For disclaimers see chapter 1.
Part 219:30
Friday, May 19th, 2006
Bethesda Naval Hospital
Cafeteria
Harm was jostled out of his daydreams by the sound of children squealing. He looked up from his coffee to see a young petty officer with 4 small children. The petty officer approached Harm's table, "Excuse me, Sir…would you mind if I borrowed one of the chairs from your table?"
"No, go right ahead…you look like you have your hands full," smiled Harm.
"Yeah, my wife just gave birth to number five. That leaves me in charge of the tribe for a few days…I just hope I survive," he grimaced as one of the kids threw a cup at her sibling. "You know we never planned on having this many kids, but somehow God thought otherwise."
"Yeah, I guess you're just lucky that way," Harm replied with a fading smile.
"I don't know if I'd call it lucky, but it's never boring," the petty officer smirked. "Look, I'm sorry sir…I better run interference before they destroy the cafeteria," the petty officer quickly took off to stop the food fight that was about to ensue.
Harm continued to watch the young family, muttering to himself, "You have no idea how lucky you are." He took a sip of his now cold coffee and grimaced. A glance at his watch told him he'd already been gone a half an hour. He thought he should really get back to Mac, but mused that he might have to watch more of that movie. He couldn't comprehend what Mac and Harriet saw in that actor, what was his name, David…Elliott…James, something like that. He shook his head, 'women.' Now if the movie had had Catherine Bell in it that would have been a different story. Something about that actress reminded him of Mac.
Falling back into his daydreams, he continued to ponder his marine's pregnancy course. The medications had stopped the preterm labor and the leaking of fluid had sealed within 48 hours. Dr. Abrahms had been able to stop the IV magnesium after a week; instead changing Mac to meds by mouth. Mac, to her credit, had remained on strict bedrest just as ordered. In fact, Harm had even had some fun helping her with a sponge bath or two. He had even snuck in some contraband food, including hamburgers and steak, when no one was looking. When Mac questioned his offering of meat, he replied with a shrug, "I figure if you put on weight then Sophie will put on weight. What's more fattening then meat!" Mac laughed at his logic, but enjoyed the treats nonetheless. An ultrasound 1 week later showed reaccumulation of some of the amniotic fluid and Sophie had gained a half of a pound, the burgers were paying off. A follow-up ultrasound, on May 10th showed that the fluid level was almost back to normal and Sophie had almost cracked the 10th percentile on the growth curve. Dr Abrahms was happy with Mac's progress and even contemplated giving her back bathroom privileges. All seemed to be progressing according to plan until one week ago.
xxxxxxxxxx Flashback xxx Friday, May 12th, 2006 xxxxxxxxxx
Harm walked into Mac's room during lunchtime. He'd taken an hour lunch break to come eat with her. When he got close to the bed, he noticed that Mac was rubbing her leg and grimacing. "What's up Marine, muscles getting soft from lounging around in bed," he smirked.
"No, thank you very much. My legs just ache…they're kind of swollen too," she grumped as she pulled back the blankets.
Harm's eyes widened in shock when he saw the size of Mac's feet and ankles, "How long have they been like that?"
"I don't know, since yesterday I guess," she whined rubbing at her uncomfortable feet. "You wouldn't think they would swell like this when I've had them elevated in bed."
Harm's internal alarm started to jiggle, "What does the doctor say about the swelling?"
"I haven't had a chance to tell him yet. He breezed through here so quickly this morning, I'm not sure he was even here…Harm could you rub some lotion on my legs and feet; they're really uncomfortable."
Harm nodded and grabbed the lotion from the bedside table, "Is everything else OK…Your blood pressure isn't up again is it? He seemed to remember something about high blood pressure and swelling from one of the pregnancy books.
"I don't think so, the nurse didn't say anything…but then she isn't one of my usual nurses. Sally doesn't work again until tomorrow."
Harm slowly massaged the lotion into Mac's legs resulting in a groan from Mac. "Did I hurt you?" he gentled his touch.
"No, it feels great…don't stop…ever!" she said with a grin. He smiled back, but continued to be concerned. He'd have to check with the nurse before he left.
Harm gave Mac a full 30-minute leg massage before kissing her goodbye and promising to return that evening. He stopped at the nurse's station on the way down the hall. "Could you please tell me who my wife's nurse is today?" Harm questioned the unit clerk.
The clerk checked the patient assignment board, "Yes Sir…that would Phyllis…I think she just ran to lunch, can I give her a message, Sir?"
"Yes, tell her my wife's legs are really swollen and I wondered if her blood pressure was OK?" Harm replied with concern.
"I'm sure it's nothing to be concerned about but I'll pass along the message…Sorry Sir, I need to grab the phone."
Harm nodded and gestured that he'd be back that evening. He was determined to talk to Dr. Abrahms. His internal alarm was blaring now, he wanted to get back to the office and check the internet. Something just didn't seem right.
xxxxx
As Harm breezed into JAG ops, he ran straight into Harriet Sims. Grabbing her arms to stabilize the petite blonde, he muttered his apology while quickly attempting to get to his office computer.
"Captain, what's the hurry are you late for court?" Harriet inquired.
Harm stopped in his tracks and turned towards the bubbly mother of four. His eyes brightened, as he realized he had found the 'fountain of truth' for the knowledge of all things pregnant. If anyone would know about swollen legs it would be Harriet mused Harm as he recalled an earlier incident involving one pregnant lieutenant, a desk chair and a lunch date. "Harriet, when you were pregnant with Jimmy your legs were sore and swollen right?"
"Well yeah, as I recall you were the only one to show me any sympathy."
"Did your doctor say if this was normal?"
"Harm, most women exhibit swelling in their feet and legs at some point in their pregnancy. Why do you ask?"
"Mac's legs were really swollen today, but you don't think that's unusual?" queried Harm. Please say no he begged with his eyes.
"Well, I guess not, although with Mac on bedrest it might be a little more unusual. My legs tended to swell more through the course of the day."
"Were they ever swollen after you'd spent the day with your feet up?" questioned Harm.
Harriet chuckled and shook her head, "Boy do you have a lot to learn. I had a preschooler hanging on to said legs, and Bud was still getting back into stride after his injury…Captain, my feet were never up!"
Harm laughed back, "I get the picture Harriet, thanks for the info."
As he was about to head to his office, he was intercepted by Petty Officer Coates. "Captain, the Office of Homeland Security is on line one and the General would like to see you in his office in 10 minutes."
Harm sighed, "Thank you, Jen…I'll be with the General shortly." So much for his internet search he thought. He'd just have to secure early to make it back to Bethesda before Dr. Abrahms made rounds.
xxxxx
The remainder of the afternoon had been harried, leaving no time to call Mac and check-in. It was now 17:30 and he hoped he hadn't missed the doctor's evening rounds as he ran into the hospital. He met up with Dr. Abrahms just as they both approached Mac's room. "Doctor, I'm so glad I caught you. I'm really concerned about the swelling in Mac's legs, should we expect that at this point?"
The doctor looked puzzled, "What swelling…I was just going to check on Sarah, but the nurse didn't mention any swelling? Let me run grab the bedside chart and I'll be right in."
Harm nodded and proceeded into the room to check on Mac, "Hey Marine, why are the lights out…it's kind of dark in here. I just ran into Dr. Abrahms, he should be right…" Harm paused as he noticed Mac's pained expression, "Mac what's wrong? Are your legs still bothering you? You know I can rub them again once the doctor's done."
Mac looked up through squinted eyes and with a soft voice replied, "Yes they still ache, but I have a wicked headache...that's why the lights are out."
Harm started to pace just as Dr. Abrahms arrived, "Doctor, Mac also has a headache…" he started at the same time as the doctor began to speak.
"Sarah, I understand your legs…" Dr. Abrahms stopped mid sentence. "What did you say, Harm…Sarah has a headache?"
"A real doozy…" Mac answered quietly so as not to increase the throbbing.
The doctor anxiously began flipping through the bedside chart to the vital signs. He sighed, "Guys, we have a problem here."
Harm's eye opened wide, "What's wrong, now?"
"Sarah's blood pressure is markedly elevated again and I suspect the headache and swelling are associated with a condition called preeclampsia…I'll need to run a urine protein sample and some blood chemistries to be sure…I'm sorry I wasn't aware of this sooner, but the nurse taking care of Sarah today isn't one of our regulars…I don't think she noticed the changes in Sarah's condition."
"What do you mean she didn't notice," Harm exploded. "We've been on a tenuous course for weeks, how incompetent can she be," he fumed.
"Harm, calm down…my head is killing me," Mac grimaced. Harm threw a sheepish look her way in apology. "I didn't tell the nurse about the swelling because I didn't think it was important…and the headache just started an hour ago."
Dr. Abrahms approached the bed and began to examine his patient. He tested reflexes, pushed on her abdomen and checked her eyes. "Alright Sarah, let me get something ordered for your headache and we'll get those labs sent…I'll be back to talk to you both in about an hour once I have the results." The doctor breezed out of the room to find the nurse.
Harm circled back to the bed and sank restlessly into the bedside chair. Mac peered up and grabbed his hand to still his movements. "Harm, you need to calm down…your nervousness isn't helping you or me," she whispered.
"Sorry, I just can't believe after things were starting to look up…" his voice cracked. "Sarah, I'm just so scared…what if…"
"I know Sailor, but I really need you to keep it together for both Sophie and me right now…I don't feel well enough to be the strong one," she grimaced with tears collecting in her eyes.
"Hey, hey don't worry…we'll get through this too. We've survived the last 11 weeks of ups and downs, I'm not gonna quit now," he settled onto the bed beside her and pulled her close. "Dr. Abrahms just needs to give us the next battle plan," he placed a gentle kiss on her temple. "Just lie back and rest until the nurse comes back with your pain meds."
A few minutes later, the nurse arrived with supplies in hand. "I'm sorry Captain but you'll have to move while I collect the Colonel's blood and urine samples. Sarah, I'm going to need to start an IV again and catheterize you to collect a 24-hour urine sample. Dr. Abrahms wants me to restart the magnesium drip."
Harm began to pace the small room. "Why are you starting magnesium again, she's not in labor?" His fingers now running through his hair at a feverish pace. "And why didn't you note all these changes earlier, you should have been paying closer attention…"
"Harm, STOP!" Mac cried. "You need to calm down, this isn't helping…why don't you go down to the cafeteria while the nurse does these procedures."
"I'm not leaving you."
"Sir, you're upsetting your wife and that will only exacerbate her high blood pressure…she needs to stay calm. Why don't you do as she suggested and get something to eat…Dr. Abrahms won't be back for at least an hour…I promise to page you if he comes sooner."
Harm's eyes pleaded with Mac to stay, but she slowly shook her head 'no.' He could see the pain in her eyes and finally acquiesced. Grabbing his jacket, he headed for the door, "I'll be back in 30 minutes. Hang in there…I love you."
When Harm returned 30 minutes later Mac was sleeping quietly. He settled into the chair to wait for the doctor's return. Dr. Abrahms entered the room shortly thereafter with a solemn look on his face. Harm gently aroused Mac from her sleep, "Honey, the doctor's here…you need to wake up so we can talk." Mac slowly stirred and then quickly came to attention as she noticed Dr. Abrahms' expression.
"Sarah…Harm, I have some good news and some bad news. The bad news is that the lab work confirms the diagnosis of preeclampsia. As you know, Sarah, you developed hypertension early in pregnancy. This had previously been well controlled with medication. However, your blood pressure is again elevated despite the meds, and you are now spilling protein in your urine, the 24-hour urine sample with tell us to what extent. This setback will most likely alter our management plans for delivery."
"What do you mean by alter, I thought you wanted to get to at least 32 weeks and hopefully longer before Sophie is born…Mac's only 29 weeks now…you aren't planning on delivering her now are you?" Harm nervously questioned.
"No I don't plan to deliver the baby tonight…but I don't know that we'll make it to 32 weeks either. The good news is that Sarah's liver functions and platelets are normal…if they had been affected I would have been forced to intervene sooner. For the time being, I've restarted Sarah on a magnesium drip, this should help her blood pressure come down and stabilize her neurological status." At that phrase both Harm and Mac's eyes widened. "Don't worry, I just want you to remain on bedrest…try to stay calm and relaxed," at that suggestion he raised an eyebrow toward Harm. "Dad, I need you to work on being a little more laid back; I don't want Sarah to be upset." Harm glanced down to his feet with a chastised expression.
"I also want to perform an amniocentesis on you tomorrow, Sarah. At her questioning look he continued, "I need to collect some amniotic fluid from around the baby to check the status of her lung maturation. We gave you steroids about 3 weeks ago when you were in preterm labor to help Sophie's lungs mature. I need to know if they worked, in case, I need to make a decision about delivery. If the lung studies are immature, I will want to put off delivery as long as possible. The amniocentesis involves placing a needle into the sac around Sophie to collect the fluid. We would do this under ultrasound guidance so that the needle stays far away from Sophie and the placenta."
"Is the procedure dangerous for Sophie or Mac?" Harm questioned.
"I will give Sarah a local anesthetic so that she should feel very little pain. The skin is cleaned with an antiseptic solution to decrease the risk of infection, and by using the ultrasound to guide the needle insertion we can usually prevent any bleeding from the umbilical cord or placenta. There is a slight risk of preterm labor after the procedure, but in this case that risk is low and the need for the lung information out weighs that risk."
"Will this tell you if Sophie's lungs are undergrown," asked Mac.
"No, I'm afraid we won't know the answer to that question until after Sophie is born…I wish I could be more helpful. I am going to have a neonatology colleague of mine come talk to you about what to expect with preterm infants…I think at this point, it's a sure bet that Sophie is going to come early. Do you have any other questions?" At Harm and Mac's negative reply Dr. Abrahms got up to leave the room. "Hang in there guys, Sophie needs you to stay strong and optimistic," with a smile and a wave he was gone.
Harm climbed back onto the bed and pulled Mac close, "I'm gonna have to call the General to get tomorrow off."
Mac shook her head, "Harm, I'm a big girl and it's a simple procedure…you don't need to be here."
"Not an option, Marine…you couldn't keep me away tomorrow, but I do promise to try and behave," he said with a grin. "You know patience was never one of my virtues. Besides, Dr. Abrahms said that the neonatologist would come by to talk to us…I have tons of questions to ask, but I'll try and tone it down," he said with 'flyboy' grin firmly in place. "Why don't you settle down here and try to get some sleep."
"Harm, you need to head home before you're to tired to drive…I worry about you staying so late."
"I promise to leave soon…I just miss having you in my arms…so humor me and snuggle in for awhile," he sighed as she did just as instructed.
Just as she started to nod off, she looked up, "I love you, you know…I'm glad you're the one going through this with me…I never imagined having a baby with anyone else," she smiled.
"I love you too, always have…I never imagined the mother of my children being anyone but you…Now close those eyes and go to sleep," he mused while leaning over to place a kiss on her lips.
Twenty minutes later, he was awakened by the nurse, "Captain, you need to go home…Sarah will be fine tonight, and you have a busy day tomorrow."
"I know, but neither of us sleep well when we're apart…I don't suppose I can spend the night?" he said with a grin.
"Go home, Captain!"
"Yes, Ma'am," he laughed as he rose from the bed. He leaned over to give Mac one last kiss. "Sleep well, Marine…I love you," was whispered as he walked out the door.
xxxxx
The following morning, Harm arrived by 08:00 with two bagels, a cup of coffee for him and herbal tea for Mac. As he handed Mac her breakfast, he greeted her with a kiss and settled into the chair. "How was your night…is your blood pressure down…how's the swelling…did Dr. Abrahms come by yet…is Sally working today, because I didn't care for the nurse from yesterday…what time is your procedure…did they say when…"
"Good morning, I love you, too," Mac interrupted with a smile.
"What?" Harm stopped in his tracks.
"Remember calm, in control, relaxed, patience, toning it down…any of these ring a bell?"
"Oh yeah, I forgot…I'll try, I promise," he slyly replied. "You can answer any of the above questions at your leisure…by the way, I have a list of questions for the neonatologist…I was on the internet until 0200…"
"Harm!"
"Stopping now…Eat your breakfast, Marine."
xxxxx
Mac was taken to a procedure room, to have the amniocentesis performed, at 10:00. As Dr. Abrahms finished the procedure, he smiled, "Well that wasn't so bad was it?"
Mac responded, "Not really, the needle stung a bit, but overall it was nothing compared to everything else I've had to go through."
The doctor turned towards Harm who was sitting in a chair in the corner, still looking somewhat pale, "Captain, how are you doing? I know that needle is really long, but Sarah did great. Based on your response, I'd say it's a good thing Sarah is having this baby instead of you."
"You can say that again," laughed Mac.
"Hey, no ganging up on the Dad here…I just didn't like seeing my girls put through that," grumped Harm. "Beside I think I'll do just fine with the delivery."
"We'll see," said Mac. "I promise not to share the fact that you nearly fainted with everyone in JAG ops, if you bring me something good for lunch…and it better not be a salad or Bud and Sturgis will hear the whole story of how the big brave naval fighter pilot almost hit the floor at the sight of a little needle."
"I didn't almost hit the floor…I just needed to sit down really fast…and that little needle was at least 6 inches long…and you are not to even hint to Bud and Sturgis about that fact, or else…"
"Or else what…are you going to ground me…limit my privileges or food choices…Harm, I'm already held captive on bedrest and the food in this joint just stinks. Besides how am I going to talk to Bud or Sturgis…unless…I think Harriet was going to visit this evening…."
"Mac, I'm warning you," menaced Harm
"All right you two, I'm beginning to understand the admiral's comment about 'patience of a saint.' I'll see you two after lunch; I should have the lung maturity results by then," Dr. Abrahms noted as he left the room.
xxxxx
Dr. Abrahms found the couple playing cards when he returned that afternoon. "Who's winning?"
Mac smirked, "Me has usual, poker is his forte. Did you get the lab results?"
"Yes I did, unfortunately they showed that Sophie's lungs haven't matured yet…although, that's not uncommon at this stage in pregnancy. I had just hoped that if we had to deliver we could take that one concern out of the equation."
"Is there anything else you can do to speed up the maturation?" questioned Harm. "Maybe you could give another dose of the steroids?"
"I really don't want to expose Sophie to any more steroids at this point. The literature doesn't support giving repetitive doses. In fact, it can do more harm than good by causing growth failure of both weight and head size. Taking into account that Sophie already has significant growth failure, I really don't want to exacerbate the situation."
"So what do we do?" asked Harm.
"We'll just sit and wait. As long as we can keep Sarah's blood pressure down with the magnesium and bedrest, we have the luxury of giving Sophie time to get stronger. I've asked one of my neonatal colleagues to speak with you this afternoon. Her name is Dr. Catherine Williams. She should be able to explain some of the problems that Sophie might have after delivery. Relax you two, I'll touch base again this evening before I leave."
xxxxx
Two hours later a tall female naval commander entered the room, "Hello Sir, Ma'am, I'm Dr. Catherine Williams, the neonatologist or newborn intensive doctor. Dr. Abrahms asked that I speak with you about preterm infants. Colonel, I see from your medical record that you've had quite a difficult pregnancy. May I ask if you know if the baby will be a boy or a girl?"
"A girl," responded Mac, "and her name will be Sophia Elizabeth Rabb, but we plan to call her Sophie."
"What a beautiful name. Before I begin, please feel free to interrupt me at anytime to ask questions. I'll describe for you what might happen if Sophie were to be delivered today…but that doesn't mean that I know anything," the doctor replied with a smile, "it just allows me to explain what might happen should that occur. Do you mind if I sit down?"
"Not at all," smiled Harm. "In fact, it might be a good idea…I have lots of questions!"
The doctor smiled back, "that's great I love having a family who is involved in their child's care. Shall we begin?" At the couple's affirmative nod, she continued, "I usually start at the top of the head and work my way down, that way we don't forget to discuss anything. You are now 29 weeks into your pregnancy, is that correct?"
"Yes that's correct," confirmed Mac. "I'm sure that you've read that despite the gestational age of 29 weeks, that Sophie is very small for her age. Dr. Abrahms said that that could cause additional problems especially with her lungs."
"Yes, I did note that Sophie does have intrauterine growth restriction." At Harm's questioning look, she continued, "That just means that she's small for her age. At 29 weeks the usual chance for survival is well over 95, but in Sophie's case that survival chance is likely lower due to possible pulmonary hypoplasia."
"You mean the chance for undergrown lungs?" questioned Harm. "Dr. Abrahms said that could affect her chances to survive. Taking that into account, what are her chances?"
"Well, that's hard to predict until after she's born." At the couple's frustrated gaze, she explained further, "We can't really tell whether Sophie's lungs are too small yet. If we had other stigmata of restriction from low fluid, such as, contractures of her arms and legs, or a flat face or ears, I could confirm that her lungs would probably also be affected. However, Sophie doesn't have those findings as best we can tell by ultrasound. The fact that she doesn't have those physical findings is encouraging because it tells us there was enough fluid to allow movement and growth of those body parts. We're getting ahead of ourselves though, maybe we better go back to our original plan and start at the top. I know that you've been most focused on the lungs, but a lot things can affect survival and long term outcomes."
Harm and Mac both shifted to get more comfortable and nodded for the doctor to continue.
"Starting at the head, when babies are born early they are at risk for bleeding into the fluid spaces of the brain or the brain tissue itself." At the couples panicked look, she quickly noted, "Now the risk for an intraventricular hemorrhage, or IVH, is actually relatively low at this stage. You'll have to excuse my medical terminology, in the NICU we live in 'alphabet soup land,' so if you don't understand our abbreviations just ask. You'll get use to them after awhile. As I was saying, the risk for a brain bleed at 29 weeks is approximately 20-30, but the risk for a severe bleed is only about 10. The risk decreases markedly between 30 to 32 weeks gestation, and is close to zero after 32 weeks.
"Dr. Abrahms said that he wanted to get Mac past 32 weeks if at all possible…is 32 weeks a critical stage for most problems," asked Harm.
"In many ways 32 weeks is a critical stage for a lot of the complications that can develop. Ideally we would like to get to at least 35 to 36 weeks, because than there is a chance that the baby wouldn't even need the NICU."
"Dr. Abrahms did say that that was his original goal, but he now thinks that is unlikely to occur," noted Mac.
"Yes, with all that is going on with your pregnancy, I seriously doubt that you'll get to 36 weeks. Getting back to our discussion…we look for an IVH by doing an ultrasound through the baby's soft spot. The ultrasound won't hurt Sophie, but it does allow us to evaluate for bleeding. We usually do the first ultrasound at a week of age."
"So if the ultrasound is normal then Sophie won't have any neurological problems," stated Harm with a pleading voice.
"Well, I can't actually say that. Premature infants are at risk for learning problems; although, that risk also decreases the further along in pregnancy you get. The additional factor for Sophie is again her small size. Her poor growth may have also affected her brain growth, so she's going to need close follow-up of her development throughout her first few years." Harm heaved a heavy sigh and nodded understanding. "The next problem related to the brain is having periods where babies forget to breathe." Harm and Mac's eyes again widened. "The portion of the brain that controls breathing is again not fully developed in prematures. Hence, Sophie may have periods where she forgets to breath, we call that apnea, and when that happens her heart rate may slow down, we call that bradycardia…or in alphabet soup land, those are 'A's and B's.' Most preemies have these events and I just wanted to warn you before Sophie scares you to death. She will outgrow the events before she goes home. If she is having frequent events then we can start a medication to help remind her to breathe…we actually use caffeine as a stimulant."
Harm started to laugh, "I knew she was your daughter, only a marine would want coffee after birth." Mac rolled her eyes and smacked him on the arm.
"The next topic to discuss is the lungs. Now I know that Sophie's lung studies were still immature when checked this morning. Let me explain what that means…when babies are born early they don't make enough of a chemical called surfactant…to explain what surfactant does…You know how when you blow up a balloon, it's hard to get it started, but once you do it's easy to blow up?" Harm and Mac both nodded 'yes.' "Well, surfactant helps hold Sophie's airways open so she can breathe easily…without it her airways want to collapse making it harder for Sophie to take a breath. If her lungs are immature then we will need to place a breathing tube through her vocal cords and into her windpipe in order to put her on a ventilator. Once we place the breathing tube we can actually put the surfactant chemical down the breathing tube to help her breath. Hopefully she would only need to stay on the ventilator a few days, but might still need oxygen much longer.
With tears in her eyes, Mac asked, "Does it hurt her to be on the ventilator?"
"We'd give her pain meds to keep her comfortable so she can remain relaxed and allow her lungs to heal."
"What about if her lungs are undergrown," queried Harm, while grabbing for Mac's hand to soothe her.
"In that case, Sophie may need to remain on the ventilator for a much longer period of time or we may need to try a more aggressive ventilator, called an oscillator to assist her with her breathing. Worse case scenario, neither ventilator would work and Sophie would not survive." At that remark, Mac began to quietly cry and Harm pulled her closer into a hug.
Dr. Williams gave them a few minutes to compose themselves then continued. "The other problems that we may encounter can include blood infections, anemia, jaundice, eye problems, feeding and intestinal complications. Would you like me to explain these now or come back another time?"
"No…," Harm's voice cracked. "No, please continue, we need to know what Sophie is up against."
"Of course, I know this is all a bit overwhelming…and while all of these problems are a potential risk, the odds of many of them happening are quite low. The potential for a blood infection is about 20. Babies don't fight infections as well as you or I…and all of the IV lines and ventilator tubes that we place, put the babies at risk for even normal skin bacteria to cause an infection. Initially most sick preemies are placed on antibiotics until we confirm that the blood work shows no sign of infection. The antibiotics are stopped after a couple of days if everything is negative. We will then watch Sophie very closely for signs of infection. The signs are similar to things that preemies do anyways, such as an increase in the 'forget to breathe' spells or not tolerating feedings or worsening breathing status. If any of these were to occur then we would draw blood to evaluate for an infection and start antibiotics again."
"Wouldn't it be better to just keep her on antibiotics to protect her," came Mac's tearful reply.
"No, actually that would put her at risk for infections from resistant bacteria. Our goal is to get her off antibiotics and make sure we're careful about not exposing her to extra bacteria. That means careful handwashing, getting all the IV lines and breathing tubes out as soon as possible, and utilizing breast milk to help her fight infection."
"You mentioned anemia, should I donate blood now for Sophie to use?" asked Harm.
"It's a bit too early for that just yet. We try to be careful about how much blood we draw from the babies. However when you only weigh a pound or two, it doesn't take much to drop your blood count. We often start a medication when the blood count starts to get low to help the babies increase their own blood production. And if we need blood, I feel very safe utilizing the blood from the blood bank, it's carefully screened and comes from reliable long term blood donors."
"Ok, just let me know if I can donate. I'd like to do something to help," sighed Harm.
"I understand, it's very frustrating to stand by and watch, but just being there for Sophie day-in and day-out is often therapy enough," smiled the doctor. "Colonel, do plan to breastfeed?"
"I really wanted to breastfeed, but is that even possible given how sick Sophie is likely to be?"
"Absolutely…initially Sophie will be fed through her IV with a solution that contains sugars, fats and proteins… but once she is ready to begin feedings into her gut, we prefer to use breast milk."
"How is that possible, won't she be too little?"
"To start with, we'll feed Sophie through a tube inserted into her nose and down into her stomach…once she is a little older then we'll begin allowing her to try feeding by mouth. Babies don't really know how to feed by mouth until at least 32 weeks, and don't do it well until 34 to 36 weeks. Feeding is usually what keeps them in the hospital the longest and is the most frustrating for parents."
"But if she can't feed by mouth, then how do I breastfeed her?"
"We'll have you start pumping your breasts after delivery. It takes 3-4 days for your milk to come in so don't get discouraged. We will feed Sophie what you provide. Breast milk is the one medication that only you can give your baby and it is one of the most important since preemies tolerate it best. It also helps to prevent blood and intestinal infections. One of the ways to help with your milk supply is do something called 'kangaroo care.' Once Sophie's breathing has stabilized, we'll let you hold her skin-to-skin. We'll place the baby on your chest under your clothes. Your body temperature helps to keep her warm and the bonding helps Sophie to get better and grow quicker. If she happens to find your breast while she's there…you and she can have a 'good time.'"
"I know I would," laughed Harm. Mac turned into Harm and blushed feverishly.
The doctor chuckled, "You don't get out of this Dad…we allow fathers to 'kangaroo' too. You just don't have to breastfeed." Harm blushed in return, while it was Mac's turn to laugh.
"Most of the rest of the problems are pretty routine baby issues, such as jaundice. If you've ever been around a newborn, you've noticed that their skin gets yellow…that's jaundice. All babies get jaundiced, preemies are just a little slower at clearing it…so Sophie will get to sunbathe under some special lights…that should take care of the problem. Because she will be small and not have a lot of fat to keep her warm, she'll be placed in an incubator to keep her temperature up and help her grow. I would expect her to be in the hospital at least 7 to 8 weeks, maybe longer depending on how she does. Do you have any other questions?"
"Will she be OK long term after she comes home or can we expect her to have significant problems?" asked Harm.
"When a baby is born this early they are at risk for long term problems. These might include asthma, learning disabilities, cerebral palsy, or vision and hearing problems. In most instances, we don't know if these are gonna occur when a baby leaves the hospital. Certain things can increase the risk of these complications; such as asthma after being on a ventilator, or cerebral palsy and learning disabilities with a brain bleed. But even if these problems occur in the NICU, Sophie may still do well long term. She will just need to be followed closely by her pediatrician for developmental milestones. In addition, we run a follow-up clinic here at Bethesda. We like to follow all the small preemies born at less than 3 pounds-5 ounces, to ensure that their development is progressing appropriately. If we see delays, then we refer the babies for therapies as indicated. Therapy won't make the problems go away, but it will help both you and Sophie learn how best to deal with them."
"Any other questions?" At the couple's negative reply, the doctor rose from the chair. "At this point I like to give the parents a tour of the NICU. It's kind of nice to see all the equipment before it's actually on your baby…less scary that way. Colonel, since you're on bedrest I'm afraid you won't be able to come. Captain, are you interested in a tour?"
"Sure," sighed Harm with a nervous voice. "Mac, do you care if I go?"
"Not at all, you can come back and give me a report," she smiled.
Harm started for the door, but then turned back to give Mac a quick kiss. "I love you…I'll be right back…sure you're OK?"
"Go ahead Dad, I'll be waiting…Love you, too."
xxxxx
Harm came back 20 minutes later, pensive and quiet. "Hey, how was the tour?" asked Mac.
"Scary," was his overwhelmed reply as he slid onto the bed and pulled her into a hug. "The babies are so small, and they're hooked up to all kinds of monitors and equipment. There are alarms going off constantly. Mac, do you think Sophie can survive all this…because I don't know if I can. I was terrified in there…the doctors and nurses just go about their business as if everything's normal…but I…"
"I know Harm…but we'll get through this together. We have to for Sophie's sake. We're not giving up on our 'princess,' remember."
"Yeah, I do…thanks, sweetheart," he murmured into her hair as he kissed the top of her head. Mac cuddled in close as they both contemplated the events of their stressful day.
xxxxxxxxxx End of Flashback xxxxxxxxxx
Harm was again jostled from his reminiscing by the same petty officer. "Sir, thank you for the use of the chair," he nodded as he placed it back under Harm's table.
"Heading home, Petty Officer," smiled Harm.
"Yes Sir, the tribe is getting restless. I need to get them home to bed…thankfully the cafeteria is still standing. Thank you again, Sir…have a nice evening."
Harm nodded back, "Same to you, Petty Officer."
Harm glanced at his watch and noted that he'd now been gone for an hour. Mac was gonna kill him. He got up quickly to get the requested ice cream and headed upstairs. He passed Sally at the nurse's station on the way to Mac's room, "You're here late tonight."
"Yes Sir, we were short staffed and the paperwork never seems to end. Have a nice evening, Captain."
Harm breezed into the room exclaiming, "Mac, I got chocolate ice cream with chocolate fudge sauce and chocolate sprinkles. That should be enough chocolate to send even you into sugar overload…" the comment died on his lips as he noticed that Mac appeared to be sleeping. As he quietly approached the bed, he whispered, "Mac, are you asleep?"
"Haaarm," came Mac slurred response. "I don't…feel…very…good."
"What's wrong, sweetheart? Should I get the nurse?" The words were barely out of his mouth, when Mac's monitor began to alarm for a low breathing rate. To his horror, Mac's arms and legs began to jerk rhythmically as her body thrashed around in the bed. As he ran closer to the bed, the fetal monitor that assessed Sophie's heart rate began to blare as the audible signal for the heart rate began to slow. He momentarily froze at the scene before him, 'how could this be happening now…what else could possibly go wrong.' As he reached for the call button to summon the nurse, Sally came running into the room.
"Captain, what's going on…" Sally began but instantly stopped when she noted the look of panic on his face. She quickly ran to the bed and maneuvered it flat as she pulled the oxygen mask from the wall.
Sally yelled into the call remote, "Call a code and get anesthesia and Dr. Abrahms in here stat…the colonel's seizing, I need Ativan and the code cart in here now…Call the OR and set-up for an emergency C-section!"
Harm backed away from the bed in shock as medical personnel rushed into the room. Words began to blur, "Seizure…fetal distress…oxygen…intubate…need to move now…crash section…." One of the staff ushered him quickly from the room to wait in the hall, "I'm sorry Sir, but you'll need to stay out of the way. Someone will be with you shortly."
"Wha…What's…happening…are they going to be OK?" he whispered aghast.
"Sir, I really can't answer your questions. You'll have to wait for Dr. Abrahms."
At that moment, Dr. Abrahms hurried to Harm's side. "Harm we're gonna have to perform an emergency C-section. Someone will be out in a minute with a consent to sign."
"But…what's going on…I…I don't understand…I…I…didn't think you wanted…to deliver Sophie yet."
"Harm, listen I don't have a lot of time to explain. Sarah is having a seizure due to the preeclampsia. I need to deliver the baby to get the preeclampsia under control…and Sophie's heart rate is dangerously low…if we don't get her out we might lose both of them…I'm sorry, but I have to go!"
Harm nodded his assent and gaped as he watched Mac being rushed from the room to the surgical suites. She had a breathing tube in place in her mouth and medical staff surrounding the bed as orders were barked at a furious pace.
Sally appeared moments later with a surgical consent for him to sign. He scribbled his barely legible name to the form at the indicated line and then slowly backed up into the hallway and slid down the nearest wall. With tears in his eyes he looked down into the ice cream cup that he still clutched in his hand and with shaking breaths began to sob.
Sally had grabbed Mac's hospital chart and started down the hall when she looked up to see Harm collapse. She quickly opened the chart to locate the contact number and dialed. "Admiral Sir, you need to come to the hospital immediately…the Captain is going to need you."