Life Isn't Fair

Still in pediatrics, I am now part of the team that attends deliveries if there is any reason to think that there might be a problem with baby. I was half-hoping that this experience would help calm my fears regarding pregnancy and childbirth as the centre I'm at now handles much more low-risk and uncomplicated stuff than the centre where I actually did my baby-catching rotation.

Just before midnight last night we were called to a delivery because there was some meconium in the amniotic fluid. This means that the baby passed its first bowel movement in utero, which can be a sign of fetal distress. On top of that, if the baby manages to inhale meconium with its first breath, it can cause a very serious pneumonia and breathing complications. So that's why we were there.

Baby came out pink and wailing. These are good things. The nurse put the baby under the warmer, and I went to work. Rubbing the baby dry, suctioning his mouth and nose... soon the gurgles quieted and he seemed to be the perfect newborn boy. But as I was doing the quick head-to-toe exam required in all newborn assessments, it quickly became obvious that the baby lacked tone. Instead of holding his elbows and knees bent, arms and legs curled against him, his limbs were splayed out limply to his sides. I pointed this out to the attending after the rest of the exam proved normal. The attending spun the baby around an looked carefully into it's face.

"Did you have prenatal testing?" He called out to the new mom having her fun parts stitched up behind us.

"Yes, the integrated prenatal screen" she replied.

"And it was all negative?"

"It was. Why?" asked the new mom, understandably growing concerned.

"We need to look at your chart for a minute. We'll be back to talk to you soon."

And with that, we left the room.

Once we were safely out of the family's earshot, the staff pediatrician swore under his breath.

"That kid has Down's Syndrome."

"What? Why? But she had a negative IPS!" I didn't understand how such a thing could have been missed by such a sensitive test.

"Micrognathia, macroglossia, slanted eyes, low-set ears, nuchal fold, transverse palmar crease and hypotonia. I couldn't be any more certain without having the chromosomes laid out in front of me."

I was stunned. I always thought that the IPS protected people against surprises like that. The biggest risk of IPS is that it is sometimes TOO sensitive, identifying risk where there is none and exposing women to unnecessary tests as a result. And now this perfectly healthy 28-year-old woman has to be told that the similarly perfect child she was expecting will suffer from one of the exact syndromes that she thought she was safe from.

The reason that this scares me so much is that I, personally, don't think I would be able to handle the challenges of raising a child with severe developmental delay. I don't want my children to be physically dependent on me for the rest of my life. And as shallow as it might sound to many, my husband and I have agreed that we would likely terminate a pregnancy if something serious were found to be wrong. We will get IPS, and if a positive result occurs we will have an amniocentesis. How am I supposed to work up the nerve to get pregnant if even IPS can't predict outcomes?

Before you all comment that I'm deluded and juvenile and that nothing in life comes with a foolproof guarantee, I know. But I guess I just figured that when it comes to pregnancy and childbirth, there is SO MUCH that is still out of our control that it's nice to have some control when you can.

Now, back to worrying. This may have pushed back the babymaking schedule another 6 months, easy. Sorry, mother-in-law.

Just Do It.

Although maybe not what you think.

Just vaccinate your damn kids already. I am so tired of having the same argument over and over with people who 'know someone whose friend had a niece who got autism from a vaccination'. Sure they did. But right now there is a young boy on the pediatrics floor with meningitis because his mother didn't believe in vaccinations. When questioned further about her beliefs, the mother admitted that she didn't have any concrete evidence or research to back up her decision, but a friend of hers suggested that vaccines were like 'putting poison into her child'. So she put it off. And refused it when her family doctor offered it. Repeatedly. She had been meaning to do the research herself, she said, but she just didn't have the time.

Hope you have the time to deal with a brain-injured child.

I have yet to come across anyone who can provide me with actual fact-based evidence to support a decision not to vaccinate. Particularly with the tried and true vaccinations-- MMR and DTaP-IPV. I am more likely to understand the hesitation to incorporate the 'new' vaccines with the (albeit misguided) reasoning that new vaccines have less safety data backing them up. But childhood vaccinations have changed the face of disease in the past 50 years. Smallpox has been eradicated. Polio has been eradicated in the western hemisphere, with the exception of some confined outbreaks in religious communities that are anti-vaccination. Diseases such as mumps, measles and whooping cough are so rare that when a child is admitted with one of them, medical trainees parade through the room at a constant pace to see how it presents.

And with the newer vaccines (Hib, Menjugate) even during my short medical career we've seen the impact. Meningitis used to be a much more common childhood killer. Since the advent of the Hib vaccine (hemophilus influenza B being one of the most common causes of meningitis in infants and young children) the incidence of meningitis has gone down dramatically (I think it's by about 90 percent, but don't quote me). Epiglottitis, an airway emergency that we're taught to be suspicious of in any child coming into the emergency room with stridor and drooling, is actually now more common in adults.

This topic infuriates me. If anyone out there in cyber-land can give me evidence (and by that I mean peer-reviewed trials, not the word of your next-door neighbour) that backs up the decision to avoid childhood vaccinations, I'd love to hear it. Because every time I see another kid come in suffering from a vaccine-preventable disease, I have to bite my tongue not to point out to the parents that their inaction was directly responsible for their child's suffering.

Judgemental? Sure. But YOU try treating a kid with meningitis who, up until admission, was a totally normal kid and is now deaf and brain-injured. And then find out that mom had opted out of vaccinating because she decided to take the word of her cousin's friend over her family doctor or pediatrician. And let's see how judgemental YOU become.

My First Day of Pediatrics.

I learn a lot at my job. Here are the gems that came out of my first day of peds.

1. Don't ever, ever assume that just because you are a doctor, you are allowed to touch your patients. First, make sure to ask permission from the nurse, the peds staff, the senior resident, the child's parents, the baby herself, the cafeteria lady and the housekeeping staff.

2. If your patient is a newborn, you are not allowed to touch it while it is sleeping or after it has eaten. So if you need to do a physical exam, that leaves about 8 minutes in the early morning and another 4 minutes sometime in the afternoon. Nurses will enforce this rule with the ferocity of a rabid pit bull.

3. If there is a parent in the room, it is best to assume that they believe that you are there to do their child irreperable harm. Regardless of whether or not you actually intend to touch the child. In fact, the fastest way to befriend your patient's parents is to agree that everyone working at the children's hospital is horribly incompetent. Yourself included.

4. Many people in pediatrics have devoted their lives to children because they aren't that great at relating to adults.*

5. Every crib on the pediatrics floor will work slightly differently. Which means that you will look like an idiot trying to release the side of the damned thing for 10 minutes while the parents of your patient stand by, amused. It's hard to garner any respect after that.

6. Children are very different from adults. Don't ever think that anything you've learned in your previous 14 months of residency will prepare you for dealing with children.

7. Pediatricians and pediatric residents spend an inordinate amount of time discussing how no other physician in the medical universe knows the first thing about treating children.

8. Parents will describe every episode of vomiting as 'projectile' if it is coming out of their child. Even if it just dribbles down the front of their sleeper.

9. At some point in parenting school, parents learn that if they smoke outside their cigarette smoke cannot possibly have any effect on their child's asthma. This is a belief that they will defend and argue to the death.

10. Trying to get back into a regular schedule after two months of shift work requires copious quantities of caffiene.



* Vitamin K is, of course, the glaring exception to this rule. Cause she's just wonderful to everyone. Even when she's sleep deprived.