Maldistribution

I've been researching dogs lately, as a possible prelude to getting one, and I'm impressed by the amount of money we spend on pets each year. There's food, veterinary care, and, of course, toys and trinkets for our little darlings. A recent Newsweek article puts the figure at about $40 billion annually in the U.S. Can we justify spending so much on pets when there is so much human need in the world?

I think we're making strides in the war on hunger in the world, but you can be sure that it still exists in some areas. Malawi, for example, a poor country in southeast Africa, after a drought a couple of years ago needed about $150 million to prevent wide spread hunger during the winter. $150 million is a lot of money to a country like Malawi, but in the grand scheme of things it's not much, only a fraction of what we spend on dog food each year in the U.S. (and, for what it's worth, the amount of money it costs to wage the Iraq war for about half a day.)

The above is only one area in which there are great inequities of material goods and other things. I wrote before about how the amount of money spent on one very small premie, say about $500,000 for his hospitalization, could buy insecticide treated mosquito nets for 50,000 Africans at risk for malaria. That same amount of money, if used toward some basic infant care like giving a bath after birth with a disinfectant soap in a third world country, could save perhaps hundreds or thousands of lives.

How do we allow this to happen? Why do we continue to give our dogs and cats meat and treats when we know there are people who could use the money for basic needs? I think the answer is that we are only human, and humans can't seem to do without pets, and we also can't seem to appreciate the needs of other people unless they are right under our noses. I am well aware that people in the Sudan or elsewhere could use my money, but if I don't get a dog it will be because I don't want the hassle and not because I'm going to spend my dog money on aid to Africa (although after I publish this post I might send some money to one of my favorite charities.) I'm guessing that there are even some people in Malawi that have pets; maybe even some hungry people there have pets and feed them.

Actually, I've only begun to talk about all the inequities there are in distribution of resources. Looking at just health care in the U.S., think of how much we spend on dialysis for the very elderly or ventilator care for people with massive head injuries and no hope of recovery, and think of how many prescription drugs that money could buy for people who can't afford their blood pressure medication. The inequities are astounding, the more you think about it. The fact that we are only human, while a true reason for why we treat our dogs better than humans halfway across the world, still should not be an excuse to ignore completely this maldistribution of resources.

P.S. You find out some interesting stuff when researching pets. I've come across information about holistic pet food and a book called Animals and the Afterlife, and discovered that April 24 - 30 was National Scoop the Poop week.

Barrier

I watched some professional fishing on TV the other day. I was working out and there didn't seem to be much else on, so I gave it a try. It's not the kind of sport you would think would lend itself easily to professional competition, let alone compelling TV, but it was actually pretty interesting. The pro fishermen wear shirts loaded with brand name decals, just like race car drivers, and they high five each other when they pull in a big one. I think it's better than actual fishing, because they edit out all the boring parts where you're just sitting around waiting for a fish to bite, and only show the fun parts of reeling in the catch. It's also a lot less slimy on TV than in real life.

This was a redfish tournament, where the fish caught were between about 2 and 6 pounds, weights, I noted, pretty similar to those of the premature babies we take care of. The fishermen got credit for their two biggest fish of the day to be weighed. If they already had two and caught a bigger one, they would throw back a smaller one.

Sometimes we wish we could throw a tiny baby back into the uterus to grow some more, but it obviously doesn't work that way with humans. (That doesn't stop people from joking about it, though. If I had a nickel for every time I heard an obstetrician joke about throwing a tiny one back, I'd be able to retire now.) Occasionally someone talks about a need for an artificial placenta, but nothing has really come of it.

And that might be a good thing. We already struggle with the ethics of taking care of 23 and 24 weekers, babies with mortality and disability rates higher than we would like. What if we had an artificial placenta that we could hook 20 weekers up to? What if we could save some, maybe 20 percent, with a 50 to 75 percent major disability rate in survivors, rates worse than those of our current 23 weekers? Would we be offering that care to parents of such babies? What if some babies at even lower gestations survived, but only a small percent? Where would we stop?

Now, at least, we have a barrier at about 22 to 23 weeks below which no babies survive, because the alveoli - the air sacks in the lungs - are just too far away from the blood vessels that go to the lungs, so carbon dioxide and oxygen can't be exchanged. It's sometimes said that our advances in technology outstrip our advances in ethics (although I don't really think that's true), but hey, it could be worse. Maybe it's good we have the barrier of 22 to 23 weeks - although that's hardly any comfort to the parents of a lost 21 weeker.

Numbers

The 620 gram baby was born at 24 and one-seventh weeks gestation, based on a 17 week ultrasound. Her temperature on admission was a little low, 35.9 degrees. We gave her 2.5 cc's of surfactant and placed her on a ventilator with settings of a rate of 46, peak inspiratory pressure of 20, Peep of 4, FiO2 of .60, and an inspiratory time of 0.3 seconds. Her first blood gas had a pH of 7.26, pCO2 of 50, and pO2 of 56. Bingo.

We also started her on ampicillin 100 mg/kg/day and gentamicin 5 mg/kg every 48 hours. We started her fluids at 120 cc/kg/day but by age 24 hours her sodium was 153, potassium 5.4, chloride 118, and bicarbonate18, and the fluids were increased to 170 cc/kg/day. That made her blood sugar go up, though, to 278 so we started an insulin drip at .06 units/kg/hour or 0.3 cc's per hour. When her sodium rose to 156 we had to increase fluids further to 200 cc/kg/day. On the second day we started feeds at 1 cc every 3 hours or 13 cc/kg/day.

The above numbers are not from a real patient but rather a fictional composite of many patients like this. The number of numbers used in neonatology can be daunting. Some medical students and residents rotating through have trouble handling it.

Personally, though, I love the numbers, and they are one reason I went into neonatology. I love the way we can manipulate the baby's sodium levels by the amount of water we give him and the blood gases by changing the ventilator settings. Remember the story problems you used to have to do in elementary school math? Well, I loved those things, and neonatology is like the ultimate story problem.

The challenge, of course, is remembering that these babies are not just a mass of numbers but real human beings. We can get so caught up in adjusting the fluids in a tiny baby like this that it seems almost as much like a physiology experiment as it is care for a live baby. Sometimes I like to go look at the babies, see their fingers and toes and ears. I like to see the moms visiting them and letting the baby's fingers wrap around her finger. I like the numbers because they are part of a human baby, and managing them helps them become larger and better humans.

Selective

We were discussing a mother pregnant with quintuplets at our weekly perinatal conference. This was many years ago, when five to six fertilized eggs at a time were routinely placed in a woman during in vitro fertilization, and we were grappling with the ethics of that and ways to prevent such high order multiple pregnancies.

"In my opinion," said one of my partners, "A woman should have to agree to have selective termination if more than three embryos result before we agree to have that many fertilized eggs placed." One of the perinatologists agreed. Hmmm, I thought. So much for the non-judgmental approach.

The subject of selective termination came up, not surprisingly, in the comments section of my previous post about sextuplets. Selective termination means reducing the number of embryos in a multiple pregnancy, by terminating them, until there are two or three embryos remaining - a number that is much less likely to result in extremely preterm delivery. Since it involves abortion, it is not surprising that it can lead to heated, emotional discussions. Although in this post I don't really want to get into the whole abortion debate, I do want to say why I think that selective termination will never be the best answer for multiple pregnancies caused by infertility treatments.

For one thing, whether you are pro-abortion or anti-abortion (or pro-choice or anti-choice), we can all agree that there are many people who, because of their anti-abortion beliefs, will simply never consent to selective termination, and this is probably a sizable proportion of the population. Are we to deny some infertility treatments to that many people because they do not agree to selective termination?

The thing that bothers me the most, though, when people talk about selective termination as a solution for these pregnancies is that it's like closing the barn door after the horse got out. Selective termination after we've caused a pregnancy with, say, five embryos? Wouldn't it be much better to be more careful and do a better job of not making a woman pregnant with quints in the first place? If this requires changes in insurance reimbursement for infertility treatments, then so be it. If this requires better education of couples to assure that they don't have sex when the woman's ovaries are releasing six eggs due to infertility treatment, then lets do that.

But acting as if selective termination of a multiple pregnancy that we have iatrogenically caused is a fine way of dealing with the problem - regardless of your abortion beliefs -is just bass ackwards.

Septuplets

The birth of two sets of septuplets within hours of each other last week reminded me of the time a couple of years ago when an internist colleague of mine asked me what I thought of the birth of another set of septuplets back then. I sighed and replied, " It's a failure of modern medicine."

That is certainly still true today. Modern treatments for infertility have helped many childless couples conceive, but until we lick this problem of higher order multiple births we cannot consider our work with infertility a success. The septuplets in Arizona were apparently born at about 30 weeks. Most of those kids should do fairly well, although raising six kids at once will still be tremendous undertaking. But the Minnesota septuplets show how truly bad the results of our infertility treatment can be sometimes.

Those kids were born at 22 weeks gestation, weighing between 11 ounces and 19 ounces, or about 330 grams and 570 grams. Personally, I don't usually resuscitate 22 weekers, and I certainly wouldn't go all out on a 330 gram 22 weeker, but when you've got a combination premium/celebrity pregnancy like this, I guess you do some things you wouldn't normally do.

The latest Vermont Oxford Network data shows that the survival chances for a 22 weeker are eight per cent. For a 330 gram 22 weeker the chances are basically nil. The chances of all six surviving, if you figure each one has an eight per cent chance, is 0.00002 percent. The survivors each have at least a 50% chance of having moderate to severe impairment.

Is anybody proud of this? Do the infertility doctors think they're doing a good job with this? Do they realize how much this will affect the lives of these parents and kids? I doubt it, because if they did, I think they would do a better job of preventing such multiple pregnancies. I also think the parents are not fully aware of the risks as well or they would not accept the risk of having quads, quints, or septuplets.

I'm not up on all the latest infertility treatments, but I'm sure we can do a better job of preventing such multiples. In the early days of in vitro fertilization, doctors used to implant 5 or six fertilized eggs into the mother in the hope that one or two would survive. Unfortunately, that meant that occasionally 4 or 5 would survive. Fortunately, I'm pretty sure there are now limits as to how many fertilized eggs are put in. However, we still can get multiples from other types of infertility treatments such as those that cause many eggs to come from the ovary at once, although I suspect that with close monitoring we could tell the couple when too many eggs are ovulating so they shouldn't have sex because of the high risk of multiple births.

Money used to play a role in this, and maybe still does. In the early days of in vitro fertilization, several eggs were put in at once partly because it was cheaper to put 6 eggs in at once versus 3 eggs twice. Of course, the post natal costs of a set of quads or quints dwarfs the money saved by doing one high order implantation versus two lower order ones, but our medical economics system has never been set up to take advantage of those kinds of savings.

I don't think the media helps at all either, making each birth of quints or septuplets into a Good Housekeeping warm and fuzzy moment. It's time the press started treating such high order multiple births like the iatrogenic disasters they are.

Advocates

Why, my friend wanted to know, would I definitely resuscitate a baby with Down syndrome, who has a near certainty of having an IQ in the severely impaired range, but for a 23 weeks gestation baby, who has a 50% chance of being in the normal range, give parents the choice of whether or not they wanted their baby resuscitated?

I sighed when I heard the question. It came at a time when on my blog, in response to strong advocates for parents of premature babies, I was trying to stick up for the rights of extremely preterm babies by saying it was hard to let them die when you knew a certain percentage of those you let die would have been normal. At the same time I was having on ongoing conversation with my friend, a strong advocate for babies with gestational ages at 23 and 24 weeks, who thinks that all 23 weekers should be resuscitated, regardless. No fair, I thought. I was taking heat from both sides.

But it's a good question, without a readily apparent answer. I told my friend that with 23 weekers you had to be worried about the kids who might get severe cerebral palsy and require total care, which could be a life of suffering for the child and a huge change in the life of the parents. In other words, twenty-three weekers can turn out better than kids with Down syndrome, but they can also turn out a lot worse. I also mentioned that with the legal climate and the history of the Baby Doe rules, we are reluctant to let Down syndrome babies die without resuscitation. My friend was less than overwhelmed by my arguments.

Having thought about it, though, I think there are a couple of other reasons why we treat the Down syndrome kids differently than the earliest premies, even though the premies have a better chance of having a normal outcome than the Down kids. For one thing, Down syndrome kids don't usually require the huge resuscitative measures and months of intensive care that a 23 weeker does.

But perhaps just as importantly, most parents of Down syndrome kids have already had their chance at saying no to having the baby. Most cases of Down syndrome are diagnosed prenatally now, and parents are often given the chance to terminate the pregnancy. Although I haven't personally seen the hard data on this, I've heard it said that 60 to 90% of parents opt to terminate the pregnancy when told the baby has Down syndrome.

It's funny. When last year I said that Down syndrome kids had no chance of having normal intelligence, I was raked over the coals by some of the parents of Down syndrome children. When I speak up for 23 to 24 weekers, though, it seems the opposite side, those in favor of more parental choice regarding resuscitation, are more vocal. Why is this? Where are the parents advocating for the premies and their right to resuscitation? I don't know, but I'll just keep plugging away in the middle.

Oxygen

Whoever said you can't get too much of a good thing didn't know about neonates and oxygen. We try to keep a premature baby's oxygen saturation - the level of oxygen in their blood - in a certain range, 88% to 94% for example, because not only can too little oxygen be harmful, but also too much can be harmful, especially to the eyes and lungs. We continuously measure the oxygen saturation with a monitor and adjust the amount of oxygen we give the baby based on what the monitor tells us. If the oxygen saturation goes too high or low, an alarm on the monitor goes off to let us know so we can adjust the amount of oxygen we're giving.

Over the past several years we have learned that it's better to keep the baby's oxygen level at a lower range than previously done. We used to keep their oxygen saturations at, say, 92 to 97%, whereas now they might be kept at 88 to 94 % or maybe 85 to 92%, the level varying from NICU to NICU.

There's one problem, though. It can be tough to get the people who adjust the amount of oxygen given, primarily the nurses, to accept that too much oxygen is bad for a baby and that it really is important to keep the oxygen level from going too high. It's pretty easy to get a nurse to increase the amount of oxygen given when a baby's oxygen saturation falls to, say, 80%, but it seems harder to get them to decrease the amount of oxygen given when the saturation is, say, 98%. It's understandable; all our life we're taught how we need enough oxygen. The too much oxygen thing almost goes against our nature.

One way we try to keep the oxygen levels lower is by setting lower the level at which the monitor alarms. If we want to keep the oxygen saturation level below 92%, we would probably set the monitor so it alarms when the saturation goes above 94%. Here, too, we have a problem sometimes with getting the nurses to set the alarm at a lower level that we used to, and this bothers me some. Why do we have trouble getting some of the nursing staff to do this?

It's not because it's not explained to them. A few years ago when we decreased our suggested oxygen saturation range and monitor alarm limits we gave inservices to the nurses explaining why we were doing so, showing them the research that proved it was beneficial. Some nurses caught right on and were very conscientious in adjusting the amount of oxygen given and the alarm limits, but others didn't seem to take it too seriously. My experience is not unique, because an article in the latest Pediatrics shows that in the NICU studied the upper monitor alarm limit was set correctly only 23% of the time, with it usually being set too high.

Why, I wonder, is change so hard for some people? Change can be hard for me, too, but when it's explained to me why a change will be better, I change. Also, if a standing order or policy changes, I follow the new standing order or policy. So why don't some of the nurses follow the new policy of setting the oxygen alarm limits lower? It can drive me a little batty at times.

Please don't take this as a broadside against nurses. Some of them change admirably and want to keep up with the latest information. Also, nurses are hardly the only people who have trouble changing. I know there are some doctors who are set in their ways or are just not conscientious about making certain important changes. But still, it bugs me.

A few years ago I gave one of the inservices explaining why we now wanted to keep the oxygen levels in a baby's blood lower. One of the nurses dozed through most of my presentation, which was short and, hey, not that boring. When my inservice was done, I said,"Okay, now, let's keep those oxygen saturations in the normal range."

The nurse sniffed sarcastically. "Oh, is that what we have to do now?" like it was a totally ridiculously thing to do and a waste of her time. I wanted to kick her behind out the door. We're taking care of babies here, not making widgets, so when a change improves their care, doggone it, we'd better change.

Dreadlocks

My seven year old great nephew is growing his hair long because he wants to have dreadlocks or cornrows. He's not sure which yet, but he'd better decide fairly soon because his hair is getting pretty long and shaggy. Adopted by my nephew from a former Soviet bloc country several years ago, he'd been born prematurely and spent most of his first year of life in an orphanage. In spite of that rough start, he's a pretty good kid, although he does have some ADHD, and he spends a little more time in the principal's office than a seven year old should. When I heard that he wanted dreadlocks already at the tender age of seven, all I could think was, man, he's going to be a handful as a teenager.

When my nephew and his wife went to pick him up several years ago, they went as part of a group of parents, all of whom were adopting kids. The kids were at different stages of life, and one of them was a 12 year old with poorly controlled epilepsy. The doctors in her country had done all they could, and one of the reasons she was up for adoption was so she could come to America and get better care. That meant, though, saying a permanent good-bye to the foster family that had cared for her for years and was in essence her family. My nephew said the farewell scene was pretty emotional, as you can imagine.

Personally, I don't think I could have done it if I were the adoptive parent. My heart breaks just thinking of tearing a 12 year old away from her family. I think I would have said, look, we'll get her care for her epilepsy in the U.S. and then bring her back after a few months or a year or so. To forever remove her from a family she was attached to at that age? It shouldn't have to happen.

I've written before about my ambivalent feelings towards adoption. It's hard enough to give up a baby for adoption, but a 12 year old? Even though her foster parents weren't her biological parents, they had had her for many years, so it's no surprise it was wrenching to all sides of the adoption.

The things we do to kids sometimes. I'm glad my nephew made it out of there before his first birthday, and I hope he sits still for his dreadlocks.

Unsolicited

I have some unsolicited advice for John Edwards. Go home, John. Spend some quality time with your wife and kids.

John Edwards, as most of us are aware, is a presidential candidate whose wife has breast cancer that has metastasized to the bone. The condition, as one news source said, is treatable but not curable. I'm not an oncologist but a physician friend tells me that her life span is measured in years, not decades, and probably just a few years.

It just seems to me that if your wife is slowly dying of cancer that you would want to spend those last few years spending time together doing relatively enjoyable things. Campaigning for president does not seem like a great way to spend that time. I don't say this because of any political reasons. I have no strong feelings one way or another about John Edwards as a presidential candidate, but as a human I think he'd be better off doing something else.

It seems that John Edwards especially would get this. They lost a teenage son in an automobile accident several years ago, so you would think that he more than others would realize how precious life and time can be. They also have two young children. Now is the time to spend time with them, not when they are adults and your wife is no longer around.

I realize that this is none of my business, that it is between Edwards and his wife. I have read that she insisted he continue. Maybe campaigning is what they enjoy doing together. Some would say that seeking the presidency is more important than spending time with your dying spouse. I don't think so, though. There are lots of people who could be president of the United States, but there's only one guy who is Elisabeth Edward's husband.

Harassment

The woman was in active labor and feeling the pain that goes along with it. In the room with her were her husband, an OB resident, and myself. The OB resident rubbed her leg in a reassuring way. That gesture in itself, a brief pat or rub of the lower leg to offer comfort, was not that unusual, but then it got weird. The resident, a man, started rubbing her upper leg, along the inner thigh, going up and down, up and down, getting uncomfortably close to her business area. He acted like he was simply trying to calm her.

The woman looked at her husband with an anxious expression, one that became more anxious as this continued. The husband, looking uncertain as to what to do in this unusual and uncomfortable situation, seemed to be avoiding her looks. Finally the resident stopped the rubbing and the labor story went back to normal.

This happened when I was a third year medical student. If it happened today, I'd haul the resident into the hallway and tell him to knock it off, but I'm sorry to say I didn't do anything about it then. Partly, it was because as a third year student you are pretty low on the totem pole. I mean, this resident would be filling out an evaluation on me - a bad excuse, I know - and he probably would have denied he was doing anything wrong. Partly I didn't do anything because like the husband, I could hardly believe it was happening. Also, this was long before Clarence Hill was confirmed as a Supreme Court justice and sexual harassment came to the fore of America's consciousness.

I'm glad to say that personally I have seen practically no instances of a physician taking sexual advantage of a patient, other than the episode above. Maybe women will tell me otherwise, but I suspect it doesn't happen too often, at least not in the labor and delivery area where I would see it. That's not a surprise to me. No offense to anyone, but a very pregnant, laboring woman is simply neither sexy nor tempting.

Physicians who do take sexual advantage of women must be real scumbags. It's pretty sad that they have to resort to it to get their jollies, because frankly, having an M.D. behind your name gives you a bit of a head start with many women whom you might be trying to impress in a legitimate dating sort of way. I have little sympathy for them if they are caught. Off with their heads, I say, or at least off with their licenses.

Moms

It was recently Mother's Day. Congratulations to all the moms out there.

I think of all the different kinds of moms there are. There are the moms who are really into it, who read about kids while they are pregnant and know everything they are supposed to do. I think of the teenage single moms pregnant not by plan but by accident of passion. I think of drug using moms, who may love their kids but are simply unable to do right by them.

I think of stepmoms - boy, that's got to be one of the toughest jobs in the world. I think of moms of special needs kids. Although any mom's work is never done, that's especially true for moms of special needs children. I think of working moms, trying to do it all, or maybe shirking either their work or child rearing responsibilities. I think of moms whose husbands died young and had to raise multiple kids by themselves. (Rest in peace, Mom.)

But most of all, I think of three nurses in our unit who would like to be moms but cannot get pregnant. In their 30's, they have been trying for years to conceive, all the while watching babies born to some mothers who barely gave a second thought to getting pregnant. I don't know the details of their infertility, and I don't dare ask. It's such a private thing.

One Mother's Day morning I was leaving work when I saw one of the nurses with infertility problems by herself, and I said to her, "Darcy, I know Mother's Day might be hard for you, but I sure hope that by this time next year you can be a mom, too."

"Oh, I hope so too!" she said, with such earnestness that it showed the pain it must be for her. That was two years ago, and she is still childless. I really don't know what to say to her now.