Ligation Wednesday!

I have decided to do what the NICU does when they call us on our cell phones:  begin each post with “The twins are doing fine.”  (Which hopefully reads better in a blog post than in a phone call.  After all, dear readers, by now you must be accustomed to reading all kinds of things from placenta recipes —who could forget that one—to obscure movie quotes.  In a phone call, one thinks, “If everything is fine, then why are you calling me?”)

So—the twins are fine.  Now for more stuff you never wanted to know about really tiny babies.  Ligation.

Ligation is one of those words that get tossed around frequently and carelessly (in our circles at the NICU, anyway) as if everyone knows what it means and no explanation is necessary and after it gets used in context often enough you figure it out.  Like the word “escrow.”  Or maybe it’s one of those words that everyone but me knows the definition of.  Like the word “escrow.”

In our context, ligation means baby heart surgery.  Which is probably why they call it “ligation” instead. 

It turns out that our babies, like ALL babies, have a PDA.  No, not one of THOSE; it’s a Patent Duct Arteriosus, meaning that the valve of the pulmonary artery (from the heart to the lungs) is open and flapping.  And it’s important to have a closed PDA because then blood from the heart goes to where it should, like to other blood vessels instead of where it shouldn’t, like to the lungs. 

Usually, this valve closes shortly after birth.  But in preemies, often it doesn’t.  The PDA is diagnosed by an echocardiogram (or simply “echo” for the cool kids) and is treated by either a) waiting; b) ibuprofen or c) baby heart surgery.  We tried some of a) and some of b) and I kept thinking, well, at least we can always try this ligation thing instead of baby heart surgery.  Then I found out that ligation IS baby heart surgery.  And I burst into tears and fled from the hospital. 

After Tuesday’s echo confirmed what the doctor’s stethoscopes had detected—that the boys’ PDA’s were still open—the surgery was scheduled for the next day.  The head nurse practitioner described the surgery and even offered to show us pictures, to which I said, “You know, I’m cool, but I’m not that cool.”

Now, ligation surgery in the scheme of baby surgeries, is really no big deal.  But it does involve a lot of “-tion” words and “-sion” words that you didn’t want to associate with your newborns, such as “sedation,” “incision,” and “morphine drip.”

On Wednesday morning, the surgeon, Dr. Olaf GuutDoktor (mostly not his real name), imposing in stature and nearly albino, explained the procedure in a very calm and reassuring manner.  But all I could think was, “Where are his eyebrows?”

For the curious, the procedure starts with a small half-moon shaped incision under the left shoulder blade.  Then they spread the ribs a little, gently push the lungs out of the way and with the help of sci-fi binoculars to navigate through teeny tiny vital organs, clamp a teeny weeny metal clip to close the PDA.  And then they attach Steri-strips, which is basically just tape.  It’s done bedside at the isolette by expert doctors like Dr. Olaf and takes about fifteen minutes.  It takes longer to set up the surgery than it does to perform the surgery. 

On Tuesday night, the boys were moved from the room they shared to individual rooms for Wednesday’s surgery.  The only reason they had to move at all is to adhere to state regulations: the babies in the most precarious condition have to be closest to the exit.  So Michael moved 12 feet from Room 3 to Room 1 and Wagner moved 6 feet from Room 3 to Room 2.  After the surgery Wagner moved to Room 1 to be with his brother.

The doors to all the NICU rooms are big, sliding patio-like doors with a second set of glass doors that adjoin to other rooms (so each room has at least two “exits”).  Parents aren’t allowed to watch the procedure (whew), and to prevent this, the curtains are drawn and paper is taped over the windows.  Which didn’t prevent us from trying to peek over the paper nor did it prevent us from hearing the doctor, anesthesiologist and nurse crack jokes.  We don’t know what they were laughing at.  We can only guess that it was our terribly funny ligation clearance sale joke.

[Matt and I made the same joke to different nurses—thankfully—what an embarrassment if we had made the same joke to the same audience!  Me in Michael’s room: “It’s Ligation Wednesday!  Buy two ligations, get one free!“  Matt in Wagner’s: “Today only!  3 ligations for the price of 1!”  It’s like we’re turning into twins, too.]

Laughter is not really something you want to hear during surgery.  You want the surgeons to take this VERY SERIOUSLY; it’s baby heart surgery, for Pete’s sake.  On the other hand, if the surgeons are laughing, they’re not panicking and if they’re not panicking, maybe things are going really well. 

In our case it seems to have meant that the surgeries went really well.  Dr. Olaf seemed really pleased and then he went to the next room to crack more jokes, I mean, perform more baby heart surgery.  Michael’s surgery went first, then Wagner, then a third baby (who had moved from Room 6 to Room 3 the night before and then from Room 3 to Room 2 for the surgery). 

After the surgeries the babies stayed on their morphine drip for 48 hours.  Michael got .188 milliliters of morphine an hour and Wagner got .156 ml per hour (it’s based on weight.)  For those of you who are metric system challenged, a tenth of a milliliter is really just about a drop. 

On the second day they upped Wagner’s dose a smidgen because he seemed to be in pain.  Pain is determined partly by the volatility of their numbers: heart rate, oxygen-saturation rate, amount of oxygen needed, etc. and partly by watching the twins themselves.  Are they really fidgety or are they calm and sleeping soundly?  After they got weaned from the morphine, they got Tylenol suppositories.  Which I’m pretty sure is just as much fun as it sounds.

The twins did better than expected.  Their oxygen needs went down.  They went back on their trophic feedings (they get 2 ml of breast milk injected every 3 hours into tubes to their stomachs).  Their ventilator settings came down in a way that I would explain to you if a) I understood it well enough to repeat it or b) it was remotely interesting.

Today is Sunday.  Each of the boys had a couple of rough patches here and there over the weekend, but nothing a couple of drops of morphine couldn’t cure.  Both were extremely squiggly on their backs (read: lying on their incisions) which is understandable, so they stayed on their tummies (they get turned every three hours).  But today things are good. 

And so ends a big surgery week for the Kovac family: Grandpa on Tuesday, the twins on Wednesday and on Thursday, our poor beloved Jetta had her transmission rebuilt.  I’m happy to say that all are doing well.

© 2010 Janine Kovac