Empty Crib

I will remember the empty crib. On my last day of my pediatric surgery rotation, we returned to round in the intensive care nursery. As we made our way to the west side, we walked to the crib and the baby was not present. Right away, we all knew what had happened-- the baby had died.

My fellow medical student and I had been following this infant's course during his hopsital day. Each day we reviewed his numbers, noting little signs of improvement. We would come by and examine him and speak with the mother. At one point, he was being maximally sustained on pressors and the maximum ventilation support. Despite all the interventions, the infant failed to improve, something we had expected from the start.
***

In the neonatal intensive care nursery, each infant receives the most specialized attention from a large team of healthcare providers, including physicians, nurses, social workers and students. Every conceivable piece of information is recorded on large elaborate flow sheets, everything from vital signs to infusions to amount of urine and stool to when the baby moves or sleeps. The life of an infant is chronicled by the hour. The fluids and output are meticulously measured. Medications and drips titrated exactly to the infant's weight. The amount of detail is nothing short of perfect.

And when the decision to withdraw all forms of life sustaining treatment is made- the flowsheet detail decreases, eventually disappearing. The infant is whisked away to a seperate room, where he can be with his family for the last few moments of his young life.

***


During my last week of pediatric surgery, I observed the spectrum of interventions to sustain life, from basic to complex procedures.

I watched as we sewed the ends of an esophagus for a baby that was born with esophageal atresia, where the esophagus ends in a blind pouch. The physician meticulously laid each suture to create an anastomosis between the blind bouch and the remaining esophagus, which was located more distally.

I watched how we managed acute renal failure in a baby with an obstrution secondary to a large cyst. I saw numerous inguinal hernia repairs and catheter placements.
I saw how we fix congenital diaphragmatic hernias, a defect in the diaphragm that develops when the diaphragmatic folds fail to fuse during development, which results in abdominal contents herniating into the thorax and preventing proper lung growth. Infants with this defect are born in respiratory distress and typically require ventilatory support prior to surgery.

We performed two repairs this week, on infants who had severely defected diaphragms. With the thorax open, the abdominal contents were carefully redirected into the abdomen and the diaphragm defect was patched and sutured close.

When I asked the neonatologist about the prognosis for infants with severe hernias, he told me the following-

"Fifty per cent of such infants will make it out of the hospital alive."

He was right. Only one of our infants survived.