03/17/10 Mistakes

Patricia called me at work to give me an update on how Eli was doing today. It's part of the little routine we've established. She said the Eli had an elevated heart rate over night and the doctors were a little concerned but they weren't sure why his heart rate was elevated. Patricia also said Eli pulled out his NG feeding tube last night. We have been warned that kids have a tendency to pull out their feeding tube so it isn't a big deal...unless you have to put it back in at which point it becomes a real pain for the care giver. Everything appears to be normal now and he had a great night with no oxygen desaturations.

They decide Eli can be off the CPAP all day today. He is on normal low flow oxygen through a nasal cannula. I think he is getting three quarters of a liter. This is fairly standard and he seems to do really well on it.

Eli's belly button hasn't fully healed up yet either. The umbilical cord has fallen off but it's still weeping a little fluid. Yesterday one of the doctors came in and examined it and said Eli has an umbilical granuloma. Off to the internet we go to look up more medical terminology. It turns out an umbilical granuloma isn't a big deal. An umbilical granuloma is a piece of living tissue that remains on your baby's belly button after the umbilical cord falls off. Rather than healing up and becoming covered with skin cells, a bright red stalk of living tissue remains on the belly button. If not treated, this spot will continue to produce a sticky mucus-like substance which can cause irritation and eventually become infected. Granulomas occur in about 1 in 500 births. Normal treatment includes tying off the granuloma and allowing it to wither and fall off, freezing it off with liquid nitrogen, or cauterizing it with silver nitrate. They decide to use silver nitrate to cauterize it.

Later in the morning Patricia went to change a diaper and discovered a bandage on Eli's belly button covering about a silver dollar sized burn. It looked more like a wound that a treatment for the umbilical granuloma. She asked what was going on and the nurse said they treated his granuloma with silver nitrate but some of it got outside the belly button. This, my friends, is called a mistake. Patricia was livid. The hospital wound specialist came in and all the doctors in the NICU examined Eli today. The hospital has a special nurse who documents skin and tissue injuries like this so she came in and took some photos of Eli's wound. This is the second time she's been to see Eli. When we were down on the floor they bandaged his foot too tightly with some rubbery self adherent medical tape called Coban and it left bruises and broken blood vessels near the skin fold on his foot that took weeks to heal.

So how did this happen? Well it turns out that it was one of the younger nurses who treated Eli. Apparently they don't teach people about silver nitrate in nursing school anymore because she liberally smeared it on his belly button and surrounding skin. Silver nitrate is a chemical compound that burns. The actual umbilical granuloma doesn't contain any nerve cells so burning it off to cauterize it isn't a big deal. No pain and no fuss. When you liberally spread it on someone's belly button it burns and causes pain. They applied the silver nitrate at about 10:00pm last night. Let's put the timeline together now. Apply burning chemical to my son's skin at 10:00pm followed by an elevated heart rate over night (aka pain response) followed by pulling out his feeding tube (aka thrashing and squirming) and resulting in no oxygen desaturations (aka no sleep apnea because he was awake all night). I'd say the mystery of the elevated heart rate is solved.

We're starting to feel like every day we're in the hospital we are putting Eli at a greater risk for these stupid little mistakes. We're averaging one mistake every 15 to 20 days.

It's evening now and Eli has been off his CPAP all day. They drew a little blood to test his CO2 levels and they are elevated. His CO2 level is 67. When we take Eli off the CPAP he is on oxygen. This keeps his oxygen saturation levels up but it masks the underlying problem. Specifically, the underlying problem has to do with the fact that Eli isn't exchanging gases efficiently. He is hypoventilating or shallow breathing so he's pushing CO2 out and sucking it right back in making it hard for his body to rid itself of the CO2. The oxygen helps prevent desaturations but it doesn't help him push air in and out. The CPAP uses positive pressure to ventilate and helps to increase gas exchange resulting in lower CO2 levels. It's clear that Eli needs the CPAP support at this point so our roadmap to get home is looking a little bumpy. Hopefully tomorrow will bring some more answers. They are going to try the BiPAP mask on Eli during the day tomorrow and while it's a little too big right now it might not be impossible. We'll hope for the best.