Mostly Bewildered

Foot in mouth disease

2007-02-14T21:21:00.000-08:00

During my residency and fellowship, it has been my pleasure to take care of many different kids, and to have interacted with their families. There have been a few times when a parent will recognize me, and even if they don’t remember my name they will usually offer their greetings. Many times though, I won’t remember them as well.

I’ve always felt that it would be poor form of me to come right out and say that I don’t recall them, so I always smile, say hello, and ask how things are going. To try to keep the encounter from being awkward, I have developed a general rule; a Prime Directive of running into parents of past patients.

If you can’t remember with a high degree of certainty who the parents are, and what happened with their baby, DO NOT ask any questions directly about their child.

This may seem rude, but it’s to avoid asking questions like:

“Oh! How’s he/she doing?”

If the baby had a bad outcome, saying this reveals that you have no idea who the parent is, and it implies that their child's life must not have had all that much of an impact on you, because if it had, you would obviously have remembered. That's certainly not the case, it's just that I’ve taken care of a lot of kids over the years, and I am terrible with names.

Usually, it works out, because most parents pick up on the fact that you don’t really remember them, and then supply information voluntarily:

“Oh, she’s fine. We just came from ENT and it looks like they’re going to take out her trach soon…”

You can then offer words of encouragement, a smile, and well wishes.

The other day, I violated the Prime Directive. And as we have often seen in Star Trek, badness followed thereafter. I was in the elevator, and one of the hospital employees caught my eye, and said that I had taken care of her son in the NICU a while back. At first I couldn’t recall who she was, but then an image of a baby and his mom popped into my head- he was a little 30ish weaker who had a bit of RDS, went to Level II and then home. I wasn’t sure though, I and plowed straight ahead with Exactly the Wrong Question:

“Oh! How’s he doing?”

Immediately her face fell, and an image of Mr. Spock looking on disapprovingly flashed before my eyes.

“He died last year.”

I was stunned at the enormity of my screw-up, and couldn’t even find my voice to say, “I’m so sorry.”

She went on to say that, despite her loss, she was now working for the hospital. She also said, with a noticeable catch in her voice, that she would always be grateful for all the help we gave her son. It was all I could do to stammer “It was my pleasure to take care of him,” as my floor arrived.

I wanted to say more, how remarkable it was that she working to help other children like her son, how wonderful it was that she had taken her grief and turned it into something positive. But I was still reeling at my brutta figura, and didn’t manage to get it out.

Sometimes, I'm not too bright.

Lazy, lazy me...

2007-01-16T08:39:00.000-08:00

Geez, where did my blogging enthusiasm go? I guess trying to finish the research project, looking for a job, and taking call all took their toll. But, as part of my New Year's resolutions, I am going to try and update this thing at least once a week. Maybe with fewer references, and more off-the-cuff stuff. I have some good ideas (well, ideas, anyway) swimming around in my head that I'd like to get down.

Happy New Year!

Post Call Poem

2006-06-26T08:37:00.000-07:00

Here I Sit

by Austin Guerber

Here I sit
Fit to be split
Can't go to sleep
Can't stay awake
I feel cold and clammy
As i sit and think
Don't know what to do
I try to sleep, but can't
It's nearly 3 and I'm tired
Sleep won't come
She's under my skin
Can't get her out
Didn't know I could feel like this
I pray that there's a chance
But fear there isn't
I try to no avail
To make understand
Whats going on
I have learned one thing
love is not a toy
You will loose sleep
you will loose your mind
And love will leave you Sitting
With eyes wide shut.

Last night was a good night- but there have been call nights when I have felt similar to the author of this poem.

Post Call Poem

2006-06-14T11:35:00.000-07:00

The Den

by Raynette Eitel

Sleep comes to this place
Silently like snow
And just as deep.
Each breath is an occasional sigh
And a heart barely beats.
Blood stirs slowly
As an ice-clogged stream.

No dream would dare disturb
A sleep so near to death,
No memory of forest trails, nor trees
Swarming with a mighty hum of bees
And oozing honey.

Here is only time and sleep,
Soundlessly solidified,
One great berg of ice,
Melting slowly, slowly.

Yet when the sun at last
Is warm upon a northern slope
And the thawing earth
Proclaims once more the hope of life,
This silent sleep will end and
The den will be empty.

Post Call Poem

2006-06-10T12:21:00.000-07:00

The Hammock

by Harry Haigh

Snared within its spidery web,
Back and forth we gently sway,
Your little head upon my arm
Oblivious of the passing day,
Resting in the hammock's fold
Because you're young... and I, too old.

If old were suddenly young again!
If time could only swing like this!
Rejuvenated, reversing course...
But all would end in chaos, not bliss.

Caught inside this pendulum ride,
You cradled snugly by my side,
I dare not move ... you soundly sleep.
My pillowed arm begins to ache,
But that's all right. Too soon you wake,
And soon I sleep ... and sleep ... and sleep.

Too early

2006-06-10T12:01:00.000-07:00

A while ago, our unit had a patient who only completed 22 weeks of gestation when delivered. Even in our unit, which seems to contain the "ultrafiltrate" from other level III ICNs (intensive care nurseries), having a baby that premature is unusual. The fact that he even survived long enough to reach our unit is a testament both to the increasing sophistication of NICU care and the uncertainty in approaching the resuscitation and care of babies who are this premature.

The incidence of both premature and low birth weight deliveries are rising. There have been a number of postulated causes, but the result is that NICUs have not been lacking for business. particularly challenging are the infants in the extremely low birth weight group (ELBW), who are less than 1000 grams (two pounds and change) at birth. These infants are usually less than 27 weeks gestation, and have a higher incidence of preterm morbidities.

When we look at very premature infants, at 22-26 weeks, we see that although survival has increased, the incidence of long term neurologic impairment has remained the same. Babies born at less than 24 weeks have a mortality of around 70-80% in a large study by the National Institute of Child Health and Human Development (NICHD). Most studies have shown that major neurologic impairment rates have remained the same, from 30-50% in babies born at 23-24 weeks.^1-3

The ones who survive undergo all the trials of the NICU, including spending prolonged periods on the ventilator, getting one or more infections, and potentially undergoing several surgical procedures. If they survive to leave the NICU, they usually need access to specialized services throughout their lives, especially in school. This obviously takes a large emotional and financial toll on their families, many of whom come from disadvantaged socio-economic backgrounds.

For all of the above reasons, not initiating resuscitation measures in the delivery room may be an option for the very premature infant. The AAP's Committee on Fetus and Newborn noted that the Neonatal Resuscitation Program suggests that not initiating measures for infants born less than 23 weeks or 400 gm is appropriate.⁴ Different hospitals and different states have their own guidelines. However, these are guidelines, not the Ten Commandments, so there may well be situations when parents insist that "everything be done" to try to save the baby's life, including all that the NICU has to offer.

In my limited experience, if even a slim chance of survival is present, parents will opt to have everything done. It is certainly understandable, as I'm sure no parent wants to be left with the nagging fear that they did not give their child every chance possible to live. The outcome with this particular infant unfortunately followed the expected course, and the baby died after a few days of hospitalization. It wasn't the first time, and given the improvements in medical technology without a concomitant increase in medical wisdom, it won't be the last.

¹Lemons JA, Bauer CR, Oh W, Korones SB, Papile LA, Stoll BJ, Verter J, Temprosa M, Wright LL, Ehrenkranz RA, Fanaroff AA, Stark A, Carlo W, Tyson JE, Donovan EF, Shankaran S, Stevenson DK. Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network. Pediatrics. 2001 Jan;107(1):E1.

²Watts JL, Saigal S. Outcome of extreme prematurity: as information increases so do the dilemmas. Arch Dis Child Fetal Neonatal Ed. 2006 May;91(3):F221-5.

³ Markestad T, Kaaresen PI, Ronnestad A, Reigstad H, Lossius K, Medbo S, Zanussi G, Engelund IE, Skjaerven R, Irgens LM; Norwegian Extreme Prematurity Study Group. Early death, morbidity, and need of treatment among extremely premature infants. Pediatrics. 2005 May;115(5):1289-98.

⁴ MacDonald H; American Academy of Pediatrics. Committee on Fetus and Newborn. Perinatal care at the threshold of viability.
Pediatrics. 2002 Nov;110(5):1024-7.

Post Call Poem

2006-06-06T12:47:00.000-07:00

Sleep

by Russell Edson

There was a man who didn't know how to sleep; nodding
off every night into a drab, unprofessional sleep. Sleep that
he'd grown so tired of sleeping.
He tried reading The Manual of Sleep, but it just put him
to sleep. That same old sleep that he had grown so tired of
sleeping . . .
He needed a sleeping master, who with a whip and a
chair would discipline the night, and make him jump through
hoops of gasolined fire. Someone who could make a tiger sit
on a tiny pedestal and yawn . . .

Blogging has been very light of late, owing to on-service time and a research project that is demanding my attention. I have some ideas that I'm going to get down soon, I promise.

Post Call Poem

2006-05-28T09:21:00.000-07:00

Sleep well

by Erica Francis

Sleep well, my friend.
Although we've never met.
Sleep well, my friend.
You did what you needed to do.

Sleep well, dear child.
Your life will go on
in my mind forever
although we've never met.

Sleep well
because it is your time
for rest
from your chaos.

Post Call Poem

2006-05-16T13:02:00.000-07:00

I got this idea from Hugo Schwyzer's blog. Every Thursday, he posts a poem. One day I decided to post a poem each day I was post call. The poems naturally reflected what I was thinking about the most, namely sleep. Since becoming a resident/fellow, sleep has taken on almost salacious proportions.

Especially when I go without it the night before.

Peace on Earth

by William Carlos Williams

The Archer is wake!
The Swan is flying!
Gold against blue
An Arrow is lying.
There is hunting in heaven--
Sleep safe till tomorrow.

The Bears are abroad!
The Eagle is screaming!
Gold against blue
Their eyes are gleaming!
Sleep!
Sleep safe till tomorrow.

The Sisters lie
With their arms intertwining;
Gold against blue
Their hair is shining!
The Serpent writhes!
Orion is listening!
Gold against blue
His sword is glistening!
Sleep!
There is hunting in heaven--
Sleep safe till tomorrow.

Twins and More

2006-05-06T23:31:00.000-07:00

All neonatology training programs require its fellows to spend some time rotating through maternal-fetal medicine (MFM), the branch of obstetrics that deals with high risk pregnancies. The idea is to give us a better appreciation of the management and diagnosis of at risk pregnancies, and to acquaint us with obstetric ultrasound and other methods of assessing fetal health. So when I read things like “BPP 6/10” or “reversal of diastolic flow” in mom’s chart when doing a prenatal consult, I will have an appreciation of what this could mean for the baby when he/she arrives in my loving arms. One of the complications of pregnancy I have become familiar with is multiple gestations.

In popular culture, when we hear of twin, triplets, et cetera, we have a tendency to think of things like: “Awww...how cute!” or “Those poor parents…two (or three) kids keeping them up at night.” In reality, there are significant morbidities associated with multiple gestation pregnancies. Moms have a higher risk of developing conditions such as pre-eclampsia, gestational diabetes, and pre-term labor¹. In addition to the higher incidence of prematurity, the infants themselves² have a higher risk for developing complications such as cerebral palsy. Some studies have shown a four-fold higher incidence of cerebral palsy in twins, and as much as seventeen-fold higher in triplets. Assisted reproductive technologies (ART) have resulted in an increase in the number of twins and higher order multiple gestations.

I have to admit to a great deal of ambivalence toward ART. I can appreciate how heartbreaking it can be for couples who cannot conceive, but there are real public health consequences to consider. The whole episode of the McCaughey Septuplets and the resulting media storm make me shake my head in exasperation. I am glad the kids are doing reasonably well, but being pregnant with seven kids is by no means normal, and should not in any way be encouraged. Of course, I only see the poor outcomes of ART, so I am biased in the matter. It certainly keeps me busy.

1. Maternal physiology and complications of multiple pregnancy.
Semin Perinatol. 2005 Oct;29(5):338-48.

2. Long-term outcomes in multiple gestations.
Clin Perinatol. 2005 Jun;32(2):495-513.

First One

2006-05-05T22:34:00.000-07:00

Good evening.