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 Posted: Wed Dec 5th, 2007 12:03 am
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Doc C
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Just got back from my annual medical meeting in D.C. - Hot Topics in Neonatology. As a bit of background before I pose my question. Neonatology is one of the youngest subspecialties in medicine having its origins in the early 50's but not being recognized as a real specialty until the late 60's - early 70's. I started in the practice during the mid 70's and can vividly remember taking care of infants just 34 weeks gestation (full term 37 - 38 wks) and how precarious their survival was then. Little was written in the literature regarding the care of premature infants much less about the "standard of care". Jumping to the present time, 34 week infants essentially pose no problems for us to care for now and we're currently working with infants (fetuses) 23 - 25 weeks (another ethical discussion which I'd be happy to discuss). At that early period, we were essentially flying by the seat of our pants in caring for these infants, i.e. incorporating treatment modalities which were not verified by studies,(using them because we thought they'd work), using adult treatment modalities and scaling them down to these babies. What was driving us in part was the general public/parents and our own desire to do everything we could for these infants, who left untreated would have died (one of Pres. Kennedy's children was born at 34 weeks and died in the early 60's). We're currently are finding that some of the treatment regiments, rather than doing the babies good, were potentially doing them harm (not intentionally). My question to the lay public, was it right for us to use these unproven treatment modalities, even though we had no proven studies to their effectiveness, to try to save these babies or should we have said we won't use them and potentially let these infants die. Would be interested to see what those individuals out there have to say. (An interesting aside, the McClellen statue was across the street from the meeting on Connecticut Ave.)

Doc C



 Posted: Wed Dec 5th, 2007 12:44 am
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ole
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Doc C:

Inasmuch as the experiments were done simply because you had no other recourse but to try something -- anything -- to try to save a life, I'll venture to say that something, however ill-informed, is better than nothing.

Just a thought.

ole



 Posted: Wed Dec 5th, 2007 02:14 pm
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Don
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Doc,

In so far as my understanding of the Hippocratic oath goes, did you really have any other option than to try to help them if you could?

Don



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 Posted: Wed Dec 5th, 2007 06:46 pm
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younglobo
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Doc C .. As a Former premature baby myself born in the era you are speaking of 11-9-70 I would like to thank you and others like you for taking the steps weither proven or unproven to keep me alive. I was born 2 1/2 months early and have been told my chance of survival was not very good in the early going as it was I didnt get to come home from the hospital till Christmas eve. My father tells me you could litterally hold me in the palm of your hand. My mother also gave birth prematurly to my brothers a set of twins in 68-69 which only lived hours due to the stituations you described above. So Kudos to you and the others in your profession for doing what they could with what they had.



 Posted: Wed Dec 5th, 2007 07:10 pm
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Doc C
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I was a premature twin myself. In that era, put you in an incubator, put you in the corner and wish you a lot of luck. Bama, correct about RLF, now termed retinopathy of prematurity (ROP). In a nutshell, it's when abnormal blood vessels form around the retina eventually leading to scar tissue which could lead to detachment of the retina thus blindness. Too much oxygen can promote the growth of abnormal vessels prior to 32 weeks. Now with frequent exams and laser or cryotherapy blindness is an extremely low occurrence. The incidence quoted is between 3 - 6% foe infants less than 32 weeks. I know 2 pediatricians who cared for premature infants in the 50's and lost a major malpractice suit due to oxygen administration and subsequent blindness. In this current time, if you have a baby with ROP/blindness, you'll soon be hearing from a plantiff's lawyer. We still do not know what the correct amount of oxygen to give these infants, i.e. what is too much or to little. Another problem is 3rd world countries where the incidence of ROP is skyrocketing due to their inability to monitor oxygen levels appropriately in their premature patients. By the way, oxygen is the most common drug used in the NICU's. One of the main reasons I stopped taking care of extremely premature infants (1lbs, 23 - 25 weekers) in Level III NICUs and just do part time in Level II NICU's (regular, health baby nurseries are termed Level I) was the ethical issues I was having to deal with. I had serious concerns about the long term consequences for these infants, i.e. blindness, deafness, severe mental retardation, cerebral palsy.

Doc C



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 Posted: Wed Dec 5th, 2007 08:43 pm
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Doc C
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Hopefully the trend of using evidence based medicine (decisions which are thoroughly reviewed and studied) will continue to grow rather basing treatment decisions on antidotal, small studies, we think it will work philosophy, thus eliminating some of these commonly used treatment modalities which either do no good or do harm. An excellent source for evidence based topics - http://www.cochrane.org/reviews/

Doc C

Last edited on Wed Dec 5th, 2007 08:44 pm by Doc C



 Posted: Sat Dec 8th, 2007 04:29 pm
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susansweet
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Doc, when I was teaching first grade gifted kids I had a family of girls  that over the years I taught.  When the second one of the group was in my class the mom had her fifth and last daughter.  The baby was a premie, so tiny as others have said you could hold her in the palm of your hand.  Mom had to be in bed most of the pregancy Dad had his hands full.  The daughter in my classroom and I bonded .  We still stay in touch to this day. 

She could have hated the baby for taking all the attention but we worked with her to make the baby hers.  The little one had to have a shunt , couldn't come home for a long time from the hospital , I believe she was seven weeks premature .  Not much hope was given to her.  They told the parents the chance of retardation was 80 per cent. 

The two sisters, the one that was in my class at the time and the little premie bonded . Everything the older one did the little one had to do and do better. 

Six years later the child with 80 percent chance of retardation was in my gifted program.  She did well all the way though.  In high school she went into the theatre arts program .  I never missed one of her plays . She was the star of the company each play for four years.   She went on to a conservatory for theatre .  I saw her play the mother in Glass Menagerie last spring.  Thanks to some wonderful doctors for saving this talented young lady's life as a premie. 

I also had a roommate in college that had been a premie blinded by too much oxygen. She never let her blindness be a handicap.  She vaulted over the vaulting horse in gymnastics.  Last I hear of her she was marrying a ski instructor she met when she took skiing lesson and moving to Colorado. 

Thanks Doc for all you do . 

Susan 



 Posted: Sat Dec 8th, 2007 07:58 pm
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ole
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It would seem, Doc, that giving the gift of life is about all you can or ought to do; however, imperfect or chancy. The old saw: anything is better than nothing.

Is it better to live with whatever impediments than it is to die? I'm not into eugenics to that degree. And so, I have no comment other than that every life is sacred, however flawed.  Your oath is to do no harm. It need not be taken a greater extent. Are you doing harm by preserving a life that will ultimately prove to be useless? I won't make that judgement. And I will cheerfully oppose anyone who presumes to make that judgement.

Would civilization be better off without that burden? Unquestionably. Ought civilization be trusted with the distinction? No way! We pays our money under the existing moral rules, and we takes our chances. That we get a few aberrations is to be expected. But the moral rules do not permit letting this or that one die without a chance. And, in that, my hat is off, sir.

ole



 Posted: Sat Dec 8th, 2007 08:03 pm
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ole
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That's it! I just flipped off the cretin on TV. I am totally incapable of rational thought from this moment on.

ole



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