal at sea level, where we were). As a last-ditch effort to try saving his life, and years before we were fully aware of the extent of negative effects of these treatments in preterm infants, we also decided to start inhaled nitric oxide gas and intravenous steroids. I carefully explained the risks and possible benefits of these drugs to the family as best we understood them, and they were in agreement to go ahead. But within an hour, Baby Daniel’s condition continued to worsen and his oxygen saturation now could barely be maintained above 70 percent, a level that will not sustain life or brain function for very long. I became quite sure that all was lost and death was imminent.

  When a child’s condition reached the point where I felt death was a certainty, I always believed it was important for a family to hold their infant, even if only for a brief time, so it was clear to them that however short the infant’s life, it would always be real and a part of their consciousness forever. At the time, “kangaroo care” (named for the way marsupials carry their infants, and first practiced with pre-term infants in a facility in Bogota, Colombia, in the late 1970s) was a relatively new practice in American NICUs. It involves direct skin-to-skin contact between a baby and his mother. In practice, for a premature infant like Baby Daniel, the first step was to make sure the breathing tube in his throat was carefully secured with tape to his face. He would then be placed naked, except for a diaper, on his mother’s chest. Although now commonly practiced in many nurseries, and especially useful for premature babies to enhance bonding, we hadn’t had much experience with this technique, but I felt it would be an ideal way for this mother to hold her dying child one last time.

  With the assistance of the nursing staff, we cautiously moved Daniel from his warmer bed and placed him on his mother’s chest. She asked me how long he had to live, and I told her that at some point, as his oxygen levels continued to decline, we would simply discontinue the breathing machine support and make him comfortable with medication to ease any terminal discomfort he might have. It would be a gentle way to die but, needless to say, everyone in the room was profoundly saddened for this lovely family who so wanted this child. I began to go through the usual inner recriminations of what I had missed, where I had failed, what could I have done differently.

  What happened next, I have no explanation for, and I do not recall another child I have ever cared for where my assessment of imminent death was so wrong. I turned to Baby Daniel’s oxygen saturation monitor, expecting the value to have fallen further on its way to his death, but to my astonish-

  ment, since being placed on his mother’s chest his oxygen saturation had suddenly risen to 92 percent! The baby’s color, which had been gray and ashen, sudden
ly appeared pink and rosy. His father, seeing the puzzlement on my face, asked me what was wrong. I told him nothing was wrong and, in fact, this was Baby Daniel’s best oxygen saturation level in many hours. His mother asked me what we do now, and I told her we should just wait and see, but this was likely to be just a brief interlude and they shouldn’t get their hopes up too high.

  As if to mock me, the oxygen saturation continued to climb over the next few minutes, rising to 95 to 96 percent. The baby went from oxygen saturation plummeting toward death to an absolutely normal oxygen level within mere moments of lying down on his mother’s chest. At that point, his mother said to me that she was absolutely not moving from her chair. And she didn’t for the next two days, only allowing for brief respites during which time she would allow her husband, and only her husband, to slip in and replace her in holding the baby. Her husband’s chest was quite hairy, and during his time with the baby, it almost appeared as if the tiny infant vanished in a forest.

  With this remarkable parental addition to our therapy, Baby Daniel steadily weaned from the high-frequency ventilator, went back to the conventional breathing machine, and continued to improve from there. Almost unimaginably, he was discharged home a few weeks later. I was able to follow him for several years and he did wonderfully, even winning a soap-box derby in his home town at about age eight. His proud mother sent photos of the event to me.

  With all the high technology in our NICUs, and the newest innovations in the care of premature babies, Baby Daniel reinforced for me the irreplaceable impact of parental love in altering an infant’s outcome, no matter how small the baby, and no matter how ill. I wish I could explain what happened that day in our NICU. But for Baby Daniel, his parents, and for me, it was very real, very powerful and, perhaps, even miraculous.

  3

  Breathtaking Resuscitations

  When the heart stops, the clock starts. Without adequate blood and oxygen circulation to the brain and other vital body organs, permanent damage or death occurs. The longer the cardiac arrest lasts, the more likely there will be a tragic outcome.

  The essays in this chapter describe patients whose hearts were stopped far longer than should be survivable, despite desperate attempts at cardiopulmonary resuscitation (CPR) by skilled and trained personnel. After being pronounced dead, or presumed to be brain dead, the miracles began.

  Date of event: March 2015

  A Spirit of Calm, an Aura of Awe

  Frank Maffei, MD

  Richard L. Lambert, MD

  Gardell was the lead story in all the local, national, and international news media.1-5 “Toddler Survives after 101 Minutes of CPR.” “Pennsylvania Toddler Survives Near-Drowning after 101 Minutes of CPR.” “Miracle Toddler Who Fell in Stream Brought Back to Life after 101 Minutes of CPR.” “Toddler Dead for 101 Minutes Is Now Alive.” “Toddler Revived after Nearly 2 Hours of CPR.” But no media description could do justice to what we saw happen before our eyes that night and morning.

  It was mid-March and the pediatric intensive care unit (PICU) where I work was still busy from a winter that brought us severe respiratory disease and a facility filled to near capacity. I was coming on call for the evening and had just been briefed on all the patients in the PICU from my partner and close friend, Dr. Richard Lambert, who had been on call before me. As he finished going through the youngsters’ cases one-by-one, a call came from one of our emergency department (ED) physicians: “I don’t have all the details yet, but there is a two-year-old boy who drowned and they have been doing CPR (cardiopulmonary resuscitation) for over forty minutes. We may decide to stop the CPR once we fully assess, but just giving you a heads-up.” A mere moment after I hung up, I thought about a run I had taken by a lake just the day before, and remembered there was still ice on the surface. I called the ED back.

  “Was this a bathtub drowning or was this an outside drowning?”

  “It was a creek but we don’t know much more,” he answered.

  I responded, “Do not terminate CPR; let’s assume this was a true ice-water drowning.”

  It turns out the local Emergency Medical Service (first responders) team and community hospital where the child was first taken were assuming exactly that, and they diligently continued high-quality CPR without interruption. In an ice water immersion, hypothermia (low body temperature) is the primary event and cardiac arrest follows. In these rare cases, the initial deep hypothermia produces a state where the human body has very low metabolic and oxygen needs. This may lead to a protective effect on vital organs, in particular the brain. But there is a limit as to how long the vital organs can survive even with deep hypothermia. Had this little boy passed that limit?

  As I left my office for the ED, Rich went to quickly scour the most recent scientific literature for any new and useful information pertaining to hypothermic drowning. He would then join me to assist with the child’s resuscitation. When we arrived in the ED, the highest level trauma alert had been sounded and there were more than enough personnel standing by ready to help.

  That being said, even with the best intentions, too many sets of hands can lead to chaos. We took the ten minutes prior to the helicopter landing to quickly assign roles and places. We had key staff ready to do the primary evaluation, airway management, heart monitor and breathing machine set-

  up and, of course, CPR. We assigned four doctors to line up on the toddler’s left side and rotate every two minutes to provide high-quality chest compressions. CPR is very tiring to perform and can quickly lead to exhaustion of the person performing it. The ED doctor who made the initial call to me earlier would oversee the CPR and keep track of time and medications being administered. Rich and I would do the initial examination, attempt to insert IV (intravenous) lines, and guide the rewarming strategies. I called our heart surgeon and asked him to be ready to place the child on a cardiopulmonary bypass machine for rewarming if our efforts in the ED did not result in a return of spontaneous circulation. Cardiopulmonary bypass is the same technique used for open-heart surgery, a pumping machine that takes over the job of a patient’s heart and lungs. By warming the blood in the machine, it can also be used to rapidly warm a hypothermic patient’s core body temperature.

  I could hear the helicopter landing. The crew reported: “Two-year-old went missing at 6 pm for 30 minutes. EMS was dispatched. Neighbor found him a quarter mile downstream in a swollen icy creek that runs past the back of the yard. CPR was started a minute or so after he was pulled from the creek and has been continuous since. Accounting for the scene, the stop at the community hospital and the helicopter flight here, we have CPR for one hour and 16 minutes. Gardell’s initial rectal temperature was 25 degrees Celsius (77 degrees Fahrenheit).” So that was 30 minutes of the child being missing and 76 minutes of CPR with a core body temperature more than 20 degrees below normal. Surely this was pushing the limit of even the most dramatic ice-water drownings.

  The resuscitation was transitioned from the transport crew to us, and immediately we were all struck by the spirit of calm in the room. Everyone had a role, everyone knew how to perform that role, and we all had a shared purpose: save this little boy if at all possible. We didn’t dare allow ourselves at that moment to think it might not be possible. Some of those doubts started a little later.

  Start at the top. The child’s airway was secured with a tube in his trachea (windpipe), allowing the ventilator (breathing machine) to breathe for him. We determined our CPR heart compressions were effective and we could hear appropriate air movement in his lungs from the breathing machine. Yet, Gardell had absolutely no signs of life. No movement, no response of his pupils to light, no response to pain, no breathing on his own, no heart rate. He looked awful, worse than awful, but something told me he was still in there, that he was not truly dead.

  Get to work. The ED doctor kept track of the CPR, vital sign monitors were activated, and then we needed to get him warm. Cold would no
longer be protective at this point, and in fact prolonged cold could now do more harm than good in our efforts to revive this little boy. Warming blankets were placed around him and warmed, humidified oxygen was delivered through the tube in his trachea. Warm fluids were flushed in and out of his stomach and urinary bladder. This all occurred within minutes of his arrival amidst that spirit of calm determination from everyone in the room. I don’t think I’d ever before experienced that universal calm in a situation as harrowing as this. So much was getting done, still without any sign of life; there was much more that still needed to happen.

  While cold may temporarily protect the vital organs, it does so at a price—blood vessels throughout the body leading to and from the body’s surface clamp down and finding veins for IVs can be very difficult. For that reason we had initially relied on a special type of IV, called an intraosseous line, directly into the little boy’s bone marrow. “The intraosseous line is not working well,” someone called out. We needed access to a large main vein immediately.

  I looked at Rich, “I’ll go to the neck and you go to the groin.” It’s tough enough to get an IV into a major blood vessel in small children, but in a youngster who is cold and being bounced around from the CPR, it can be nearly impossible. We knew we would have to temporarily stop the CPR to get access into a large central vein, but also knew we had to minimize any CPR interruptions, so we timed our needle punctures together.

  “Ready . . . stop CPR, now.” Almost immediately, and almost too easily, we both succeeded in putting IV tubes in the large veins of the neck and groin, allowing us to give Gardell warmed IV fluids and medications as close to the heart as possible. His temperature was now up to 84 degrees Fahrenheit but still no signs of life. Emergency medicines intended to jump-start his heart and treat the acid that builds up in a body under these circumstances were repeatedly given but with no change in his status.