Sexuality and Digital Media

(Photo credit: http://www.sciencephoto.com/media/349386/enlarge)

Jamie is 13 and hasn’t even kissed a girl. But he’s now on the Sex Offender Register after online porn warped his mind… (Read more: http://www.dailymail.co.uk/news/article-2135203/Jamie-13-kissed-girl-But-hes-Sex-Offender-Register-online-porn-warped-mind-.html#ixzz1tC9S3XSW)

My mind was blown when I read this headline. It was benumbing to learn that a 13-year-old boy, who never touched a girl gets enlisted as a sex offender (for the rest of his life). He is now in the same ranks as those adult perverts who actively, sexually violated other individuals, even if he never committed any similar offense but merely accessed online pornography materials. This is disturbing as it could be a precedent of what will happen to our young and succeeding generations, what with the wide array of accessing the digital media.

SIGMUND FREUD’S PSYCHOSEXUAL DEVELOPMENT

(REFERENCE:  http://psychology.about.com/od/theoriesofpersonality/ss/psychosexualdev.htm)

Freud believed that personality develops through a series of childhood stages during which the pleasure-seeking energies of the id become focused on certain erogenous areas. This psychosexual energy, or libido, was described as the driving force behind behavior.

If these psychosexual stages are completed successfully, the result is a healthy personality. If certain issues are not resolved at the appropriate stage, fixation can occur. A fixation is a persistent focus on an earlier psychosexual stage. Until this conflict is resolved, the individual will remain “stuck” in this stage. For example, a person who is fixated at the oral stage may be over-dependent on others and may seek oral stimulation through smoking, drinking, or eating.

1. THE ORAL STAGE

   

Age range: Birth to one year

Erogenous Zone: MOUTH

During the oral stage, the infant’s primary source of interaction occurs through the mouth, so the rooting and sucking reflex is especially important. The mouth is vital for eating, and the infant derives pleasure from oral stimulation through gratifying activities such as tasting and sucking. Because the infant is entirely dependent upon caretakers (who are responsible for feeding the child), the infant also develops a sense of trust and comfort through this oral stimulation.

The primary conflict at this stage is the weaning process–the child must become less dependent upon caretakers. If fixation occurs at this stage, Freud believed the individual would have issues with dependency or aggression. Oral fixation can result in problems with drinking, eating, smoking or nail biting.

2. THE ANAL STAGE

Age Range: 1 – 3 years

Erogenous Zone: Bowel and Bladder Control

During the anal stage, Freud believed that the primary focus of the libido was on controlling bladder and bowel movements. The major conflict at this stage is toilet training–the child has to learn to control his or her bodily needs. Developing this control leads to a sense of accomplishment and independence.

According to Freud, success at this stage is dependent upon the way in which parents approach toilet training. Parents who utilize praise and rewards for using the toilet at the appropriate time encourage positive outcomes and help children feel capable and productive. Freud believed that positive experiences during this stage served as the basis for people to become competent, productive and creative adults.

However, not all parents provide the support and encouragement that children need during this stage. Some parents’ instead punish, ridicule or shame a child for accidents. According to Freud, inappropriate parental responses can result in negative outcomes. If parents take an approach that is too lenient, Freud suggested that an anal-expulsive personality could develop in which the individual has a messy, wasteful or destructive personality. If parents are too strict or begin toilet training too early, Freud believed that an anal-retentive personality develops in which the individual is stringent, orderly, rigid and obsessive.

3. THE PHALLIC STAGE

Age range: 3 – 6 years

Erogenous Zone: Genitals

During the phallic stage, the primary focus of the libido is on the genitals. At this age, children also begin to discover the differences between males and females.

Freud also believed that boys begin to view their fathers as a rival for the mother’s affections. The Oedipus complex describes these feelings of wanting to possess the mother and the desire to replace the father. However, the child also fears that he will be punished by the father for these feelings, a fear Freud termed castration anxiety.

The term Electra complex has been used to described a similar set of feelings experienced by young girls. Freud, however, believed that girls instead experience penis envy.

Eventually, the child begins to identify with the same-sex parent as a means of vicariously possessing the other parent. For girls, however, Freud believed that penis envy was never fully resolved and that all women remain somewhat fixated on this stage. Psychologists such as Karen Horney disputed this theory, calling it both inaccurate and demeaning to women. Instead, Horney proposed that men experience feelings of inferiority because they cannot give birth to children.

4. THE LATENT STAGE

Age range: 6 to puberty

Erogenous Zone: Sexual feelings are inactive

During the latent period, the libido interests are suppressed. The development of the ego andsuperego contribute to this period of calm. The stage begins around the time that children enter into school and become more concerned with peer relationships, hobbies and other interests.

The latent period is a time of exploration in which the sexual energy is still present, but it is directed into other areas such as intellectual pursuits and social interactions. This stage is important in the development of social and communication skills and self-confidence.

5. THE GENITAL STAGE

Age range: puberty to death

Erogenous Zone: Maturing sexual interests

During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. This stage begins during puberty but last throughout the rest of a person’s life.

Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas.

Given such background, it is but appropriate that the opportune time to educate children regarding human sexuality is during the Latent Stage, the age when rational, cognitive thinking begins. It is but proper that human sexuality be taught as a formal, standardized lesson, incorporated in their curriculum. Surely it will draw laughters and giggles while being taught, it being a formal lesson will eliminate the awkwardness and taboo that comes along with it when discussed by inexperienced and ill-prepared parents. If at this age we already can teach our children how to cook, what the ingredients are, and how to mix them up together to make the best recipe they can enter for a junior masterchef audition and competition, why can’t we teach them about sperm, ovum, penis, vagina, uterus, prostate gland, fertilization, zygote, fetus? Why can’t we teach them about their body parts? If we avoid educating our children at the most appropriate occasion, they will find different ways to fill in the void in their knowledge and nagging questions about themselves and their sexuality. The more it is hidden from their consciousness, the more it triggers their inquisitive minds and curiosity to find out about it through other means possible.

Digital media is a dangerous venue for this exploration, and is easily accessible. Even if parents prohibit their kids at home exploring through adult websites, these kids will just save their allowance and surf through those websites in internet cafes. Shop owners won’t mind nor do they regulate the websites accessed by their customers, as long as they pay. And if this happens, how many “Jamie” who got introduced to online pornography during a seemingly innocent “sleep over” in a friend’s house, are we breeding? Will it bring you pride if your child’s innocent life has been tainted with a lifetime label, a SEX OFFENDER?

 

Much Ado About Children’s (0-6 years old) Hepatitis B Vaccination Schedule

(Image credit: http://huehueteotl.wordpress.com/category/science/natural-sciences-technology/page/2/)

Not all people can afford to have their children vaccinated at a private clinic but I must say some are just so thrifty that they avail vaccines from health centers for free, then catch up at a private clinic for what’s not been provided. I don’t mind and I actually appreciate these parent’s reasons and practicality. I often do not have conflict of schedules except for the last (third) dose of hepatitis B vaccine.

The acceptable and recommended dose of hepatitis B vaccination is as follows:

1st dose: birth

2nd dose: minimum interval from the 1st dose is 4 weeks

3rd dose: minimum interval from the 2nd dose is 8 weeks but it is emphasized that the final/third dose should not be given earlier than 24 weeks. If given earlier, it should be readministered.

The problem with health centers is that they schedule the 3rd dose to be given 4 weeks after the 2nd dose. I instruct my patient to insist in health centers that the 3rd dose should be given by 6 months of life. Some do oblige but yesterday, one of my patients was insistently given as it is their “mandate” to do so. The other health workers who listen to my patient’s prodding learn, while those who are close minded just blindly follows the antiquated recommendations shoved into their system by whoever is responsible.

Reference: CDC MMWR – Immunization Management Issues (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a3.htm?s_cid=rr5416a3_e)

IMMUNIZING PREMATURES OR THOSE WEIGHING <2KGS

Another confusion comes when dealing with low birth weight infants and/or weighing less than 2 kgs. The recommendation depends on the maternal hepatitis B status.

1. If mother is infected with hepatitis B

• both hepatitis B vaccine and hepatitis B immunoglobulin (HBIg) should be given within 12 hours from birth
• do not count the 1st dose of hepatitis B vaccine as part of the series
• administer another 3 hepatitis B vaccines with the following schedule: (a) single antigen vaccine at 1, 2-3, and 6 months of life, or (b) hepatitis B-containing combination vaccine at 2, 4, and 6/12-15 months
• test baby for HBsAg and anti-HBs at least 2 months from the last dose of vaccine but not earlier than 9 months of life.

2. Mother’s hepatitis B status is unknown 

• administer both HBIg and single dose hepatitis B vaccine within 12 hours of birth
• test mother for HBsAg
• do not count the birth dose as part of the vaccine series
• administer 3 additonal dose of hepatitis B vaccine doses (as above)
• if mother turns out positive for hepatitis B infection, test baby for anti-HBs and HBsAg as scheduled above.

3. Mother is definitely not infected with hepatitis B

• delay 1st dose of hepatitis B vaccine until 1 month or hospital discharge provided weight is at least 2 kgs.
• give (a) single-antigen vaccine: 2nd dose at 2 months, 3rd dose at 6-18 months or (b) 2, 4 and 6/12-15 months

Reference: http://www.cdc.gov/vaccines

 

Prematurity and Post-Natal Malnutrition

(Photo courtesy: http://trendsupdates.com/global-malnutrition-one-sixth-of-humanity/)

Few days ago, a colleague of mine from a different region called and referred a preterm baby for transfer to my service. The case is that of a preterm baby who had blood infection but wasn’t apparently improving with anti-microbials. Baby already was given series of strong antibiotics and seemingly isn’t showing signs of improvement. After about 2 weeks being in the hospital, the first attending doctor talked to them and apparently told them that the baby has a nil chance of survival. They were asked to decide whether to keep baby in the hospital costing them unnecessary expenses or bring home the baby and wait till the baby expires at home. Distraught with the options, the parents brought the baby home. One week passed, and with the baby still alive, they brought him to another doctor, my friend. She honestly told them that it is not her expertise to take care of such case, thus she called me up if she could transfer the baby to my care. I gladly obliged. I really got puzzled why the first neonatologist told the parents the baby has no chance of survival when everything hasn’t been explored yet.

The baby arrived and weighed 1.0kg, he weighed 1.2kg at birth. Babies, whether term or preterm, normally lose weight few days after birth but are expected to regain their birthweight by the end of two weeks from birth. In this case, the baby was already 23 days old so he is expected to be 1.3 to 1.4 kgs. He thus have what we call postnatal malnutrition brought about by several factors – infection, inadequate feeding and gastroesophageal reflux disorder. Baby was immediately worked up and treatment started. During the first few days, baby was already showing signs of improvement; he was gaining weight daily. Unfortunately, he would still have occasional arrests in breathing (apnea). This became increasingly frequent until the day his abdomen distended causing prolonged apnea. Aside from anemia, prematurity as plausible causes of the repeated apnea, I considered infection already of the intestine (named as necrotizing enterocolitis). I had to withhold feedings and resume IVF nutrition, switch antibiotics and add antifungal coverage. I also had to correct the anemia as well as minimize or control the esophageal reflux. It took several days before the apnea could be controlled, and for the abdominal infection to resolve. At present, the baby is no longer on antibiotics, he is already feeding through bottle/dropper, but is still malnourished. Baby being stable and with continuous weight gain, I will be sending home on the next day and requested to follow him back quarterly for his developmental surveillance. His regular follow-ups will be done by my friend in their province. He is now 1.5 kgs, but still a far cry from 2.5 kgs which should be his minimum weight at present.

 

Breast Cancer or the Pregnancy: Which Should Prevail?

(Photo courtesy: http://www.pregnancyandbaby.com)

The tweet exchanges yesterday made me remember one very controversial case I ever encountered during my medical student days, I was a rotator in pediatrics then. It was that of a married woman who was diagnosed to have breast cancer, but it was too late already as she was stage 4. Meaning, the cancer has already spread to distant organs (brain, lungs) from the breasts. Because of this, the oncologist became aggressive with the treatment in an attempt to reverse the condition, if not prolong the life of the patient. But in doing so, the oncologist forgot one important patient data: that SHE IS MARRIED, she forgot to ask when was the last menstruation nor do pregnancy test. So what makes this case controversial after all?

The patient was PREGNANT at the time she was diagnosed to have breast cancer, but neither the patient nor the oncologist have known it that time. Chemotherapy was already started and it was only after the first dose of chemotherapy when the pregnancy was discovered. Also, this happened during the first trimester of the pregnancy! What is dangerous about this is that, chemotherapeutic agents are known to stop the multiplication of cells whether normal or abnormal cells. During the first trimester of human pregnancy, many organs of the fetus are just beginning to form. Rational thinking thus will make you understand that all organs of the developing fetus could be affected by the chemotherapeutic agents the mother has consumed. If the baby will survive, she might be born with several congenital anomalies. I couldn’t imagine the guilt and anguish the oncologist was having at that time. I wouldn’t want to be in her shoes.

The mother decided to keep the pregnancy, she decided not to have further chemotherapies to avoid unnecessary exposure of the baby. This meant her breast cancer will worsen further, considering that it was already stage 4 at the time of diagnosis. Around 25 weeks gestation or barely 6 months, she fell into coma. As it was irreversible, relatives have accepted her fate… but the baby, she’s too premature at that time to be delivered (and there was still no neonatologist available to take care of the baby). Remedy then was to keep the mother alive and her body will serve as baby’s “incubator” until such date when baby would be “safe” to deliver. As they were service case and couldn’t afford sophisticated intensive care intervention, mother remained in the ward, slowly agonizing in pain (a pain not even pain relievers would afford to stop). Unfortunately, on the 28th week of gestation (barely 6 1/2 months), mother succumbed. Immediate cesarean section delivery was then performed bedside (yes, she was no longer brought to the operating room) to deliver the baby. It was a healthy baby girl (female preterm babies have a better survival chance than male). She was then brought immediately to the neonatal ICU at that time and we were just so lucky she did not have the complications of being a premature baby. Also, no visible effects of chemotherapy was observed in the baby, how lucky. The mother on the other hand, after the cesarean section, lifeless, was brought to the morgue.

There are several questions, including ethical ones, surrounding this case. For one, would abortion be an option so mother can continue her treatment? In regions where abortion is legal and allowed, that wouldn’t be a question. But in the Philippines where it remains illegal, this poses dilemma. The argument there would be, the mother and the baby was exposed to chemotherapeutic agent at the point where rapid mitosis and organ formation is ongoing, and where teratogenic would usually exert its effect. Since the developing fetus was already potentially harmed, why allow such pregnancy to continue when you expect the baby to be abnormal in the end? So, abort it (not). Another question would be, shouldn’t the mother have gone cesarean section immediately when she was already in coma so that at least, chemotherapy would have been resumed and might have averted the mother’s condition, right? The problem there is, there’s no better place for the baby to grow but the mother’s womb. Also, chemotherapy wouldn’t have done the mother any good. After all, it was late stage when she was diagnosed for the first time. Prolonging her life would just be prolonging her pain and agony, and there’s no assurance that she can survive the cancer so she could eventually take care of her baby. If baby were delivered earlier, baby might not have survived from prematurity as at that time, surfactant, is deficient from her lungs, and the drug is not readily available in the locality at that time yet (it had to be purchased from centers in Manila, and the drug transport is not that easy). This decision-making indeed may not be conventional but pushed against limits, they’re being done in the field of medicine. Choosing between two evils, and the more beneficial and less controversial option may be the only choice.

 

INLUENZA VACCINATION OF PREGNANT MOTHERS IS PROTECTIVE TO YOUNG INFANTS

Maternal Influenza Vaccination and Effect on Influenza Virus Infection in Young Infants

Eick AA, Uyeki TM, Klimov A, et al
Arch Pediatr Adolesc Med. 2011;165:104-111

Study Summary

Infants younger than 6 months may experience higher morbidity and mortality rates from influenza than those 6-12 months old. The United States Advisory Committee on Immunization Practices (ACIP) currently recommends that pregnant women receive influenza vaccination, but the recommendation is owing to potential influenza morbidity while pregnant. It is less clear whether maternal vaccination against influenza during pregnancy provides protective benefits to the infant after birth.

This study evaluated whether maternal vaccination against influenza during pregnancy protected the offspring. The participants were Navajo Indian and White Mountain Apache Indian children. The study was conducted from 2002 to 2005, covering 3 influenza seasons. The study population was chosen in part because Native American infants experience higher rates of influenza morbidity, and influenza vaccination rates among eligible pregnant women are generally less than 10%.

Eick and coworkers collected demographic information from the mothers through the use of a questionnaire that included information on breastfeeding, influenza risk factors, and the influenza vaccination status of household contacts. The primary outcome of interest was whether the infant experienced influenza-like illness (ILI) during the first 6 months of life. An ILI was defined as a medical visit with at least 1 of the following findings: fever of 38°C or higher, respiratory symptoms, or diarrhea. The investigators identified visits meeting these criteria by reviewing visit records at Indian Health Service sites and nearby private facilities during the respective influenza seasons. In addition to visit surveillance by the investigative staff, mothers were encouraged to contact the investigators whenever they made a medical visit for respiratory, diarrheal, or febrile illness. This voluntary reporting was supplemented with chart review. Serologic studies were obtained from the mothers within the first 14 days after delivery. Infant samples were obtained from umbilical cord blood, within 14 days of delivery, again when infants were 2-3 months old, and a last time at 6 months of age.

In addition to evaluating the effect of vaccine on ILI, the investigators evaluated the effect of vaccine on laboratory-confirmed influenza, which could include influenza-positive nasopharyngeal aspirate specimens, a 4-fold rise or greater in influenza antibodies, or a positive rapid influenza test. The investigators initially attempted to adjust for potential confounders such as tobacco exposure, daycare attendance, and breastfeeding, but these variables were not related to outcomes.

The investigators enrolled 1169 mother-infant pairs. Approximately half of those (n = 573) were born to mothers who had received influenza vaccine during pregnancy. An episode of ILI occurred in 908 (77.6%) infants, 17% of the children were hospitalized for an ILI, 36% had ILIs requiring only outpatient care, and 48% had no ILI episodes. Among the 605 cases of ILI, 83 (14%) had laboratory-confirmed influenza. When comparing children born to mothers who had received vaccine with children whose mothers who had not received the vaccine, investigators calculated a 41% reduction in the risk for laboratory-confirmed influenza virus infection. The relative risk was 0.59; 95% confidence interval (CI) 0.37-0.93. No protective benefit against ILI was evident (relative risk [RR], 0.9; 95% CI, 0.73-1.16).

There was a 39% reduction in risk for infants born to a vaccinated mother when the investigators restricted the analysis to severe ILI requiring hospitalization (RR, 0.61, 95% CI, 0.45-0.84). They concluded that vaccinating pregnant women against influenza was associated with a 41% reduction in the risk for laboratory-confirmed influenza virus infection and a 39% reduced risk for ILI requiring hospitalization. The researchers commented that it was not clear whether this protective effect resulted from reduced influenza illness among the pregnant women or whether antibody benefits are extended to newborns. However, they did find higher anti-influenza antibody levels in infants born to vaccinated mothers, suggesting that some of the benefit was indeed from transferred antibodies.

Viewpoint

In an accompanying editorial, Ortiz and Neuzil^[1] comment that influenza vaccination rates in pregnant women in the United States are poor despite recommendations by ACIP. As pediatric providers, we have an important role in helping expectant mothers understand everything they can do to help their newborns and young children grow and develop safely. Focusing on maternal vaccination that may protect newborn infants, such as vaccination against influenza and boosters of pertussis vaccine, gives us a chance to make a real difference in the early lives of these newborns.

 

ANTIBIOTICS: To Give or Not To Give?

One of the most common problem in the newborn is infection. As a matter of fact, the WHO 2008 data on causes of death among under 5 years old lists infection as one of the top 3 leading causes. The problem is that there is no one single manifestation that is pathognomonic for it; also it may mimic other conditions besetting the newborn. There is diagnostic dilemma and that waiting for the occurrence of symptoms first before beginning treatment may already be late. Guideline in the management of infection vary from one institution to another.  The best approach is to identify risk factors from the maternal history and the physical attributes of the newborn at birth. However, often than not, even maternal history might not be helpful in some instances and cloud the judgement.

(WHO CHERG.org: Causes of Mortality in Under 5 – 2008)

Many newborn care providers are confused as far as dealing with newborns with suspected or definite infection is concerned. Other caregivers are overzealous in their approach such that babies who don’t need antibiotics at all are unnecessarily began with. Is there a danger of starting babies on antibiotics?

American Journal of Epidemiology has reported a result of a cohort study on December 2010 where antibiotics exposure by age 6 months is linked to asthma and allergy by 6 years old. According to senior author Michael B. Bracken, professor of Epidemiology at Yale University School of Public Health in New Haven, Connecticut, “early antibiotic exposure, especially broad-spectrum antibiotics, may suppress the developing immune system and produce a reduced anti-allergic response.” Infants with asthma were excluded in the study. The study found out that those infants who have no family history of asthma, after exposure to antibiotics, have a stronger risk of developing asthma by age 6 years old. The risk for atopic asthma and allergic asthma was also increased.

This should alert pediatric caregivers to use antibiotics conscientiously. Indication of antibiotic use should be ascertained meticulously so as to avoid the infant’s unnecessary exposure, and thus avoiding this increased risk to developing allergic disorders.

(The abstract of the study may be read on this link: http://www.medscape.org/viewarticle/735646?src=cmemp)

 

Parangal 2012-2

Hosting the graduate’s Tribute to their Parents (Parangal)

 

Parangal 2012

Recognition from the graduating class

 

My Rest Day… Gone!

WARNING: This is again another self-serving blog entry. Read at your own risk.

Thursday is supposed to be my rest day, a day for me to rejuvenate and be at peace with myself. On these days, I don’t do outpatient consultation. What I only do is rounds if I have inpatients, go to class if I have one, and then work out. Sometimes, I pamper myself as well. But April 19th, 2012 was different. The original plan for the day was:

1. rounds of inpatients

2. lecture on “breastfeeding of infants with special needs” by 11 am

3. wait for delivery of one baby, which I estimated to take place by lunch time

4. rest or roam around

5. workout by 4:30 onwards

(Photo courtesy: http://www.guardian.co.uk)

This is what actually happened

I slept already at almost 1am of the night before..

6:15 am… my mother called me to inform me that my nephew and aunt will be bringing my laundry. After that I tried to reclaim my sleep but I really cant doze off anymore.

My aunt and nephew arrived, did their thing then left. Since I can’t go back to sleep, I stayed online.

8:30 am… hospital called, the mother’s labor didn’t progress as expected, so she was scheduled for cesarean delivery at 9am. (Huuuwaaat? And to think I even haven’t prepped to go out yet!) I rushed then to shower and when ready, drove fast but alas, traffic trapped me.

9:28 am… arrived at the hospital. Damn, I am sooo late. But as I entered the operating room, the anesthesia was just inducted. Hoooray! I made it to cutting time. haha

10:06 am… baby came out. While waiting for baby to nurse from her mom, I asked permission from the OB to go to other hospital, do my quick rounds at the same time get the VGA cable of my ipad that I will use to lecture in a few minutes. I proceeded to a nearby hospital but came back real quick. Upon arrival, true to my expectation, baby was still suckling. I got ready already for my lecture.

11 am-12 nn… delivered my lecture to the newly hired employees of the hospital. This is in keeping with the hospital’s Mother and Baby Friendly Hospital Initiative certification. Then I had my lunch. After which, I went to my last hospital stop.

1:30 pm… I arrived home. Checked some tweets and messages then decided to take a nap. I set my alarm at 3 pm so I could go to Camp John Hay later to buy something before proceeding to my work out. I conked out at 1:45pm…

2:15 pm… While asleep, I got awaken by a phone call. An OB was referring her patient for pedia care. The mother is on her 32 weeks of pregnancy but is currently in labor. She will be admitted for control of labor… Okay, again, interrupted sleep. Now I was beginning to ask, where is my rest heading? Will I be able to consummate my siesta?

2:38 pm… the OB called me again that the patient is scheduled for emergency cesarean section as her labor is nonstop. “Come to the hospital now,” that’s what she said.

What’s happening to my rest day???? This cannot be!!!

BUT… duty prevailed. So I then proceeded to the hospital. While waiting for the cutting time, I was only informed at that moment that the preterm baby to be delivered is twins! Oh good Lord. Now I panicked. The only consolation I have was that the baby is already 32 weeks as per ultrasound aging. The OB didn’t already inform me of the expected weight.

4:00 and 4:01 pm, the baby boys came out respectively. I was supposed to be doing again the Unang Yakap, but I noticed that both has difficulty establishing a good respiratory effort so they were brought to the NICU for further care. Both have respiratory distress syndrome due to surfactant deficiency. Oh, and yes, they were younger than the estimated age at 31 weeks. Both were on mechanical ventilatory support and both needed surfactant replacement therapy. The father was willing to provide said medicine so off he went to buy them. I did all the necessary procedures – intubation, umbilical vascular catheterization for both, alone. The resident never bothered to peek or assist me. At 8:15pm, the father arrived. So I instilled the surfactant into the lungs of both babies.

8:21 pm… I was done. Finally!!! I left the hospital… Sigh, I missed my workout for the day… So I went to Camp John Hay instead to buy what I intended to, then went home.

As I sit and write this, I am again waiting for a mom to deliver a preterm baby, with premature rupture of membranes. Boy, this one’s again risky.

I am not complaining here… I’m just describing one of the days that happen in my life, and I was hoping that it wont happen again on my supposed rest day. I do acknowledge and realize the importance of rest and break in a physician’s life as this is one manner that helps us maintain sanity and avoid early burn out from the practice of profession. So I guess, better luck next time dear self.

 

How Do I Tell The Mother?

I dont even know what to write, or how to start writing this… One thing for sure is that DEATH is inevitable… At the end of everything, DEATH is the only victor, it will conquer us all, no matter how much we try to avoid and evade it.

(Photo courtesy: http://thinkinlikegavroche.wordpress.com/2011/11/08/a-grieving-mothers-wish-pantoum-poetry-by-toni-cross/)

A mother on her fourth pregnancy was scheduled for emergency cesarean delivery as the fetus’ heart rate and activity is reflective of ongoing distress. Baby had immediate respiratory distress requiring her mechanical ventilatory support to breath effectively and with ease. Despite the assisted breathing, baby still showed progressive respiratory distress typical of preterm babies with deficient surfactant. Within hours, surfactant was administered affording slight relief. Baby’s response wasn’t dramatic as expected; perhaps due to delay from the ideal time of administration from birth. Few days after, when favorable response was expected and weaning from mechanical ventilator was expected to be quick, another problem arose, a patent ductus arteriosus. This now prevented us from weaning off the baby from the respirator. I administered an anti-inflammatory drug in an attempt to close it. After few doses however, the artery remained patent, otherwise baby was doing well. The next day saw poor blood gas status requiring appropriate adjustment of the respirator settings. I saw baby in the middle of the night as I had another baby born at the same hospital.

On the fifth day of life, everybody was surprised by the baby’s status: she was in severe shock. The right forearm to the hands changed in color similar to the hands of Dumbledore that destroyed the ring of Marvolo Gaunt. She was bleeding from her lungs, stomach and all puncture sites would take a long time to clot. Her skin was doughy dry and pulses were thready and barely palpable. Her abdomen and lower extremities were swollen. Blood gas were abnormal and needed correction. Medications were revised, blood products were secured for transfusion, respiratory settings were increased accordingly and cardiac drug support was added. Blood gas analysis had to be done serially but to no avail, she kept on having uncompensated mixed acidosis. Ventilator settings were increasing; urine output was decreasing signifying failing kidney as well. When she was “stabilized” (and so I thought she was), I went to other hospitals to round other patients and consult those at the clinic. Having a stable update at the end of the morning shift, I proceeded to my workout (this keeps me sane), while waiting for another possible preterm baby to be delivered. Then I went back to check on her after I was done, making sure she was stable. I then decided to go home and do my waiting there for the call to deliver the preterm baby. While waiting, I received a referral about the problematic baby, saying that color became worse. She immediately requested for blood gas analysis; the result made my intestines knot several times as the figure clearly spoke of death. The pH was 6.7! (In medical parlance, a blood pH of less that 7 or more than 7.7 is NOT compatible with life). I ordered for aggressive correction and while doing so, I got called to another hospital; it was time to deliver the preterm baby. It turned out that the baby was term. Upon making sure that the newly born baby was well, I went back to the other hospital where my problematic preterm is. Yes, I brought blanket with me as I expected to keep vigil and watch over her. She remained stable and early in the morning, I repeated the blood gas analysis. It was still below 7 at 6.8. I already knew that “Death” has already claimed baby with his scythe, and I was just waiting for exact time her heart will beat last.

(Photo courtesy: http://www.medscape.com)

I saw the mother… I was helpless, I didn’t know what to tell her but I know that she already had the feeling. Mother’s have instincts, they would know when their child isn’t doing well. I just didn’t want to underscore and concretize the fear that she was feeling inside. Was that the right approach? I don’t know. I just didn’t want to sound and appear mean to her that early hour of the day. So, in my attempt not to crack the bad news, I asked her religion and if she wants baby to be blessed/baptized while there’s still a chance. So far in my mind, this was an indirect way of saying she will not make it. She agreed and arranged for the minister to pay the baby a visit. Before I left, I told her that it is up to baby’s response where this treatment will go. Then I went home at around seven o’clock to have my breakfast and for few hours rest. I was anticipating then that I will be called during lunchtime when the baby’s heartbeat has ceased. I finished my clinic consultation and rounds at other hospital when I finally got THE CALL. When I saw in my phone’s LCD that name of the caller (the hospital where the problematic preterm is), I already knew it was TIME. True enough, even without me asking, the first sentence of the caller said “We can no longer appreciate a heartbeat.” So I rushed… checked on her, and called the time of death.