Two newborns are coming to the unit, and nurse Barbara Gallagher is a slingshot pulled taut, eager to launch.
"All I know," she says, opening supply drawers and grabbing syringes, "is that they're 32-weekers, they were up on 5 West, and for some reason they're coming."
Twins, eight weeks premature. They were just born at Women & Infants Hospital, in Providence, R.I., and are now on transport beds rolling down the corridor toward its neonatal intensive care unit, or NICU.
Gallagher prepares two small warming beds, arranging on each white sheet the monitor wires, a stethoscope, a thermometer, a vitamin K shot and a tiny paper diaper. There are already 71 babies in the NICU this day, about a dozen of them in bassinets in the room where Gallagher is working.
"Here they come," Gallagher says as the beds roll in. "Hello, kids! Happy birthday!"
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Nurse Barbara Gallagher gives a newborn just brought to the Women & Infants' NICU an admissions check over. |
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The NICU is ground zero in the prematurity epidemic, the place where the too-small babies arrive after birth, where the first big bucks are spent, where the wonders and horrors of extreme medical intervention unfold. The rate of premature births has been increasing nationwide -- the result of social, environmental and biological problems that remain little understood. A visit to the NICU gives a glimpse of the first consequences.
Gallagher is a small woman of swift and sure movements. Wearing flowered scrubs, her dark hair secured in a bun, she lifts one of the babies -- a girl, labeled Baby B -- dries her, weighs her and lays her on the warmer, where an overhead light provides radiant heat. At the same time, another nurse picks up Baby A, a boy. They are the first babies to be admitted this day, but several more will follow.
Newborns come here for constant medical attention, the majority because they were born before 37 weeks' gestation, before their bodies are able to draw oxygen from the air, take nutrients from food and repel infections.
In several minutes, Gallagher completes a multitude of tasks for Baby B, including attaching wires to measure heart rate, respiratory rate, temperature and blood-oxygen levels, ascertaining that the baby's lungs are functioning well, checking for birth defects and raising the temperature in the warmer. These little ones get cold easily.
Then she notices that the little girl's nostrils are flaring. "I gotta do your nose," she tells the baby. "You're not going to like it, but I gotta do it. I apologize."
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As parent Michelle Gray visits with her child, Rashaan, one bassinet over, Gallagher attends to Nicholas Chin in one of five open bays in the Women & Infants NICU. Each bay has about a dozen bassinets. |
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As expected, the baby wails as Gallagher inserts a tube to suction out mucous. Her cries, though forceful, are almost drowned out by the beeps, bongs, dings and squeals of the monitors and by the overlapping voices -- barking information, cooing to babies, calling for help. Close to a dozen different types of professionals attend to these babies, moving among visiting parents.
The ceaseless cacophony has led Dr. James F. Padbury, pediatrician-in-chief, to liken this place to a casino. People who work here can become so noise-sensitive that they can't bear to run their car's air-conditioner on the drive home.
Barbara Gallagher, 49, loves this job -- this scene, this racket, these babies, their families and her ability to help them. Since 1996, she's been one of about 150 nurses (roughly 30 on any given shift) who work in the NICU.
Gallagher wishes she had always worked here, but it took her until her 30s to discover her calling, spurred by a personal tragedy. When she was 28, her husband, her high school sweetheart -- a strapping young man who worked as quahogger -- died from a torn aorta.
"It was the death of our dreams," she says. "I think I can completely empathize with some of these families who have a plan, who expect things to go a certain way and then all of sudden, out of nowhere, with no warning, things can change -- your whole life can change."
At the time, she had a degree in psychology and had been working with the most difficult autistic children, the violent and noncommunicative. In the years after her husband's death, Gallagher looked for a new plan for her life, and decided to go into nursing.
One day during her training, she followed a nurse in the NICU. On that day, a baby coded -- stopped breathing -- and Gallagher witnessed the astonishing choreography of saving a baby's life. "It was stressful and it was tense … but everybody was tuned in. And people were leaning over, reaching their hands out, saying ‘I need' and all of a sudden it was in their hand and they would use it … and I thought, ‘They're saving this baby!' And I thought to myself, ‘This is what I want to do the rest of my life.'
"I still want to do this the rest of my life."
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Amid a nonstop day, Gallagher consults a newborn's X-ray. |
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BARBARA GALLAGHER continues to work on the baby girl, one of the twins who just arrived. She gently pierces the baby's abdomen to place an IV for nutrients and antibiotics. "I'm going to make you a nest," she says, putting rolled-up blankets on either side of the baby so she rests in a little hollow. It's one of those low-tech advances in medical care -- doctors have learned that preemies fare better in such "nests" rather than with their arms and legs splayed.
The baby's arms are flailing and sometimes trembling. She's an active little girl. She may also be withdrawing from drugs; her mother was addicted.
But there are also babies in the NICU whose mothers did everything right. That's the maddening thing about premature births -- no single culprit, no obvious solution.
Advances in the care given at places like Women & Infants -- from big discoveries, such as the drug that keeps immature lungs inflated, to incremental changes in nutrition and ventilation -- have saved the lives of babies who even a decade ago might have died. Usually, that's a cause of great joy, but not always.
Among the youngest babies, those born at 23 and 24 weeks' gestation, the nurses know the risk of lifelong impairment is high; babies can suffer brain damage and cerebral palsy. "We struggle about saving babies," says nurse Kathy McIntyre. "What are we doing? What kind of life are we giving these parents? We talk about it all the time."
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Gallagher catches a quick breather during her 12-hour shift, as nurse Jennifer Kuzmickas grabs lunch in the nurses' room. |
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But it's impossible to know, at the outset, which tiny baby will thrive and which will struggle. Nor can one predict who will grow up to need nothing more than a pair of glasses, and who will have mental limitations. So each one gets the maximum effort. And when a child starts to falter, no parent wants to give up. It's difficult, the nurses say, when parents push to save babies who stand little chance of surviving, or who clearly will suffer severe disability.
"We love the babies and we love the families," Gallagher says, but in those circumstances, "we feel like we're doing a disservice to both. … We know they're not all going to be OK. Some will have severe handicaps or delays."
"We're thinking, ‘What are we doing? Why are we doing this? Is it ethical?' " says nurse Nancy Braga. "If the parents want everything done and the doctor says OK, then we're going to do everything … But are we doing the right thing? What's the future life of this baby going to be? Are we helping? Or are we contributing to a bad outcome?"
Yet if you ask any NICU nurse what sustains her, she'll tell you it's the joy of watching the babies who overcome their obstacles and thrive. The walls in the nurses' lounge are covered with photos of "NICU graduates" and many nurses stay in touch with the families for years. Each has many stories about babies who didn't seem to have a chance, and now you can't even tell they were born too early.
GALLAGHER IS always on the move. "I'm never bored," she says. "I love the rush, I love the action. I don't love the stress, I don't want babies to be sick, but I like to be busy."
Heading down the corridor to get supplies, she pauses to peer into an isolette, an enclosed bassinet with portholes for hands. "Look how cute this baby is. Is he the cutest little thing you ever did see? He was born at midnight last night." The baby is perhaps 12 inches long. Fine hair covers his bony back and his reddish skin looks like jelly.
The NICU is a place out of time. "A third of my day has gone by," Gallagher remarks at one point. "I have not looked out the window once. I don't know if it's raining, snowing, or if there's a tornado going on outside because I've got my own little tornado going in here."
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Martha Mance, a nurse practitioner, left, inserts a breathing tube in a newborn baby, assisted by Dr. Sylvia LaCourse, second from left, Gallagher and others — one of dozens of procedures that occur daily in the NICU. |
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The unit is divided into five open bays, and each holds a dozen or more bassinets, always with someone -- a doctor, nurse, therapist or parent hovering nearby. Here you witness surprising juxtapositions.
A cardiologist presses the rounded probe of an ultrasound machine on an infant's chest, just two feet away from a mother lifting her baby to feed him.
A cloth screen blocks the view as a medical team performs a bedside surgery in the corner of the bustling room.
A small mob clad in green scrubs descends on the bay, rolling a cart full of medical records and a couple of laptops on stands. This is rounds; it happens three times a day. The attending physician -- surrounded by fellows, residents, pharmacists, dietitians, case managers and respiratory, occupational and physical therapists -- hears a report on each baby, a process that can take an hour.
The attending, concerned about one baby's breathing, orders that he have a tube put down his throat so oxygen can be delivered directly to his lungs. Instantly, a team materializes at the baby's bedside and surrounds his head. A resident struggles to insert the tube. Meanwhile, barely inches away, the folks on rounds continue discussing the other babies.
Padbury, the pediatrician-in-chief, says a group of researchers came to Women & Infants a few years ago to study why the hospital was having such good outcomes -- comparatively low rates of complications, 94 percent survival rate (in 2008) for those born weighing between 1 pound 10 ounces and 2 pounds 3 ounces (750-999 grams). They were looking for one big thing that other hospitals could emulate. But they didn't find it. "The difference between good and great," Padbury says, "is details."
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Gallagher stands by as new mom Xiulian Li changes the diaper of her newborn son, Nicholas Chin, who had respiratory problems at birth. |
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CERTAINLY THE details are what concern Barbara Gallagher -- giving each baby precisely calibrated doses of oxygen, food and medication, scrutinizing every nuance of his vital signs, attending to every hint of infection or other problem. "I love the power that I have as a NICU nurse," she says. "We have great autonomy. We have the ability to say to the doctors, ‘I saw this; this baby needs that.' It comes with awesome responsibility."
But just as powerful, Gallagher says, is the ability to help families cope. "I can help make things better one on one. I can help the families feel stronger and healthier and feel competent to take care of their child. … This is a place where a parent has the least control they're ever going to have with their kid."
She coaxes a mother who looks scared and tentative to change her day-old baby's diaper. The mother, who had delivered by cesarean section, arrives in a wheelchair with an IV still in her arm. "Let him hear your voice," Gallagher urges her. "He really doesn't know my voice. He really knows your voice. You're going to make him feel better."
Later, she remarks as the mother strokes the baby's leg, "Whatever you're doing, he's loving it."
That's not just talk. Gallagher can see the effect on the monitor: the baby had been struggling to breathe, but with his mother at his side, the oxygen level in his blood increases.
"It's so beautiful," Gallagher says, "to see how a mom and a dad can make their baby feel better in ways that we could never do. It just makes my heart sing."
About one in 20 babies who come to the NICU dies, typically because of extreme prematurity or a severe birth defect. Gallagher volunteers to work with the families coping with a child's death. She helps them have the ending they desire -- remembering, with lasting pain, that she was not with her husband in his last moments.
One family had bought a snowsuit for the baby. When it became clear that the baby would never come home, Gallagher dressed her in the snowsuit and wheeled her, with all her equipment, into a quiet family room where every sibling got to hold her before she died.
Another couple just wanted some time with the baby without all the noisy equipment. So Gallagher led them into a private room and hand-ventilated the baby for hours -- squeezing a bag, normally used during power failures and emergencies, that forced air into his lungs to keep him alive. A priest administered last rites. "The priest left, it was just me and them, and I took the tube out of the baby. The baby looked up, opened his eyes, put one hand on his mother's finger, put another hand on his father's finger and opened his eyes and looked at them. … It was magic. It's why I do what I do."
WHEN EVENING arrives, the NICU lights are dimmed. On one night three parents, visiting after work, are sitting in a row, each in a rocking chair, each cradling a baby's tiny head in one hand, and holding a bottle with the other. A white man. An olive-skinned woman. A black woman. Occasionally they exchange words but mostly they share a companionable silence. Though the monitors clang and nurses rush about, the parents seem ensconced in a bubble removed from the clamor, as they feed their infants, each gazing into their child's eyes.
Gallagher will be leaving soon. During her half-hour drive home, she'll worry about the twins born exposed to drugs. She'll worry about the babies born so tiny that their future is murky. She'll worry, just as much, about those who are thriving in the NICU but heading home to families riven by poverty or abuse.
But Gallagher has a rule. If she's going to attend to tubes and monitors and lab reports with ceaseless vigilance, if she's going to teach and comfort parents, or place warm soothing hands on a writhing baby as a tube is thrust down his throat -- if she's going to do all that with precision and care, for three 12-hour shifts each week -- she also has to let go.
She draws the line at the entrance to her wooded lot in Coventry. At the moment she turns into her unpaved driveway, Barbara Gallagher leaves the NICU behind.
ffreyer@projo.com
