Small

Small
Author: Catherine Musemeche

Background

What are the intricate skills required to operate on the smallest and most vulnerable newborns? What are the tools which rescue the most delicate organs and which save lives which have hardly begun? With so much at stake and everything hanging in the balance, this book graphically depicts the complex disorders and the intricate operations that constitute the life of paediatric surgeons. Describing her work as ‘intense, demanding, and sometimes lonely’, the author narrates her experiences of attending to infants with life-threatening diseases in ‘the operating room, the newborn intensive care unit, the emergency room, and…the bedside’ (page ix). The book is also about the non-technical skills required to navigate the fragile emotions of distraught parents and complex multidisciplinary teams. Along with the clinical narrative, the book explored the history of the field, celebrating the innovative pioneers and exhilarating breakthroughs that continue to define what is still relatively a young specialty.

Small Baby Images. Sam N on Flickr. https://www.flickr.com/photos/168592423@N02/45973288514/

Synopsis

The author’s personal experience of challenging and complex operations forms the bedrock of the book, and she narrated this with a vivid prose that portrayed the intricacies and uncertainties involved. This is symbolised in the duodenal atresia correction surgery she carried out on a baby who was ‘born eight weeks early’ and ‘weighs only four pounds’. In this account, she detailed how she opened the baby’s abdomen and peered ‘at a crowded landscape‘ in which the duodenum was ‘three times the normal size’ and appeared ‘like a highway that ends abruptly in a cul-de-sac‘. Her illustrative account also captured the technical difficulty of operating ‘on an area no bigger than a postage stamp‘. Similarly challenging was the procedure she performed out on an infant with gastroschisis, a condition she depicted as ‘both horrifying and fascinating’. She metaphorically portrayed the baby’s intestines as having ‘lost their way‘ and they now ‘hung free from her tiny belly like a tangle of garden hose‘, all reminiscent of ‘an astronaut locked out of the space station with no way back inside’. All the surgical stories the author narrated highlighted the peculiarities and subtleties that make operating on children much more hazardous than on adults; the author for example pointed out that paediatric patients had ‘shorter, smaller-diameter airways‘ and ‘it takes only a slight imprecision to throw everything into chaos‘ during anaesthesia, and even ‘getting an IV starred in a tiny baby’ is ‘a gift, acquired with skill, experience, and patience’ (pages 1-11, 48, 3 and 16).

CC BY-SA 4.0, Link

A particularly inspiring theme of the book is the author’s chronicle of the birth of paediatric surgery, and of the brilliant minds that charted its course. The historical account centred on the achievements of the pioneers of the field whom she celebrated as ‘the giants who came before us in this unheralded field of medicine’. Two figures who stood out in the author’s account were William Ladd and his protégé Robert Gross who worked at Boston Children’s Hospital – ‘the epicenter of pediatric surgery in the 1940s and ’50s’. Her uncensored account was very exhaustive, and it included such unsavoury details as the falling out of these two ‘founding giants of the specialty’ after Gross carried out the first successful operation to ligate a patent ductus arteriosus. Also outstanding amongst the innovators were surgical resident Stanley Dudrick who introduced and painstakingly refined the technique of total parenteral nutrition, a revolution that was to impact the whole of medicine; anaesthesia resident David Massa who invented ‘the first plastic IV catheter that could be inserted through the skin with a needle’; and Bob Bartlett who introduced extracorporeal membrane oxygenation (ECMO) – ‘the most invasive, high risk therapy that modern technology can muster’ to treat newborn respiratory failure. Equally inspiring were the stories of paediatric surgeon Melvin Smith and orthopaedic surgeon Robert Campbell who pioneered the use of vertical expandable prosthetic titanium rib (VEPTR) to treat thoracic insufficiency syndrome caused by missing ribs; obstetrician Ian Donald and engineer Tom Brown who introduced prenatal ultrasound; and paediatric surgeon Barbara Barlow whose phenomenally successful public health campaign cut down the high incidence of, and morality from, childhood trauma (pages ix, 20-22, 32, 37-47, 28, 63-70, 141-148, 175-176 and 85-101).

Boston Children’s Hospital. Jeremy Brooks on Flickr. https://www.flickr.com/photos/jeremybrooks/5125197350

Of the most improbable advancements in paediatric surgery, the emergence of foetal surgery stood out prominently in the book for its audaciousness. Noting that the idea of operating on the baby before it was born was the brainchild of Michael Harrison, the book explored the technical and professional obstacles he overcame to translate his outrageous idea into ‘a reality’. Describing foetal surgery as an arduous undertaking defined by ‘danger, risk, and controversy‘, she likened it to operating ‘on a patient you cannot examine, a patient floating in a small, dark, murky container‘. She further emphasised the perils of foetal surgery when she highlighted the ever-present risk of breaching the uterus, an organ she described as ‘a hungry pit bull on steroids – unpredictable and looking for a fight‘, and the hazard of disrupting the placenta, a structure she symbolised as ‘the restricted airspace of an enemy country’ which must be mapped ‘to avoid potential catastrophe‘. The book also conveyed the unique challenges posed by the foetus being ‘inherently the smallest and most physiologically vulnerable patient a pediatric surgeon will ever have’. In applauding the remarkable breakthroughs that have advanced this field, she commended ‘the ingenuity and tenacity of surgeons who refused to give up just because a clinical problem seemed next to impossible to solve’ (pages ix and 168-174).

CC BY-SA 3.0, Link

The increasing challenges of operating on older children was also a focus of the book, and this was reflected in the author’s painstaking review of the impact of the rising tide of obesity on paediatric surgery. In an account that brilliantly blended clinical medicine and public health, the author characterised childhood obesity as an ‘alarming‘ epidemic which is compromising the types of operations she performs, and she illustrated this complexity with her rather disquieting experience of performing an appendectomy on a 10-year-old obese boy. She described how, despite bringing the operating table to its lowest level and standing on a footstool, she struggled to get access into the boy’s protruding abdomen which loomed ‘large and imposing as a sack of cement’ above the table. She then likened herself to ‘a snorkeler making his way through a dense sea of algae‘ as she navigated through his ‘yellow globules of fat’ and ‘oily slick leaching out of the thick abdominal wall’. The author regretted that obesity has not only made ‘the ordinary, everyday operations…more difficult‘, it has also led to an ‘alarming’ increase in the frequency and complications of interventions such as gallbladder removal (pages 103-105 and 115). 

3a48411r. Children’s Bureau Centennial on Flickr. https://www.flickr.com/photos/67331818@N03/6186002200/

Less formidable than the technical challenges of paediatric surgery, but equally relevant to its outcomes, are the delicate conversations between surgeon and parents that overshadow every operation. Addressing this sensitive subject honestly and realistically, the author mapped out her approach to the requisite dialogues that take place before, during, and after every operation. She discussed how she prepares for such conversations by attempting to put herself in the position of the parents, aiming to understand their deepest worries and concerns, and watching out for their tendency to blame themselves for their children’s predicaments. She argued that ‘finding the right words‘, and ‘knowing when to say them‘, are as challenging as learning how to operate, emphasising that expressing her ideas ‘in just the right way is as important to these parents as anything else I have done all day’. She described the diverse themes that constitute her interactions with parents during which she tries as much as possible to assuage their tendency to ‘always want to fault themselves when their children are suffering‘ (pages 5 and 14).

 

Baby Faces II. sandy.redding on Flickr. https://www.flickr.com/photos/dotdoubledot/541769308/

Opinion

This book is an interesting insight into surgery at its most delicate. With both historical and futuristic perspectives, the author successfully demonstrated the development and future direction of paediatric surgery. It is a well-written narrative that weaves the historical with the contemporary, the author explaining the technological and human dimensions of operating on the most vulnerable patients. The comparative history helps to put developments in the specialty in perspective, and it gave credit to the founders of the field who faced enormous challenges. Some of the stories appeared over-dramatised for effect, perhaps unnecessarily so as they were gripping enough without the elaboration. Some of the stories were also occasionally only tangentially related to the subject of the book, such as the detailed description of the development of the Heart Lung machine, and the personal anecdotes of operating on adult patients. These apart, the book is a welcome insight into a critical field of surgery; all the chapters were very well-researched, and all the stories were carefully sculpted.

Overall assessment

This book provides a balanced account of paediatric surgery with helpful depictions of the technical skills and the human relations that constitute it. The author describes a specialty that is symbolic of the breakthroughs and innovations that advance the field of medicine, and of the trailblazers who constantly and imaginatively push the boundaries of what is possible. The book also covers an extensive array of themes, from public health to foetal medicine, putting forward concepts which are transferable to all fields of healthcare. It is an interesting and revealing work which firmly anchors paediatric surgery within the wider context of medical practice, and which teaches lessons that go far beyond the operating room, and I recommend it to all doctors.

Book details

Publisher, Place, Year:  Dartmouth College Press, New Hampshire, 2014
Number of chapters: 12
Number of pages: 229
ISBN: 978-1-61168-442-1
Star rating: 4
Price: £19.99

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.