Lucky

On Christmas Day I attended a cesarean section. The baby was full term and came out crying and vigorous. As usual, his birth and initial cries were met with expressions of happiness and contentment, and I couldn't help but smile at him. It was the mother's third delivery, her second C-section. She was eighteen years old.

The delivery perhaps epitomized the sum of our emotions working with these patients. On the one hand, any new life is special and can be celebrated, especially one born on Christmas Day, a holiday that means so much to so many people, both religious and non-religious. On the other hand, though, an 18 year old with three babies is just downright discouraging.

I was chatting with the obstetrician and OB resident at the nurse's station after the delivery and mentioned my disappointment that this was mom's third pregnancy. The conversation turned to young mothers with multiple pregnancies, and the obstetrician told us of a 19 year old she had seen with her 13th pregnancy, which was mind boggling even for a jaded guy like me. The OB resident - a young black woman, a contemporary of the mothers we were discussing- shook her head and said "Those women just need to be beaten."

A commenter on my previous post asked what I meant when I said "Some women degrade themselves," and other commenters noted the courage of single women for having babies instead of aborting them. As I've said before, I don't mind it so much when a young single woman comes in with her first pregnancy, because anyone can make a mistake. But when that woman gets pregnant repeatedly, time after time, she degrades herself and her children, by condemning herself to a lifetime of dependency and irresponsibility, and by starting her children in life with two strikes against them, poor and with no strong male role models around. She degrades herself because she just doesn't care about herself or her kids. As for choosing life by deciding to bear the children rather than abort them, I suspect that as often as not the reason they are not aborted is because they sought prenatal care too late to have an abortion.

On New Years Day I'll gather with extended family for the day. I'll see a variety of siblings, nieces, nephews, and great nieces and nephews, from ages 6 to about 66. We'll watch football and play foosball, and there will be lots of fun stuff to eat. It's always good to see the kids, who for the most part are well raised and respectful, except for the trash talking during foosball. It will be a surprise if most do not finish college and a shock if any are young, single parents. I can't help but wonder: Are these kids better than the 18 year old who had her third baby - or just luckier?

Peace

Dear readers, I'm going to put my blog on a holiday schedule for awhile. After tonight's post, I'll take the Christmas weekend off. I'll probably write one or two posts next week, and then take the New Year's weekend off. Merry Christmas, and peace and love to everyone.

* * * * * * *

Last year on Christmas Eve our family decided on the spur of the moment to go caroling at a nearby nursing home, so we blew out the candles on the tree and drove over there. Most of the residents seemed unaware of their surroundings, and it was the kind of nursing home where that might be a blessing. Some of the residents, though, were pretty with it, and a couple of visitors asked us to sing in their rooms. One of those was a Hungarian woman who told us about her mother, a patient who was suffering from Parkinson's disease. The woman sadly said that she didn't think her mother would make it to next Christmas, and you didn't have to be a doctor to see that she was telling the truth.

At her request we sang "Silent Night." The woman started crying shortly into the song, and by the end of it my eyes were feeling pretty leaky too. Anyway, we came home to open our presents, and after seeing those patients and how fortunate I was compared to them, I really didn't care anymore what I got for Christmas.

May all of you be fortunate enough to not care what you get for Christmas. Have a wonderful holiday.

Passage

Jeane Kirkpatrick, former U.S. ambassador to the United Nations, died recently. Regardless of your political persuasion: Dicit nihil sed boni de mortui.

What interested me is that the news article said she "died in her sleep", a phrase we commonly hear, and I always wonder what that means. Do people really die in their sleep, passing from comfortable sleep and dreams seamlessly into non-existence? Or do they awaken for one or two terrifying, perhaps painful moments, maybe clutching their hand to their heart or struggling for breath before they die?

I have seen many human beings die, most of them, of course, very premature babies. When they die, most often they just sort of drift off. They are asleep or unconscious because they are very sick, and we know they are dying because we see the heart rate drop on the monitor, not because there is any significant change in their activity. Sometimes, if we take them off the ventilator before their heart has finally stopped, they will take a deep gasp or two, more of a primitive reaction than a willful last stab at life, although it can be very hard for the parents to see.

With adults, though, the circumstances are often different. Sometimes they are very ill and comatose and drift off like our premies do, but other times they have a fairly sudden event, like a heart attack, or have painful last days, especially if they have terminal cancer.

I remember the first time I saw an adult die. I was an orderly during my college years in a men's ward of a hospital, and we had an elderly patient with terminal cancer who was a no code. One day as he was sitting awake propped up in bed, he just started breathing deeper and deeper, and the breaths came farther and farther apart. As the interval between breaths increased, the nurse aide and I urged him, "Breathe, Mr. Doe, breathe!", but it was to no avail. He didn't seem in pain and over a few minutes time just sort of drifted off into unconsciousness and finally didn't take another breath. It was a little weird for a 19 or 20 year old kid to see, and I still remember it vividly. It wasn't a terrible way to die and was preferable, in fact, to waking up in the dark in the middle of the night, alone with your last gasp.

"Dying in your sleep" probably means different things for different people. I don't know why I worry about it; it's not like we can choose how we go, anyway.

Waiting

A Sunday or so ago I was on duty for the entire day and evening. As I walked by the family waiting room outside the NICU in the late morning I noticed a young woman, a teenager, there with a small baby and a toddler.

I didn't think too much of it, but as the day wore on I kept seeing them there. The baby looked very young; the toddler looked to be just shy of two years old, so to say he was cute is almost redundant. Sometimes when I walked by he would smile and point at me. I would point back at him and he would smile more.

Finally, in the evening, after they had been there at least ten hours or so, the mother waved me over as I walked by. "Do you work here?" she said in a quiet voice. When I replied yes, she asked me if I could get her some formula for her baby. I inquired about the baby and discovered she was only three days old. The teenager was the mother and had run out of formula.

When I went to get the formula some nurses heard about the situation and one went out to obtain more information. It turned out the teenager was here with her aunt, whose daughter was laboring in the delivery area. Not expecting to be at the hospital that long, the teenage mom had run out of food and formula. In addition to the formula, the nurses got some milk for the toddler, who had been drinking cool-aid or juice all day, and a sandwich for the mom. When asked why she hadn't stayed at home with her three day old baby and toddler, she replied that she was afraid to be alone there.

I wish I knew what to do with people like her. Spending all day in a hospital waiting room with a three day old baby and a toddler? That's almost mind boggling. Part of me wants to take her under my wing and give her a good home with lots of support, but I know that she is just one of many, and I can't take care of all of them. Also, society would look pretty askance at a middle aged guy who takes in teen-aged women who aren't related to him. And part of me just wants to keep living my comfortable lifestyle and act like I did something good by getting her a little free formula, when really, that's like just a small drop in the bucket of her problems.

Honesty

In a comment on my Pawns post a few days ago, Stacy, a mother of an ex-25 weeks gestation baby, makes an earnest plea for us to be honest with parents. She means (I think) that we should not only tell them the statistics about survival and major adverse outcomes - cerebral palsy, mental retardation, blindness, deafness - but also about the more "minor" problems; her daughter, for example, has emotional problems, fine motor problems, epilepsy, and other issues. As a member of ex-premie parenting groups, Stacy knows that her daughter is not alone in having these things.

Stacy, first of all, I hear you. I agree that we must be completely honest - some might say brutally honest - with parents when we discuss outcomes of extremely premature babies. I not only tell parents the chances of a child having major or moderate disabilities, such as varying degrees of the afore mentioned CP and mental retardation, but also try to convey to them that children classified as "normal", because their motor and mental capabilities are in a normal range, still have an increased risk of what I call "soft" neurological problems, such as learning disabilities, attention deficit disorder, clumsiness, and so on.

On the other hand, though, I don't know how much good it always does, because the parents so often just don't seem to hear it. This is not a criticism of the parents; I think it's just part of what happens around the birth of an extremely premature baby. Not surprisingly, parents are not at their most rational and understanding at the time. They are both fearful about the prematurity and excited because they're having a baby. Also, the amount and type of information we have to give them about premies is difficult to take in at any time, let alone when they are in such an emotional state.

We still have to try, though, and I think most of us do. But how often do we mention it? Although I realize that we must repeat some things before they sink in, we can't be daily bombarding them with discouraging statistics. We have to give them some hope, because the fact of the matter is that there are still many reasons to be hopeful. A child may have attention deficit disorder or fine motor problems or emotional issues - but may still be the love of his or her parents' life, a huge source of happiness and fulfillment for them. (For that matter, children with mental retardation and cerebral palsy can also be a source of that joy.)

Often we are giving parents information about premature babies because they are trying to decide whether to have their extremely premature baby resuscitated or not. I understand that the prospect of a child having severe mental retardation and cerebral palsy, with a quality of life thought marginal or unacceptable by many people, can affect the decision whether to resuscitate or not - but should the possibility of having a more minor problem like attention deficit disorder make a difference in the decision to resuscitate? I'm not quite ready for that eugenic a society.

The other day I was talking to the parents and grandmother of a newly born 24 weeker. I told them the survival statistics, using both percentages (50 to 60%) and fractions (5 out of 10). I told them other outcome possiblilities, of the immaturity of all organ systems and the consequences of that. When I was done with my spiel I asked if they had any questions, and the grandmother asked, "When 24 week babies are born, do any of them survive?" I had just covered the subject in detail. Now I simply said "About half of them survive." That, I guess, is all she could handle at the time.

Pawns

The note on the front of the chart read "If the father of Mary Doe's baby comes up here with any female, do not let him or her in to visit," and it was signed with the mother's name. I sighed. Once again, a mother was using her baby as a weapon in a fight with the father.

It's not that unusual and typically goes like this: The parents are unmarried and sometime before or around the birth of the baby have an argument. Maybe dad has taken up with another woman, or maybe it's something small, but being unmarried the mother has the right to control who visits the baby, and in her anger towards the father uses one of the only weapons at her disposal - visiting privileges for their child. Sometimes the parents fight and make up and visiting privileges change daily for the father, depending on the couple's status. If the parents are married or the father officially claims paternity, then the mother cannot keep the father from visiting, but those circumstances are fairly uncommon in our NICU.

Our social worker and I really don't like this, and even though it's legal for mother to do this we generally tell them they cannot do it. Let's face it; there are too many kids in urban America without a strong father or male influence in their life, and we hate to allow anything that might contribute to the father's absence from his child's life. Just because the parents don't get along doesn't mean the kid should be deprived of his or her father. Sometimes when we put it to the mother in those terms, she will let the father visit (although not necessarily the father's girlfriend, and who can blame her for that?)

It's not that we don't sympathize with the mother. Any father who impregnates a woman and then leaves her before the baby is born doesn't rate real high in my book. He's especially a rat if he shows up in the nursery with another woman as his girlfriend. But parents splitting up are a fact of life, and the children shouldn't be pawns in the disagreement between them, whether it's at birth or later in life.

Sure, the father should claim paternity, and we encourage them to do so if they want to visit, but that is not always done immediately. Also, the flip side of the father's bad behavior in showing up with another woman is the mother having multiple affairs so the father isn't sure if he's really the father. There's crap all around, but let's let the kids have two parents, even if they're not together.

Menu

I go to eat at the hospital cafeteria on Friday night and stare at the entree choices, which are lasagna, deep fried shrimp, and deep fried wing dings. Our hospital is kind or sadistic enough to list the nutritional content of them, so, theoretically, we can make healthy choices. The lasagna and shrimp both have pretty high fat contents, with the number of calories from fat hovering in the neighborhood of 50%. The wing dings, though, those fried chicken wings that are mostly fat, skin, and bone, take the cake, so to speak, with nearly 1,000 calories per serving and somewhere around 70% of them from fat. Good grief, why don't they just do a cardiac cath and inject a french fry directly into our coronary arteries?

There's an article in the December Pediatrics journal about fast food in children's hospitals. Interestingly enough, fast food restaurants are found in 29.5% of hospitals with pediatric residency programs. People who went to a hospital with a fast food restaurant in it were more likely to eat fast food, and not surprisingly the article takes a dim view of this, noting the increasing rates of obesity in America and the less than stellar nutritional value of fast food.

My point, though, is this: Who needs fast food restaurants in hospitals when you've got cafeterias like ours? Some days the meals we serve are worse than the choices in fast food restaurants. At least fast food restaurants usually have one healthy choice or so; our cafeteria sometimes has none - witness the above menu. (Somedays, when they don't have wing dings, they list french fried onion rings as an entree. An entree?)

It shouldn't surprise me too much. The cafeteria is just trying to please its customers, to sell those products that sell well, and believe me, those orders of wing dings and fries fly off the shelf like hot cakes. We are a hospital, though, and don't we have some responsibility to keep people within our walls healthy? I guess it's not surprising to me that our cafeteria sells food that's not particularly good for you; that's just life in the U.S.A. What gets me is that it serves food that is so spectacularly bad for you.

In closing, I note that my computer's home page has an article about a restaurant called the Heart Attack Grill. It's menu includes items such as the Quadruple Bypass Burger and Flatliner Fries, and, in the piece de resistance, the waitresses wear "naughty nurse" costumes featuring plenty of leg and cleavage. Nursing groups have complained about the image portrayed. Hmmm...would it offend anyone if I said I wanted to go there for dinner?

Missed

The baby looked pretty good when I examined him on morning rounds, but his abdomen didn't feel quite as soft as I thought it should. It wasn't distended, though, and he had been tolerating his feeds, which generally means a baby doesn't have significant abdominal problems. I just wasn't quite satisfied with the feel of the abdomen and asked the nurse not to feed him while we observed it. About an hour later the nurse asked me to look at the abdomen once more. Again, it didn't look bad, wasn't distended or anything, but just didn't feel quite right. We obtained an x-ray and bingo, there it was: free air in the abdomen, air that should have been contained in the intestines but wasn't, indicating that he had a hole in his intestines.

We got the pediatric surgeons involved as soon as possible. They operated, found a spontaneous intestinal perforation, and removed a very small portion of intestine. The baby was pretty sick after the operation but gradually improved.

I felt pretty good, a little smug even, about picking up the problem early, before the baby developed feeding intolerance and worse abdominal problems, but then I reviewed a chest x-ray taken two days previously. There, in the little bit of abdomen that showed on the chest x-ray, was a little patch of free air. I should have noticed it then. I had missed free air two days before, letting the baby go for two days with a perforated intestine.

I felt terrible. In fact, even as I think of it again now, I still feel lousy about it. Like most doctors, I hate making a mistake that harms a patient. Sure, the baby survived, but if the perforation had been noticed two days earlier like it should have been, maybe the baby's post-operative course wouldn't have been so rocky.

The problem is that there is no good way to comfort yourself when you make a mistake like that. I try to do so by noting that the radiologist - one of the best at our hospital - also missed the free air on the chest x-ray, but that doesn't help much. I still should nave noticed it. I know that when you get a chest x-ray you should look at the chest on it last, noting the abdomen and bones first precisely so you won't miss something like this. I just blew it, and there's no getting around it.

I tell myself that as long as I learn from this, it's not completely terrible, and I did learn from it. For the next several months you can be sure I'll be checking for abdomen abnormalities on all the chest x-rays. But then, being human, my memory will start to fade, and a few years from now I might be tired or hurried, and when I get a chest x-ray not look at the abdomen....

Stink

I was called to the delivery room in case there was a problem with the baby, but before the baby even made it to me from the obstetrician we could hear her crying and breathing normally. She didn't need any resuscitation, just some drying off, but there was one thing wrong with her: she stunk to high heaven. In fact, the whole delivery room stunk.

Sometimes babies will stink because they are infected or just came from an infected uterus, but that wasn't the problem here. As I rapidly looked over this baby, I found the source of the smell: there, on her upper chest and neck, were feces, the mother's feces. Mother, as she was pushing her baby out, had also pushed some of her own feces out and they had gotten on the baby. The nurse and I wiped off the feces and threw out the dirty towel, giving some relief from the smell.

This may seem gross to some of you (and it is), but it's actually not that uncommon for mothers to have bowel movements while pushing during childbirth. In fact, mothers are often exhorted by the caregivers to "push like you're going to have a bowel movement," so it's hardly a surprise that they sometimes do. Usually it doesn't get on the baby, but it still manages to stink up the delivery room.

It's just one more thing that makes me feel sorry for moms during delivery. It's bad enough, dehumanizing enough, that they have to lay there with their feet up in stirrups and their bottom exposed to the few or several people in the room, but then to have those people witness you having a bowel movement seems just downright degrading. However, I think that many women don't realize it when they have a bowel movement during delivery, and even if they do, they might not care given everything else that is going on.

I don't think I could be an obstetrician. The sight of the blood and fluids I can take, but man, the smells and sounds would bring me down real fast.

Unappealing

I was in a nursing home yesterday, because as a favor we gave a ride to one of its residents, bringing him home there. He had a stroke many years ago, and the left side of his body is pretty much paralyzed. After getting him out of our car and into a wheelchair, we rolled him inside.

I almost gagged when I went through the doors, partly at the smell, but partly at the whole depressing atmosphere of the place. It was lunch time, and the smell was a combination of that of hospital food, disinfecting cleaning agents, and recently used bathrooms. Seeing the people there was almost as bad as the smell. Many were just sitting in the halls in wheelchairs, with nothing better to do. One was talking nonstop and nonsensically, another was smiling with an other worldy look on her face. The majority of residents didn't seem intact mentally, perhaps from Altzheimer's, maybe from a stroke, or maybe from previous long standing mental disease.

I don't write this to mock these people. I just feel tremendous sympathy for them; what an awful way to spend your waning years on earth. For the people who are mentally intact, it must be almost worse, because they can realize how lousy this is. And this, I might add, seemed like a fairly clean nursing home, although it was far from luxurious, making me wonder how much worse some less clean nursing homes can be.

It reminded me of one reason I went into pediatrics. It was partly because I could deal with dirty kids, maybe with smelly clothes, or babies with dirty diapers and the like, but I was somewhat repulsed by adults who were unbathed or incontinent, even if they couldn't help it. Kids are almost supposed to be dirty, at least at times like when they've been playing hard or before they are toilet trained, but a dirty or incontinent adult can be very unappealing. It's a bit ironic. When we get very old and infirm, we revert to the ways of infants and toddlers, unable to care for some of our basic bodily needs and functions. Unfortuately, we don't revert to the cuteness and hopeful potential of young ones.

When we walked out of the nursing home into the fresh air, I took a huge breath, trying to purge my lungs of the air and smell inside. "If I ever need to go into a place like that to live," I said to my companion, "just shoot me." I don't know if I really want that or not, but I would sure give it serious consideration.

P.S. Check out a new pediatric grand rounds - and a yummy recipe - at the Granola Rules.

AIDS

When I was doing my neonatology fellowship in the mid 1980's, we had a baby who was HIV positive, the virus having been transmitted from her mother during pregnancy. This was early in the AIDS epidemic, and people didn't really know or understand much about how contagious AIDS was. The baby was fine but had been removed from the mother's custody and thereafter spent months in our special care nursery, simply waiting for a family willing to take an HIV positive baby into their home. I don't remember how long the baby waited, but it was sad to see a baby languish in a hospital nursery when she really should be enjoying the stimulation of a home environment.

Yesterday was world AIDS day, which gives us a chance to see how far we've come in the fight against the disease and how far we still have to go. Today I don't think an HIV baby has nearly as much trouble finding a foster home, since we know people can live alongside HIV positive people without becoming infected. Also, anti-HIV meds have been somewhat surprisingly successful, at least for those who can afford them. Did anyone really think Magic Johnson would still be alive in 2006 when he first announced his HIV status?

But we still have a ways to go. Too many people continue to be infected, and too many people cannot afford anti-HIV drugs, especially in developing countries. It seems to me that one problem in the fight against AIDS is the conflict between the individual's right to privacy and the public's right to health. An HIV positive patient can go to a surgeon for a problem not related to his HIV, say for a hernia repair or appendectomy, and he has no obligation to tell the surgeon that he is HIV positive. Sure, the surgeon and all health care workers should practice standard precautions against catching HIV, but the fact of the matter is that we're a little more careful when we know that someone is HIV positive versus when we don't know their HIV status.

If I know a mother of my patient is HIV positive, information I need to know to properly treat the baby, but the mother has not told the father of the baby, her sexual partner, her HIV status, I have no right to tell the father of the baby that mother is HIV positive even though that information could be life saving for him. It seems like an unlikely scenario, but I'm certain it happens, and is that really right? If the mother refuses to tell her sexual partner that she is HIV positive, her right to privacy, which prevents us from notifying her partner, trumps the public's right to health by enabling the partner to contract HIV. Sure, the county public health agency is supposed to help with this, but it doesn't always work. I'm all in favor of privacy rights, but it seems that in this situation a little more emphasis on public health and less on individual rights might be appropriate.

P.S. Fat Doctor has a new Change of Shift up.