Confluence at Life's Extremes

I spent last winter in the Neonatal Intensive Care Unit (NICU). This was a radical change from my usual venue, where the average patient is 86 years of age and the typical child past menopause. Although I am a faculty member, because I am a geriatrician my privileges in the NICU were defined by parenthood. Delivery of our first child was precipitated by placental abruptio, after a gestation too brief for Sarah Beth to survive without the expertise of physicians, the risks of high technology, and the mercy of something I don't quite believe in. One cannot grow from fertilized egg to free-living baby girl in just 28 weeks without singular help, substantial resources, and a bit of luck. She was 2 pounds, 4 ounces at birth and at her smallest weighed 1 pound, 13 ounces. We were warned that she would probably need mechanical ventilation and, barring complications, she'd be in the hospital about 3 months. And the list of complications? It was long and potent, even without the respiratory syncytial virus that went around that spring, killing two of her comrades. I was nearly driven mad by the bells and buzzers in the NICU. I nearly drove the neonatologists mad by seeing and comprehending too much and too little. When there was a moment to talk, they wondered aloud about this odd Beast, the geriatrician, for whom there seemed to be no Beauty.

“When we win,” I was told, “we get 80 years of life. What do you get?”

“A moment of comfort; a treatable disorder revealed; a fracture prevented; an hour of dignity; a week or decade of improved function; a well-lived life repaid; a 70-year-old child at ease with a parent's care; a sensible death, safe from intensive care units for bigger people”

Everything was not always said aloud.

“If you lose, you get a dead baby, or a handicapped one, or parents beating their breasts in torment”.

“If you lose,” they thought, “does anyone give a damn?”

“The person whose burden of illness has not been eased will know”.

Still, we had common interests. Neurologic function was one. The importance of the brain's well-being never diminishes with age. Neonatologists are rightfully attentive to its status. (Enough oxygen? Too much oxygen?) Then, for most of us, the welfare of the brain is a nonissue until we fall into the hands of geriatricians, in whose patient population brain failure provides abundant stereotypes.

Neonatologists and geriatricians are also especially attentive to the gastrointestinal tract. Our tiny girl needed to grow and mature enough for her gut to work and to gain adequate strength for eating. Enteral feedings started at 12 calories per day and progressed slowly. We endured two radiographs to look for a “nec,” as the intern called necrotizing enterocolitis. Sarah Beth was never cursed with that malady, but we saw its monstrous effects in her peers. Elimination was also an issue. For a while she was dependent on 0.5-cc enemas. At the nursing home, gastrointestinal function, related both to feeding and defecation, if unsuitably dealt with, is also emotionally and physically costly as well as potentially lethal.

I thought that the infant across the aisle had a bad pressure sore on her buttocks. At last, something with which I was familiar. However, the look-alike was a giant hemangioma that had undergone painful necrosis. Treatment at that stage was not dissimilar from that rendered the unfortunately more common geriatric consequence of compromised capillaries.

Other parallel themes were also braided together: surrogates, ethics, hope, abandonment, and courage. They never visited or perhaps they visited too much. Whose best interests did they have in mind? They really loved their parent or child, even though they were so different from what they were or will become. Who is going to pay for all this?

The neonatologist and the geriatrician were unlocked momentarily from the extremes of existence, where the problem of life begins and where the solution is seen with its end. The life barely begun and the life nearly done bond physicians who seem at first to be far apart, but who in fact can easily touch because life traces a circle, bringing into proximity its beginning and its end. The geriatrician is familiar with death coming after a long life. Part of the job is to get it done right. Death is no stranger to the neonatologist either, although it is oddly different after a short life.

Sarah Beth did well. She was never artificially ventilated, had no ventricular bleeding, no sepsis, no necrotizing enterocolitis, no lung disease, no brain disease. She was the tiniest and most precious being in the world, and she kept her parents running scared for 3 months. Now she's big; she laughs and talks and thoroughly enjoys the world. So hard to think of her as ever getting old, so hard to think of a woman named Sarah who died yesterday as ever having been young.

• Copyright ©2004 by the American College of Physicians