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Archive for the ‘infant anesthesia’ Category

I’ve just discovered my new bible–the book that explains me to me perfectly. Louis Tinnin, MD and Linda Gantt, PhD’s The Instinctual Trauma Response & Dual Brain Dynamics: A Guide for Trauma Therapy is THE book to read if you want to understand all types of early trauma: invasive medical procedures and infant surgery without anesthesia, sexual and physical abuse, abuse from foster care and orphanages, burns, rape, combat trauma, and captivity. The book discusses the authors’ understanding of how the brain copes with trauma, how the symptoms manifest, and how to best heal survivors of trauma. It  describes techniques and strategies in-depth and gives many excellent examples of cases in which people have successfully resolved their traumas. And, perhaps most importantly, the text is understandable to a lay person. I applaud them for this.

I feel immense gratitude, for this book has explained things to me that I have not been able to get a handle on no matter how I have tried. I’ve had SO many revelations and I’ve only read half the book. Here’s an example of a life experience that I’ve gotten a handle on: The difficulties I had learning to scuba dive were instantly clear to me. The book affirmed the fact that I was intubated without anesthesia before my infant surgery. That is, a breathing tube was forced into my throat while I was strapped down so that I could be breathed by a respirator. (Right now I am staring blankly out the window, slightly ‘frozen’ just thinking about it.) The scuba equipment replicated the respirator, sound included. I’ve always felt shame and disappointment about the fact that I could not become a scuba diver (especially since I was a marine biology major at a university in warm water Florida) and now, my experience is completely understandable. Post traumatic stress symptoms from the early trauma took over, a condition that I did not know I had at the time. Had I known, I would probably have been able to work through my reactions and soothe myself as I went along or even avoid certain reactions altogether.

Here’s a big excerpt from the book so that you get a flavor of the narrative and a glimpse into their approach. Go slowly. You’ll get it. They really do try to make it clear to a non-scientist type reader.

“Humans are double-minded. They have dual brains and dual minds. Yet, they do not know it. They have not known it since they first became toddlers using speech and verbal memory. That happens around age three when the two cerebral hemispheres begin  to exchange information across their maturing connection, the corpus callosum. When one hemisphere becomes dominant over the other, a compelling illusion of unity develops. This is when the individual acquires ‘I-ness”and begins life as a unitary agent in the world of verbal communication. The dominant hemisphere (usually the left) becomes the verbal brain, with a mind that operates by the logic of language and imposes a sense of self as unitary agent with willed action in linear time (past, present, future).

“Dominant verbal consciousness rarely yields to the nonverbal mind except during one’s instinctual response to trauma when cerebral dominance surrenders to nonverbal survival instincts. When the person recovers from the lapse of unity caused by trauma, the instinctual experience remains outside of verbal recall, unremembered in words but unforgettable in feelings and images. The nonverbal mind, unconstrained by narrative structure, remembers it all: the fear, the thwarted impulse to escape, the near-death experience of the freeze, the altered state of consciousness, the automatic obedience, and finally self-repair (as in animal wound-licking).

“We contend that it is nonverbal memory of the traumatic survival experience, held as unfinished and forever present but outside of verbal consciousness, that causes posttraumatic intrusive, avoidant, arousal, and dissociative symptoms. Understanding the brain dynamics of cerebral dominance, verbal and nonverbal thought and memory, and the interaction of verbal and nonverbal minds can lead to specific therapeutic measures for posttraumatic disorders” (Tinnin and Gantt 9).

Until we extract our trauma story from the right brain, post-traumatic stress often has its way with us. And if the trauma occurred before the age of three, then strategies other than verbal recall, such as drawing, must be employed. Stay tuned for more about this book. I’ll quote some of the case studies and share more of my impressions. In the meantime, you might want to go to the authors’ website for more information: www.traumatherapy.us or to Dr. Tinnin’s blog http://ltinnin.wordpress.com. Get ready to get clear.

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A scar is a reminder that something happened to you, something that was likely painful. And sometimes, as in my case, the scar is ugly and ragged, something I learned to be ashamed of. But today, I feel differently. I feel lucky to have a scar–a mark that actually pinpoints the location of the early torture and pain. My brother Wayne was not so lucky. My brother had no scar from his early hospitalizations, but he had the unresolved trauma and the post-traumatic stress. Trouble is, he didn’t know.

my brother

My brother, who died in 2010, had anger issues all his life.  He could go into a blinding rage in zero to .1 of a second flat. I once watched him chase down the driver who cut in front of our car, pull out a tire iron, and threaten the man with a beating. During a knock down drag out fight when we were teenagers, he threw me into a window so hard I felt the glass bend–pure luck that I didn’t crash through. He broke my mother’s wrist when, angry about something or other she’d done or said, he whammed the book he was holding down onto her arm as she was washing dishes. (It was an accident; he’d meant to hit the counter.) There are many other instances. His rages were felt by all who knew him. And while he was so much more than his rages, of course, they were a defining factor for him.

Where did this anger come from?  I was a very angry girl and young woman, but I took it out on myself. I cut myself, pulled out my hair, scratched into my skin, burned myself, and tried to kill myself a few times, once very seriously. I now understand these actions–symptoms of post-traumatic stress disorder (PTSD) from unresolved early medical trauma. That’s why I think my brother had it, too.

My brother was very sick when he was four or five. The doctors thought he had leukemia and, my mother told me, conducted so many tests she joked that she kept the hospital funded for a year. He spent several weeks in the hospital. My mother was distraught, thinking she might lose him. After all the tests proved negative, the doctors realized that he had a severe allergy to cow’s milk. My mother used to say that he was raised by a goat.

He was also hospitalized in the intensive care unit as a newborn. My mother gave birth to him in the backseat of the Ford as my father raced to the hospital. Unfortunately, my father had stored car radiators or batteries back there and somehow, he had ingested fluid from one of these types of car parts. He was put into an incubator as soon as he arrived at the hospital. So twice in his very early life, he was hospitalized, isolated from my mother, and subjected to many procedures and tests, some of which I’m sure were quite traumatic. (Back then, medicine believed that babies did not feel pain and, therefore, did not generally use anesthesia or manage pain. Please see two previous posts from Feb. 10 and Feb. 25 for more information about this.)

My brother died in pain. He had a major heart attack. For the few years before he died, he was very stressed and often scared that he would lose his home. He had lost his job several months before his death. He had no health insurance and constantly worried over the mounting bills and debt. He’d had many high paying jobs in his life as a mechanical engineer and businessman, but in the financial meltdown, he really crashed. After he died, I learned that he’d spent a lot of time in his last few years making bullets and storing ammo in his garage. He was frightened. He was armed. He was defended.

I believe that he had post-traumatic stress like I do. I believe that many of his personality “traits” were actually “states” of PTSD. I think his rage was a lifelong consequence of unresolved and untreated trauma due to invasive medical procedures at the beginning of his life. He had no scar to point to and say, aha, here’s the origin, here’s the wound. My mother had told him of his severe sickness as a baby and young boy, but whenever she brought it up, he silenced her. He did not want to be portrayed as a weakling. He was not vulnerable. His trials were over. And no scar reminded him of the pain and suffering.

So while I have cussed and groaned over the fact that I have an unsightly scar at the center of my body, it reminds me of why I suffer the symptoms that I do. It helps me have compassion for myself and remember that my personality quirks are not always me but symptoms of PTSD. (It’s a relief to know there’s a reason for some of the crazy ways I’ve acted in my life.) It helps me explain myself to myself. Since my brother had no battle scars to show for his warrior wounds, his wounds were invisible. Perhaps a scar would have helped my brother explain himself to himself. Perhaps not.

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As it turns out, finishing the Anand and Hickey article, “Pain and its Effects in the Human Neonate and Fetus,” was relatively easy. The bulk of the chemistry and the neuroanatomy was contained in the first half of the piece, on which I reported in my blog post Feb. 10, 2013 “Just Above Water.”  I feel relief and pride in having accomplished what I set out to do. Following is some startling material from the article and my responses to it.

“Tracheal intubation in awake preterm and full-term neonates* caused a significant decrease in transcutaneous partial pressure of oxygen, together with increases in arterial blood pressure and intracranial pressure” (6). — Imagine a tube being pushed into your  throat without your having been anesthetized.  Any wonder that stress caused physiological changes to take place?  A baby would probably feel as though her life were threatened!

“Changes in patterns of neonatal cries have been correlated with the intensity of pain experienced during circumcision and were accurately differentiated by adult listeners. . . . neonates were found to be more sensitive to pain than older infants (those 3 to 12 months old)” (8). — Turns out that newborns are not just sensitive to pain but very sensitive!

“A recent controlled study showed that intervention designed to decrease the amount of sensory input and the intensity of stressful stimuli during intensive care of preterm neonates was associated with improved clinical and developmental outcomes. . . . the behavioral responses observed suggest that the neonatal response to pain is not just a reflex response” (9). — I want to say duh but am restraining myself. In order for the field of medicine to know something, measurements must be made. Data must be replicable. The scientific method is extremely important, but other ways of knowing should carry significant weight as well.

I am grateful that Anand and Hickey were able to prove scientifically what they observed–that infants suffered and often died from the uncontrolled pain and stress during and after surgeries and invasive medical procedures.

*newborns

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In a recent article  “Dosing Down” published in O Magazine, writer Robin Rinaldi states, “. . . nearly 23 percent of American women between the ages of 40 and 59 take antidepressants.” That’s a helluva lot of women. According to psychologist Dr. Bob Murray, “recent research has shown that men are actually just as likely to be depressed [as women], if not more so.” That’s a helluva lot of men. What’s going on here?  Why so much distress?

The answer is complex. This blog is not the forum to unravel all those threads. But what is important to note is that a good percentage of these folks, I’m sure, have depression due to unresolved infant trauma. It’s just not a subject that we talk much about. But there are those rare moments.

After dinner one evening, my friend’s husband and I were chatting. He asked me about my blog, so I told him about my infant surgery for pyloric stenosis, likely without anesthetic, and the years I spent depressed in my early twenties as a result. As I talked, he was leaning more and more forward and his facial expression was changing from interested to shocked. Next thing I knew, he was telling me about his inexplicable bouts of deep depression and the details of the surgery he had as an infant. It was astonishing. Fireworks were going off inside him, and I had the privilege of watching his sky light up with insight after insight.

One of my theories is that the rage a baby feels from an early medical assault is sublimated and unable to boil to the surface, and it doesn’t go away. The life-threatening situation takes precedence and, as Dr. Peter Levine puts it in his book Waking the Tiger, we go into freeze mode since babies can’t defend themselves or run away. We cut ourselves off from our bodies and emotions in order to attend to the emergency but then don’t circle back to shake off the somatic shock and recover our connection to ourselves. Post-traumatic stress can result, which reminds me of another story.

I was teaching a unit in medical humanities at a community college when a student had the insight that the nightly crying of her infant might be due to the 6 attempted, and the one successful, spinal taps he had recently endured. When I asked her if he had gotten adequate pain control, she stated that she did not know. She had assumed  her baby was given an anesthetic. Don’t we all?  My mother certainly had.

The groundbreaking research revealing that newborns do feel pain (see my previous blog post) did not appear until 1987. There’s a whole lot of people out there who as infants were subjected to invasive medical procedures and/or surgeries without anesthesia and/or adequate pain control. (And it’s still going on!) Could this be one factor in the epidemic of depression that we see today?  Absolutely.

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I’m sitting in my well-let living room on a Sunday morning on a hard folding chair, hoping both the light and non-comfy seat will keep me on task: reading the seminal article “Pain and its Effects in the Human Neonate and Fetus” by Dr. K.J.S Anand and Dr. P.R. Hickey published in the New England Journal of Medicine in 1987. Am I a scientist? NO. Am I a doctor or medical professional? NO. I am a survivor of infant surgery, carried out without adequate pain control and likely, without anesthesia. And since I consider myself a health activist of sorts, I figure I need to be as versed as I can in the subject about which I blog.

The study I’m reading was groundbreaking. It provided a point of view in the field of medicine that was lacking–that infants feel pain and that the administration of anesthesia and analgesics is necessary for babies who require surgery or other invasive medical procedures. I’m paraphrasing, of course. And I’m only half way through the article. Why?  Because in each paragraph, I’ve had to look up at least two or three words in my huge Random House Dictionary or the Bantam Medical Dictionary and then connect those meanings to the point of the paragraph in general, which sometimes requires my taking notes or drawing diagrams in the margins. Yikes! Who would bother!  That’s why people like Dr. David B. Chamberlain interpreted this article for us. He  wrote the essay “Babies Don’t Feel Pain,” in which he introduced the findings of Drs. Anand and Hickey and gave us a history of medicine’s thoughts and conclusions about infant pain. Thank you, Dr. Chamberlain.

But my having read Dr. Chamberlain’s article is not enough. I’m interested in not only my reactions to reading a challenging scientific article, but also my emotional response to what I’m reading. You can imagine how I felt when I read this sentence: “Despite recommendations to the contrary in textbooks on pediatric anesthesiology, the clinical practice of inducing minimal or no anesthesia in newborns, particularly if they are premature, is widespread” (2). OMG!  Couldn’t any parent tell you that his or her newborn feels pain?  If it’s not proven though–if no tests were done that provides replicable data–well, then medicine too often ignores what we all intuitively know. Frightening?  Yes. That’s why we owe so much gratitude to Drs. Anand and Hickey who connected the data dots. They provided the numbers and made the argument that the medical profession needed in order to change clinical practice.

Wish me luck in finishing the article!

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I just finished reading an article “Centennial of Pyloromyotomy” in the Journal of Neonatal Surgery by Dr. V. Raveenthiran, a pediatric surgeon with SRM Medical College and Hospital in Chennai, India. Since 2012 was the year to celebrate the discovery by Dr. Conrad Ramstedt of the Ramstedt procedure, a surgical technique which saved my life as an infant, several articles have been published about the doctor and pyloric stenosis, Dr. Raveenthiran’s being one of them. In brief, his article discusses and evaluates some of the articles that report on the treatment of pyloric stenosis in the 100 years since Ramstedt’s discovery, including new diagnostic and surgical techniques.

A bit of background: Dr. Ramstedt discovered that he could best save babies suffering pyloric stenosis by cutting into the pylorus muscle of the stomach, in order to alleviate pressure and open the passage between the stomach and small intestine that had been blocked, and then by not stitching the incision on the pylorus muscle. (Previously, the pylorus muscle incision was stitched closed.) On Fred Vanderbom’s blog survivinginfantsurgery.Wordpress.com, he summarizes Dr. Raveenthiran’s article quite beautifully.

One point that Dr. Raveenthiran makes struck me most. He writes: “Colossal success of a curative procedure usually obviates the need for further scientific research by solving the underlying problem.” To paraphrase, Dr. Ramstedt’s surgical outcomes were so great, so successful, that the search for the origin of the often fatal condition in newborns, pyloric stenosis (PS), was no longer of immediate concern. Most of the article discusses the plethora of new techniques that have been developed over the years to reduce the scarring of the baby’s skin and to make the operation overall more efficient. What disturbs me though is the lack of energy being directed into discovering the etiology or cause of PS and working to prevent this condition in the first place. Pyloric stenosis has been known to humans for several hundred years, yet little is known about the cause.

I think it’s high time that medicine put a stop to PS altogether. Why?  I’m coming from the baby’s point-of-view. Surgery sucks!  The last thing a baby wants to go through shortly after he or she arrives in this world is hospitalization, separation from Mom and family, immobilization on a surgical table, and an invasive procedure or assault on the body. Years ago, the surgery was barbaric as anesthetic was often not used. An infant may have been brandied up (yes, given alcohol!), given a local anesthetic or given a paralytic, whereby she couldn’t move but was aware. Generally, from 1912 to the 1940s, no anesthesia was the norm. Then, the patient is left to cope with post-traumatic stress symptoms that can, and often do, persist well into adulthood. Over time anesthesia began to be used. (The history of the development of pediatric anesthesia and pain control for infants and neonates is a long and complicated one that varies significantly country to country.). Now more often in operating on babies with PS, anesthesia is administered, the recovery time is shorter, the baby is less isolated from family, and the incision is smaller. Yea!  But wouldn’t you rather be cured so that a surgery wouldn’t be necessary?

Dr. Ian M. Rogers discusses his findings about using antacid therapy to change the pH balance in the stomach and stop the pylorus from becoming super spasmotic and ultimately blocking the os or opening into the small intestine. (Read “Pyloric Stenosis-The Real Cause” dated June 17, 2012 in myincision.) He encourages doctors to give an antacid, if appropriate, as soon as the baby is suspected of PS to see if gastric changes will prevent the need for surgery. Ah, prevention–a breath of fresh air!

The 21st century should no longer parrot the paradigm of the past. It’s time to work in new ways. Albert Einstein said:  “We cannot solve our problems with the same thinking we used when we created them.” So while I am deeply indebted to Dr. Conrad Ramstedt, it’s time to let go of the thinking of the past by taking some of the focus off of all the new iterations of the Ramstedt procedure and proceeding to a new era in treating pyloric stenosis, that is, early detection, treatment, and prevention. Babies, parents, families, and the practice of medicine itself deserve it. Let’s try what Dr. Rogers is offering. Let’s get other ideas on the table, for example, reducing stress on the pregnant mother. Let’s use Ramstedt’s technique when early treatment isn’t working or wouldn’t be advisable. Let’s work to make Ramstedt’s technique a strategy of the past.

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The WordPress.com stats helper monkeys prepared a 2012 annual report for this blog.

Here’s an excerpt:

600 people reached the top of Mt. Everest in 2012. This blog got about 9,300 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 16 years to get that many views.

Click here to see the complete report.

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