Friday, November 16, 2007

Time for the morbid hospital post

Last week was my Pediatric Intensive Care Unit (PICU) week. For the most part, I really enjoyed it. I got some interesting patients, and I really like the feel of an ICU. Nursing is better, and there's more information at your fingertips to play with. Vitals are charted meticulously, labs are drawn frequently, and rounds happen twice a day. It's an OCD dream.


It also makes you think about children and death and maybe living but not really living. One patient was an infant born at 24 weeks. She essentially had no brain, just a bit of brainstem, thalamus, and cerebellum. But no actual, thinking brain. And she was in foster care, because whoever her parents were didn't have the abilities to take care of her. She also had problems with just about every other organ system, but the brain thing was what really bothered me. She couldn't interact, and she was the age where she should at least be smiling and making eye contact and cuddling. But she didn't. She showed distress when we tried to draw blood (she was very obese, so that made it extra difficult), but even that was not really emotion, just being agitated. Taking care of her was frustrating for everyone. At one point, one of the doctors on the team said, "The NICU [Neonatal ICU] made her; they should take her back."

It sounds callous, but it pointed to something I've been thinking about. Sometimes, maybe, the NICU doesn't really do good by saving these early, early preemies. Sometimes, you're just prolonging suffering. Sometimes you're creating a being that has no consciousness, essentially a baby Terry Schiavo. But sometimes, the baby you're trying to save grows up to be a person who has thoughts and interactions, and thank goodness you fought for that life. And you don't know, at 24 weeks, which sort of situation you're dealing with.

So what do you do? I have to admit that I'm glad I won't have to make that decision. I can help with genetic counseling in the prenatal period, but I won't have to deal with the aftermath of whatever my patients decide. And I can work to deliver those 22, 23, 24 weekers as safely as possible. But then I get to pass them off to the NICU folks and focus on making sure the mom is okay. For me, it's just an ethical argument to contemplate when I'm post-call. But for many, it's a real, practical decision.


ellen in minnetonka said...

At least your work will help as many babies as possible be born healthy. We are just biology experiments, really, so it won't be all of them. But you will shift the balance, I am sure.

Jan said...

I don't know that I would characterize this post as morbid. Rather, I would call it sobering. And brave of you to put your thoughts out there. Thanks for reminding us of how precious is our ability to connect. To me that's the essence of what that child is missing.

Paula said...

Your comments take me back to my former world of ICU nursing. I'm encouraged that nursing care is still better there. Of course, it was when I was on duty ;-)
How difficult it must have been to watch that baby. I never got used to seeing a human being of any age with only reflexive brain activity remaining. With such an array of lifesaving technology at our fingertips, it's a tough call to know when to do the full court press and when to let the patient go. As you go through clinical training, these experiences will help build practical knowledge, insight, and courage. Although it doesn't happen very often these days, the patient in question could be the mom, and you could be the person influencing that decision. You do the best you can with your knowledge---and your heart---at the time.

Mersidots said...

I had similar thoughts just the other day as I was standing in the lobby of my hospital. Although I'm entirely removed from the clinical side of the picture, I still see - albeit as I'm walking through the halls to a meeting- the little people who have, at best, extremely limited function. And it does make one think about what sort of quality of life those children have and what quality of life they can expect, and yes, if the situation would be better had someone made a different decision near the beginning of their lives.