Resuscitation

"You may go ahead and push the fentanyl.  Slowly, please."

I instructed the nurse at the neonatal intensive care unit to start administering the sedation medication to the baby as I started to arrange the sterile medical supplies and equipment for the procedure.  The patient was an infant girl with serious neurological deficits who needed supplemental tube feedings for nutritional support, and her attending neonatologist asked me to place in her a special feeding tube through the abdominal wall into the stomach.  It is a relatively simple but also painful procedure, and as a rule it is performed under sedation or anesthesia.  I have performed many of these procedures in infants without complications, and was optimistic that this one would also go well.

As the nurse started to give the medication intravenously, I spoke with the doctor and two nurses who were immediately assisting me, and reminded them that the first two minutes of the procedure, during which an endoscope (a small, thin, flexible tube with a camera) is inserted into the stomach, could be the most critical, and dangerous.  I explained that the sedated baby could potentially stop breathing as a reaction to the scope, and that it might be necessary to temporarily interrupt the procedure to resuscitate the baby by giving her supplemental oxygen.  I also reassured the team that nearly all my patients who previously experienced this temporary interruption was able to have the procedure completed without difficulty.  One of my nurses nodded in agreement, as she had previously assisted in the same procedure many times before.

The assisting doctor suddenly directed my attention to the baby's cardiorespiratory monitor, and appeared quite concerned.  The baby's oxygen saturation started to drop precipitously because she was not breathing.  I asked the nurse to give the baby oxygen by mask.  Still no improvement.  The baby's oxygen saturation, which normally should be about 100%, now dropped to about 70%.  I asked the nurse to start ventilating the baby with the bag-valve-mask assembly and 100% oxygen, while the other doctor repositioned her head to allow air entry into the lungs.  I looked at the monitor, and was dismayed to see that there was no evidence of chest movement.  We were trying to push air into the baby's lungs, but air was not getting inside her.  The oxygen saturation reading now dropped below 60%.  She might die soon if things didn't improve quickly.

The baby likely experienced what is known as "rigid chest syndrome", a rare but well-known potential adverse reaction to fentanyl, the sedation medication used for the procedure.  A patient with this condition develops severe tightness and spasms of the chest wall muscles that it becomes impossible to breathe, and sometimes the only thing that can be done is to medically induce muscle paralysis so that oxygen from a ventilator can move into the lungs to save the patient.  The other doctor and I were seriously considering the possible need for this, when suddenly a couple of faint chest movements were noted on the monitor.  I asked the nurse to keep resuscitating the baby, offering reassurance that the baby appeared to be recovering slowly by herself.  A few seconds later, the monitor showed that the oxygen saturation started to rise from 57% to 60%, and after a few more ventilation attempts with the bag-valve-mask assembly, oxygen finally started to move freely into the baby's lungs as the chest relaxed and started to rise and fall visibly with each delivered breath of air.  Within a couple of minutes, the oxygen saturation appeared stable, and we eventually felt confident enough to actually start and finish the procedure, with no further difficulty.  I appeared calm throughout the situation, but emerged from the procedure drenched in sweat, knowing that the baby could have died.  Thankfully, the baby did well after the procedure, had no trouble with tube feedings, and was being prepared for hospital discharge within a few days.

The only reason that the baby survived the ordeal was that she, for a lack of better words...stayed alive.  It would be impossible to resuscitate a dead person.  "Dead" is also the word that describes us before we become Christians:

"And you were dead in the trespasses and sins in which you once walked, following the course of this world, following the prince of the power of the air, the spirit that is now at work in the sons of disobedience - among whom we all once lived in the passions of our flesh, carrying out the desires of the body and the mind, and were by nature children of wrath, like the rest of mankind.  But God, being rich in mercy, because of the great love with which he loved us, even when we were dead in our trespasses, made us alive together with Christ - by grace you have been saved."  (Ephesians 2:1-5)

Unless God first breathes life into us spiritually and awakens us, we will remain spiritual corpses that will not respond to the most valiant effort by men and women who try to blow the air of the Gospel message into us.  May we who believe in Christ thank God for giving us life in the first place!