Friday, February 22, 2008

Skeletons


The first things I did when I woke up this morning, waking after ten hours of glorious comatose-like sleep to the sound of the rain instead of my radio alarm, was think about work.

I can’t seem to leave it alone. Yesterday I had a seven week old patient come in who is still at his birth weight. Now it is normal to lose some weight after birth—in the first few days baby’s can lose up to 10% of their birth weight—but by 10 days of life they should be gaining about 33 grams, or one ounce per day. This child had gained exactly 1 ounce in seven weeks. He looks like a tiny skeleton. His cheeks are hollowed out and the muscles on his legs have none of the baby fat to hide them; they tense with every frantic movement. His mom is adamant that he only be fed breast milk, without calorie supplements, without pumping and giving him a bottle. She may not produce enough (judging by the size of him, no where close) since she had a breast reduction 20 years ago so she has recruited other women to give him their extra milk, which she tries to give him via a dropper held next to her own breast. During my interview of her, he frantically sucks at the breast the entire time, using what precious little calories he gets trying to find more food. She nurses him for one hour every two hours. Nursing is the equivalent to running a marathon for a baby. Their only jobs are eating and sleeping. He spends so much time energy and time trying to nurse that he has none left over to grow, barely enough to survive.

When I have finished talking to the single mother who’s ex (father of the baby) has left her for another woman, as she coos over her tiny skin and bones first child, I order nutrition consults, social work consults, lactation consults, failure to thrive consults, pre/post nursing weights, hemoccult stools, vitals, limited time spent on the breast, and more with the donated breast milk; and I call her pediatrician. We share our frustration over the failed interventions over the past seven weeks, perhaps a combination of the mother’s insistence on giving him only breast milk (which isn’t there) and her midwife writing her notes saying, “Baby is doing great today!” which the mother shows to me proudly. Instead of worrying about this baby for the past couple hours, his pediatrician, Dr. Whitney has worried about him for the past seven weeks when he has failed to show up for several appointments while continuing to lose weight, “Worrying about this child keeps me up at night. I don’t know what else to do.”

And so it is. I now wake up worrying about this child. On my one day off, I roll over in bed, reach over my pseudo bed companion (two pillows I line up next to me) and turn on my phone. My first call is to the nurse. She reports that the baby is sleeping next to mom. “Good,” I think, “better than wasting all his energy trying to nurse. He needs to sleep.” I make sure I have added the lactation consult. The next call is to the California Newborn Screening project to see if he has any underlying metabolic abnormality that might explain his skeletal-like appearance. In bed, I remember his date of birth, hospital of birth, how to spell his unusual first and last names. These details already ingrained in my memory. His newborn screen is normal. So we’re back to calories. More in, less out.

The opposite of what I tell my obese adolescents, who I worry about too. Like the 87 pound second-grader with a family history of diabetes. I see his future health problems, if he doesn’t lose the weight and change his habits now.

This is not a profession easily left at the office. One of my residents in medical school told me that being a doctor isn’t a profession, it is a life. Now I see the veracity of his statement. And so it is.

It’s no wonder I can’t focus on anything else well. I have flashes of loneliness curled up to my pillows late at night in the seconds before I pass out from exhaustion. I feel guilty about the things I cannot do—about the things I do not know. I read “The Four Agreements” in the few minutes I take to eat breakfast in the gray dawn and remind myself to “always do my best” and forgive myself when I feel that my best isn’t good enough. I listen toNPR to remind myself that life exists beyond my small corner of concern. I blast my “happy” iPod playlist while I workout, trying to drown out the noisy thoughts of the things I should have done, or should do, or should review. I read “Three Cups of Tea” and realize how blessed I am to have learned what I have learned and know what I know. I think of dates I’ve avoided or men I have don’t take time to know, telling myself I’m not worth it and don’t have energy anyway. It’s easier to hide behind work sometimes. Is it because it hurts less? It hurts differently, somewhat less personally. Emotions in, emotions out. My personal life is an emotional skeleton. I wake up worrying about tiny babies, wondering what else I can do. Trying to fix things that someone else has broken, because I want things to be perfect. Because I want to be perfect, and I know I can’t.

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