I always get hooked by the opening song, “Teardrop” by Massive Attack, which is like one of my favorite songs. So the episode I’m watching right now has House seeing babies. Crazy.
And, yet within seconds of the show starting, I find myself deconstructing everything.
(1) The difference between a baby spitting up and a baby vomiting is generally pretty dramatic.
(2) Bowel obstruction is not the first thing you would think in a 12-hour old who is vomiting, febrile, and seizing. Most of the time, it’s probably not even related to the GI tract at all.
(3) Unless you’re pulling out an endotracheal tube because the baby has stopped breathing, the crash cart is not the very first thing you open up if a baby starts seizing. Surprisingly, seizures are fairly common, especially in the setting of a high temperature.
(4) Three septic babies in one call night, while awful, is, from what I remember, par for the course in a level 1 NICU.
(5) Besides the fact that they made an awful decision on what antibiotics to start, the idea of pulling off antibiotics on a septic patient because their kidneys are failing is laughable, unless you have absolutely no doubt that it’s a virus or you’ve convinced the parents that the patient should be receiving comfort care and no heroic measures. Continuous dialysis would be the next step. For all you know, the kidneys are failing because of sepsis and not because of the antibiotics.
Which reminds me of a rather dramatic episode during my residency (but which would most likely make for an extremely boring TV show since the events unfolded over the course of several months.)
My very last call night in the NICU, we picked up a transfer who was what we call a train wreck. A premature baby born to a crack cocaine user who didn’t have any prenatal care, who goes into asystole and gets three rounds of epinephrine and atropine (as well as chest compressions and bag mask ventilations) until a perfusing rhythm is obtained. The baby turns out to have Acinetobacter, one of the most resistant bacteria known to humanity. While antibiotic overuse is certainly not helpful, Acinetobacter has always been a hardy bug. It’s pretty much ubiquitous in the environment, and if you have a normal immune system, it’s usually not a problem.
Of course, babies, especially premature babies, especially premature babies who have been brought back from the dead, don’t have normal immune systems.
And this particular Acinetobacter had the dreaded resistance known as extended-spectrum beta-lactamase activity. This limits the number of antibiotics you have to work with.
After I rotated off the NICU, I found out that my patient was the veritable patient zero. By the end of the next month, one-third of the NICU was infected by Acinetobacter. (I swear I washed my hands every time, and besides, I never took care of the subsequent babies who got infected. I swear!)
I don’t think anyone died. The only upside of multi-resistant bacteria is that they tend not to replicate as fast as wild-type, non-mutated, sensitive bacteria, so if the antibiotics you choose actually work, you’ve got a good chance of saving someone’s life.