New Novel Coming: Book 2 in NICU Series
Updated: Oct 22, 2022
Four months since last blog post? Shameless! Why the hiatus?
Learning advertising for first novel with some success. Sales in the year and a half since publication of Baby Doe, for the combined ebook, paperback and audiobook are hovering near 2000. Mostly from advertising success with FaceBook/Meta ads. You can get Baby Doe at your local books store or by clicking here to the book from Amazon, a gorilla one ignores at their peril.
Second thing: Been working through revision after revision of next novel in the NICU series (Neonatal Intensive Care Unit for you few who haven't read Baby Doe, yet) that describes what happens next for a minor character in Baby Doe--Eli Kurz MD, the arrogant, smart, and ambitious senior resident,
The tentative title of the second book is DiBene's Offer.
Here's the first chapter:
For Dr. Eli Kurz, a busy night—without thinking, he’d agreed to cover for one of his division members on emergency family leave. The next day Eli would face a high-profile panel that was conducting a triannual review of his division's research. It was Eli's first review at Harvard. After he finished his sign-in rounds at the three nurseries his division was responsible for, he hoped to get some downtime to finish work for the next morning's review. Fortunately, the nurseries were all within fifty yards of each other in the three venerable hospitals on Longwood avenue: Beth Israel, Boston Children’s Hospital, and Brigham and Women’s Hospital. Eli's girlfriend, Caitlin, had warned him he should have finished preparing for his presentation days ago, but of course, after he'd finished checking the nurseries, at 8pm his pager went off. The obstetricians at Brigham and Women's were considering a C-section for a 28 week preemie with an unstable heart rate. By 8:30 they'd decided the baby had to come out.
Eli went to the OR, gowned, and scrubbed. One of Eli’s favorite residents was on call with him, Jim Sudbury, a fellow sailor and squash player was there with an intern and a medical student in tow, the med student uncertain where to stand in the operating room.
The mom was asleep and stable on the operating table. The baby came out surprisingly active. The intern took the baby from the OB resident and the nurse put the baby on the scale. “Shit,” she said. “I thought we were expecting a 900 gram kid.”
The baby did look smaller and less mature than 28 weeks. He was a micropreemie,680 grams, more like a 25 weeker. After suctioning mucous and amniotic fluid from his nose the micropreemie had reassuring movements of his arms and legs, but the baby was not making much effort to breathe on his own. The nurse gave him breaths with a bag and tiny mask. Eli asked the other nurse to get the respiratory therapist to ready a ventilator in the NICU aka neonatal intensive care unit.
The obstetrician came over and for a look. “Sorry guys. Guess we were off on the dates. Mom came in a few hours ago. Prenatal care in Tennessee. No prenatal steroids for the lungs. Not enough time. And maybe there’s infection. She has a low fever and thinks she was leaking amniotic fluid for the past day. We also think the kid may have been in trouble from mom’s high blood pressure. Says she forgot her meds on this trip.”
“Lungs are stiff. Hard to ventilate. The heart rate’s coming up though,” the nurse said.
They watched the baby over the next few minutes, but even with the nurse bagging the baby, the student and intern, under Jim’s supervision, reported poor air entry in his lungs. Jim asked Eli, “Respiratory distress syndrome?”
“Think so, Jim. Needs a tube. You do it but talk the intern through it first,” Eli said.
After explaining the procedure of getting a breathing tube into the trachea, Jim missed getting the tube through the vocal cords on his first pass. The nurse bagged the baby again and brought the heart rate back up.
“A problem?” Eli asked.
“Just can’t get good visualization of the glottis,” Jim said. “A lot of goo down there.”
“The glottis, with the vocal cords. That’s the narrow neck of the bottle,” Eli told the medical student.
The nurse suctioned the baby again. Jim looked at Eli, who nodded. Jim made another quick pass. Shook his head. “Secretions are gone but just can’t get a good view. Everything’s so damn small down there. You do it.”
The obstetricians were watching. Everybody in the room knew the baby needed intubation. Sooner rather than later.
"Take a big breath Jim. You can do it. Get the laryngoscope blade on the side of the mouth for better visualization of the glottis. I’ll give a little tracheal pressure.
Jim was sweating but on his third pass, he inserted the tube and stood up. “Think I’m in,” he said. The intern connected the tube to the bag and the nurse ventilated the baby while the medical student listened for breath sounds.
“Better breath sounds on both sides.”
Jim wiped his forehead with the back of his gloved hand. “Whew. Thanks for getting me through it. I’ve never tubed a kid this small before.”
“Not to worry. The first time I intubated a preemie this small, it felt like I was trying to thread a needle with a firehose.”
The nurse handed Jim a syringe filled with pulmonary surfactant to inject into the intratracheal tube. While the intern carefully worked out the dose of antibiotics, the nurse started an IV, and the med student rechecked the breath sounds. Jim had prepped them well.
“Way to go team. Nice work.” Eli said. To the medical student and intern he said, “Don’t worry. You guys will be able to do that soon enough.”
The student shook her head. “No way. I’m going into Derm.”
The attending obstetrician came back again while his resident finished stitching up the mom. “Whatta you want us to tell the mom when she wakes up, Eli? She’s in Boston alone for a job interview.”
Eli looked at the ID band on the baby’s wrist. “Tell Ms Simmons she has a boy, a little less mature than expected. Will be in the NICU for a spell. We’ll place an umbilical artery catheter. So lines and tubes, Isolette, the whole NICU ball of wax. Hope we avoid a head bleed. Too bad about the steroids. And high time you guys learned how to prevent premature births, even though it’ll put us out of business. Have the recovery room page me when she wakes up and we’ll come over and talk with her.”
They moved the baby to the NICU and adjusted the oxygen and ventilator, settings, got Xrays, more blood gases, and other tests.
After they reassured the mother as much as possible, Eli hung out in the NICU for an hour and wrote his attending note about the resuscitation, initial lab results, and therapy. Because the baby still needed high ventilator settings and a lot of oxygen, Eli told Jim that he’d hang out in the vicinity for the night.
Eli found an unused office and lay down on the couch. He was tired so he set his alarm for 5am so he’d have some time to check the baby again and still time to work on his talk in the morning. The review was routine, and he'd heard a week ago that his grant renewal had received a fairly good score from the National Institutes of Health (NIH), so he wasn't too worried. He intended to make a few notes on a yellow pad but he dozed off. His pager woke him up at 3am. Emergency in the NICU.
Eli hurried over. The Simmons baby had crashed. He did a quick exam. Loss of spontaneous movements, a bulging fontanel on the baby’s head and dropping blood pressure. Eli asked the med student, “What’s the diagnosis?"
“Intracranial hemorrhage,” she said, without a pause.
“What else?” Eli asked. Blank stares. Even Jim shrugged. “What you’d expect in a micropreemie. About 30% risk of a bleed.”
“You’re right. But whatever was bothering this kid in utero, the obstetricians must have fixed it. He looked good at birth, his initial blood gases were okay, and you’ve adjusted the vent to keep them that way.”
“What’s bothering you, Dr. Kurz?” Jim asked.
"Granted micropreemies can bleed. But that’s often associated with some asphyxia, shock, volume pushes, or difficult delivery. This kid was surprisingly good looking at birth. Just his damn lungs are immature, but the surfactant seemed to help, and I thought he’d sail.”
“Just bad luck?” Jim said.
Eli paused. “Maybe, but let’s talk with the mom again.”
And they did. After some digging, they found a family history suggestive of hemophilia. Neither the mom or pop had it, but the mom remembered two males on her mother’s side had bleeding problems and died young. It took more time to explain to the mother and to the dad on the speaker-phone the possible consequences of both the prematurity and the probable head bleed.
Later when they sat together in the cafeteria with their Danish and coffee, Jim said to Eli, “Thanks for the help last night.”
“No problem. It was nice you nailed that intubation. No harm asking for help, but always feels good to finally get the hard ones done yourself.”
Jim took a large breath. “Yeah, I was doing the right thing. Just not doing it right. And you set me straight. You mind being at my side for the rest of my residency? And you also made a nice call for us to dig up the hemophilia.”
“Mutual admiration, Tim. I liked how you assigned roles to everyone during the resuscitation, and the way you talked with the parents. Not easy talking to the frantic pop over the phone. I’m glad he’s flying up here.”
Jim and Eli were both exhausted. The review of Eli’s division started in two hours.
After a fast shower, Eli entered the small auditorium in Boston’s Children's Hospital and saw that coffee was still available. His boss, Ellen Larkin, chatted easily with a few of the reviewers who'd come at her request. She introduced Eli to Joel Prusner, a bushy white-haired Nobel laureate. He seemed nice enough for one of the gods of academia and was on a first name basis with Ellen. With the July 4th weekend, and the NICU's busy, Eli had only led his team through a practice presentation once, but the atmosphere was pleasant, the reviewers were there to help if need be.
Ellen gave Eli a gracious and complimentary introduction, and when Eli walked to the podium, he felt relaxed. "Thank you all for taking the time to be with us today. First, I’m going to quickly outline some of the clinical successes of our division in recent months, and, though our research output has a few bright spots (witness Dr. Ivan Cole’s publications), many of the rest of our young faculty, myself included, have been taken up with refiguring and smoothing the clinical care, teaching, and staffing of our three NICU's. Ivan will tell you about his most recent work in neonatal hematology. Next you’ll hear from some of our trainees, and after a short break, I’ll wind up our presentations by 11am as promised."
Ivan was dependably brilliant. Then, with no more than the expected nervousness of ingénues, three of the division trainees uneventfully presented their promising research before the review panel. The reviewers seemed interested, supportive, and positive with their questions.
Finally, Eli closed by describing the project that he'd planned to study closely the night before. Though Eli had some involvement, the protein labeling experiments were done in a colleague’s lab by the trainee. Eli presented a summary of her findings, scanting the methodology and maybe implying he had a bigger role in the project than he’d had. The whole thing seemed like a good way to end the morning. Promising results and important work.
During the routine question and answer period, Eli fielded some friendly comments and was about to leave the podium when Professor Prusner asked whether the key protein in the experiment was labeled with I-125 or I-131, a routine methodological question. “I believe it was I-131,” Eli responded.
A woman’s voice from the back whispered loudly, “I-125, a gamma emitter.” It was one of Eli’s people, the post-doc who'd done the hands-on stuff.
“Er. I-125, I think.” Then Eli thought he heard another voice in back say I-131, so he said, “No it was I-131.”
“Well godammit, which is it?" his interlocutor huffed. "It could make a major difference how to interpret the results.”
Eli hurried off the stage after saying he would recheck the methods and let them know.
The Noble laureate frowned and said, “You do that.”