Toad in the Hole

August 25, 2005

Hunger and Memory

Pica commented on the rant below that we can't imagine the kind of protein starvation Barbara Kingsolver described in The Poisonwood Bible. She's mostly right; I'm convinced that the letter-writer I was ranting about was guilty more of a failure of informed imagination than even of arrogance... though those might be synonyms.

I didn't exactly have to imagine it. I've seen kids starve to death on the most expensive diet on the planet.

They starved because they didn't have enough small intestine to digest even that carefully designed diet -- which was a powder we mixed with sterile water and put into a hanging bag for continuous NG-tube slow feeding. As I recall it cost something like $385.00 a can at pre-1980 prices, and which lasted a few days to a week depending on the size of the child and how much supplement we could deliver parenterally -- that it, through another line that ran into a scalp vein and down through the neck to (again IIRC) the vena cava.(It's possible I'm naming some wrong vessels here; this was a long time ago. I do remember the reasons and the arrangement.) It took surgery to place this line, and we had to be very careful the child didn't pull it out. This meant carefully placed restraints. We did manage to get time, or assign a helper sometimes, to free the kids' hands and play with them.

This location was necessary because the nutritious stuff was also quite caustic to blood vessels, so it had to be run into the vessel with the most volume and fastest possible flow, to dilute and move it enough that it wouldn't erode the line it was poured into. It ran continuously too. I don't know what the solution cost, and I'm not even factoring in the cost of all the plumbing, most of which had to be changed at least daily. (Fortunately, it's easy to put an NG tube in a baby; I could do that myself as a mere LVN. Bet I still could.)

Typically, these were infants who'd suffered an intussusception, in which the small bowel telescopes on itself and ends up becoming necrotized -- gangrenous. When the dead gut is cut out, there's little left to digest with.

An infant's or young child's nutritional needs are less flexible than an adult's; there was (at least 20 years ago) often no way to get enough calories and nutrients into them, even with all this parenteral nutrition and continuous tube feeding, to keep them alive, let alone let them grow. I have heard of adults living for years on Total Parenteral Nutrition, but that's recent, and they were adults.

Sometimes we did get one healthy enough to go home, even to grow and prosper. That's why we didn't give up, even when we wished we could stop the struggle, even when the child's parents wanted to. Nobody knew, except through experience, what the lower limit was, and I remember seeing one chubby three-year-old I'd taken care of, when his mom brought him back for a visit. I also remember a beautiful kid I fell in love with, who had 10 centimeters of small intestine left. He died, after two big-shot hospitals had tried their best for him, at about two and a half. When I knew him, he was also uncommonly cheerful, curious, bright, playful. And I swear to the god of your choice that he had slightly pointed elven ears.

Starvation hurts, if you're conscious, if you're otherwise healthy. (I've seen elderly people just give up eating and dwindle away, and that didn't look painful. There's definitely something else going on when you get into neurological problems.) Starving babies get furious, then irritable, then detached, then listless. They move as if moving hurts. They want to be held, they they don't want to be touched. They get cold. Actually, they get cold early on, and this process I'm describing in the nursery is so on the razor's edge that we had to watch them closely for shivering and such, because they could shiver away all the calories we'd managed to pump into them in one night.

That kid I fell for, his mother wanted to give up several times, especially after he'd pulled his parenteral tube and had to go to the OR to have it replaced... again. In retrospect, she was right. But I stayed neutral, let her cry on my shoulder when she could come in (she, her husband, and their two other kids lived hours away) and let the docs persuade her yet again, because like them I'd seen that chubby three-year-old.

If you want a moral education, try a few years working where there's no right answer, and you can't even tell what's merciful.

Posted at August 25, 2005 08:43 PM


Thanks for taking care of those babies and making a difference while you were there. I was one of those babies that needed a tube surgically put in. Still have the scar on my ankle.

Posted by: Janis at August 27, 2005 12:54 AM