Houston, TX- When Bamanda Ellis delivered her first baby at one of the premiere academic birthing centers in the country, the last thing she expected was to be discharged home without her child. But instead of driving off with a car seat full of hopes and dreams for the future, Bamanda and her husband Tab had a tracking number and a promise to be notified as soon as their baby was found. Their child had joined a growing number of newborns being lost in hospital pneumatic tube systems across the United States.

Pneumatic tube systems are a standard technology in large healthcare facilities. When seconds count, rapid and reliable delivery of blood products, tissue samples, medications, and patients weighing less than 3 kilograms can literally save lives. But according to a recently published report from the Office of the Surgeon General, 7% of newborns are lost in these popular delivery systems every year, the majority of which were born prematurely or at a low birthweight for their gestational age.
"It might take a nurse or transport team ten to fifteen minutes to move a critically ill baby from point A to point B in this facility," Neep Gunderstone, an expert in neonatal logistics at Texas Children's Pavilion for Women. "The sooner that a lifesaving intervention can be initiated, the better the outcomes tend to be. And in the rare cases where a neonate is lost, they have usually just been tubed to the wrong station and we typically find them within 3-5 business days."
Though a common practice in large neonatal intensive care units and nurseries, "tubing" newborns is not without its critics. According to the most recent United States Surgeon General Vivek Murthy, MD, this century-old technology needs to be updated before being used to transport patients. "Frankly, it's embarrassing. I kept telling them not to use the tubes for that but nobody listened. Maybe they will now that he's in charge, and when he picks Hannibal Lecter to be my replacement.
Thankfully the story of the Ellis family has a happy ending. Their child was eventually found in the radiology reading room and returned to the worried parents. And according to the relieved mother, there may be a surprising silver lining. "I know he's just a week old, but I think he really learned a lot down there. Just imagine, my baby...a radiologist."
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