Sunday, August 13, 2006

Baby Killer



The potential to do dramatic good, as is the case with surgery, means that sitting and staring back at you at the other end of the see-saw is a grinning dysmorphic ogre. He keeps his eyes locked on yours, staring with the smug certainty that you can't toss him off, up when you're down; down when you're up. The ugly little sonovabitch never goes away. It's an issue for every healthcare provider. Were it front and center at all times, it'd be paralyzing. But if it's completely out of mind, you'd become dangerous, or careless at the least.

So there's craziness: much as I find doing surgery exhilarating and fun, and much as I'm amazed at and grateful for the willingness of people to turn their bodies -- with their most intimate secrets -- over to me, in the entryway to the back of my mind resides the awareness that it's a dangerous thing I do. Thin ice. There's a lizard under every rock. Sometimes the realization comes upon me like a bucket of ice-water. (I should acknowledge that -- maybe unique in the "dangerous" professions -- in my case the danger is the patients'. A mentor of mine said, "The patient takes all the risk, Dockie." I don't minimize that. But to harm another is, in many ways, worse than harming yourself.)

Imagine being the parents of a perfect baby. All the fears of pregnancy and expectations of birth have resulted in a beautiful boy, thriving. Looks like his dad. Other than being tired all the time, you're ecstatic with the love you have for this little thing. He coos, he looks lovingly back at you as you feed him. And now he's six weeks old, and you're being told he needs an operation.

Having fed quite normally for the first month or more, the baby is now vomitting, more and more forcefully, until it seems he's keeping nothing down, and isn't gaining weight. Hypertrophic pyloric stenosis, the surgeon says, speaking Greek, or Martian. Like a raw doughnut tossed into the fryer, the circular muscle at the bottom of the stomach has grown, and it's preventing food from leaving the stomach. The treatment is surgery.

As operations go, it's quite simple. Many years ago, part of the stomach was removed: in starving kids, that's a big deal, and lots of them didn't do well. The modern operation is quick and comparatively trauma-free, and works great. You make a small incision on the baby's belly, find the enlarged muscle, and slice into it, splitting the muscle fibers (it looks strange: instead of the healthy pink, the muscle looks like the meat of a white peach) and spreading them apart.

Imagine a tight ring over a glove on a finger. You want to cut the ring, but not the glove. You want to see the glove fabric bulge up into the cut you made, indicating it's free. But if you cut the fabric, you've done a bad thing. The glove is the inner lining of the stomach: the mucosa. A hole in it means leakage of stomach contents. Making it tricky, it sort of folds over on itself exactly at the bottom end of the muscle. You need to cut the entire muscle or the operation won't be effective; but if you go too far, you make a hole. Doing so isn't the worst thing in the world: if you recognize it, you sew it up and there's no problem. The danger is puncturing the mucosa and not noticing. That can be deadly.

So you explain all this to the parents. You tell them about the possible problem, but say that prevention is what we're all about in doing the operation. You say that the kid might still vomit a bit for a few hours, but in all likelihood, he'll be home in a day or two, doing fine. Like magic. They agree, of course.

There's something completely wrong about a tiny baby on a big table in a huge OR. I could cover the entire person with my two hands. All the machinery, the tools, the drapes, the surrounding team seem terrifyingly outsized. It's like a joke. We're playing dolls. Except it's real and the stakes are high. It's one of those times when I ignore the reality and just focus on the job at hand. Tiny hole, tiny instruments, fine little sutures at the end. It goes fine.

"Shit," I say, as the phone rings at two a.m. It's my usual response, whatever the call. This time the nurse tells me the baby has a fever of 103 and his abdomen is rigid. "I'll be right there," I tell her, the words finding great resistance, barely squeezing out through my suddenly constricted throat.

It's easy to describe how I felt, because I feel that way again whenever I think about it. Had my wife awakened, she'd have seen me appear ghost-white, I'm certain. My stomach was hollow; my hands were ice. I could barely tie my shoes; my hands were shaking, and not following commands. It felt as if a cold hand were gripping my neck; I could hardly swallow. I splashed water on my face, made it to my car, raced to the hospital. As I drove, hands so tighly on the wheel that they were getting numb, I was thinking I'd do whatever was in my power to save the kid, do whatever it takes. Never leave him until it was over. And then I'd never, never, ever, ever do a pyloromyotomy again. And if he did poorly, I'd never operate again. This was a baby. Someone's precious baby.

As I headed to the pediatric floor and entered the baby's room, saw the nurse standing by, I felt as if a million eyes were on me, accusing and hateful. (They weren't. But that's how I felt.) And there he was. Fussy face flushed with fever, but moving around like a baby, looking not so bad. His belly was soft as, well, a baby's bottom. An xray looked fine (before surgery, to make the diagnosis, he'd been made to swallow some dye. It still showed up, some in his stomach, some happily in his intestine, and none at all outside the proper confines.)

Who knows what it was? The kid did fine and went home, as promised, in a day or so.

I drove home nearly limp, still shaking, barely able to control the car, wrung out like a wet sock. I lay on the bed exhausted; relieved, but absolutely spent. An hour or so later, I dragged myself to work. And next time a pediatrician called for a consult for a kid with pyloric stenosis, I took a deep breath, considered it carefully, and said... "I'll be right there."

20 comments:

Jordan said...

They used to describe Anethesiology as 95% routine interupted by 5 % utter panic and fear. I think this holds for all medicine. But nothing is as scary as working with kids!

Intelinurse2B said...

As a mom of 4, I know I never want to do Peds nursing. I have been the mom who paced the room when my youngest was weeks old and in the PICU. I knew how it felt to be the worried mom, sleeping in the chair, wishing I could sleep in his hospital crib w/ him. Your post gave me pause to now consider how the docs may have felt as his condition took turns for the worse. Another two thumbs up.

scalpel said...

Damn....your ogre is ugly! And it looks like you've kicked most of his teeth out over the years. Mine still has lots of sharp pointy teeth.

Allen said...

I have a nice RUQ scar from the same surgery, age six weeks. (I also have a cutdown scar on my right ankle I didn't understand until med school).

Thanks to a surgeon like you, only different. Thanks for the scars, and for the chance to grow up.

GruntDoc

Mother Jones RN said...

I don't know how doctors do it, or
why more don't crack under the pressure. Thanks for sharing your story.

S. R. said...

Sid, that would scare the living $h*t out of me. Then again, I have club hands. I can't even fix my toilet plunger.

beajerry said...

Interesting stuff.

Noah's Mom said...

You just described what I went through with my son last year at 4 weeks of age. I will never forget seeing him in the hospital bed and then seeing him wheeled off to the OR. He is now a healthy, happy 9 month old thanks to surgeons like yourself.

Moof said...

Dr. Schwab ... it takes special people to be able to do what you do. I'm grateful that you, and others like you, are willing to put yourselves through all of that.

ripple of hope (difficultpt) said...

Thank you for sharing how you felt/feel . . . As a patient and a mother, sometimes I wonder if the doctors care, and then I read blogs like yours, Jordan's, Dr. A's, Dr. Charles', etc, and I'm reminded that you do care, you feel, and you are there to help us. Thanks for sharing . . .

Hmmm, I think more doctors should blog.

kdoctor said...

wow what a story.
You are a great writer!

M. Dyspnea said...

Your descriptions made me want to vomit, and I mean that in the best way.

Moreena said...

After my daughter's last surgery, she suffered a bowel perforation. I remember how her surgeon, the day before they went back in, discovered it, and fixed it, kept looking at her in the PICU bed and saying, "That just *can't* be the problem." At the time I wondered why it was so difficult for him to consider the idea that perhaps a known complication of the surgery had occurred. Now, reading this, I guess I'm coming to understand how hard it is to contemplate these things happening and still keep going, even if you know it might happen.

Of course, we never even considered blaming the surgeon or his team. We'd be fools and hypocrites to do so.

Anyway, all I'm saying is "Thanks." What strong mental stuff you all must be made of.

dr peg said...

Courage is doing what you fear, in spite of the fear. Well done, doc!

Dr. Willow-Esque said...

For some reason, this post reminds me of something I tend to avoid thinking about. I was rotating through OB/Gyn and a 28 week gestation with severe abnormalities was to be delivered. Nobody expected a good outcome. The parents, recent immigrants, had been prepared, as best they could be, for the worst, which seemed the most likely. Being a rather green young doctor, I had delusions that this fetus could be saved, somehow. As soon as the uterus was opened, it was immediately apparent this would not be possible. Anyway, after doing what had to be done, I went outside and did the unthinkable. I went outside, lit a cigarette, and had a good cry.

Anonymous said...

I've never read a better description of the fear that descends when you think you have caused a serious complication. It is almost enough to stop me from ever operating again. Great story.

That Girl said...

I'll try to remember this the next time they call a code on my son in the ICU.
It is with wonder that I looked at my 2 lb, 14 oz son and contemplated the skill involved in performing a Norwood on a child whose veins were the width of a hair.
It's awe-inspiring.

kim said...

Oh my....I'll wait until my gut drops back out of my throat before going to bed...

That ogre nearly made me leave nursing school, with the mantra "You know nothing. You'll kill somebody" playing in the back of my head with just six weeks to go until graduation.

It took a couple of years to subdue him. Oh, he's still around, but it keeps me on my toes and I tell him to shut up.

Figuratively speaking, of course...

N said...

Hi Mr Cutter,

There'd be nothing more reassuring to me if I was consulting a surgeon than to be sure that they suffered from your adrenaline-pumping ogres.

That way, I'd be reassured that they would be assiduous in working on complications -- adrenaline facilitates single-handed truck-lifting, I hear!
:-)

The MSILF said...

The first surgery I scrubbed in on in general surgery rotation was a teeny baby with intussusception (pretty big one too). THAT was terrifying. This post captures it.