DIARY: When work and home life collide
By Andrew Jermy
First published on the Nature Microbiology Community on on 3rd August 2017
You find me sat, beginning this diary entry typing left-handed into my iPad since cradled in my right arm, head resting on my shoulder in a satisfied post-feed slumber, is the young man of the moment, Jermy minimus. The scene is spoilt only slightly by the plastic cup taped to the top of his head, placed such to provide some measure of protection to the cannula inserted into a vein in his scalp and the tubes protruding from it. To my right, Mrs Jermy gently sleeps atop a fold out bed, fully clothed but beneath a face mask to shield her eyes from the summer sun breaking through the blinds covering the double height windows in the small hospital room that we have re-occupied, back for the second time in 10 days. Elsewhere, Jermy minor is alternately chasing and being chased around the garden of the Jermy inlaws (aka Nanny & Gramps); his daddy will collect him in a few hours and bring him to the hospital to see his mummy and still fairly new little brother, although with the attention span expected of a toddler always on the move, it will likely be but a fleeting visit as he has built up no resilience against the cabin fever affecting Mrs Jermy and yours truly.
What, the reader might rightly be asking, happened over the four weeks since minimus finally made his entrance that led to this moment, and why should readers in this community be interested? Well, unfortunately this is a case of work and home life colliding; the Jermys have become germy.
Before starting proper, I should note that minimus is happy and well, and has been for the vast majority of his 25 days thus far. Let your nerves not jangle in suspense unnecessarily here. No sudden twist below, you have my word.
Back to the start then, and a happy birthday. Minimus was eased into the daylight by a calm and stress-free caesarean at the Princess Alexandra Hospital, Harlow, which, after the 40 hour labour culminating in an emergency c-section with complications that heralded Jermy minor's debut more than three years ago, was exactly what the patient ordered. Actually, with minimus weighing in at an eye-watering 11 lb and 3 oz (probably not the most appropriate moniker I'm using for him here then), with adhesions still present from minor's exit, and judging by the grunting, straining and perspiration demonstrated by our surgeons, the procedure was perhaps not so calm and stress free for all in the room. A swan birth then; placid and elegant on our side of the curtain wall, feet paddling furiously on the other.
From operating theatre and into the maternity ward and recuperation over a couple of days. Luckily, without needing to sneak in early and put a towel down, we snag a bay next to the windows and a door out into a verdant and nicely secluded courtyard, a fine space to recover and get to know our second son. Minor meets minimus - the verdict very positive ('he's so cute') - as well as the rest of the Jermy branch, inlaws and various friends. We are soon establishing a new routine as a quartet, eating, sleeping, pooping, changing, playing - a most enjoyable fortnight of paternity leave. Of course, I would not be recounting the matter if the status quo had prevailed.
On the eve of my return to work, for a day minimus ceases to eat or poop, and is visibly distressed, seemingly in quite some internal pain. trapped wind or constipation is suspected yet despite much bicycling of legs and tummy massage things do not get moving. Later, an episode of lemon yellow vomit after his first real feed of the day sees us call the NHS non-emergency number for a doctors opinion. 5 minutes later your diarist is in the car with minimus en route to the emergency room, 5 minutes after that we are straight into triage, 10 minutes after that we are in an examination room with a junior doctor. Some prodding and poking and recounting of the above tale (albeit in all it's hour by hour detail), and we move to some tests: his temperature, normal, his blood pressure and chest cavity, normal, his abdomen is full (well it would be after a day without a stool). I hold minimus as blood is drawn from his heel, I hold a small cardboard tray to capture some urine as he pees. The former is lowish for glucose (he hadn't had much of an appetite all day) while the later has some markers of potential infection, raised CRP and WBC levels. Swabs are taken from his belly button, which is a little gungey (his umbilical cord fell off just that morning), which together with the urine and blood are also sent off for culture.
Mrs Jermy arrives, having been reinforced at home by the inlaws rapid return from a weekend away, and a registrar is brought in for a look as minimus is (understandably) quite agitated, the entire tale is recounted once again. In light of the signs of potential infection, it is decided that he should be given antibiotics as soon as possible, so a cannula is inserted into back of his hand, and a course of the broad spectrum 3rd generation cephalosporin, cefotaxime, begun. Further, as a precautionary step, a lumbar puncture is carried out to allow some cerebral spinal fluid to be checked for menningitis, which turns out to be fine. Mrs Jermy and I are asked to remain in the examination room during the latter procedure to save our somewhat fraying minds the extra distress, although we can hear his protestations from next door well enough. Minimus is admitted for the night and taken up to an individual room in the children's ward - at less than 3 weeks old, he has had no immunisations and so can't be risked in the open ward.
For three days Mrs Jermy and our new son reside at the hospital, while rangling Jermy minor and keeping things ticking on the home front falls to me, as well as swapping in for the day shift so that Mrs Jermy can sleep for a few hours. Surviving a stay in hospital in this way is in part a logistical challenge: clothing, toiletries and reading materials have to be arranged, each morning large flasks of tea and coffee filled and lunches and dinners assembled (the hospital cafe is decent enough, but quite pricey, so better to self cater). Jermy minor is deposited with family for the day and collected later, and a delicate balance of working while looking after minimus and Mrs Jermy is sought. Throughout, minimus continues to receive cefotaxime twice daily but improves rapidly and by the second day is pretty much back to normal (or a close approximation thereof). An ultrasound reveals his kidneys and bladder to be 'unremarkable', which is the only time one would like to hear such a thing said of their child. By way of an added bonus, Mrs Jermy is diagnosed with an infection also, and is prescribed metronidazole and cefalexin to take for a week. On the fourth day minimus is moved onto the once a day antibiotic, ceftriaxone, and we are allowed to return home on the proviso that we return each day for the next dose to be administered.
On day 6 the results from the cultures are returned, calamity! Rather than being a day away from completing our treatment course, the cultures identify an extended spectrum beta-lactamase bearing E. coli strain in the urine and umbilical swabs, resistant to a bunch of the antibiotics normally used for treating UTI's in neonates, curiously including cefotaxime, the drug whose initially administration had coincided with an improvement in all symptoms. So a new 7 day course of antibiotics must be begun, we opt for the three-times a day meropenem rather than the once a day gentamicin (which brings with it a low risk of damage to kidneys and hearing) and so minimus must be presented in the ward at 7am, 3pm and 11pm for another week so that the drug can be infused. Better to be dog tired with too-ing and fro-ing than risk permanent toxic side effects in our assessment, no matter how low the chances are. I try not to think about his poor microbiota.
One of the difficulties in treating neonates is finding a suitable vein for a cannula to be inserted into, and our case proved to be no exception. The first cannula in his right hand goes in on the third attempt, and lasts well enough through to day 5. The second goes into the same hand following unsuccessful needling of the left hand and right foot, each prodding a painful and draining experience for child and parent alike. By the time a third cannula is needed, bruising and non-compliant veins in hands, feet, wrists and inner elbows mean that the only option is a scalp vein. Initially squeamish about a needle in his head, this parent soon overcomes any doubt when a suitable vein is located rapidly and a cannula inserted with minimal fuss and little pain or discomfort. Heads it is then, for this and the final cannula - the only drawback being that it is necessary to be admitted to stay on the ward once again, and so it is back to the same little room for a further 4 days staring at the same walls, the whole episode now becoming a blur of Groundhog Days, while our minds slowly start to shut down to the real world outside of our two sons, getting one healthy and keeping the other happy.
At last we are freed to return home and try to reestablish some much needed normality, albeit with a final course of trimethoprim and a series of check ups and tests in the next few months. We are coming up for air, able to breathe and start to think once again, some perspective at last. Friends and family send their kind wishes for a speedy recovery and concern for what must have been a tough and stressful time. While much appreciated, such assessments don't feel exactly right - aside from the first day or two, minimus has been seemingly well for the other 10 days, and we have instead been trapped in a course of action that (rightly) just had to be seen through. So it's not necessarily that tough, or stressful or heart wrenching (although there is perhaps a little of each), but rather tiring, boring and mind-numbing. Indeed at times it actually feels mildly embarrassing to have a big, happy and seemingly healthy baby with others on the ward (and elsewhere) going through far worse. Of course inaction on our part could have seen minimus in a worse position, but such feelings remain - once the visible symptoms abate in tackling this infection one couldn't help but feel part imposter.
Similarly, I wonder at the scale and cost of all of this: 7 nights in an individual hospital room, variously 3 consultants, 4 registrars, 5 junior doctors, upward of 20 nurses, 1 microbiologist, 1 pharmacist, 2 cleaners, an unknown number of administrators, 4 antibiotics for Jermy minimus (2 for Mrs Jermy), 4 cannula inserted and much more. We are fortunate to live in the UK and have access to healthcare that is both free at the point of use, and in this case truly outstanding. I salute the staff of the Princess Alexandra Hospital, Harlow, every single one of whom treated our son and his parents with a care, dedication and professionalism that is admirable. Never short or sharp, always with a smile. If any reader makes it this far, and hails from the US, I wonder what sort of price tag would be placed on the treatment we have received on that side of the pond, and whether it would have seen us needing to remortgage our house. Of course the NHS is not perfect, and is not free, we have already paid into the pot through taxation for years and will happily continue to do so for many more to come. But on this occasion they really were Neonate Healthcare Superstars - the germy Jermy's thank you.
Back to work proper tomorrow then, and an editorial to write. If only I had a topic in mind...