Administration and Leadership, Columns

Education Plays Vital Role in Premature Baby’s Resuscitation

Issue 7 and Volume 40.

It’s hard to believe it was 25 years ago when little Rodney Barron, Jr., a 2-lb., 27-oz. apneic baby (born at just 27 weeks gestation), was thrust upon me as one of the most challenging but rewarding cases of my EMS career.

I’m sharing this case with you after receiving a note of thanks on Facebook recently from Rodney’s dad for my resuscitation of his son “that fateful night” in 1990. In his note, Rodney Sr. also announced the birth of his new grandchild to me. What a rush to know that my miracle baby was now a father himself.

It was May 24. I was a volunteer paramedic for Bethlehem Township Volunteer Fire Company (BTVFC), one of the first paramedic response agencies in eastern Pennsylvania. The call was initially received as a “woman with abdominal pain.” It turned out to be much more.

I was dispatched at 1:44 a.m. to assist another paramedic unit already on scene that requested assistance with what was now being declared an imminent birth. En route, I assumed my role was to assist the primary paramedic with a complicated birth.

When I walked through the kitchen door to the home, I saw the crew on the floor attending to the mom, who I thought was about to deliver her child right there on the floor. I didn’t know she had already delivered a premature baby who wasn’t breathing.

I was immediately handed what I thought was just a folded towel by Bethlehem Township Police officer Scott Lapare. But he shocked me by stating, “Here, this is your patient–just born!” I then moved the towel back to reveal the smallest, most lifeless body I had ever seen in my career.

I knew from my training that less than 1% of babies born earlier than 28 weeks survive, and the 12–15% that do survive stand a good chance of having neurodevelopmental problems and respiratory distress syndrome. But nowhere in my paramedic training did I feel prepared to make the go/no-go decision about resuscitating such a preterm baby.

What challenged me the most in my decision to begin resuscitation was that babies born at less than 28 weeks look very different than full-term babies. Their skin is wrinkled and reddish-purple in color and, because they haven’t had time to put on any fat, they’re so thin you can see their tiny blood vessels underneath the skin.

Rodney’s tiny body was covered in fur-like soft hair, called lanugo. But, most frightening for me was that my tiny neonatal patient’s eyes were closed and, because his eyelashes hadn’t yet developed, his facial appearance made me wonder if I was starting care on a patient too young and underdeveloped to survive.

I had to go with a gut decision, and once I decided to begin the resuscitation I knew it would require every bit of my education and every second of my attention. I also knew that his only chance for survival was truly in my hands.

As I exited the kitchen, I cradled his tiny body in my hands like a piece of precious china. As I walked carefully toward the ambulance, I moved my head down toward his tiny chest while at the same time lifting his tiny lifeless body to my face. Above the noise at the scene, I looked for chest movement and listened for the precious sound of air movement; but I heard none. So I placed my mouth over his tiny nose and mouth and began breathing small puffs of air into his fragile lungs. I used my stethoscope to obtain an apical pulse, which I guesstimated at the time to be over 100 beats per minute.

Once in the ambulance, I placed him on a blanket on the stretcher, suctioned him with a tiny bulb syringe and asked the EMT with me to wrap him in an aluminized silver swaddler to ensure we maintained his body heat. There was still no respiratory response so I continued to deliver tiny puffs into him with my mouth.

I made a decision to divert from the closet hospital six minutes away, where the baby’s mom was being taken, to the neonatal unit where I had trained as a student paramedic. It was 20 minutes away, but I knew this was the best place to take him.

I asked officer Lapare to drive our unit so my EMT partner could stay with me in the patient compartment. About a minute into transport I heard a tiny grunting sound and saw the baby start to breathe on his own. His skin color was also “pinking up” and he started to move his tiny limbs. My partner and I looked at each other as if we had just won the lottery.

I then started to administer oxygen in a blow-by manner by placing a pediatric mask next to his tiny face. Again using my stethoscope to assist in getting accurate vital signs, I found his respiratory effort to be 26 and his pulse to be 140.

When we arrived in the neonatal ICU, (NICU) their team swarmed the little guy. One nurse rapidly threaded a tiny IV catheter into his anticubital fossa as another suctioned him and placed a small circular oxygen dome over his tiny face and neck.

Rodney Barron, Jr., at one hour old.

Their professional approach made me realize that I had made the right decision to divert him to their specialized unit. But, because we had done so, we knew we were depriving his mother of the chance to see her newborn son. So, we retrieved a Polaroid camera from our unit (used to take and deliver trauma/mechanism of injury images to flight crews and trauma center staff) and I took a few images we delivered to his mom at her hospital as soon as we departed the neonatal center. Mom was grateful and thanked us for our efforts.

The Christmas card I received from Rodney Barron, Sr. Photo A.J. Heightman

I left her hospital wondering if her son would survive. As is often still the case today, the receiving hospital never let us know the patient outcome so I didn’t know his status until a Christmas card came to my home seven months later with a photo of a beautiful, healthy infant on it and an introductory note that said, “I made it!”

Keys to Success

This call occurred seven years after the birth of my first child, Joe, born at 7 lbs., 6 oz., and five years after the birth of my second son, Steve, born at 7 lbs., 7 oz. As a “veteran dad,” I had a frame of reference in my mind that full-term children come into this world at 7–8 lbs. and have few complications. I remember being amazed at the tiny size of my sons and initially being timid as I held them, fearful of hurting their tiny fingers or toes. I also remember watching their tiny chests rise and doing a double take many times during their early days of life to be sure they were still breathing.

But Rodney was one-third their size at birth and simply holding him was a terrifying experience, let alone breathing tiny puffs of air into his tiny noncompliant lungs.

I credit my success in the resuscitation of this premature child to my visionary paramedic training program medical director who insisted we all spend time in the region’s NICU. If it wasn’t for that special training and experience gained there, I might not have diverted my tiny patient to the specialty center.

I also credit the captain of BTVFC, who had us way ahead of the curve on pediatric care in the ‘70s. Richard (Dick) Seeds, a safety engineer with Bethlehem Steel Corporation by day and an EMS innovator by night, developed our volunteer ALS system in the early ‘70s when ALS wasn’t understood or accepted by many in our region.

In 1975, he designed a 37-foot tri-axle GMC Transmode motor home mobile ICU (MICU) that many of our neighboring ambulance services laughed at and called “the [Oscar Mayer] Wiener Wagon.” But for those of us trained to use all its bells and whistles, it was a magical time. This MICU was equipped far beyond what was standard ALS equipment in that time.

More importantly, because of his vision and thirst for medical education and commitment to EMS, Dick had us trained and prepared to handle patients of any size– particularly pediatric patients. In addition to the standard ALS equipment carried by others, Dick equipped our MICU with an electronic thermometer, silver swaddler baby warmers, a Doppler to detect tiny heartbeats and blood pressures, duplicate supplies to care for twin births, a mechanical ventilator and a small meconium aspirate suction device.

I hope to meet Rodney and his new son someday. It would be a hoot to hold his tiny son in my arms and rekindle my memory of that fateful night 25 years ago.

My closing message to you is that education in pediatric care and resuscitation is the key to success in reducing stress when you’re confronted with these tiny, challenging patients.