A Home Run

Written by Leslie Hill

Colleen Hunt clutched a preemie diaper in her arms where her newborn baby boy, Maxwell, should have been. Instead, Max (as he is known to family), weighing 2 pounds, 11 ounces, was carefully strapped into an incubator that would keep him warm and his lungs working during a two-hour ride from Madisonville, Ky., to the Monroe Carell Jr. Children’s Hospital at Vanderbilt. There he would get the services he needed to heal and grow.

“They made sure I got to see Max,” Colleen Hunt said. “It was overwhelming, seeing this tiny baby strapped in a big box with all this equipment. But it made me feel better to see him and the people who would be taking care of him.”

The mobile NICU
For 38 years, the Neonatal Transport Team has provided safe and specialized transport for ill and premature newborns in need of critical care. With a fleet of four ambulances that  serve as mobile NICUs, the transport team takes its expertise all over Tennessee and into Kentucky and Alabama to care for the sickest newborns.

Through a mixture of Vanderbilt’s community partnerships, outreach education and skilled care, more babies have a chance at surviving prematurity, including infants born as early as 23 weeks. Nearly half of all babies who spend time in  the Children’s Hospital NICU have been transported fromhospitals in outlying communities.

“When we roll in to a hospital, we have everything on the isolette (incubator) we could possibly need,” said Jerry Ballhagen, EMT, manager of the Neonatal Transport Team. “Statistics show that we get better outcomes if we take the NICU to the baby rather than send another service that isn’t as specialized and have them transport.”

Averaging 70 transports per month, the Neonatal Transport Team prides itself on being an extension of the Children’s Hospital NICU. Most infants cared for are premature with respiratory problems, but the team also transports babies with cardiac anomalies, sepsis, genetic defects that require surgery and those who require head cooling or heart/lung support.

The team travels most often by one of their four ground ambulances, but depending on distance and weather conditions, may also use a fixed-wing aircraft. Each ambulance can hold two isolettes, enabling the team to transport twins or two babies from the same facility.

The isolette is where the magic happens. Weighing 500 pounds, it has all the supplies and equipment an infant could possibly require, all available in small sizes for premature babies. The heart of the isolette is the bed, a plastic shell usually set at a balmy 32 degrees Celsius (89.6 degrees Fahrenheit) to keep the infant warm.

“Temperature is more important than anything. A baby can go into cardiac arrest just from being cold. If the baby is in an open bed next to a door, just that draft can cause them to go into a decline,” said Stephen McCluskay, EMT.

Below the bed are drawers like a handyman’s tool chest, holding 155 pieces of equipment, and the EMTs know exactly where each item is located. They have supplies for chest tubes, intubation and intravenous lines; adapters for air and oxygen at different hospitals; oxygen masks and nasal cannulas; and even extra batteries.

Neonatal Transport isolettes carry medications and equipment that community emergency medical services don’t always stock. The team also offers surfactant, a medication that helps the baby’s lungs work. The i-STAT machines allow the team to do lab-quality blood testing en route.

Ready to serve
Twenty-four hours a day, two transport teams are ready to serve. Each team has a neonatal nurse practitioner (NNP), neonatal nurse and an emergency medical technician (EMT). A respiratory therapist (RT) now goes on the majority of transports.

A unique aspect of Children’s Hospital’s Neonatal Transport is that the staff routinely works with inpatients in the NICU.

“Our NNPs and nurses pick up a shift about once or twice a week in the NICU. We think that’s extremely important to make sure we keep up our skills and knowledge with this population,” Ballhagen said.

Children’s Hospital’s neonatology fellows cover a 24-hour call line that is free for community hospitals. Sometimes they offer advice for treatment at the hospital and no transport is necessary, but if the fellow realizes the situation merits transport, the team immediately dispatches. The fellow gathers information and updates the team en route.

Upon arrival at the outlying hospital, the NNP takes the lead, gets the patient’s history and makes orders. The nurse will manage the IV and medications, while the respiratory therapist manages the ventilator or other airway equipment. The EMT retrieves equipment, takes care of logistics and drives the ambulance.

Unlike traditional ambulances, where the goal is to get the patient to the hospital as quickly as possible, the Neonatal Transport Team may spend an hour or more at the outlying hospital stabilizing the baby. With everything they need on the isolette, there’s no rush to get back to Children’s Hospital.

Once the baby is ready to ride, the team’s focus turns to the family, and they make every effort to assuage their fears. Parents are given a folder with directions to Children’s Hospital, and the team gets their contact information and calls them with an update as soon as they arrive back at the hospital.

“Sometimes the moms aren’t able to hold their baby but we can at least roll in with the isolette and let her touch the baby and get pictures before we leave. We also give them a little T-shirt that says they took their first ride with us. It gives them something to hang onto until they see their baby again,” said Amanda Whitlock, R.N., B.S.N., assistant manager of the Neonatal Transport Team.

A perfect example
The Hunts were able to drive to Nashville the day after Max was born, but it was three days before they could hold him. He came at 27 weeks gestation, and babies born under 32 weeks have significant complications. (Full term is 37 weeks.) He had severely underdeveloped lungs, and also had a high risk for bleeding in the brain, jaundice and eye problems.

“He had no fat on him. He was bare bones. His skin wasn’t translucent but it was very light. His eyes were fused shut. We didn’t see his eyes for a couple of weeks. When I got to hold him, he was not any longer than my body is wide. Normally, a baby’s feet hang over your arms, but his didn’t,” Colleen Hunt recalled.

During his 73 days in the NICU, Max experienced terrifying, but normal (for a preemie) spells when he quit breathing. He also had a patent ductus arteriosis (PDA), a blood vessel in the heart that normally closes after birth but can be delayed in premature babies. His PDA closed with the help of medication.

“The transport team and the NICU were amazing,” said Colleen Hunt. “Everyone at the hospital said he was a tough kid from the beginning, and they were there for us every day. We went home two weeks before his due date. My two victories were that he didn’t have any surgery and he went home before his due date – besides getting to take home a healthy baby of course!”

Now a vivacious 2-year-old, Max has a passion for playing with balls and reading. He is small for his age, but evaluations show he is developmentally on track with peers and has no lasting effects from his prematurity. The family now lives in Brentwood, Tenn., and added a baby sister, Stella, in March, in a perfect, full-term delivery.

“Stella was born at 9 pounds, 2 ounces. We joke that we don’t do average-size babies. They’re either tiny or huge,” Hunt said.

Colleen Reilly, M.S.N., a neonatal nurse practitioner who works on the Transport Team and cared for Max in the NICU, said he is a perfect example of the team’s success.

“What is so awesome about Max is we were able to get there so quickly after his birth and provide the care he needed at Vanderbilt. It shows that even if you’re not born at Vanderbilt, we can help you,” Reilly said.

“I love going out and helping people in their most needy time. The relief I see on the faces of parents and staff just fills my tank up. It’s such a neat way we can work outside Vanderbilt proper and make a difference. We’re taking our training and experience to the babies who need it most.”

Reaching out
For nearly 50 years, Vanderbilt has been a national leader in caring for premature infants. In the 1960s, Mildred Stahlman, M.D., created the first modern NICU, and when doctors in the region began to call asking if she would accept a premature baby struggling to breathe, the need for a transport system was apparent.

“The baby would arrive, sometimes dead on arrival, sometimes so cold that it took a lot of time to get the baby warm. There was no oxygen, there was no special care during this transport. Essentially the baby was bundled up and told, ‘They’re expecting you at Vanderbilt.’ That baby could be coming from hours away,” remembered Cheryl Major, R.N.C.-N.I.C., B.S.N., of her early days as a nurse in Stahlman’s NICU in the 1970s.

The babies needed better care during transport to have any hope of survival. A retrofitted bread truck, christened “Angel,” served as the first neonatal ambulance. With lights and sirens blaring, the truck began speeding to hospitals around the state.

Doctors in Knoxville and Memphis with similar experiences joined with Vanderbilt to create state legislation that regionalized perinatal care. Vanderbilt was assigned the Middle Tennessee region, comprised of 37 of Tennessee’s 95 counties.

Stahlman also asked Major to start an outreach program to educate providers at outside hospitals about how to care for a newborn until the ambulance arrived. Major continues that outreach today, assisting providers in the region Children’s Hospital serves.

“In every one of these counties, I know who is there, what kind of perinatal or neonatal care occurs or does not occur, and I have relationships with every one of them,” she said.

As county hospitals have closed over the years, Major has had to adapt to a new climate in which 19 counties no longer have obstetrical services. In these counties, her focus has turned to educating the ER staff who cares for women in labor.

“When I hear the OB department is closing, I immediately find out who the ER director is. I call them and tell them not to let that OB equipment go away and tell them to set up a room in their ER as their delivery room,” Major said.

For providers in this situation and anyone caring for infants at birth, Major teaches a Neonatal Resuscitation Program (NRP). Another course, called S.T.A.B.L.E., is aimed at providers who care for babies waiting for transport. The course is a mnemonic for the most important factors in the first hours of a critically ill baby’s life:  (blood) sugar and safe care, temperature, airway, blood pressure, lab work and emotional support.

All courses are free, and Major is able to offer them to any community providers, regardless of the competition.

“That’s something I really value because there are other states I see when I travel that aren’t that lucky. If there is a competitor, they’re not allowed to offer them help. But we serve the citizens of Tennessee and a citizen cannot be prevented from accessing the care and knowledge we provide. We’re doing good community service and good public health,” she said.

Rhonda Carnell, M.S.N., director of the Women’s Center at Henry County Medical Center in Paris, Tenn., appreciates the support from Children’s Hospital because “what’s routine to them is not routine to us,” she said.

Henry County has a Level I NICU, equipped to manage newborns who need oxygen for a short time, but infants any sicker must be transported. Carnell said the transport system works well because mothers can deliver close to home but help is available if something goes awry.

“The team is so calm and we’re so happy to see them come in,” she said. “A lot of the time we’ve been dealing with something way above our acuity for a long time, and we’re happy to pass that off.”

Once a baby has healed and grown in the Children’s Hospital NICU and is stable enough for a lower level of care, the Transport Team also provides “back transport,” a ride back to a community hospital for continuing care. This lets families return to work and be closer to their support network at home.

Often, it’s not until years later that the Neonatal Transport Team members see their work’s impact. The “success story” is realized when they encounter the strong, healthy child who was once a sick and fragile infant.

“That’s when you really know the impact this team makes on the community, seeing the true outcome,” Ballhagen said. “When the patients come back to the NICU or up to our booth at We Care For Kids Day (an annual celebration of children), that’s when we can see how the technology and skill and knowledge of this team is taking care of babies.”