I process my thoughts by writing. I wrote this years ago and
was reminded of it now because of some of the recent public discussions regarding
the beginning of life. I am reminded that real issues in life rarely fit into a
campaign slogan or on a bumper sticker.
I think about him sometimes even though
it has been more than twenty years and I only spent about twenty minutes with
him. I do not know his name or even know if he was male or female.
But I refuse to call a baby "It" and have arbitrarily elected to
use masculine pronouns.
I was the resident on call in the
Pediatric Intensive Care Unit (PICU). A friend and fellow resident was on
call in the Neonatal Intensive Care Unit (NICU) right next door. At some
point during the day, our paths crossed and she told me that there was a woman
in Labor & Delivery, one floor up, who might deliver a premature baby that
night. Her dates were unclear but they thought she was somewhere between
22 and 25 weeks gestation. She asked if I would go to the delivery
with her if it happened, and I readily agreed. Although I had no
responsibility to be there, our group of residents often helped each other in
stressful situations. When you are scared to death and in over your head,
it is nice to have company, even if your company is likewise frightened and
inexperienced. I assumed it would probably not happen that night and went
back to caring for my unit full of kids with diabetic ketoacidosis, babies
recovering from heart surgery, and victims of motor vehicle accidents and child
abuse.
Sometime in the wee hours of the
morning I was stat-paged to Labor & Delivery. I ran into the delivery
room and found my friend at the head of an infant warmer on which laid
a tiny person. He was just over or just under one pound, I can't
recall exactly. His heart was beating, albeit a bit slowly, and he was
making some minimal, gasping attempts at breathing. He was not completely
blue but headed that way. Three weeks may not sound like a big difference
but, at that time, 22 weekers had no chance of survival and 25 weekers had a
small, but real, chance of being basically normal children. In between 22
and 25 weeks, and in between dead and normal, was every gradation of
disability and relative risk that one could imagine. We were not
experienced enough to know where he was on that continuum. He was
obviously alive and trying to stay that way so we decided to proceed.
The first step was to establish an adequate airway and help him breathe by inserting a plastic tube into his
windpipe so we could pump oxygen directly into his lungs. As I was
preparing to do this, the attending obstetrician, who I had not noticed
beside me, quietly told me that the mother wanted "no heroic
measures." Physicians, ethicists, and clergymen could discuss this
for days without reaching a consensus on what constituted heroic measures in
this case. Clearly, without intubation the baby was going to die
soon. We needed to decide something in seconds, maybe a minute if we were
lucky. Providing adequate ventilation seemed like a pretty basic step
given the circumstances and choosing not to would have been an irreversible
decision. I also doubted my ability to intubate someone so small.
If I tried and could not do it, the question would answer itself.
I took the laryngoscope in my left hand
and a 2.5 endotracheal tube in my right. I gently pulled the baby's
tongue and epiglottis forward to expose the vocal cords and slipped the tube
through them. I was surprised that it worked and when we started bagging
oxygen into his lungs his heart rate and color improved. Things were
looking up. This tiny person was alive! Suddenly, I heard wailing
and turned to see the baby's distraught mother being wheeled out of the room in
her hospital bed. The OB resident pushing the bed was scowling at
me. That was the first time that I realized that my actions were “heroic.”
Meanwhile, my friend and colleague was on the phone with the
neonatologist. He was on his way and wanted us to do our best to keep the
baby alive until he arrived. So with a mixture of triumph, confusion, and
anger, I helped transport the baby down to the NICU. The
neonatologist was there and I was now superfluous so I slinked back to the
PICU where I could review ventilator settings in peace.
It was only recently that I
started to wonder why we were even called to the delivery. Was the
expectation that we would show up, do nothing, and watch the baby die? If
so, it seems like a terrible intrusion into a private and painful moment of a
woman we did not even know. And obviously our intervention was even more
unwelcome. Would it have not been better to not call us to come?
I went about my work in the PICU,
checking on patients before the rest of the PICU residents and attending
arrived, presenting the patients on morning rounds, and trying to get my
paperwork done in hopes of heading home by mid-afternoon. Sometime during
the day, I heard that the baby in the NICU had died. I was numb and
confused and did not know whether this development was good or bad.
I wonder about his mother. If I still think about
the events of that night, she must be haunted by it. I would like to talk
to her but I do not even know her name or where she is from. And what
would I say? "I'm sorry that I tried to save your baby"? I
hope she is not mad at me. I hope she knows that I did what I thought was
best. But I really wonder about him. Did he feel
distress when he was gasping to breathe? Did he feel discomfort when I
intubated him? If he could have told me, what would he have asked me to
do or not to do?
If I could do it all over again and
knowing what I know after more than twenty years in practice, I would wrap him
up in some blankets, hand him to his mother, and express to her my sorrow at
her loss. Years later, a wise friend of mine asked me in relation to
another event, "Did you do the best you could with the information you had
available at the time?" My answer would be an emphatic
"Yes!" I think that is all anyone can expect of any of us.
