TY - JOUR
AU - Mendelsohn, Bryce A.
AB - “There's a home birth rolling into the emergency department,” droned the overhead paging system. I went downstairs from the Intensive Care Nursery, where I was the resident, to see our newest patient. The baby was a little under 24 hours old and had been born at home with the help of a midwife. When the midwife returned the next morning, she found the baby breathing too quickly for a normal newborn and convinced the parents to bring the infant to the hospital. When I arrived in the emergency department, I was instantly confronted by angry parents. They had intended for their child to come into this world naturally, at home, with lots of love and breast milk, and now their brand new baby was covered in wires and being filled with intravenous fluids and antibiotics in a sterile hospital room. This was not natural. A few weeks later I encountered a fascinating contrast to this family in the cardiac intensive care unit. A young mother had known that her daughter had a serious heart condition from a prenatal ultrasound. The cardiologists were cautiously optimistic that the defect could be surgically repaired, and plans were made to help her grow after birth until the operation could take place. Unfortunately, when she was born it became apparent that the heart condition was but a part of a more complex syndrome that affected most of her other organ systems, including her brain. As preparations for surgery were under way, she began to deteriorate, first slowly, then more quickly. Before long a machine was breathing for her, several medications were forcing her malformed heart to keep beating, another machine was replacing her failed kidneys, and she received all her nutrition through tubes. After several wrenching discussions about withdrawing care and allowing this child to die naturally, it became clear that her caring mother was utterly uninterested in what might be “natural.” She wanted her child to live. When the end finally came, she pleaded with the medical team to do chest compressions in spite of the sheer futility. Nothing natural remained of this child, whose mother begged us to bathe her dying baby in the artificial. Everywhere children are seen—in every clinic, emergency department, or intensive care unit—there is a presence that both physicians and parents often fail to look directly at or truly acknowledge: Nature. Our perspective on Nature is as important to a patient's care as the diagnosis itself. For an ill child, Nature can be the enemy, and medicine a sanctuary. For a healthy child, Nature may be a trusted ally and guardian, while medicine with its artificiality is suspect. Such differing views seem reasonable from the point of view of a given family. As a resident, however, I am thrown forcefully between the worlds of healthy and sick children and am therefore left to reconcile this paradox in my own mind. I want to understand why parents trust Nature, how they lose faith in Nature when their children become ill, and how I can offer a comforting middle ground to the parents of well and sick children alike. This duality is played out most vividly once each week when every pediatrics resident in the country leaves the bizarre hospital world and goes to a primary care clinic. There, children do oddly normal things like get hurt playing soccer or catch colds, and I often argue with mothers who don't want to vaccinate their children and who decline health screening and don't return for follow-up appointments. Yet scarcely an hour earlier, I had been in the pediatric intensive care unit trying to explain to the mother of a dying 2-year-old that it would be a terrible idea to intubate her child, that she would never come off of the machine, and that her suffering would only be prolonged. At one moment, any intervention is an assault on a natural childhood, and in the next, no therapy can go too far. The dissonance is jarring. Generations ago, when half of children never grew up, the tragic outcomes that are still too common in children's hospitals were simply a part of life. Now, ironically, by preventing so many of Nature's cruelties with medicine, I believe we have slowly started to “trust” it again, even to long for it to the exclusion of modernity. Childhood cancer isn't caused by bad luck or mutations beyond our control. It's caused by chemicals. Autism is caused by vaccines, or maybe plastic. Such assertions are common and belie certain perceptions of, and trust in, the natural world. One cannot blame a resident for having a skewed view of Nature. At first glance one would think that a pediatrician-in-training would have a front row seat to the glories of Nature's handiwork, spending all day with sweet babies, babbling toddlers, and teenagers in their prime. Unfortunately, this is not the case. A residency in pediatrics is a ruthless introduction to Nature, in all its horror. In about 3 years of training thus far, I have seen children devastated by strokes, bleed to death in their bellies, have their brains eaten by bacteria, drown as their lungs fill with fungus, try to hang themselves to end the pain of chemotherapy, and cry out to God asking what they did to deserve all this. Nature is cruel. Nature kills babies every day. I will never forgive Nature for the things I have seen it do to children. Yet at the same time, medical advances have allowed us to keep some children alive longer than perhaps we should, leading their parents to discard any trust in a natural order just when they need it most. Many of these children have had operations, bone marrow transplants, feeding and breathing tubes, drugs without number, and frequent intensive care admissions. A product of Nature's indifference to human suffering, there is nothing “natural” about the very sickest children. Nature only offers a simple one-size-fits-all end point for such children—death—and we strive mightily against it. During my training I have been profoundly bothered by this stark contrast between the parents of healthy children and those of sick children. At some point, parents' skeptical “Do nothing, do nothing” prompted by a faith in Nature turns into pleas to “Keep going, keep going” when Nature betrays them and their child. To offer the best care, I have come to believe, I must gently cure the parents of healthy children of their misplaced faith in Nature, yet quietly remind the parents of sick children that they are still part of a Nature they can neither cheat nor escape. Indeed, a child suffocating as a tumor fills her chest is as natural as acne and colic. I remember a mother who only fed her 1-year-old daughter pureed vegetables. Her diet was meat free, dairy free, gluten free, sugar free, and completely organic. When I suggested a simple blood test to screen for iron deficiency anemia, the mother looked at me as if I were crazy. How could this diet steeped in Nature not provide her daughter the perfect mix of nutrients? How could a cold steel needle in her daughter's arm do what such a lovingly crafted diet could not? I tried to explain my reasoning, but my words were wasted. She never got the blood test. Similarly, I cannot forget a young boy with a lethal genetic condition who is years beyond the life expectancy of his condition, is profoundly neurologically injured, and always appears uncomfortable. His family presses on, keeping his body alive. There have been many discussions about reasonable goals of care, but how could death be a reasonable goal? And so the invasive interventions go on. The rapidly breathing infant I admitted to the Intensive Care Nursery recovered fully and went home a week later. I mused at the irony that her family had snubbed a hospital birth in favor of a more natural experience, and Nature had uncaringly given their daughter pneumonia, only to be humbled as my thoughts turned to the baby with the cardiac defect, for whom we fought for months to no avail but probably caused much suffering in our hubristic battle against Nature. I worry that healthy children will not get the preventive care they need to stay healthy and that their parents will take unnecessary risks to avoid contact with the medical system. I also fear that as seriously ill children worsen, invasive care will continue without any introspection. As a resident, I am discovering that an unspoken facet of my training is to understand what is natural, when it is time to fight Nature to the end, and when it is time to yield to its wishes, as difficult as they may be to accept. This process is doubly challenging for the pediatrician because truly nothing comforts one after the death of a child. But at the end of this hard road is the appreciation that death is inevitable, unavoidable, and wholly natural for everyone, from the elderly to the newborn. Cruel, but natural. Back to top Article Information Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
TI - What Is Natural?
JF - JAMA
DO - 10.1001/jama.2012.205105
DA - 2013-05-01
UR - https://www.deepdyve.com/lp/american-medical-association/what-is-natural-mVyloR09Gs
SP - 1783
EP - 1784
VL - 309
IS - 17
DP - DeepDyve
ER -