NeoNatal Nurse

(article by Donna Cardillo, RN MA)

While recently traveling on business, I noticed a billboard with a picture of a police officer on it. The caption read, "I save lives. What do you do?" What a powerful statement and a great way to illustrate the significant work police officers do. The same billboard could be used for nurses. Because, when all is said and done, that is the essence of what we do. We save lives, and we improve lives. No matter what specialty or work setting we’re in, our impact is significant and far-reaching.

It’s always challenging to convey to outsiders what we do in terms that are meaningful to them. There is still a widespread belief that nurses are “helpers” to the physician, obediently and selflessly following orders. What most people (even some nurses) fail to recognize is that nursing is an independent and autonomous profession. It is a knowledge-based profession with its own body of science, research, and practice standards.

Nurses develop their own plan of care for patients - just as physicians do. We use critical thinking skills, initiate life-saving measures, and conduct comprehensive, precise evaluations, and monitoring. We teach, counsel, coach, nurture, and support. We are healthcare experts in our own right. Nurses possess a great body of healthcare knowledge and experience - even right out of nursing school.

And while part of our job is sometimes to coordinate orders and treatments, we do not blindly follow orders. We interpret, translate, evaluate, and apply judgment. We also consult with and advise other members of the healthcare team. We then skillfully plan, implement, administer, manage, and coordinate all aspects of care to established standards of nursing practice.

When I am out in non-healthcare circles and people find out I am a nurse, some say with a tinge of disgust in their voice, “Oh, I could never do what you do.” I often say to them, “You’re right - you probably couldn’t. Nursing is not for everyone. It’s challenging to have someone’s life, health, and well-being in your hands at all times.” When people sympathetically say, “Nurses work so hard,” I sometimes respond, “Yes, it is hard work saving lives, promoting health and wellness, and improving the welfare of the planet.”

But the question I find most remarkable and annoying is, “You’re so intelligent. Why didn’t you become a doctor?” It’s as if intelligent people become doctors and less intelligent people become nurses. When I was recently asked that question - for the first time in decades - I gave the questioner my standard answer: “It is precisely because I am so intelligent that I chose nursing. Nursing and medicine are two entirely different career paths. One is not an elevated version of the other. I chose nursing because it keeps me in closer proximity to healthcare consumers - where I believe I can do the most good.” Sometimes I add, “Don’t ever underestimate the amount of intelligence, science, and the skill needed to be a great nurse. We make it look easy because we’re so good at what we do.”

So the next time someone asks you what you do, consider responding, “I save lives and improve health. I’m a nurse. What do you do?”

(This is a re-blog from http://eheavenlygads.wordpress.com/2007/06/12/progeny-at-what-price/)

Progeny At What Price?

June 12, 2007

"Allow me to begin here by thanking my favorite blogger, Jane, for tipping me off to the recent births of two sets of sextuplets in Arizona and Minnesota. I read her postIt’s a Uterus, Mrs. Masche, Not a Clown Car last Friday and preached over the canning jars all weekend. I strongly recommend you read it, too.

Some may view these births as a miracle, but like Jane, I do not. I happen to personally know well the opposite is true. If you happen to view technological advances in infertility as progress, I’m here to tell you it comes at a huge price. At the very least, the incredible escalation we are witnessing in large multiple births is medically unethical; at the top of the spectrum is its undeniable virtual effect of child abuse.

On the surface, the stories of the Morrisons and Masches sextuplets born in the last few days sounds wonderful and glorious. You can’t help but be elated at what appears to be nothing less than a miracle that finally allowed both women to have their own children.

Brianna Morrison, 24, tried to conceive naturally for a whole year, then sought a fertility clinic recommended to them by members of their church. She went through two cycles of Clomid injections that failed (Chlomiphene citrate, the most commonly used drug — typically administered as a pill — to increase the production of eggs and stimulate their release) and then was given Follistim (Follitropin beta, a relatively new synthetic hormone (injected in concert with hCG hormones) to stimulate egg production and used when Clomid fails).

Within a matter of a few weeks, the Morrisons learned Brianna’s ovaries had released ten eggs, four of which were not viable, and six that had fertilized. Without fertility drugs, human ovaries release one egg, or in exceptionally, unbelievably rare instances two.

Mrs. Morrison was dealt Follistim’s greatest side-effect of all: Ovarian Hyperstimulation Syndrome (OHSS). Google that one.

During Brianna’s pregnancy, she took a myriad of medications to prevent miscarriage as well as to help (basically force) her body to handle the enormous nutritional and physiological strains during gestation of an unnatural number of fetuses. In the last three months or so of her five-and-a-half-month pregnancy, she was confined to bed rest and had 24-hour nursing care to monitor the health of Brianna and her fetuses and dispense medication.

As is the norm in large multiple births, Brianna’s infants were extremely prematureas she was only able to carry them for 22 weeks — the EARLIEST gestational age in which infants are considered to have any chance for survival, although that chance at most generous is considered to be a mere 10%.

Most hospitals have a policy against resuscitation of 22-week infants, since survival without profound disabilities is so rare. In fact, nationwide, almost all 22-week infants are recommended hospice care. Did you know that? It’s true. The average human gestation — without obstetric complication — is 40 weeks (calculated from the first day of one’s last menses). With thanks to huge technological leaps made in medical care of premature infants in the last decade, babies are generally considered “full term” at 37 weeks and have every likelihood of survival without having any developmental defects.

Just before midnight on Sunday, June 10, Brianna gave birth to four sons and two daughters. All six remain in critical condition in Minneapolis’ Childrens Hospital Neonatal Intensive Care (NICU). The largest infant weighed merely 19 ounces (appx. 539 grams) and the smallest a terrifying 11 ounces (appx. 312 grams).

Ten hours later down in Phoenix, Jenny Masche, 32, gave birth by Caesarian section to three boys and three girls also premature, but which she was miraculously able to carry to 30 weeks gestation. That eight weeks’ difference in the two gestations was profound and resulted in much stronger, much better developed infants to the Masches. The largest weighed three pounds (appx. 1361 grams), but the five smaller babies required ventilation. All are now breathing on their own two days post delivery.

Jenny and her husband tried for years to conceive and she did, although she suffered two miscarriages. Last year, the couple sought fertility therapy through the nation’s leading fertility clinic, Nevada Fertility CARES Wellness Center in Las Vegas. Jenny was given ovulation stimulation drugs, presumably Clomid, and likely hCG injections. Then, when the timing was just right, she was artificially inseminated.

Jenny’s ovulation stimulation drugs caused many eggs to be released at once. Six eggs were fertilized. And the rest, as they say, is history. Jenny’s babies will hopefully be released from the hospital to head home in six to eight weeks, but no one is dare speculating on when Brianna’s sextuplets will go home…the bare minimum of time likely months.

It all seems wonderful, “miraculous.” I’m a mother and I know these two families are elated! Of course they are! And I wish them every joy and blessing God gives to parents. But when the cameras quickly fade away from these sensational, spectacular births of twelve infants, these families will face nearly insurmountable challenges ahead.

The very least of problems ahead are the medical costs. In 1994, the American Academy of Pediatrics released a comprehensive report on NICU care costsaveraged across the U.S. Back then, NICU-only costs per day to care for an infant with a gestational age of less than 24 weeks was $2,346. Per day. For an infant born between 30 and 32 weeks, the cost was less than half at $945. Per day.

Then, the average cost nationwide of NICU care alone for a very low birth weight baby under 750 grams was $89,946. Today, the hospital costs alone of treating very low birth weight infants (under 1500 grams) is over $1,000,000 per child, per hospital stay from its birth until the child is finally developed enough to be released. That does not factor in costs of doctors, medicines, lost wages, prenatal care (which has been staggering for these families) or the huge sums reaped by the fertility clinics and their staffs.

All US health insurance carriers have lifetime maximums in benefits they will pay and typically cap benefits at $1,000,000. You’ve got a cap — check the fine print in your explanation of benefits, or just call the number on the back of your card and ask. At the most conservative speculation, these babies (especially the Morrison’s) will exhaust their allowed medical benefits long before they reach their first birthday.

The March of Dimes has been beating the drum about prematurity for more than 20 years. I strongly encourage you to poke all around their site and learn why it is the Number 1 killer of infants and the Number 1 problem in Obstetrics. The information they offer freely is amazing and 100% dead-on accurate. Learn, people. Thanks to fertility endeavors, this problem of large multiple births is growing by leaps and bounds.

Also very least of problems ahead are the costs of diapers (both families are soliciting donations), food (both families are soliciting donations), and once comfortable homes now found to be overwhelmingly small (both families are soliciting donations).

Way, way down on the list is the sheer number of PEOPLE who will be required to care for these children once home. Fortunately, both families have church families who are volunteering. That is a sincere blessing that cannot be understated. But even with all the help in the world, the physical and mental exhaustion of merely taking basic care of six infants will be profound to both sets of parents for many years ahead.

The money necessary to support these families over the two decades ahead, regardless of instant presentations of free college tuitions and corporate sponsorships of free food and diapers, is meaningless.

The real cost – an actual crime in my mind – is to be found in the physiological and mental tragedies that have likely been inflicted upon these children, all because their parents were determined to force nature to provide them with their own genetic progeny and, once done, refused the immediate medical advice to terminate some of the fetuses (called “selective reduction) to allow others to achieve a survivable, healthy gestational age.

Unfortunately, the actual level and number of defects and, at very least, learning disabilities will not be revealed before these children reach about eight years in age.

I’m very biased on the subjects of fertility clinics, their inherent prematurities produced in births in quadruplets and greater and, therefore, their inherent and often exceptional birth defects. For nearly a decade of my life, I was a pediatric nurse and manager of a pediatric firm with three providers. I know billings, I know codings, I know health insurance and I know intimately the problems in medical care of low birth weight babies and their common birth defects.

For the Morrison sextuplets, so exceptionally small and young at birth, the risks are tremendous. Those afflictions EXPECTED include:

Intracranial hemorrhaging. Grade 1 or 2 bleeds are exceptionally common in extremely premature infants and Grade 3 or 4 bleeds provide profound learning disabilities and hydrocephalus. Grade 1 or 2 bleeds occur in about 1/3 of babies born before 26 weeks, although there are medications that can be administered to the mother prior to birth to help lessen the chance and severity. Coming through this is Cerebral Palsy and Hydrocephalus.

Feeding problems requiring nasogastric tube feedings for more than 8 weeks (most babies require nasogastric feeding if born sooner than 35 gestational weeks). Since preemie newborns have underdeveloped gastrointestinal systems too immature to absorb nutrients, the most premature cannot even digest breast milk at first.

Necrotising enterocolitis (gut problems needing medical/surgical treatment). See above.

Patent Ductus Arteriosis. This cardiac disorder causes profound breathing difficulties. In the womb during development, an artery called the ductus arteriosis is kept wide open by a hormone called prostaglandin E that allows blood to be diverted from the developing lungs directly into the baby’s aorta, since babies do not breath until birth. At full term, prostaglandin E levels have fallen dramatically and have caused this duct to close, helping the fetus’ lungs to receive blood to finalize their development and function properly in preparation for breathing on their own.

Anemia. Preemies usually have significantly reduced levels of hemoglobin and require transfusions.

Retinopathy (an abnormal growth of blood vessels in the retina caused because the infant’s vascular system in the eye hasn’t fully developed.) Retinopathy causes serious vision impairments.

Chronic lung disease requiring ventilation (extra oxygen) for more than 8 weeks. And the longer an infant is on a respirator, the greater the risk it will develop Bronchopulmonary Dysplasia. (Because immature lungs sometimes cannot withstand the constant pressure of the respirator.)

A very, very high risk of developing Pneumonia and sepsis.

A very, very high risk of developing a myriad of infections. This is one major reason why preemies are placed in incubators and thereby isolated.

Another major reason for placing preemies into incubators is because preemies are born with almost no body fat and immature skin and are incapable of maintaining body heat until they reach the age of near-term.

Presence of recurrent Apnea/Bradychardia for the first seven weeks of life.

A very high likelihood of an IQ below 85

A 99% likelihood of being small in growth throughout life.

A 99% likelihood of having future need for full or part-time special education.

A 99% likelihood for special therapy with physiotherapists, occupational therapists and speech therapists.

A 95% chance of Jaundice needing phototherapy to protect an immature liver.

Last on the short list, but not least: Sudden Infant Death Syndrome. Preemies have a much higher risk.

Yes, survival today is possible for babies born at 22 weeks, but these preemies may face a lifetime of health problems. I’ve already mentioned Cerebral Palsy and hydrocephalus, but must also add seizures, lasting neurological problems and, at very least, developmental delays. The lucky, miraculous children suffer only with vision problems or mild developmental delays.

Not all preemies (by definition at younger than 37 gestational weeks) have medical or developmental problems. By 28 weeks, the risk of serious complications is much, much lower. And for babies born after 32 weeks, most medical problems are very short-term.

So, while the media reports the fantasticness of these two large multiple births, my focus is on the children themselves and the medical and mental challenges ahead of them that won’t be fully know for years. Strides in overcoming infertility have been amazing, but don’t think for a second that they come without a staggering price sometimes. And let me assure you the fertility clinics, doctors and medicine giants bear no liability whatsoever in any defects or disabilities these children may develop as the result of their interventions in nature. You should see the disclaimers patients must sign prior to treatment or even consultation!"