Today was one of those days where I could write about a billion different things. Should I write about how a couple of my previously mentioned patients are, overnight, doing amazing and might go home soon (my successes)? Should I write about how I was gone 1 day in the care of my patient and I come back to find this little one worse off than she's ever been (my frustrations)? I thought about these two things, among many others,...but then we got word that there was another gastroschesis baby that was going to be born at our hospital.
Apparently the mother, a 17 year old, had come in just before noon in labor without any prenatal care what so ever. Our service was full, so we were unable to take the delivery officially, but our attendings wanted us to stay in-the-know about this one, because apparently an ultrasound done after the mothers arrival had shown that the bowel was still outside of the little one's body.
You might be wondering how this happens?
When human body is developing from a fetus it undergoes a lot of changes. Every human being has a typical bowel arrangement that any 1st year medical student could sketch for you at a seconds notice. It gets into this particular "positioning" during development by, basically, protruding through the abdominal wall which has not closed yet. While protruding out of this still open cavity, the bowel twists, as it grows. As the bowel twists into the correct position it is slowly pulled back inside the abdomen which has begun to close around it, until it lays neatly down inside this cavity in just the right way, where upon the abdominal wall will seal over it. That's what SHOULD occur.
For whatever reason, this doesn't happen in some babies, so you get a hole in the abdomen through which the intestines are hanging out at birth (I often try to imagine being a physician 100 years ago. I can't imagine the surprise and horror that you would experience having a baby pop out on you like this). While these babies would normally die, with the advent of modern medicine we can save them by putting their guts in a small bag fixed up a particular way that allows their bowels to slowly "settle" into the belly, at which point a surgeon closes the abdominal wall up. This process usually takes about a weeks time and barring complications of this, they can go on to live relatively normal lives.
BUT, ultrasounds are not perfect and when this baby in question was born, the mother tragically had to face the terrible fact that her child would not survive the day. I was not present for the delivery..and honestly I'm glad I wasn't. However, as it is a teaching hospital, my attending decided we needed to see this and so even though the parents were in the room grieving, literally standing in the room holding the little one as it breathed what were it's last breaths, we were brought in to see this child that wouldn't be.
It made me sick to intrude on them as we did. I felt dirty, pathetic. The mother laying there crying. The father in tears holding this bundle that was dying or even dead. The grandparents and great-grandparents were nearby and being very stoic, but the sadness was palpable in the room. As instructed, we came in behind the attending who needed to pronounce the baby. It was laid gently into it's crib. The attending's hands were unshaken as he unwrapped the cloth that was bundling this poor infant (my hands would probably have been shaking).
Even before the cloth was unwrapped, you could tell something was wrong. I've seen very young children, only 24-25 weeks old, this child was supposed to be older, but the head was smaller and I can't place what it was about the face but you could tell it had passed away...something had "left" it. Even though we had been briefed on what to expect, only as our attending unwrapped the blanket did we truly understand why this child was laying there motionless.
We had thought initially that this small child had a condition which although complicated and uncommon can still be managed. What she really "had" though was something much more rare and still much less survivable. This little girl was born with not only her intestines outside of her body, but her liver and heart as well. We actually watched her heart, laying on the outside of her chest, beat it's very last beats feebly and then suddenly halt (her heart's lack of strength had likely killed her long before). My attending looked up at the clock and pronounced the time of death. The nurse scribbled it down and walked outside the room. I was suddenly reminded of something I had seen as a child, a small bird egg laying smashed on the rocks underneath a tree, it's small fetal body laying in the pieces of the shattered shell, an undeserved demise, in complete innocence, never aware of the sad fate they had both been delivered.
The attending didn't say anything afterwords. We quietly walked back to the resident-room to finish our work. There was no lecture or lesson to follow, no journal article to be studied, or fact sheet to be memorized; today what this little girl had taught us in her silence was lesson enough.
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