Parallel Charting
38 5-week infant born via Stat c-section delivery due to fetal bradycardia. Mother is a G4P3 with pregnancy complicated by diet-controlled gestational diabetes mellitus, chronic hypertension, and fibroids. Infant required supplemental oxygen in the delivery room and was transported to the NICU at about 12 minutes of age due to respiratory distress. Infant admitted on CPAP +5 with an initial oxygen requirement of 40% FiO2. CXR mildly hazy with adequate expansion and volume. Slightly enlarged cardiac silhouette. Initial blood glucose < 10 and a dextrose bolus was given and IVF of D10W at 80 mL/kg/day started. Mother under general anesthesia and father updated at the bedside on admission.
She is fourteen minutes old when they wheel her from the operating room into the neonatal intensive care unit. Straight black-hair, chocolate brown irises so dark they swallow her pupils; her cheeks are full and fat. She lies nestled on a pink and blue unisex blanket, while one nurse affixes sticky electrodes under each clavicle and another arranges IV supplies on a metal cart. She doesn’t move at all except the see-saw rocking of her chest as her stomach pulls in and her chest expands. Her chest glides out ninety-six breaths per minute, twice the normal rate. The blood pressure cuff ticks as it ratchets down and a blood glucose machine readout blinks low, less than 10.
Her father is already at the bedside, his broad face weathered, and creased. I update him using a Spanish video interpreter and my short sentences come out inexplicably long from a middle-aged woman wearing a headset. He nods stoically and tells me to do whatever I have to do.
Infant with worsening respiratory distress and an increased oxygen requirement. The most likely etiology is surfactant deficiency however there could be a component of pulmonary hypertension. Blood pressure is stable. Will plan to intubate and obtain an echocardiogram to evaluate pulmonary hypertension vs. an underlying cardiac etiology. Anticipate initiating inhaled nitric oxide if the echocardiogram reveals pulmonary hypertension.
After she’s stabilized, I sit in the office adjacent to the unit, talking into my computer screen when the respiratory therapist calls to say they have turned the baby’s oxygen up to eighty percent. I apologize and cut the meeting short. Then, at the bedside, I find her breathing harder, faster. Her breaths suck against the CPAP mask and her belly pulls under the tent of her ribs. The respiratory therapists work silently. One attaches hoses at the back of a ventilator while the other opens a tackle box and pulls out a laryngoscope, stylet, and endotracheal tube. A nurse stands in front of an IV pole and punches numbers into the pump.
Half an hour later, after the breathing tube is placed, the ventilator keeps up a steady cadence as a technician glides an ultrasound probe over her chest and pixels of gray, red and blue lurch across the screen, dancing in shadowy snippets.
Echocardiogram revealed supracardiac total anomalous pulmonary venous return. MAPs trended down and dopamine started at 5 mcg/kg/min. Will titrate to keep goal MAP > 38. Will contact a cardiac center and arrange transport to the PCICU. Mother updated at the bedside.
The cardiologist calls. “Total veins,” she says. “Supracardiac.” And in an instant, the fog dissipates. I can see it all before me—the blue deoxygenated blood enters the right side of her heart and is pumped into her lungs where it collects oxygen molecules. But then the rich oxygenated blood feeds back to the right side again, instead of draining to the left side to be pumped out to the rest of her body. A residual hole between the top chambers of her heart allows some blood to slosh across to the left side of her heart—it’s the only thing keeping her alive.
I stand at the office window and place a call to a pediatric cardiac center. The cardiac intensive care doctor speaks in a familiar German accent. He is a friend from training—energetic, brilliant, and stunningly capable. The nurse practitioner on the line with him helped me place a femoral line in a sick baby at 2 AM one night. It’s a conference call into the past. I look out the window while I talk. It’s late afternoon and the clouds are thick and low and a flag flutters furiously and I have an acute sensation of nostalgia. Occasionally droplets of rain are hurtled at the window, and I know it’s not flying weather; their transport team will have to drive.
After I hang up, I take the back stairs one flight down to the post-operative recovery unit where the mother recovers from her emergency c-section. I find her in bay two, sleepy and nauseous. Her face is pale and her hair sticks to the bleached pillow in clumps. They took out her breathing tube a couple of hours ago and she speaks in a hoarse whisper. She tells me her husband left a few minutes ago to check on their other three children who are staying with a neighbor. All he knew to tell her was the baby was in intensive care.
I have the consent to transfer forms in my hand. There’s no easy way to start. I try to take it step by step, but each step is a boulder. I start with the admission to the NICU, the fast breathing and the need to place a breathing tube. I tell her about the echocardiogram to check for high pressures in the lungs or a heart condition and she nods with drowning eyes. I forge ahead. I tell her about the cardiac defect and the need to transfer to a cardiac center for surgery. Suddenly she retches into a plastic bag. I stand behind the screen to give her privacy. The sound of her sobs comes through the screen.
Several days go by and my next call night is busy. We admit five babies—one for seizures, another for desaturation events, and three for prematurity. There’s one code on the unit and another in the delivery room. As I enter each note into the electronic chart, I think about the potential readers: medical professionals, insurance companies, and, unfortunately, lawyers. The entries are sterile: “Endotracheal tube visualized passing the cords however poor chest wall noted and the HR remained low”. The entries give all the necessary information and yet they are only a skeletal vessel. They hold up the frame of events but miss the details that give rise to color and sound and feel: the bloody film matted to the baby’s hair or the pallid jaundice of his chest or the way time lurches in strange convolutions as the monitor sluggishly blinks out the heart rate.
It’s then that I think about parallel charting. The objective medical data in one entry, the narrative form in another, the two forms juxtaposed. As I sit down to work out this idea, I can’t help but wonder if I’m wasting my time. The exercise serves no immediate purpose; events like these take place thousands of times a day in hospitals across the world. Yet I feel compelled to attempt in my own faltering way to capture something more from the moment. Sitting at the kitchen table, with the dog sprawled over my feet and the laptop cursor blinking, I realize why. I realize the struggle to find the right words, to string them together and remember the father’s face and the sweat sheen on the baby’s brow, molds and guides me closer to where I should be. It helps me see beyond the technical aspects of placing a breathing tube or interpreting a blood gas. It helps me to break away from the task-oriented mentality of making phone calls, writing orders and notes, filling out forms, and updating parents so I can get home for dinner. Although others may never read the narrative behind the electronic medical record, the act of writing draws me back to why I first fell in love with medicine—the sense of humanity and connection and purpose. It reminds me of who I am in the story and why I point my car towards the hospital each day and get up at all hours of the night and of the unrelenting privilege it is to be here on earth, doing this job.
Note: This is a patient composite with all identifying details changed to protect patient confidentiality.