Pediatrics- the object of my
obsession for the past couple of decades has finally been a journey that I have
traveled through. Upon entering medical school, I was convinced that I would be
a pediatrician; however, my goals were later shifted toward family medicine and
yet again pediatrics has been thrown into the mix. Pediatrics was 8 weeks of
giggling and crying, greater than 10 hour shifts and chronic hand washing/mask
wearing. It was the rotation I was warned would infiltrate my body’s immune
defenses and give me some odd stomach bug or chronic cough, but one that left
my immune system unscathed only to infiltrate my heart, heighten my senses and
make my smile one size bigger. It is a rotation I will forever be fond of and a
rotation that has truly demonstrated the vulnerability of young minds and the
courage they are capable of wielding; the purity of a child’s soul and the
darkness that is capable of tormenting the pre-disposed; and finally the joys
of health and the suffering of the sick. It was an experience that brought a
whole new meaning to one of my favorite quotes from the ever popular Hunger
Game series that states, “My mother tries to save the strongest [medication]
for the worst pain, but what is the worst pain? To me, it’s always the pain
that is present.” This clerkship has driven me to develop a new appreciation
for the expansive capabilities of pain penetration and perception. I must admit
it is much easier (for lack of a better adjective) to see adults suffer, and
let me add that watching an adult suffer is not easy. I also developed a fear
for the irrational and unjust behaviors of Illness, and how it unashamedly
creeps into even the most wholesome of souls.
UNM’s pediatric department is
filled with literally some of the best doctors I have had the privilege of
working with. They are full of innovative ideas, knowledge, enthusiasm and
humor. There were times when I felt like they were “my people,” a description
known to all my fellow Grey’s Anatomy fans. I remember warmly a moment where we
all eagerly stood in front of the long window in Tully Conference Room and
longingly stared into the distance as balloons of all shapes and sizes
participated in New Mexico’s famous mass ascension. I was pleased to share in
the excitement of these people. I was pleased that they hopped around like
little kids, just as my natural response led me to also do.
I am reminded of a time in my
pre-medical school life when I participated in a Sacred Sites class, or rather
a hands-on honors course dedicated to the study of religion. At one of the
sacred sites, we visited with a Native American man who graciously shared his
sweat lodge with us on one late afternoon in May. I remember how he discussed
the importance of the number four- there are four directions, four seasons,
four stages of life and so forth. Since then I have been not only fascinated
with this idea, but also more cognizant of the power of four and avenues for
application. I feel that using this golden rule is a unique approach to further
dividing the overly broad field of pediatrics. Pediatrics is simply considered
the specialty devoted to the care of little people, or more specifically those
under the age of 18. But imagine the diversity in of itself in those short 18
years of life? It is immense with one end of the spectrum focusing on newborns
who are precious in many ways, but capable only of eating and sleeping and the
other end dedicated to the enormously complex mind of a teenager who struggles
with the vastness of identity, the mysteries of puberty and the struggles of
conformity. For this reason, I will use the idea of a culture foreign to my own
in an attempt to organize my thoughts. Forgive my naïve approach. As a
non-parent, I am attempting to categorize those little creatures whose only
opportunity for familiarity is my very own little sisters and those little
buggers aren’t the most normal prototypes for comparison. My categories include
the cradled and crawling, the sponges, the becomers and the enigmas.
1. The Cradled and Crawling
My interaction with the smallest
forms of human life was one that began with comfort struggles and one that
ended with vengeance over comfort as I conquered my first solo surgical
procedure. Babies flooded the newborn nursery daily, leaving as quickly as they
had come. New families were created and existing families were made larger. I
was challenged with performing the newborn exam and quickly became a pro at
determining the age of gestation and comforting a crying baby. It also
triggered a memory of the first newborn exam I had seen performed. It was 7
years prior following the birth of my baby sister- Mistidawn. I remember the
pediatrician, Dr. Bunch (my first mentor and role model), as he not-so-gently
handled my newly welcomed sister. He quickly and haphazardly undressed her as
Deidra and I sighed because we had just spent the last hour meticulously
changing her diaper and clothing her while also being terrified of the
fragility she exuded. I was now on the other side of this seemingly tortuous
exam, and I was the one being stared down by concerned family members.
Initially I struggled with this exam, because I approached every maneuver in an
overly cautious manner, but within two days I was handling those little
newborns like small sacks of potatoes. You might think this is outrageous, but
it’s actually a skill that necessitates rapidity and efficiency while also
maintaining a delicate touch. I further demonstrated my continuously evolving
confidence by performing a circumcision completely solo.
Also during my interactions with
the cradled and crawling, I unfortunately witnessed the cruelest forms of
abuse. The baby was but weeks old when he had been violently shaken suffering
over a dozen fractures. I remember the first time we entered that room. I
stared at the small infant in his crib, uncertain what to feel, but wanting to
feel nothing. This precious little boy surprisingly did not suffer any lifelong
injuries, but he did lie there in his hospital issued crib with an extremely
elevated heart rate and mute as can be. I worried that he had been punished for
crying, and now was trapped in silence, cradled only in an unconscious fear.
2. The Sponges
The sponges are the little munchkins that run from point A to point B
rather than calmly walking. They repeat every word they hear and they learn to
imitate older siblings, good or bad. Take my youngest sister, for example; She
used to hold up the peace sign with her miniature fingers just as her older
brother did, and so when I was attempting to explain to her the reason our
sister, Jelly, had to miss Thanksgiving to serve our country in Afghanistan in
order to establish world peace, she looked at me somewhat confused and threw up
the peace sign. I longed for a reality that was as simple as those two little
fingers separated by a couple inches of air.
I ran into many “sponges” in the clinics and hospitals,
and I first handedly experienced the reality of “kids saying the darnest things,”
like when a young boy with flu-like symptoms told me his veins hurt. I was
fascinated by how his developing brain with a large majority of unmyelinated
fibers was perceiving illness. I also interacted with another kiddo with
Cerebral Palsy. He was bound to a wheelchair, one of the smallest I had ever
seen, and he was slumped over in obvious pain one week following an extensive
bladder surgery. As I gently examined him, he opened his eyes only briefly, stared
straight into mine and politely asked, “Can I listen too?” while pointing to my
purple stethoscope. I gladly placed the ear buds into his little ears and held
the stethoscope over his heart and over mine. I was happy to use medicine to
bring a much needed smile to his face. Another demonstration of imagination was
when I visited my young patient with scruffy hair, big front teeth and
mastoiditis. This young boy who had a rare immune deficiency was all too
familiar with being hospitalized for his numerous infections, and had even
developed his own medical lingo, which is much more entertaining than our
Latin-based terminology. One morning, as I asked how he felt throughout the
night, he replied with “I was armadillo-ing all night.” My puzzlement must have
been obvious, because he was quick to explain that “armadillo-ing” is the act
of crawling into a ball when experiencing pain. I couldn’t help but chuckle and
later shared the new addition to my lexicon with my fellow colleagues. Little
did I realize, I was participating in reverse spongosis- my very own neologism
to describe the process of absorbing some new piece of information from a sponge.
Unfortunately, there were also sponges who absorbed disturbing medical
experiences. During preparation for a tonsillectomy and adenoidectomy, a young
Arabic child who spoke only her native language sat in a room surrounded by her
parents and doctors who purposefully spoke only English to discuss the
procedure she would soon undergo. Her parents had requested that an interpreter
not be present from start to finish as they did not want to disclose the fact
that their daughter would be in surgery. It was a cultural wish that would be
respected, but one that I felt was far from ideal. As I stood there in the
Operating Room doing my best to be helpful, I zoomed around moving things to
and fro and allowing my eyes to dart back and forth between the task at hand
and this obviously timid child. We locked eyes multiple times, but it wasn’t
until the anesthesiologist began to hold the mask over her face to initiate
general anesthesia that she began to kick and scream at the top of her lungs.
Her tears must have been pre-formed, because they immediately flooded down each
cheek. The OR staff gently yet assertively restrained her and this only further
prompted her to thrash about in every attempt to escape the blue-gowned aliens.
I rushed over and whispered the only few Arabic words that I had learned while
vacationing in Egypt. “Marhaba habibi” (Hello sweetheart) were the last words
she heard before quickly drifting into oblivion, and words that I hoped had
given her some peace before waking up to the worst sore throat of her life and
once again surrounded by the strange people who had held her tightly and used
their medicines to bring about a restless sleep.
3. The Becomers
The Becomers are the pre-teens
and just before. They’re the most awkward of all the groups and they’re considerably
impressionable. They begin to develop their own sense of style. They
unknowingly put more thought into the selection of their friends, and
characteristics become permanent pieces of their lifelong personality. So when
they have grave and incurable diagnosis like leukemia and Neurofibromatosis,
these crucial moments of development become augmented with a sooner than normal
demand for maturity and worry beyond comprehension. And when these needs are
not met, understandably so, their world continues to go further awry.
I had entered her room that
morning and knew nothing more than the gossip that had traveled through the
doctor’s workroom. After a home nurse had visited this young girl in her Gallup
home, the nurse was startled with a barely readable glucose level of greater
than 670. The family was urged to quickly head to UNMH, and since then the word
had spread that this 12 year old previously diagnosed with leukemia and
complicated by Diabetes brought on by her cancer treatment had refused to
inject even a single unit of insulin into her body. Whispers roamed the
pediatric wing about possibilities of contacting Child Protective Services. The
young girl with a mostly bald head and pink punk rock clothing sat in her bed
with the thin hospital blanket up to her chin. She looked at me and even
smiled, but throughout the entire interaction she relied solely on shaking her
head yes or no. I felt conflicted. This young girl was undoubtedly harming her
body by walking around with outrageously high levels of glucose. But was she taking
a stance against her disease in an attempt to feel in control of her situation?
Or was she merely in denial? I’d like to think that she was using what little
power she had over her situation and she was strongly choosing to do something,
even if that something was nothing. People
were furious that she was refusing insulin, but could we sincerely put
ourselves in her shoes and understand where she was coming from. I thought back
to the 12 year old version of me- I was obsessed with cheerleading and student
council, I loved having sleepovers with my favorite girlfriends and I freaked
out over a simple pimple on my face much less a completely bald head and having
a cancer stigma attached to me. I felt as if we had unrealistic expectations for
this young girl. Sure were wanted a mature and strong reaction to her disease
treatment, but illness was penetrating her ability to become- to become the
best volleyball player on the team, an innocent girlfriend of the boy in math
class, or the student council president. Her life in such a short time had
become doctor’s appointments and hospitalizations, agonizing nights of dealing
with chemotherapy side effects, and
being many miles from her community. She couldn’t become her, because she was
too busy becoming who we wanted her to become- a compliant, mature, completely
rational patient constantly on the verge of death.
4. The Enigmas
The fourth and final pediatric
group is one that is composed of highly complex and nebulous individuals. I saw
enigmas ranging from 15 year old
girls with serious and even lethal diagnoses still confidently (and rightfully
so) making plans for their futures, and 16 year old boys who were already
abusing multiple illegal substances. I
saw an 18 year old who had just attempted to end her life by swallowing a
bottle of her mother’s anti-depressants. I remember telling her about all the
amazing adventures I’ve had since I was 18 in hopes of reminding her how much
she has to look forward to. By the end of the long conversation, I had her
telling me she wanted to be a doctor when she grew up. Unfortunately, it is the
most outlandish of enigmas that remain in my mind. Like the young teenage boy
who defiantly spit into his surgical wound in an attempt to draw attention to
himself, a statement he made clear while staring into my eyes with such
intensity I thought I might turn and run the other way. He was a boy who
unashamedly shared his devilish ways and also one with a solid command of the
English language choosing each word meticulously so as to manipulate the person
at hand. And when he demanded pain medication, he proceeded to tell me he was
allergic to Tylenol, aspirin and all the other “baby” analgesics out there and for
me to make sure he for the “good stuff.” He was an enigma entangled in defiance
and opposition, an enigma I, along with the rest of the world, would never
understand.
Another kid was an abandoned 17
year old boy who was brought in by his aging grandparents in hopes of finding a
better answer to his rapidly progressive isolative and odd behavior. Grandma
and Grandpa described him as a once loving grandchild who loved to sing and
play. Now he was withdrawn and spoke only minimally. He heard voices, his
language skills were deteriorating and he had quickly been transferred to
Special Education class. And worst of all his older twin brothers, as well as
the rest of society, were quickly beginning to shut him off. The young boy had
already been given a diagnosis of schizophrenia, a diagnosis that was strongly
based given the history of his schizophrenic mother who had abandoned him and
his brothers when they were children. He met all the criteria, yet the
grandparents were in search of more pleasing diagnosis, one that did not commit
him to a lifetime of shame, medications and dependence on others. They
frustratingly shared how they needed a cure, because there wasn’t a single soul
in the world who would be capable of caring for him as they approached an
elderly age necessitating care for themselves. They cried when they explained
that his older brothers had no interest in offering support, and so an
affirmative diagnosis nearly crushed their hearts. He was an enigma trapped in
his own mind, an enigma his grandparents loved dearly but feared losing.
In the end, I learned that pediatric
patients are susceptible not only to the physical changes of illness, but they
are challenged with the emotional and psychological aspects even more so than
their adult counterparts. Their bodies and minds change in ways that their
peers couldn’t even begin to comprehend. When subjected to the unjust abuse, the cradled are no longer cradled in
love and showered in kisses, but rather they become cradled in fear and
silence. The sponges continue to soak up the interactions of their surroundings
just as they were made to do, but they also teach a thing or two to anyone who
will listen- so take the time to listen. The
becoming become someone different,
because of the demands that illness places on their weary bodies and delicate
minds. And the enigmas, especially
those additionally complicated by mental health illness, are even farther from
being understood than the enigmas without health concerns. Kids, the future,
the vulnerable, the capable, they will forever be on the roster for illness,
because as I said before disease has no prejudice, and for this reason, all of
society should practice compassion, take time to listen and be a paradigm worth
imitating.
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