As Bad as it Gets

The well baby nursery, with its tiny victims of drug abuse, casts a long shadow.

The naked newborn lay in a bassinet under an electric warmer in the well baby nursery, with a heat probe taped to his chest and a clear plastic bag stuck to his bottom. The handwritten sign taped to the crib read, “I’m bagged for urine.”

I picked up the chart and read the sign-out sheet from the delivery room. The note read, “Mom does all drugs.” When I asked about this, the nurse explained that it was faster than writing “cocaine, marijuana, alcohol, and PCP.”

I examined the baby and found nothing grossly abnormal. I hated myself for wishing that street drugs caused a visible deformity, some small but tangible sign that would force parents to understand that their habits affect their infants — leaving newborns with a possible legacy of developmental delays, neurological disorders, or behavioral problems. I selected the routine orders for newborn care on the computer menu and tacked on an order for a urine toxicology screen.

My first week as a pediatric intern in the well baby nursery of an urban teaching hospital had been a bad one; by my count, almost 80 percent of the babies were drug-positive. The infants over in the neonatal intensive care unit were in even worse shape; they were the ones who hadn’t held out as well against the stresses of poverty, poor prenatal care, and street drugs.

After I had finished reviewing the prenatal records and examining the baby, I pulled my white coat over scrubs and walked over to the maternity ward to talk to the mother of “all drugs.” On my way, I thought back to the time in medical school when an obstetrician told me that it is a privilege to care for mothers and babies at the time of birth because that day will be remembered and celebrated each year.

I knocked. This mom was alone in a room without cards or flowers. She was 17, with a blond ponytail and gold hoop earrings, but her expression was one of hard control. I felt there was nothing I could tell her that she wouldn’t say she already knew. I congratulated her and said that her baby was doing fine in the nursery and that the nurses would bring him out soon. I felt tempted to throw in a line about the uncertain effects of in utero drug use on the infant, but I held my tongue and went back to the nursery to await the toxicology screen.

That afternoon I checked the results. The baby’s urine was positive for all the drugs that the mother admitted using. This polysubstance abuse was unusual, even for our hospital. I was still new enough to my nursery responsibilities to feel embarrassed about inscribing the too common scarlet letters “Cocaine Positive” on the carbon form that I put on the chart and gave to the mother to take to the baby’s doctor. The toxicology screen was a simple urine test, but to me it seemed more invasive than the lumbar punctures I did to check for central nervous system syphilis. Documenting the results of the screen meant documenting that I had looked.

The next day, before I sent the baby boy home, I read the social worker’s evaluation, which included the mother’s answers to routine questions about her support network, home environment, and drug use. This evaluation read, “Mom says she has used drugs off and on since age fourteen. Equates increased use with stressful life events: breakup with baby’s father, death of brother. States she was in rehab program once. Denies drug problem now, not interested in rehab.”

The state was allowing this mother to take her baby home because there weren’t any open neglect or abuse cases against her at the Department of Human Services. Technically, her drug use wasn’t child abuse. On the discharge summary I scribbled, “Cleared by social work” and then I returned to the mother’s room. When I knocked this time I heard laughter. Six teenage girls, decked out and coiffed, surrounded the mom and baby. “He’s too manly,” said one of the visitors, who was pregnant and looked close to her own due date. “He’s going to need some beatings.”

I asked them to excuse me while I reviewed formula preparation, smoke detectors, and car seats. Then I went over the baby’s exam and told the mother that because she had exposed her baby to drugs, it was especially important for him to have regular visits with the pediatrician to follow his development. I figured she would probably throw the paperwork away. I asked her where she would be taking the baby, and when she named a health clinic, I felt selfish relief that I wouldn’t be dealing with her again.

Experiences like this, repeated more often than I care to remember, were starting to demoralize me. This wasn’t why I had gone into pediatrics — the branch of medicine I had called happy when I was a medical student because sick children so often get better, and they get better quickly. Sure, I expected to see abuse and neglect, but I didn’t expect such behavior to be the norm.

As I watched that mother dress her baby to go home, I feared that all I was doing was making sure that the baby boy left the nursery fit enough to fall prey to the next round of health risks.

The following week, my frustration peaked when it came time to discharge the seventh baby of an HIV-positive, cocaine-positive mother whose six previous children all lived in foster homes. In disbelief I read the social worker’s note that said the new baby girl was cleared for discharge with Mom. I called the social worker, who said the decision rested with the Department of Human Services because the hospital wasn’t able to take in boarder babies and didn’t have any alternative resources to turn to.

I called the caseworker to ask if this woman’s track record meant anything to anybody. The answer was no. No, this mother hadn’t done anything to jeopardize her right to keep her latest baby — yet. As long as the mother kept appointments for the baby at the family AIDS clinic, no action would be taken.

This mother listened attentively when I went to give her the discharge sheet and instructions. I played doctor while she played mother once again, possibly trying to get it right this time. For now she had her daughter in her arms, and we couldn’t take the baby away from her. I suppressed my anger long enough to tell her how important continuing medical care was for herself and the baby and gave her a card with the date and time of the first appointment.

I returned to the nursery ranting, “I can’t believe I’m supposed to roll over and send this baby home.” I was caught in a vortex of frustration as I clicked the box on the computer screen that read “Discharge today,” grateful not to have to write out by hand the words that seemed to amount to a death sentence.

The attending physician came over and sat next to me. “This is as bad as it gets,” she said, “but it won’t always be this way. You should try to concentrate on the short term and take your small victories when you get them.”

When my four-week rotation ended, I retreated from the misnamed well baby nursery. In time, however, I began looking for — and finding — the victories my attending physician had promised. As I’ve watched my crop of newborns in the clinic grow over the months, there have been families that cheer my heart.

There’s little Jeffrey, whose mother is finishing high school and working part time. Jeffrey’s grandmother babysits him, and various relatives pitch in to take him to his mother’s workplace so she can breast-feed him on her breaks. Jeffrey’s mother calls me often, and I look forward to hearing him laugh when she holds him up to the phone.

And there’s Stacey, the daughter of a cocaine-positive mother. The baby girl is being raised by an aunt, who brings her to the clinic dressed like a Christmas present — tiny headband, flouncy dress, and white tights.

The aunt can’t undo any damage already done, but she gives the baby her steady love and advocacy. On their last visit, she enlisted me to write a letter to the day care center, which persisted in feeding the three-month-old a hodgepodge of baby foods instead of just formula.

The well baby nursery, however, casts a long shadow. I know from the older children I’ve inherited from other residents that some of these babies won’t grow right. They’ll sputter along below the growth curve and look thin and gaunt from their war with poverty and the legacy of drug abuse. Some may have behavior problems. Indeed I remind myself that many of the mothers I get so angry with were once like the children for whom I feel such pity.

Genuine preventive care in pediatrics would mean preventing drug abuse in utero, and that would mean preventing all the social ills that lead to such abuse. That is the long-term struggle that no pediatrician — no doctor, no citizen — can afford to forget. But in the short run there are the small victories, and we cannot afford to forget them either. They are what keep us from burning out. They are what give us strength to face the long run.