Sep 24, 2010

Life and Death

There are two givens about life. You are born, and you die. And medicine intersects these points. I prefer to be on the birth end of the graph. Being part of the process of a new life in this world is joyous and rewarding, and preferable to me over caring for the end. But obstetrics is the only specialty that traverses these two givens, that can unite them in a matter of minutes rather than years. We hear about life and death situations a lot, in terms of making a decision to save someone's life. But what if you have two lives to save?

Babies are born, and some babies die. It's terribly sad, but not unexpected. With what needs to happen for any baby to born healthy, it is truly a miracle that it ever happens. And it isn't surprising that sometimes things don't go right. More precarious is the balance of a healthy baby and unhealthy mama. I've only seen this a few times. One instance that sticks in my memory is of a young woman, twenty-five weeks pregnant, unconscious as an oscillating ventilator forced air into her swine flu-filled lungs. She couldn't get well with a parasite (baby) grabbing every extra molecule of oxygen she had. And so the decision became- do you deliver her for the possibility of saving this mom of a three year old, this wife and daughter, and risk a probable death of her baby? Do you watch her oxygen saturation decline in the presence of a happy, reactive fetal monitoring strip? Do you keep her alive for a few more weeks, using her body as a physiologic NICU incubator for her baby, and see what happens? This is what was opted for, and she was delivered two weeks later. Last I heard, her baby was doing well and she was newly pregnant again- a good ending for a tough call.

I saw another instance of this today. A young woman, exactly my age, came in to have her prenatal ultrasound. We looked at her uterus, measured her little boy, watched the happy flutter of his heart and his kicking feet. Swinging the ultrasound around for a cursory quick glance of a normal ovary revealed a large, nodular mass lined by enlarged lymph nodes. Most certainly an ovarian tumor, a highly malignant mass nestled against her growing child. Life and death, adjacent, growing silently together. Would this tumor be all this baby knew of his mother, both in the womb and growing up in her absence? Would the mother watch her baby's fluttering heart grow still as she underwent treatment in hopes of removing the cancer? Is there a chance of them both being okay, a chance for her existing daughter to keep her mother and gain a brother?

Medicine is imprecise, a collection of educated guesses from educated people, and that's the best you can do. And somewhere amid these calculated thoughts, there is a person. The nature of medicine is caring for fellow humans in times of difficulty, and it seems reasonable that the physician would grieve along with their patients. But they also need to learn to let go of the summation of patient pain to preserve themselves and their practice of medicine. It seems to be an unspoken competency in medical school, a skill untaught and hard-learned for most. A skill I am still learning, and expect to learn better in any field of medicine, especially obstetrics.

Sep 14, 2010

My First Baby

Here is the (long overdue) account of my first baby. Not one that I carried in my own body, but one that I cared for and delivered. The baby that changed my career as a doctor.

I thought I wanted to be a gastroenterologist. My background in clinical nutrition led me to an interest in the GI tract and how nutrients were absorbed and how nutrition affected health. Throughout my first two years of medical school I planned on become an internist and subspecializing.

And then I delivered this baby.

I was poised at the woman's vagina, easing the head, one shoulder, two shoulders, a body, and feet out of her body, clutching the newborn tightly against my too-big surgical gown. And my first, illogical, thought was "wow, this baby is really warm." Which was really stupid. Of course the baby was warm- he came out of a toasty uterus, insulated by his mother. But the first thought of a student doctor is often an expression of something that should be obvious, but just has not yet been experienced. It was a surprise to me when I first held him.

This has been kind of a funny story to friends, family, other patients, myself...I think in part because it illustrates that doctors start as children in medicine. We have these first experiences and have normal human reactions to them, instead of calculated medical answers. I think being a student gives you a unique perspective too, for your first delivery to coincide with a mother's first birth, where you share in the newness of this experience together. After that point, you are on unequal footing; the doctor and the patient, but as a student, you appreciate things along with the patient.

And I loved it. That feeling of cradling the warm, slippery baby and the happiness of laying the infant on his mother's belly was one of the greatest joys I had ever known, and ultimately changed my career in medicine.