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Archive for the ‘pediatric trauma’ Category

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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One can always be more free. As the year comes to an end and 2013 is upon us, it’s a good time to let go of things one doesn’t want to bring into the new era.

As a baby, I got wired for trauma. Being operated on at 26 days old for pyloric stenosis, a blockage in the stomach, set the stage. As a baby, my belly was cut open and part of my stomach actually drawn out of my body to fix the problem. In many ways, I am still frozen, holding my body rigidly as I cope with a trauma that occurred 60 years ago. Amazing!  It’s called PTSD (post-traumatic stress disorder).

So earlier this morning, I was sitting in bed with my legs extended, preparing for meditation. I settled in, covering myself with a blanket, allowing my body to sink into the earth and be held as I listened for my heartbeat and tuned into my breath. I realized though that my face was stuck as if it was frozen from the cheekbones up, including my nose. My lips were pulled back and my nose and brow were literally numb. I was smiling a weird lips-pressed-together-and-pulled-back type of smile, more like a snarl, and breathing as shallowly as possible.

What was going on?  I tracked the tension in the rest of my body–my shoulders, hips, chest–and realized that I was straining against something. Flash! In all likelihood, I was straining against whatever hospitals use to tie down infants who are going to be operated on. Back then, my head was secured to the table and here I was in 2012 still fighting to free myself.

Often in my morning meditation, I’m so busy dealing with the somatic repercussions of infant surgery that it’s a challenge to allow a meditative state to kick in. Some days, I simply deal with what I call somatic freeze and other times, I break through to information that my higher self has to offer.

One way I work with this rigid state is to allow my breath into the frozen area. I don’t forcefully bring breath in by taking a deep breath but simply allow my natural breath to return. I invite a quiet breath movement. In this process, I actually began to feel my nose and to exercise face muscles that I didn’t even know were there.

Another strategy to cope with PTSD freeze is imagery. During my meditation, a liberating fantasy brought excitement and a feeling of power.

I am a baby strapped to a gurney before surgery, wanting to escape. I rise and break the bands holding my head, shoulders, hips, and feet and grab the surgeon’s scalpel. It becomes a sword. I’m standing on the gurney now, a super-powered baby swinging her sword, daring anyone to approach. Oh, what fun!  I love watching their shocked and frightened faces. They run out of the operating room and I smash up the place. Oh, more fun!  

So am I suffering from frozen rage?  Am I stuck in that moment of facing my own mortality and being unable to do anything to save myself?  Yes!

I may have been given a local anesthetic before the surgery. I may have had no anesthesia but received instead a paralyzing drug. In this case, I would have been awake but incapable of fighting. Still I would have tried to be free. Certainly, my nervous system cried out, escape! Perhaps before being administered general anesthesia, I fought against being tied down. Since I had been starving for weeks and weighed only four pounds, I was pretty weak. I doubt though that I was fully anesthetized; the level of tension and stress in my body suggests I wasn’t.

My body has been engaged in a lifelong fight with itself and for the last 10 years, through meditation and Middendorf Breathwork, I’ve been finding freedom from this struggle. I am discovering my power. I am learning that more freedom is always possible. For 2013, I am getting a new face–less startle, more real. More truly me.

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I was going to write about re-enactment, a psychological byproduct of trauma from exposure to danger, but I can’t stop thinking about the shooting at Sandy Hook school.  In articles in Huffington PostSFGate, and New York Times Online, I look for pieces in which a more in-depth understanding of the psychology of the shooter Adam Lanza is revealed, but all I ever see is the tired phrase “personality disorder” as if that explains anything.

In other articles, he’s referred to as autistic or Asperger’s. In one article, a high school classmate remembered Adam as a weird kid who ducked in and out of class, carrying a black attaché case. Someone else mentioned that he was ‘one of the Goths’. I just want to know why a kid whose suffering was clear to everyone wasn’t helped. How do kids become such loners?  Why does everyone know that Adam Lanza was different or “socially awkward” or “painfully shy” and obviously needed guidance or friendship but was just left to ‘go his own way’?  And why was an adult who was head of the high school technology club to which Adam Lanza belonged charged with watching out for the boy because he couldn’t feel pain?

Another question I have is, was Adam on medication?  If so, how long?  What are the side effects of these medications?  At what age was he medicated?  What part did a drug play in Adam Lanza’s behavior?

I remember the rage I felt at age thirteen and at twenty-two. I didn’t know how to cope with it and acted out. The school psychologist was worthless; in fact, he exacerbated the situation and increased my rage. The principal of the grade school acted like a bad cop in his dealings with children, further enraging me. When I was twenty-two, the counselor at the college I attended was a Freudian analyst who frightened me. Many times, we are having problems that our parents can’t solve. Sometimes, our family is the problem. We look to society and its institutions for help. Where was the help for Adam?

What do children do with their anger?  Are they given tools to cope and understand themselves?  Is there a space for mental health training in schools?  Was Adam Lanza filled with uncontrollable rage?  Perhaps he had experienced some early trauma that he was unconsciously acting out on?  Maybe re-enactment is a relevant topic of discussion after all. Adam could have been “re-creat[ing] the moment of terror, . . . in an attempt to undo the tragic moment . . . commonly, traumatized people find themselves reenacting some aspect of the trauma scene in disguised form, without realizing what they are doing” (Herman 39-40). Was Adam suffering from undiagnosed post-traumatic stress?

Obviously, the situation is complex and all I have are questions and more questions. I am waiting for an article that honors the complexity of the human condition in its attempt to provide answers. In the meantime, I am praying that our society moves forward and changes in some big, brave ways in response to this enormous tragedy.

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Last Thursday, a dermatologist cut out a melanoma on the back of my leg just below my calf. It was a slow spreading kind and since I caught it early, I am told that it hasn’t metastasized. That’s the good news. I didn’t think the surgery and recovery were going to be a big deal. But I got twenty stitches instead of the projected seven, and I have to spend two weeks with my leg up on a pillow. And yes, it hurts when I walk. A much bigger deal than I thought it would be.

Here’s the part though that I want to discuss. As I lay down on the table while the doctor suited up, I had an experience that helped me understand how I coped with my infant surgery. The journal entry that I wrote shortly after the surgery explains it best.

What a gift that I was only given a local and so was conscious and aware of my body’s response to being cut. The old somatic pattern came raging back. When I lay down for the surgery, my jaw went through a series of unlockings–spasms of about twenty shakes until it settled down. In order for my jaw to relax, my bottom and top teeth could not be aligned; I had to let my bottom jaw slide out to the left.

My jaw spasmed once more–shudders of many shakes–and settled back down. The only way I was comfortable during the skin surgery was to let my bottom jaw slide left a half-inch, which made an awkward fit for my teeth.  Also when I lay down for the skin surgery, my right scapula (shoulder-blade) locked–a terrific force that gripped. I was eventually able to relax it.

All my life, my jaw has been misaligned due to gritting my teeth from the infant surgery. My teeth and jaw absorbed the pain. Gritting nightly stayed with me since that time. The pain must have been extraordinary to tense me up like that, to burn it into my brain, to create such an entrenched pattern. My gums weakened and made me susceptible to gum disease. As I got older, my molars became brittle and cracked. All my molars are crowned. And the scapula lock dates back to the early crisis as well. 

In my life, when I lay down for sleep, my body  goes into lockdown unconsciously. My jaw clenches and my right shoulder-blade locks, which has me breathing in a way that minimizes breath movement in the area of my infant incision. I became aware of this pattern years ago in my study of Middendorf Breath Work, which has helped me become aware of my outdated  somatic patterns and move beyond them.

I have come full circle: incision then, incision now. Let me move into a new future–no more cutting. Let my somatic pattern be released once and for all. Let me find a new way to hold my body in trust and in freedom. Let the old electricity and the old alarms be just that–old. Let me release the trauma buried so deeply in my body and brain. Let me be trauma free. Freedom calls.

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I was 25 years old, lying in sand by the Pacific Ocean. I had come to the sea to kill myself, depressed again after so many years of trying to make my life work since my suicide attempt at age 21. But I just couldn’t bring myself to harm; I had grown. So I drew words that bubbled up from nowhere. From somewhere. Pain from long ago. Ancient hurt buried until that moment where water meets shore and life called–a baby’s cry in early morning hours.

Pre-verbal trauma cannot be remembered in words. Perhaps that’s why this message came in a word picture, if you will.  There are many ways to release early pain if the brain does not get in the way. The brain that says, oh that happened so long ago, or you couldn’t possibly have felt that! That memory brain didn’t realize that it was shut off while the trauma was occurring. A different part of the brain recorded the experience, and talking and writing don’t access it. They can point the way to trauma, but they don’t release it.

Draw the story. Draw the message. Draw whatever it is that bubbles up. Begin the healing process.

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I’ve changed. My brain has changed!  It’s true. I overrode my automatic Post-traumatic Stress response last night. There I was lying in bed, enjoying an Esther and Jerry Hicks video, when I noticed the LED light behind me reflected onto my computer screen. Freak out!  That round, bright light hovering over me (the computer was on my belly and the screen tipped toward and above me) captured my gaze and sent alarm bells clanging. I was caught in a PTSD moment……..momentarily.

A part of me came to the rescue.  What’s going on, I asked myself. OK, the light is mimicking one of those surgery lamps that I saw as a baby.  I put the computer aside, thinking that I’d have to ride out the freeze response in which my body goes into paralysis mode. But then I heard myself say, No, I’m not doing that. I want to watch my video. I sat up so that the  reflection was gone and snap, just like that, I was back watching the video where a woman was saying that she cured herself from cancer without chemo or radiation. Amazing!

Afterward, I realized the magnitude of my achievement–I’d sidestepped Post-traumatic Stress! A few months back, I’d written a poem about my major PTSD moment with the heating lamp (myincision July 15, 2012). Last night, instead of going into “deer in the headlights mode,” I basically told myself, Been there, done that and went on with my life. Sound simple?  It was and it wasn’t. In the moment, it was rather easy but I’ve been working on this stuff for years. Now I’m finally harvesting the fruit.

Here’s what I think happened in the words of Dr. Daniel J. Siegel* from his seminal book Mindsight, The New Science of Personal Transformation“Traumatic experiences, in particular, can sensitize limbic [area deep within brain that helps us evaluate ‘feeling states’]** reactivity, so that even minor stresses can cause cortisol [stress hormone] to spike, making daily life more challenging for the traumatized person . . . Finding a way to soothe excessively reactive limbic firing is crucial to rebalancing emotions and diminishing the harmful effects of chronic stress” (18). In other words, post-traumatic stress can be soothed. How?  According to Siegel, by using a different part of our brain to “override” the agitation.

Here’s how Dr. Siegel puts it: “The middle prefrontal region [of the cortex] has direct connections that pass down into the limbic area and make it possible to inhibit and modulate the firing of the fear-creating amygdala [a cluster of neurons important in the fear response].  Studies have demonstrated that we can consciously harness this connection to overcome fear–we can use the “override” of our cortex to calm our lower limbic agitation” (28). In other words, we can soothe our fear when our limbic area gets triggered if we are aware and react consciously to agitation.

I’m feeling pretty damn proud of myself right now. I’ve come full circle on this surgery lamp thing. I have other PTS triggers too, but this is the first time I’ve been able to override a PTS fear in seconds and stay focused on what I was doing before the freak out hit. Dr. Siegel states, “As neurons fire together, they wire together” (40). So I can say with confidence, my brain changed. I’m newly wired!

*clinical professor of psychiatry at the UCLA School of Medicine, co-director of the UCLA Mindful Awareness Research Center, and executive director of the Mindsight Institute.

**words in brackets [  ] are mine

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An article by Dr. Bruce D. Perry et al is a must-read for all those trying to understand the impact of infant trauma on a person’s life:  “Childhood Trauma, The Neurobiology of Adaptation, and ‘Use-dependent’ Development of the Brain: How ‘States’ Become ‘Traits.'” I became interested in this article because I believe that there are aspects of my character that, rather than simply being my personality, are actually qualities shaped by early trauma. These so-called “traits” are behaviors, somatic patterns, and thought ruts that no longer serve me. In fact, while they may have saved me long ago, they disempower me now.

The article is somewhat complex, so I’ve selected some quotes to help you see what Perry et al are getting at.

“Traumatic experiences in childhood increase the risk of developing a variety of neuropsychiatric symptoms in adolescence and adulthood ” (273).

“Ultimately, it is the human brain that processes and internalizes traumatic . . . experiences. It is the brain that mediates all emotional, cognitive, behavioral, social, and physiological functioning. It is the human brain from which the human mind arises and within that mind resides our humanity. Understanding the organization, function, and development of the human brain, and brain-mediated responses to threat, provides the keys to understanding the traumatized child” (273).

“. . . traumatized children exhibit profound sensitization of the neural response patterns  associated with their traumatic experiences. The result is that full-blown response patterns (e.g., hyperarousal or dissociation) can be elicited by apparently minor stressors” (275).

In this article, Perry et al make the case that “reactivated” fear coming from an oversensitized brain stem and midbrain due to trauma can cause hyperarousal: “hyperactivity, anxiety, behavioral impulsivity, sleep problems, tachycardia [abnormally fast heart rate], hypertension, and a variety of neuroendocrine [hormonal] abnormalties” (278). These conditions and behaviors are states NOT traits.

On the other hand, oversensitized brains can be  result in “dissociation.” For example, if an outside  stimulus evokes the trauma, a person may freeze or numb him or herself. A child may “disengag[e] from stimuli in the external world and attend [. . . ] to an ‘internal’ world” (280) as in daydreaming or fantasizing. As a result, a child may falsely be understood to be extremely shy or uncooperative. Dissociation and hyperarousal are “states” created by early trauma. In adulthood, many of us have wrongly come to accept them as our personality “traits.”

Another major point from the article is that traumatized infants and children do not simply get over their traumas. According to Perry et al, “children are not resilient, children are malleable” (285). In fact, to assume infants and children were not affected by the trauma or will grow out of it is not only incorrect but destructive. Perry et al leave us with this final point: “Persistence of the destructive myth that ‘children are resilient’ will prevent millions of children, and our society, from meeting their true potential” (286).

For me, I just want my real self back.

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