Choosing on a medical specialty involves learning your own answers to a series of questions?

-Do I enjoy patient interaction or not?

If no, consider Pathology or Radiology

-Do I like surgery and procedures more, or medicine and clinical reasoning, or both?

note- Anesthesia is a procedure and OR specialty, sort of surgery-lite.

Both- Ophthalmology, Orthopedic Surgery (well peds ortho anyway), ENT, Ob-Gyn, and Emergency medicine for procedures

-Do I prefer general, broad knowledge or limiting to one area or system, Primary care or specialist?

This is often a question of knowing a little about a lot, or a lot about a little.  However, It also involves whether you prefer relatively healthy patients or relatively sick.

-Do I do I prefer to see kids, adults, or both? (remember you can do almost anything for kids that you can for adults.)

The last question was easy for me.  From my point of view, pediatric care is superior to adult medicine in so many ways.

-Kids are much more fun, examination of kids is often just playing with them and goofing off.

-Kids don’t usually have problems stemming directly from their own life choices

-Kids don’t have that unmistakable adult hospital smell

-Kids make the doctor look good with their marvelous ability to heal.

    Youth is full of life and the ability to heal.  Kids will almost always get better.  We like to pretend or imagine it is something we did, but really the young developing body is nothing if not resilient.  Most childhood illnesses resolve on their own.  Kids don’t have the annoying problem that adults have of losing their heartbeat or pulse.  The smallest of mistakes in the elderly are often fatal, while kids have a wider safety margin.  They actually routinely come back in codes.

     This is not without its drawbacks however.  For example, I have seen many infants who were born without a heartbeat, that had little or no activity coming out and severe oxygen deprivation for one reason or another.  Almost without fail, the heartbeat can be revived.  The other organs, particularly the brain, are a different story.  The oxygen starved brain develops a condition called Hypoxic Ischemic Encephalopathy, which is basically certain parts dying or stroked out by a lack of oxygen.  These parts don’t grow back.  Even then the picture is somewhat better than adults, as infants are still laying down brain cells and making connections.  The infants brain has more plasticity than they will ever have again. Infants with strokes that would paralyze an adult on one side have as little an effect as discoordination of one hand seen at 2 to 3 years old. 

     Extremely premature babies have two general strikes against them.  Their lungs are underdeveloped, so they can lose oxygenation on a whim, and the blood vessels in the brain like to bleed spontaneously.  So little by little, as we try to feed and nourish their tiny undeveloped bodies the brain takes a hit here and a hit there and can sometimes have a ravaged brain by discharge.  This presents the neonatologist with a quandary.  Keeping the kid alive is easy, particularly with the aid of G-tubes to feed with and tracheostomies to keep an open airway.  Keeping the brain alive is more difficult.  Many, many of these children go on to develop cerebral palsy.

    All this makes decisions about when care is preserving an acceptable quality of life or not very messy.  Parents are biased to want everything possible done to keep their children alive, I think appropriately so.  The problem is that the extent of their disability is not at all visible as an infant.  They can have arrested development in the infantile state, which is normal, cute, and adorable in an infant but loses its appeal in a 12 year old. 

    Perhaps this is a disguised blessing as it gives the family time to adjust to limitations and grieve for their losses.  There is an ethical specter hanging over medicine at the cutting edge of viability.  We spend a vast amount of healthcare dollars rescuing life at its very beginning, sometimes with more success than at others.   It is often asked if this is a wise use of a limited resource as we spend more and more on diminishing returns.  When does this care become futile? 

     I do hate these questions.  We have to rank who is worth giving care to and who is not.  It is a path fraught with moral hazard, prejudice, jealousness, and ranking of individual worth.  I don’t think society is equipped to give the answer.   With children the question is all the more confusing.  Their immaturity makes the level of compromise invisible.  Their resilience makes predictions unreliable.  It seems their remarkable ability to heal and make doctors look good also means ability to cause a lot of chronic disability in society.  The dirty secret of healthcare economics is that the more we are able to care for the chronically ill, the more it costs us.  This is the problem caring for sick kids.  

    Allow me to suggest that the cost is greater if we give in to an impulse to turn our backs on these individuals.  I am the last person to suggest that any life is wasted by disability.  An LDS author, Blaine Yorgason, wrote a book about the experiences he had caring for one of these children, called One Tattered Angel.   He plays perhaps a little too much into the Mormon stereotype of the super valiant spirit who didn’t need a full life experience for my taste, but it is a very good book just the same.  In it he describes how this child, Incapable of seemingly purposeful movement or speech, with his nervous system decimated, still acted as the peacekeeper in their home.  Whenever there was yelling or contention this child became very agitated, and the arguing parties had to rethink what they were doing and work to calm the child down. 

   Regardless of the premortal valiance of this child, he taught his family many, many valuable lessons about life, about caring for others, about consideration and they were better for it.  These are lessons they only could have learned by living it.  This was true despite the most severe disability imaginable, with no ability to smile at you, to see, having seizures hundreds of times per day, with muscle tightness locking into painful contractures, with no language.  Most would question if there was even consciousness, seeing the agitation as “reflexive.”   When we think of “contribution” to society, our thinking can be so limited.  Who contributes most, workers, mothers, political leaders, the rich and powerful, teachers, public servants, the master race, the young, men, women?   Our prejudice will always inform our opinion in some way.

    Many, many of my pediatric colleagues see this as some form of selfish cruelty on the part of the parents.  There is a certain point of view that sees no quality of life here, only suffering.  With an animal, we would not hesitate to euthanize this kind of baby, or at least let them die without intervention.  Princeton ethicist, Peter Singer has made a living out of arguing for infanticide of exactly these children, that babies are not yet a person because they lack consciousness.  He also sees humans as animals, and argues we euthenize animals thinking its humane, so why not babies.  Oddly, he is an animal rights activist.  I have a difficult time seeing euthanasia as a message that a certain type of person, be they disabled, elderly, Jewish, or Black, has a life that is as valued as any other member of society, any more than animals are valued equal to people. 

     Yet it is a real conundrum, when does compassion cross the line to cruelty?  If we actually take the time to ask the disabled, I think most people learn it is somewhere far beyond where we are prone think it is.

   I found in medical school that I had something of a knack for working with the disabled.  Many others were really uncomfortable with these patients.  We all are uncomfortable with differences.  We have a natural tendency to turn away from tragedy.  I don’t know if this is fear, pity, emotional self protection, or revulsion.  All I know is that we are all prone to it.   I feel a need to care for them precisely because so many turn away, and so I have dedicated a career to them.  This is why I have chosen a path less traveled.   This is why I am a Child Neurologist.   

 

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