The Smallest Human I Ever Knew

Rare teachers can deliver a lesson that another carries with her throughout life. Amelia was one such teacher who did it before she was three days old. She was a premature infant and I witnessed her birth. She was what neonatal intensive care nurses call a “micro-premie.” She will never know me but I will never forget her.

Amelia was a triplet and all three babies were born by planned Cesarean section at breakfast time on a spring day. Amelia had stopped growing because blood was not flowing normally through her umbilical cord. The two boys each weighed about three pounds more than Amelia and the trio was born six weeks early when all would have a good chance of survival. If allowed to go to term, Amelia would have died. The family also had a twenty month old boy at home and it would be sixty five days before Amelia would get there.

The delivery room was set up with infant warming tables and other equipment positioned to allow enough space for two surgeons, a scrub nurse, an operating room technician, two circulating nurses, an anesthesiologist and three complete baby teams, consisting of a doctor or nurse practitioner and a NICU (neonatal intensive care unit) nurse. There was the mom, the dad and eventually, three infants.

“Baby number one is out,” someone called as an Apgar timer was started on an infant warmer. The first boy baby, Jake, was brought to his table, dried, stimulated and assessed for complications of prematurity. He was pink and breathing on his own.

“Baby two.” The Apgar timer started on the second warmer and Garrett was placed , slippery and screaming, onto it.

My stomach fluttered as I waited for “my” baby to be delivered. I had been a nurse for seven years but was a only year rookie in the intensive care nursery. I reminded myself that there was plenty of help with twelve other medical people in the room. I scanned the warming table to make sure our equipment was all in place. Good. Any newborn could require a full resuscitation, but this baby was at increased risk due to her prematurity, small size and the state of her umbilical cord.

“Baby three.” When Bea was placed on the warmer and our eyes met for the first time, hers sticky with vernix and mine hardly believing, she weighed just 543 grams or one pound and three ounces. She was pink and breathing erratically, but on her own and trying to cry.

Fortunately, her head and thus her brain, had been spared the growth retardation of the rest of her body. The disproportionate weight of it made keeping her spine aligned and her airway open a challenge at the beginning and difficult for positioning her in the weeks ahead.

Karl, the father of the triplets, was able to see them all before the boys were placed together in a transport isolette and taken to the NICU. Amelia was placed in her own isolette a few minutes later. Triplet mom, Heidi, had been medicated and was so sleepy that she could not turn her head to see her babies. In less than twenty four hours, now mother to four children under two, she had visited with the boys but not yet with her only daughter.

Heidi did not acknowledge Amelia’s existence the day after delivery. It seemed that she was afraid her only girl did not have a chance to survive and therefore dared not fall in love with her. The boys were larger and looked more like babies, while Amelia continued to lose weight and was quiet. Heidi was a private and taciturn woman, under five feet tall and less than ninety pounds when not pregnant.

On the triplets second day, things began to change. With a pillow pressed to her post-surgical abdomen, Heidi walked from her hospital room to the NICU to see her new babies. Each was in a clear isolette, lined up like a row of boxes. Amelia was being fed fluids through an intravenous line and breathed supplemental oxygen from a mist-filled ”hood”overhead. It was hard to tell there was a baby girl in her isolette at all and surprising that Heidi chose then to touch Amelia for the first time.

She opened the porthole on the isolette and placed her hand with gentle firmness (the kind premies need) on the prone baby’s back. Amelia’s response to her mother’s touch remains an indelible memory. By cardiac monitor, I could see that baby Amelia had a regular and normal heart rate for the first time, a smooth, regular respiratory pattern and her oxygen saturations had increased.

During the previous night shift, our neonatologist placed an umbilical line for Amelia’s IV fluids. It was sutured in place on her belly button. The infant’s veins were fragile and difficult to use for a regular IV. She had the tube in her belly button, oxygen tubing on her face, was dressed in the tiniest diaper and had shrunken to 500 grams by day three. She was no longer the feisty pink baby she had been at birth. Her skin was jaundiced and sallow, her eyes deep and sunken like dark round holes. Her head seemed huge in comparison to her body. She weighed less than a large bag of M&Ms and measured eleven and one half inches long, the height of a Barbie doll. Her neonatologist would tell me later that she had had nightmares about the baby dying.

It was at this low time in Amelia’s life that I remembered what her mother’s touch had meant to her. Amelia and her brothers were in a small room of their own in the NICU. The boys had “graduated” to open cribs, but Amelia was still in an isolette. The privacy and quiet were especially good for the smallest baby. It was this privacy that prevented more experienced nurses from stopping me from doing what I did.

The room abutted the nurse’s station and had blinds on the windows that we closed when sick or tiny babies were resident. The overhead pages were barely audible in there, but a call for a “stat C-section” came overhead. An emergency delivery was about to happen in the operating room.

A neonatologist and two nurses sailed out of the unit and down the hall to the surgical delivery room, pulling stethoscopes off a rack by the door as they went. I stayed in my assigned room with Jake, Garrett and Amelia. Heidi was still a patient herself and walked more easily now into the quiet space containing her children. She carefully lowered herself into a rocker and gazed over at the row of babies. She looked sad when her eyes found Amelia.

Intuitively I removed the nearly naked Amelia from her isolette and tucked her into the warmth of her mother, her body skin to skin with Heidi’s chest, her tiny feet resting between Heidi’s breasts, and covered them both with a warm blanket. This was known as “kangaroo care” and I didn’t know that it was highly controversial in our unit. I was careful to mind the umbilical line and the position of Amelia’s head to protect her airway. She could not hold it up on her own.

Once Amelia was curled onto her mother’s bare skin with nothing between them, I looked over at her cardiac monitor. Her vital signs were stable. Once again, the mother-child pair proved that their closeness was the best medicine. Amelia showed the most stability that she had all day. Her oxygen saturations were perfect and her heart and respiratory rates were normal for the first time in twenty four hours. It was almost as if the tiny baby was saying, “Thank you. I just needed my mother.”

Heidi sad something that fills my eyes many years after my work at the hospital was done. She looked down at the baby on her chest, put a hand on Amelia’s soft head and said, “She’s just like a real baby.”

This was the type of moment that is meant when it is said that “nursing is made of moments.” I had to share it with her doctor who had returned from the emergency and left a healthy term baby there with its mother. I stuck my head out the door and around to the nurse’s desk where Dr. Larkin sat.

“Come see this,” I whispered before the neonatologist followed me back into the room. I couldn’t see her face once she turned her back and left again, but I realized that she was furious. She was so angry she couldn’t even speak right away. I followed, asking if I should put Amelia back in her isolette, but every muscle in the doctor’s body was rigid and she gave one stiff shake of her head. Dr. Larkin, I learned, was not an advocate of kangaroo care, especially for her sickest and smallest patients.

I couldn’t sleep that night. I wrestled with what had happened. It had seemed so right to let this mother touch and hold her baby. It had brought them both such happiness, but cost me a dressing down by a senior staff member on the next shift. One of the physicians I respected most could not speak to me and I was worried, and it was suggested, that I was not NICU material.

A few days later, I addressed Dr. Larkin in the privacy of Amelia’s room. “You know, Val,” I began, “I didn’t let her kangaroo to antagonize you. I wouldn’t have come to find you if I had.”

Dr. Larkin held a stethoscope to Amelia’s miniature chest, then continued to examine her as I spoke. Her eyes stayed down even after she was done and after softly snapping the porthole closed. “I know,” she began. “Your heart was in the right place. I was just so afraid she was going to die. I’ve hardly slept worrying about her.”

“I wouldn’t have allowed it if she hadn’t tolerated it,” I said. “Amelia has been so receptive to her mother’s touch. Heidi wouldn’t even acknowledge her the first day. They are making up for lost time.” I did not know how to get my point across to her. “I think she looks better today,” I added more softly.

“Yes, she does.” Valerie Larkin slipped by me and out the door. Amelia turned her deep blue eyes on me when I got close to her isolette. She put a teeny fist in her mouth and closed her eyes.

Amelia did not have an easy time in her sixty five days in the hospital. Both boys went home a month before her. All of them were exposed to chicken pox and quarantined in an isolation nursery for three weeks. Amelia developed symptoms of infections four times and required several courses of antibiotics to save her life.

By the time Amelia was discharged, she weighed 1600 grams and was eating more than other babies of her age and weight.

When we heard from Heidi and Karl again, the triplets were three years old, and with the family living abroad, bilingual. Amelia may always be petite, but has a big place in my memory and nursing moments.

I now have years of NICU experience. Amelia and her brothers will have just celebrated their twentieth birthday. What happened with kangaroo care might not have been procedurally ideal at the time, but it was the best thing for Amelia and her frightened mother and...I’d do it again.