Transport to the Rescue

By Ridgely Ingersoll

On the morning of May 5, a beautiful baby girl with bright eyes and a thatch of brown hair was born at Sentara Williamsburg Regional Medical Center. Her parents named her Zoe, the Greek word for “life,” with no inkling that she would soon be fighting for hers.

Zoe was born full-term after a normal pregnancy weighing a robust 9 pounds. Immediately after birth, she let out a good cry.

As Zoe took her first breaths, however, her skin failed to turn the healthy color her parents and doctors expected. Hers had a bluish tinge, a sign that her tissues were not getting enough oxygen. Doctors gave her supplemental oxygen and ordered a chest X-ray. When this hinted of a heart abnormality, the pediatricians in Williamsburg did what pediatricians in area nurseries do 400 to 500 times every year: They put in a call to have her transferred to the Neonatal Intensive Care Unit at Children’s Hospital of The King’s Daughters, where she could receive the highest level of care available in our region to critically ill newborns.

The job of safely moving Zoe from Williamsburg to Norfolk fell to the capable hands of CHKD’s Transport Service, which is available 24/7 to bring patients from other area facilities to CHKD and provides life-saving treatment en route.

Every child, Zoe included, is cared for by a three-member transport team whose level of pediatric certification, training and experience is unequaled among emergency response teams in this region. Each team consists of a registered nurse with at least two years of pediatric/neonatal critical care experience, a registered respiratory therapist with at least one year of pediatric/neonatal critical care experience and a paramedic with at least three years of experience in an accredited program.

On the day that Zoe was born, registered nurse Dee Deyarmond, respiratory therapist Ed Azares and paramedic Eric Kirk got a page from the NICU at 11:58 a.m. to pick up a baby girl at the Williamsburg facility.

By 12:10 p.m., the team was through the Midtown Tunnel, heading for the Monitor-Merrimac Bridge-Tunnel to the Peninsula. The paramedic drives the vehicle, so Eric was behind the wheel. The nurse supervises the transport and communicates almost constantly with the referring hospital and CHKD physicians and nurses who will be receiving the baby, so Dee was in the front passenger seat with a patient chart in her lap, cell phones and communications radios at hand. Ed sat in a second row of seats, close enough to hear Dee’s conversations about the baby’s condition.

Between the Midtown Tunnel and the Monitor-Merrimac Bridge-Tunnel to the Peninsula, Dee checked in with the nursery in Williamsburg to give them an estimated time of arrival and learn more about Zoe’s medical history and current condition. With a cell phone tucked between her ear and shoulder, she recorded a host of details for Zoe’s medical record. When she finished the call, she turned in her seat so Eric and Ed could hear her update.

“She’s on 80 percent oxygen, and her heart looks enlarged on X-ray. I think that as soon as we get through the tunnel, we need to turn on the siren and pick up the pace.”

Eric made it from Newport News to Williamsburg in about 35 minutes, pulling into the ambulance bay in Williamsburg at 12:54 p.m. Seatbelts immediately unclicked and the trio moved like well-trained soldiers. Dee grabbed the chart and a yellow case of medications as Eric walked around the truck to operate a lift that lowered Ed and a brand-new, state-of-the-art incubator smoothly to the asphalt. Packed like Sherpas, they made their way to the nursery.

Zoe was lying on her back under a square plastic oxygen tent that covered the top half of her body. The referring pediatrician greeted the team with a quick report on Zoe’s condition, showed the team the X-ray she’d ordered, then moved on to other duties. The nursery staff and about a dozen nursing students stood back to observe as the transport team took over.

Baby Zoe
CHKD provides the region’s only transport service exclusively for children and handles approximately 1,200 transport calls every year. Zoe was one of them.

At this point, 1:07 p.m., Zoe became a CHKD patient. There’s no waiting until a patient gets to CHKD to initiate neonatal critical care. That happens as soon as CHKD’s transport team arrives on the scene.

Zoe was breathing on her own, and with the supplemental oxygen she was getting, her vital signs looked stable. That meant she did not need to be intubated and put on a ventilator, like most of the newborns the transport service cares for. That made Ed’s respiratory therapy duties a little lighter, but he still had to do a variety of tests. He measured the blood pressure in each of her arms and legs, then obtained an arterial blood gas reading. The team also noted the level of oxygen in her blood and performed a thorough physical assessment. Dee reported all of these findings to the neonatologist on call in the NICU at CHKD and received further instructions based on that information.

As a precaution, Dee began a prostaglandin infusion, a hormone that keeps open a connecting blood vessel between the lung artery and aorta that normally closes soon after birth. When doctors suspect that an infant has a heart defect that is preventing the tissues from getting enough oxygen, keeping this blood vessel open allows blood from the two sides of the heart – one side oxygen-rich and one side oxygen-poor – to mix, so the tissues get more oxygen.

As Ed documented Zoe’s vital signs and Dee prepared doses of medications to have on hand for the ride to CHKD, Eric readied the portable incubator for Zoe. Then he set up a small color printer.

With a digital camera, he took and printed several photos of Zoe to give her parents, a ritual that occurs with every transport. Then he leaned over the crib and slid his right hand under Zoe’s diaper area. He cupped her head in his left hand and lifted her, taking care not to tangle the tentacles of plastic tubing that trailed away from her. At 1:41 p.m., he placed her in the portable incubator.

When Zoe was ready to go, the team wheeled her down the hall to her mother’s bedside. With family members gathered around, Mom and Dad reached into the incubator to touch Zoe’s soft arm while Dee explained where they were going, what time they expected to arrive and how to reach Zoe’s nurses in the NICU to get updates.

Eric gave the photos to the tearful parents. There was paperwork to sign, a tiny hand to kiss and tears to brush away as the frightened parents said goodbye to their newborn. It was 1:51 p.m.

On the ride from Williamsburg to CHKD, Ed, the respiratory therapist, sat within an arm’s length of Zoe’s incubator. Dee sat three feet away, on the phone with physicians and nurses in the NICU and making notes in Zoe’s chart. If Zoe’s condition changed, they’d have the equipment, medication and expert knowledge immediately available to care for her.

Zoe handled the ride well, and at 3:02 p.m., she was rolled into the NICU, where doctors and nurses immediately continued the treatment initiated by the transport team on the road.

One of the features that distinguishes care at CHKD’s Neonatal Intensive Care Unit from nurseries in the region is its unequaled ability to promptly coordinate and deliver a wide array of highly sophisticated diagnostic and therapeutic services, ranging from advanced imaging techniques, to pediatric subspecialty care, to major surgery.

The NICU staff alerted CHKD pediatric cardiologist Jonathan Fleenor about Zoe’s serious condition while she was on her way to the hospital. By 3:19, his cardiology team was getting a better look at her heart with an echocardiogram at her bedside in the NICU. And because CHKD has the specialist on-site to immediately interpret test results, by 5 p.m., Zoe had a diagnosis: transposition of the great arteries.

“The two main vessels of her heart, the aorta and the pulmonary artery, were connected to the wrong sides of her heart,” Dr. Fleenor said. “They were reversed, so the pulmonary artery, which normally carries oxygen-poor blood to the lungs, was carrying oxygen-rich blood to the lungs. And the aorta, which usually carries oxygen-rich blood out to the tissues, was carrying oxygen-poor blood. That’s why her skin looked so blue.”

Dr. Fleenor said the transport team and the nursery staff in Williamsburg did the right thing in giving Zoe prostaglandins to keep that connecting blood vessel open and allow the oxygen-rich blood to mix with the oxygen-poor blood. “Without that mixing, Zoe’s condition would have been fatal.”

Baby Zoe

In the days ahead, Zoe would need open heart surgery to survive. To keep her stable until she was strong enough for that, pediatric cardiologist Michael Vance performed a balloon procedure in the cath lab the morning after Zoe’s birth to widen a natural opening between the right and left upper chambers of Zoe’s heart.

On May 13, when she was just eight days old, pediatric cardiothoracic surgeon Ben Peeler corrected Zoe’s heart defect in a complex open-heart procedure. Zoe spent a few days in the Pediatric Intensive Care Unit after her procedure. Every day, Dee, Ed or Eric came by to check on her.

On May 24, they were happy to learn that Zoe was well enough for her second road trip – this one with her parents at the wheel. She was going home with her grateful family.

Zoe was born in Williamsburg because her mother wanted to get her prenatal care from an obstetrician in that community. The family actually lives in Fredericksburg. Even though it is a 200-mile round trip, her parents plan to drive to Norfolk for Zoe’s follow-up care, which will continue throughout her childhood. It’s a long haul, but they’ve learned the value of traveling to CHKD.

Drs. Fleenor and Vance practice with Children’s Specialty Group PLLC at CHKD, and Dr. Peeler is with the cardiac surgery program at CHKD.

This story was featured in the third 2009 issue of KidStuff, a publication of Children's Hospital of The King's Daughters. Click to read more patients' stories.