| Kali Prasad |
Posted
on 18-Jul-01 06:39 PM
I enjoyed reading this. Some of you may like to read as well. Enjoy.
Life and Death in Neonatal Intensive Care
By JOHN LANTOS
John Lantos is a medical ethicist and an associate professor of pediatrics at the University of Chicago's Pritzker School of Medicine. This essay is excerpted from The Lazarus Case: Life-and-Death Issues in Neonatal Intensive Care, to be published in October. Reprinted by arrangement with the Johns Hopkins University Press. Copyright © 2001.
It was while I was working in the neonatal intensive-care unit that I first achieved that dream of doctors everywhere: to actually save a patient's life. That happens a lot on TV but not so often in real life. Most of medicine is much more mundane -- colds, rashes, vague aches and pains that can't be diagnosed, can't be cured, and don't go away. But every once in a while, it's not like that. For me, that first time, the patient was a 600-gram preemie, and I was on call as a second-year resident.
The obstetricians called to warn us that a woman was in labor at 25 weeks. I called the neonatology fellow, assuming that he would be there to take over. Alas, he was at home, 45 minutes away. Don't worry, he said, he'd get in as soon as he could. In the meantime, do my best.
Forty-five minutes? Do my best? Was he kidding? I was just a resident. I was just covering at night. I wasn't ready to solo. I panicked. I was angry. I felt abandoned. I froze. I didn't want to do this, didn't want to be there. It was a cold November night, nearly two years after I'd first visited a NICU and nearly passed out at the surreally minuscule patients and the machine-intensive other-worldliness of their treatment. Since then, I'd spent months caring for preemies, gotten to know the strange, almost papery feel of their underdeveloped skin, to recognize the hairline wisps of blue just beneath it as tiny veins, tiny but not so tiny that we couldn't cannulate them with even tinier plastic catheters. I was in the middle of a 36-hour shift, tired and alone, holding the bag for the neonatal fellow who was holding the bag for the neonatal attending physician.
As residents, we spent a lot of time in the NICU. Interestingly, that was not because anybody thought it was essential for our education as pediatricians to learn so much about neonatal intensive care. By this time, in the early 1980's, there was already a subspecialty board in neonatology. Any doctor who wanted to work in a NICU would have to do a three-year, post-residency fellowship in neonatology in order to become sub-board certified. Thus, most pediatric residents would never again work in a NICU, would never again take care of 600-gram preemies, and would probably never need the skills that we were so painstakingly learning and endlessly perfecting. But the NICU was the most labor-intensive unit in the hospital. Every tiny baby needed three or four professionals hovering over the bassinet. As a result of these personnel demands, such units claimed a disproportionate amount of the residents' time. The NICU needed us, and the hospitals needed the NICU, so there we were, night after night, month after month.
My anxiety and fear were gradually replaced by a seeping sense of vindictive euphoria. Screw them, I thought, I can do this, or at least I'll try, and, in the end, nobody will really know or care how well I do, because the task itself is so meaningless. In a moment, they will hand me a baby who by all rights should just die, and I will run through the paces of the resuscitative routine that I've rehearsed and rehearsed and rehearsed until I could do it in my sleep. You could learn this stuff by watching TV. The ABC's: airway, breathing, circulation. Suction the trachea, intubate, check a pulse, start an umbilical intravenous line, give some fluid. If the heart rate is low, give some adrenaline. This wasn't magic. It wasn't rocket science, either. I made sure my hair was combed, put on a clean scrub suit, and strolled over to the delivery room to see how the mom was doing.
It was a quiet scene. Doctors and nurses talking in whispers. I thought to myself, I should go to the woman on the table, who was the quietest of all, should introduce myself, should try to give the predelivery spiel: "Very high risk, may not be viable, we won't know for sure until the baby is born, we'll do what we can, I'll let you know as soon as we know." This conversation seems to offer important information but really offers almost none. It's just a chance to check each other out. How does she look? Caring and concerned, or strung out and indifferent? Is there a man in the picture? Another woman? The mom, perhaps? A friend? A lover? The words are place-holders, a vague recognition of shared humanity, a verbal handshake, valuable as gestures of caring rather than for what they mean.
Her eyes searched mine quickly, then turned away. What was she looking for in the gowned, gloved, masked figure who presented himself, out of the sky, at the precise moment of her life's most profound distress, at the moment when everything that was supposed to be good and beautiful and life-affirming had become horrific, terrifying, mournful? At the moment when fear and dependency defined her life as never before? She was certainly no health-care consumer negotiating a contract, purchasing some healthcare services, dispassionately evaluating the risks and benefits of this or that intervention. She was sizing me up -- not because she had a decision to make, but just to see what hand she'd been dealt. Did I look experienced, trustworthy? Was I nervous? Did I know what I was doing? Would I be there for her? Could she talk to me?
for more go to Chronicle of higher education
www.chronicle.com
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