I recently finished my clinical rotation at a prestigious regional pediatric hospital. I didn't have any special trouble with the skill set. I didn't lose my nerve, dealing with tiny preemies or very sick little people. For me, it was the families, the decision-makers that I couldn't handle.
In adult intensive care, most patients have had an opportunity to express what sort of care they want, somewhere along the line, formally or informally. That isn't a bullet-proof guarantee that granddad won't die a long and tortured death because family members are battling over him and his stuff. But nearly always, there is up front discussion about how granddad probably feels or what he might want. In neo-pedes, this isn't the case. Children have no rights, so discussion about what they feel or what they want is always 'in the air'. It is always up to someone else to interpret their situation and decide what is "best" for them. My point is it is never up to the child. Never.
For me, the breaking point was a beautiful little boy born full term to a very young teenaged mommy. The baby had been diagnosed in utero with a collection of 'blue-baby' heart defects. These sorts of problems run the gamut from small holes in the heart's septum than can be fixed in one surgery, to little hearts that are so jumbled up that even after many surgeries they are sort of functional but nowhere near 'normal'. This little boy was in the latter category. His mixed up heart worked just well enough for him to breathe and eat and be alert as a newborn. As soon as he grew a little bit, his heart would be unable to keep up and he would die (rather peacefully, though). Multiple heart surgeries, if he lived through them, would leave him able to live in questionable condition for a few years, in the hope that more successful surgeries might be invented in the mean time.
The surgeon, the cardiologist, and the neo-pediatrician all concurred on the baby's slim chances in surgery. They all outlined the option of comfort care, and a very brief but normal life with a peaceful end. After listening and thinking, the grandfather said, "if there is a 10% chance to save my grandson's life, then I want you to do everything you can to save my grandson's life."
So off to surgery went the baby. He looked his mom in the eyes for the last time when he was 3 days old. Back from surgery, we were obliged to leave his chest open so we could access the heart directly for manual massage. He had had that many arrests. Before long he was on ECMO (extracorporeal membrane oxygenation), along the with the open chest. His lungs began to clear up on ECMO, but then we had to take him off it, because the blood thinners that must be used for ECMO resulted in a massive grade 4 brain bleed. We removed the ECMO, we closed his chest. His reflexes never returned and his eyes never opened again. But his little heart kept strokin' on, and his grandparents talked about how excited they were to take him home soon, with a tube in his abdomen for nourishment and a tracheostomy in his little neck for a ventilator. They said they loved him even though he wasn't 'perfect'. And they were smart, educated, middle-class people who were only trying to do the right thing for their pregnant high schooler and their new grandbaby.
It's not just that I would have made a different decision if it had been mine to make. I understand the passion one has for one's babies. Yes, I think I would have decided to bring my baby home on comfort care and let him be a completely wonderful little baby for whatever short life he had. I have NO criticism for the grandparents who decided differently. All I know for sure is that I don't want to use my new skills to close the bright eyes of a little baby as I help intubate him for surgery, knowing I will get him back by evening after helping put great tubes in his carotid and jugular, while his blood pressure and heart rate jump and the anesthesiologist struggles to balance him between life and unconsciousness. I would rather use my skills to torment a dehydrated drunk with a TBI back to life, so that he can decide if he will take this one last chance to have a relationship with his family. I felt ashamed to place this forever unconscious baby back in his mother's arms, thinking how they could have gone home together and loved each other so vividly, although not for very long. I knew for certain, at that moment, that this was an area of medicine I was unfit to facilitate.
The economy is bad, and the pediatric hospital is hiring. But I won't apply. I have a casual position at a big metropolitan hospital with a big trauma unit and an even bigger ICUs -- also a huge hospice floor. These are areas where I work hard, but I come home at peace with myself.
Every RT is different. Someone else will be right for Neo-Pedes. It won't be me.
Namaste,
Maize
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