“Dr. Cohen, can you come check on a baby?”
When I got the call, I was busy arranging for the transport of a sick teenager from the community hospital where I work to an intensive care unit at a nearby children’s hospital. A maternity ward nurse wanted me to examine an infant who had not had a bowel movement in the 40 hours since his birth. Most healthy newborns have their first bowel movement within 24 hours; if 48 hours go by without a stool, doctors worry about a number of possible problems, including intestinal obstruction. I asked if the baby had a distended abdomen or had been vomiting, and the nurse said no. I told her to order an abdominal X-ray and said I’d be there soon. The infant had looked healthy when I first examined him the day before. His anus was not blocked, and there had been no unusual masses or abdominal distension.
Just as I was finishing up with the other patient, the radiologist called to say that the baby’s X-ray showed no sign of obstruction. Nor was there any sign of free air in the abdomen, which would have signaled a rupture of the intestine, a potentially catastrophic condition. The intestinal tract appeared intact all the way through. As I approached the nursery, I decided that if the baby looked OK, I would wait a few more hours before ordering any additional tests.
I walked over to the child’s bassinet, then stopped short. This baby did not look OK. His skin was pale, and his abdomen was slightly but definitely distended. In the next second I heard a loud gurgling sound, and the baby vomited a large amount of liquid with an ominous color: fluorescent lime green. That hue invariably comes from bile, and bilious vomiting means a major intestinal problem, usually a complete obstruction. This infant also looked as if he was in shock.
“Sandy!” I called to the nurse, who was busy with another newborn. “I need your help, now.”
I had turned the boy onto his side and was using a bulb syringe to suction out his mouth. When I checked his breathing, it was a bit shallow but steady, and his lungs were clear. His pulse, however, was rapid and weak. His skin was still pale, and I also noticed a very faint but definite tinge of yellowish green.
Although “turning green” is a common description of appearing ill, the physiology is not very well understood. The color seems to be related to the redirection of blood flow from the skin to the internal organs that occurs in shock or in certain gastrointestinal conditions. Light refracting through the relatively bloodless dermis may then take on a greenish cast. Whatever the mechanism, I got the message loud and clear: This child was in trouble.
“Oh, my goodness,” Sandy exclaimed, helping me move the boy to a bed that would keep him warm. “He didn’t look like that a few minutes ago.” Whatever had happened had happened very quickly. I had to act quickly too. Babies who look this sick can die right in front of you.
“This baby’s obstructed and shocky,” I said, listening to his abdomen and hearing, ominously, no bowel sounds. I was already reaching for the oxygen mask and turning the valve on full. “Put him on the heart monitor and get respiratory therapy to set up an Oxyhood. We’re going to need a few more hands here.”
Sandy was already waving at another nurse through the window. “We need to get an IV in him right away, then give him 60 cc’s of normal saline as fast as it will go in,” she said. “He also needs an OG tube to straight drainage. Call X-ray for a stat abdominal series, flat and upright. And I mean stat.”
The OG, or orogastric tube, would be inserted through the mouth and threaded down into the stomach to draw out any trapped air or fluid. The tube is a stopgap measure; it only buys some time until the obstruction can be determined and removed. Meanwhile, another X-ray might help me figure out what had happened. “And somebody please call the transport team and tell them there’s been a change in plans,” I said. “They’re going to have to take this baby to a neonatal intensive care unit before my teenager.”
Fortunately, we managed to get an IV in right away. After we administered a large volume of fluid, his pulse became a little stronger, and his skin was still pale but no longer green. But his abdomen was still distended, and I was still very worried. The X-ray technician came and took two pictures, one of the child supine and one of him lying on his side. If there was an obstruction, it might show up in the pattern of air inside the intestines.
A few minutes later, the tech came back with the films. The supine film showed distension of the bowel, which, though abnormal, didn’t provide any clues. But the image taken on his side showed a dark, crescent-shaped shadow of air that clearly was not in the intestines. It was floating up at the side of his abdomen. I felt my own stomach sink: It was free air.
This baby had a perforation in his intestine. Now I knew why he had suddenly gone into shock. Fluid and air had spilled into the peritoneal cavity. The resulting inflammation was causing the bilious vomiting and lack of bowel sounds. Typically, a perforation occurs when there is damage to the intestinal wall, such as in an infection like appendicitis. I couldn’t imagine why this baby had it.
I alerted the surgeon and the neonatologist of this alarming development. I then explained to the boy’s parents the urgent need for surgery. I kept giving fluids to prevent him from going deeper into shock and kept watching and hoping that he wouldn’t suddenly stop breathing. Finally, the transport team arrived. As they wheeled the bulky incubator out the door, I hoped they would make it back with their fragile cargo still intact.
The surgeon called me that evening. “Mark, it’s a good thing that you got to this baby so quickly. I took him to surgery just as soon as they brought him in the door. The baby did have an intestinal perforation. He’s still extremely critical. I hope he won’t need any more surgery soon, because I doubt he’ll survive another operation.”
“Why do you think he had the perforation?”
“I don’t know—we’ll have to see what the pathologist says when he reviews the tissue I sent him.”
Things were touch and go for several days, but eventually the child came off the ventilator and could breathe on his own. He went home a couple of weeks later. The surgeon told me that the infant had been as close to dying as any newborn she’d seen. As for the big question—why?—the pathologist did not have an answer. The boy had apparently been born with a weak spot in his intestinal wall, and for some reason it had perforated spontaneously sometime that morning. Perhaps a blood vessel had broken while that part of the gut wall was forming, or maybe a small cyst had formed and then ruptured.
We’ll never know what caused the perforation to occur, but we were lucky to find the rupture and fix it in time. Often we don’t have all the answers in medicine, so we do what we can with the information we have. Fortunately for this baby boy and his family, that was just enough.
