Archive for October 2006

Weighing something

October 28, 2006

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 The other night, I started writing about one of the things I hate about the NICU, which is that no one there talks about death. I didn’t finish it, so I didn’t post it, thinking I’d get to it the next night.

The following morning, instead of our usual attending rounds, we had a “debriefing,” which is basically a meeting of everyone in the NICU involved in the care of a patient who has died. As these things often are, it was a lovely example of the support that people can show for each other at moments when they question their own actions and motives. But beyond that, the session helped me understand why people in the NICU do what they do.

For an intern like me, there are plenty of things to hate about the NICU: long hours, patients we often can’t touch and can’t ever talk to, questionable ethics of some of the things we do. But there’s also a lot to like: acuity of disease, opportunities to educate families, interesting physiology, occasional adrenaline rushes, and the odd chance to “test neurological status” by letting a baby suck on your finger.  In our NICU, there is also as much free coffee as a person can drink, and really, isn’t that enough?

But in the NICU–and in pediatric medicine in general–we don’t talk about death. This is in direct contrast to adult medicine, where we are trained to reflexively consider what will happen if, instead of making patients better, we make them much, much worse. As part of every admission to an adult medicine service, we determine the “code status” of each patient, asking when we need to stop trying to make them live. Some people want us to withdraw care when they’re no longer able to breathe independently, others when their heart stops beating. Some people don’t ever want us to stop, and that’s fine, too–but we ask

In the NICU, we don’t ask–at least, not until it’s hardly a question any more. And in not asking, it seemed to me that we were choosing for these babies a lifetime of painful existence–the kind of existence that we give adult patients the option of avoiding having to live for even one unnecessary day. 

But that’s not exactly what’s happening, and I didn’t get it until I heard the NICU staff talk about it. Everyone who works in the NICU is at times conflicted about whether intervening to prolong the lives there is ultimately to their patients’ benefit. Nevertheless, they do intervene, and they do it for two reasons.

The first is their committment to families. Their best reason to do what they do is to give parents time to align their hopes and dreams for their children with the reality of their prognoses, and on the basis of that, to make choices. Their next best reason is their own experience: about once a week, a child comes into the NICU who, years earlier, doctors thought would never leave it alive. Our smartest attendings can’t count the number of times they’ve been wrong about a child’s prognosis; it’s hard to recommend withdrawal of care from a sick baby when you’ve seen equally sick ones live well.

The non-longitudinal nature of a resident’s contact with the NICU and our limited contact with the children who actually make it out of there makes it difficult to keep these motives in mind. And it’s hard to understand what a difficult choice it is for a family to withdraw care from their child if you’re not sure you have the instinct to breed, or if you see disability as a burden to a patient and a family. I easily fit into both of these categories.

But I can understand that in addition to treating sick infants, we’re treating anguished parents, and that you can’t force an adult to come to terms with a loss. Before they can let their child go, some parents need to see that everything that can be done has been done–and sometimes, we agree to cause a child prolonged suffering in order to fill that need. We rationalize doing this by remembering the times when the suffering, against all odds, resulted in a living, happy child. But in the absence of certainty, we prioritize a parent’s emotional well-being over a child’s pain.

I’m not sure whether this is the right thing to do, but it is comforting to know that the doctors in the NICU are weighing something when they keep sick babies alive. Even if they don’t often talk about death, they are thinking about it, all the time.

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What makes you worth loving

October 24, 2006

These days, I snicker a little when I hear doctors say it’s a privilege to take care of people. If it’s a privilege to submit to this shitty schedule, that crazy attending, and those revolting bagels, I sneer, I don’t want to know about the punishment. But in clinic the other day, I actually understood what they meant. All it took was a fat kid.

She was 13 years old and quiet in a sweet kind of way, and she weighed 250 pounds. “I’ve been fat all my life,” she said, “and I just want to lose weight.” On the parental questionnaire, her mother had written only, “I am concerned about my daughter’s overweight.” Not about her failing grades, not about her having a boyfriend for the first time. Only about her weight.

I was a fat kid, too. In my family, this was also a Big Goddamn Deal. For most of my adolescence, all I wanted was for someone to sit me down and say, “Your body isn’t what makes you worth loving,” but it didn’t come–not for years.  And now, suddenly, here is the me at 13 sitting in front of the me at 30, asking for help.

I gave her help–a few small, practical changes to make, and an appointment to follow up after a month–and found myself thinking, my God, this really is a privilege. It is a privilege to sit in a room and talk about being fat and not be the one crying. It is a privilege, whether it’s right or wrong, for the younger me to find a little bit of healing in whatever the older me offers to a patient. It is a privilege to say both to her and to myself, “Your body isn’t what makes you worth loving.”

The story of ignorance

October 21, 2006

Today, I admitted a week-old baby whose mother didn’t know she was pregnant until she gave birth to him.

Let me repeat that.

Today, I admitted a week-old baby whose mother didn’t know she was pregnant until she gave birth to him.

When her contractions started last Friday afternoon, the 13th of October, she ran a hot bath to soothe what she thought were cramps, but leapt out of the tub when she saw a head appearing between her legs. She cut the umbilical cord with a pair of kitchen scissors, but because she hadn’t clamped it first, she bled extensively prior to delivering the placenta.

Sitting in front of us in a small clinic room, she looked starved, waxen, and stunned, her skin a pale yellow against a thicket of dyed black hair. Her boyfriend said, “I thought she was just getting fat.” He and another man living in their house had debated calling an ambulance or taking the infant to the doctor, but she had begged them not to. The courts had already removed two children from her custody, she said, and she wanted to keep this one. Plus, she added, she hadn’t wanted him to be hurt by what the doctors might do to him in the hospital.

They’d weighed him against a box of rice. “He’s too small,” her boyfriend had said. He’d bought a carseat and a diaper bag, and the next day, they brought him to the hospital.

We reassured them. They had done the right thing in bringing him in, we said. He was tiny–probably about 6 weeks premature, and small even for that. He also had a very low body temperature and mottled skin, suggesting that he might have a severe blood infection. The NICU fellow, a senior member of our team, said we’d need to keep the baby in the hospital at least overnight, and the mother began to cry. The fellow comforted her: “I haven’t heard anything suggesting you won’t be able to keep him.”

Really? Nothing? Is it not possible to be too stupid to raise children? And if the story of ignorance is an invention, what are the odds that it is covering up something more benign? How much are we willing to bet?

I stood next to his isolette in the dark tonight after inflicting on him exactly what his mother had known we would–needles in his arteries, his muscles, and his spinal column–and wondered how much of his life he will spend with people who pretend that he doesn’t exist.

This unlucky little form, spat into the world on an unlucky day. If he goes back home with his parents, I will not have done him any favors by keeping him alive.

Isolette

October 20, 2006

It is 1 a.m. on a Thursday night, and the only light in my apartment is coming from the laptop that sits in front of me in my bed. In four hours, I’ll begin my third day of a monthlong rotation through the neonatal intensive care unit (the NICU). I normally do not have trouble with sleep, but every night since starting this rotation, I’ve laid in bed awake for hours, my thoughts coming fast and strange. Although I eventually sleep, I wake up in the middle of the night unable to rest for hours at a time. The only dreams I can remember are about being lonely and scared.

I’m not sure why this is happening.

I don’t think I’m anxious about working in the NICU, although God knows I’ve got reasons to be. It’s a a very different place from any other I’ve been–we work very long hours planning the care of very tiny patients who are so fragile that we are sometimes forbidden from examining them. The hours are certainly not easy–we work 27-hour shifts every fourth night, and the NICU is notorious for being a place where everyone goes over their work hour limit of 80 a week. But my colleagues are nice, and the backup in challenging situations is ample.

Although I guess the source of my insomnia certainly could be the NICU, it could also be the impending winter. It could be the distance between me and almost everyone I care about. It could be my usual insecurities, magnified by a major birthday and a longer stretch of singlehood than I’m entirely comfortable with. If it is these things, I can’t understand why they would bother me now, and why they would bother me this much. I feel a little lost.

Sitting here in the dark in front of my laptop, it’s not pushing it to say I feel a little like one of my tiny patients in an incubating isolette bed. The light shining on me only illuminates my confusion, without giving reasons or comfort. I’m reaching for things I am blind to, not sure why I’m here, not sure where I’ve come from. And even if I get sleep, I’m not getting much rest.

Hung up on the cuteness

October 14, 2006

When I started medical school, I was not into kids. It was partly a matter of principle—I didn’t want to do what everyone else was doing, and everyone else was loving kids, so it became my business to not like kids. Another part of my distaste was the spectacular humorlessness of so many people in pediatrics, their overall trend toward an inauthentic kind of hokey-jokey smileyness and their tendency to stare blank-eyed and confused at sarcasm. I was also rubbed wrong by the unspoken ethic—and not just in medicine—that kids deserve more care, more love, more forgiveness, more everything, just for their sheer cuteness.

I’m not hanging around with those moony-faced saps, I thought. Non-cute adults deserve tenderness, too, and I wanted to bring that to adult practice. By the halfway point of medical school, I had aimed myself squarely toward internal medicine.

When I did my obligatory pediatrics rotation in my third year, I spent most of my time in the pediatric intensive care unit (the PICU), where most of my patients were unconscious. As careful readers already know, unconsciousness isn’t something I mind in a patient; in the PICU, my focus was, happily, my comatose patients’ physiology. To my surprised relief, PICU docs–unlike other pediatricians–didn’t call their patients “peanuts,” or “kiddos,” or “shmoopies”—they called them “patients.” The disease process and the events around its acceleration crowded out any of the sentiment–real or false–that I found so unappealing among pediatrics types.

By the end of my PICU rotation, logic had gotten the better of me—I couldn’t rationalize giving more to an entire segment of the population just because of their cuteness, but I also couldn’t rationalize not giving them as much. And if the pediatricians in the PICU could take care of children without themselves acting juvenile, maybe there was hope for the others.

I never felt I was very good with children—I didn’t tend naturally toward silly faces or voices, and because I always worried about breaking kids by doing something wrong, I never did much with them at all. Somehow, once I resigned myself to wanting to be trained in pediatrics and began interacting more with kids, I found that being “good” with them only meant wanting to be around them. And oddly, I did want to be around them. I couldn’t really explain it, and I didn’t try too hard. I was too busy trying not to get hung up on the cuteness.

I ended up in a program that combines training in both adult and pediatric medicine, alternating between three months of each. After beginning my intern year with three months of adult medicine, I switched last week to my first pediatric rotation, which is in a pediatric emergency department. I see anywhere from 10 to 15 kids in a shift, ranging in age from 2 weeks old to 21 years old. I put stitches into eyelids, take beads out of noses, and pull shoulders into place.

I don’t make silly faces, and I don’t do silly voices. I’m more patient with the crying ones than I ever thought I’d be. And, God help me, they are sometimes so cute I can hardly stand it.

The other day, I put four stitches in the finger of a four-year-old girl who had cut herself on a scooter wheel. Her parents had to hold her down so I could work, and I was certain I was participating in some kind of major traumatizing life event. But afterward, instead of shrinking away from me, she looked at her finger, then looked at me, and with enormous, sucker-producing blue eyes, said, “Thank you for fixing my boo-boo.”

Oh my God! I’m one of them!