Sunday, October 28, 2007

this is why

(Me with Cal, October 2005)

Those of you who have been reading this blog for a good long while (or who at least have plumbed the depths of the archives) know that before I started my Anesthesia residency, I spent two years as a Peds resident. Yes, that was me in the bear costume. (Just kidding. I had a monkey costume.) (Also just kidding.) (Or am I?)

Aside from "Why did you decide to switch out of Peds?" (the short, vastly oversimplified answer: I couldn't find a career path that I was happy with in Pediatrics, and I couldn't envision what I saw myself doing within the specialty ten years down the road), the question I am most commonly asked is, "Are you going to do a Peds fellowship?" That is to say, a fellowship specializing in Pediatric Anesthesia. This question makes good sense. I think that when I switched fields with 2/3rds of a Peds residency under my belt, most people assumed that I was eventually going to specialize in Pediatric Anesthesia. Heck, I assumed as much. But obviously, I am not. Inquiring minds want to know why.

As with most big questions, there are several answers. There are knee-jerk answers that I can give that almost anyone will believe, because they contain elements of truth. Practicing Pediatric Anesthesia is stressful, because things can go wrong quickly. The stakes feel much higher. Lots of people will want to sue you. Trying to learn all those syndromes makes my head spin. And while I have thought some or all of those things at some point during my rotations through the [Children's Hospital] ORs, there is one bigger, underlying reason that I probably will not end up doing Peds Anesthesia. The reason is that, as a parent, I just don't like taking care of sick kids.

This should not be confused with not liking the kids themselves, or not liking being in the position to help. I just don't like the reaction that it elicits in me, this kind of primitive dread and sadness, empathizing with the parents and yet trying to distance myself in the attempt to fool myself that bad things can't happen to me or my family. But bad things clearly happen all the time, and the attempt at distancing never works.

I preop a five year-old oncology patient, whose mom tells me that he was perfectly healthy until he was diagnosed at age three, when routine blood testing turned up some abnormal results. The first thing I think, before I can help myself, is, "Cal isn't three yet."

I bring in a patient to the OR with her parents for a elective outpatient procedure, and we mask induce the kid, I see both parents have tears streaming down their faces. Instead of thinking that they're overreacting, as I might have a few years ago ("It's just a tonisllectomy!") I realize that I probably would react the same way were my kid having surgery.

I round with the Pediatric Pain team on a patient who has end stage disease, and who is probably going to die within a matter of days. The kid is almost exactly the same age as Cal. There have been a series of meetings with the family about code status. To the team's consternation, despite understanding the terminal nature of their child's disease, the parents want (as my attending puts it) "the full court press," meaning intubation, chest compressions, ICU transfer, whatever is needed when the time comes. Hushed conversations are held at the nurses station in which the following sentiments are expressed over and over. What are these parents thinking? This kid is dying! They're really going to put him through all that? They're just prolonging his suffering! And for what? A few years ago, I may have been arguing this exact same thing. But now, though the doctor in me agrees with the medical team, the parent in me can't quite fault the parents for holding on for every last moment. Their baby is dying, and he's only two years old. Who can blame them, even knowing that the outcome is certain, for wanting just a few more days, another hour, another minute to hold him, smell his sweet little head and give him every possible chance, beyond hope, to live? In the patient's room on rounds, I start to tear up, and I am thankful that the room is dark, and that I am standing off to the side of the scrum.

Playing the "I have kids" card is no doubt something of a cop-out. Most of the Peds Anesthesia attendings I know have kids, and virtually every Peds attending I've ever met has a family as well. Sure, they have their moments too, especially when one particular patient or situation hits particularly close to home, but overall, they are able to be empathetic without letting it get in the way of doing their jobs well. So I don't know why every time I'm rotating over on the Peds side, I become Little Miss Sensitive. With rare exceptions, I don't think it shows, and it hasn't really affected my work or anything like that, but I just don't like the way it feels to have all that extra emotion in play. When I'm at work, I want to focus on my work, thinking about every patient and reflecting back on how everything is making me feel is exhausting.

My OB once told me (over an operating table--I was administering anesthesia for a C-section that she was performing) that the moment your child is born, "so begins a lifetime of low-grade worry." That's probably one of the truest statements about parenthood that I've ever heard. And rotating on Pediatrics now, after Cal, has the tendency to fan that low-grade worry up into a flame. I could happily live the rest of my life without having to hear yet another story about how a perfectly healthy four year old suddenly and mysteriously went into fulminant liver failure, requiring a transplant. There's still some conflict in that, of course. The doctor in me finds it fascinating, wants to know the details, see the labs, hear the history. And the parent in my wishes that I could just stop thinking about it.

I'm sure that if I did this all day, every day (in short, if I did end up doing Pediatric Anesthesia), I'd get used to it all, and it wouldn't be as difficult anymore. But I'm not sure I want to do that either. Not that I'm casting any disparagement against those that can do that type of work, because clearly, they are amazing, and I'm glad that they have decided to take on what I and probably a lot of other people could never do. I'm just not sure that it's not supposed to be difficult, so see these things we see, and do the things we do. Part of me thinks it should be hard, and to lose that fear and sadness for these families, and for ourselves, is losing something important.

So, anyway, in answer to your question: that's why.