A Pathology resident shares his poignant thoughts on infants and children being brought to the white-tiled morgue of his hospital, rather than seeing them in their innocent bliss on a playground filled with colorful rides and laughter
By Thaddeus C. Hinunangan, MD
Little Pedro (not his real name) was brought to the emergency room for trismus (inability to open his jaws). His only companion was his mother, a thin unkempt woman who unfortunately gave a very poor history. The three-year-old boy’s vaccination was incomplete, and Pedro lacked his Diptheria, Pertussis, Tetanus (DPT) vaccination. He was also undernourished, and being the youngest in the brood, was constantly left to himself playing around the backyard.
“Did he step on a rusty nail, or was he wounded anywhere?” The clinicians asked.
The mother denied any such incidence.
She only noted that her youngest son was having cough over the weekend, and by Monday was having difficulty breathing.
He was treated as a case of tetanus.
Tetanus is a vaccine-preventable disease which is seen quite rarely nowadays because of mandatory vaccination of children under the Department of Health’s National Immunization Program (NIP) which includes Bacillus Calmette–Guérin (BCG), Hepatitis B, Polio, Measles, mumps, rubella (MMR), Hemophilus influenza B, Pneumococcal conjugate vaccine, DPT, and Varicella.
The disease is caused by anaerobic bacteria called Clostridium tetani, which release toxins that cause muscle stiffness and spasms. Bacteria can get into the body through cuts and scrapes, burns and even animal bites which may introduce dirt or foreign objects through deep wounds.
Usual presenting symptoms include lockjaw, fever, rapid heartbeat and painful muscle spasms which may make breathing difficult.
Pedro was admitted to the Pediatric Intensive Care Unit, and a tracheostomy was made to ensure airway, and immunoglobulins, antibiotics, and a muscle relaxant was given to control the spasm. Yet despite treatment, his condition declined, with heart rate going up to 230’s, despite several cardioversions to convert the rhythm back to sinus. His condition eventually worsened with episodes of hypotension, and eventually went into arrest. The mother consented for an autopsy.
God’s Little Angels
“Happy Father’s Day!” said my nephew.
I laughed. “But I’m not your father.”
“Ok, Happy Mother’s Day!”
I laughed even harder, “That day is for moms only.”
“Happy Tito Day,” he said.
“Yes, I think there should be Tito Day,” I said.
Gavin was a pre-schooler then, inquisitive and bright. After I came home from medical school he would sometimes ask me about abstract concepts like what “sacrifice” meant. I had to make use of an analogy about juice. I told him, “I’m thirsty, and so are you. But instead of drinking the juice, I will give it to you.”
“So sacrifice is about juice?” he said, and we laughed some more.
I have a special fondness for children. All of them have a bright, inquiring nature. They are eager to explore the world around them, and their innocence is refreshing from the regular adult dose of sarcasm every day. The world may be full of cynics and pessimists, cuss-spitting, rude, run-of-the-mill adults but you can’t go wrong with kids. They will make you smile with their witty observations and generous laughter.
Even as a medical clerk and later as an intern, Pediatrics rotations were always a highlight. Pedia is even more demanding than most specialties because these kids are not simply little versions of adults- they have a dynamic and changing physique as they grow. Even reference values for vital signs and blood parameters are different in every stage from neonate to toddler to pre-school to school age, before they start approximating the normal values in an adult. There are so many stages and milestones to memorize, and every drug dosages are computed to the last gram of body weight. Not to mention starting venoclysis or taking arterial blood samples from infants is a challenge for the inexperienced. Even so, it is always a delight to see their smiling faces and innocent eyes.
“As I unwrapped the infant in the sheet, his face was that of a sleeping angel; the hair was straight and fine, eyes were almond shaped, and the lips shaped like a bow”
In the Philippine General Hospital (PGH), as I did my rounds on my patients and even after shift, I would usually visit them at their bedside and play peek-a-boo with the infants. I high-fived with my five year old patient Crystal (not her real name) who had Dandy-Walker syndrome (a rare group of congenital human brain malformations), traded fairy tales with a child with Neurofibromatosis (tumor in the nervous system linked to genetic mutation), and indulged in small talk while extracting blood or taking their vital signs.
Now as a Pathology resident, my heart fills with dread every time I receive a referral for autopsy, because it means they didn’t make it and I had to investigate the cause of death.
An imperfect health system
A young couple were about to become first-time parents. The mother was a factory worker and the husband was unemployed. The mother’s pregnancy was uneventful, she did her homework: nine ante-natal visits, a plan for giving birth at a lying-in clinic. All her ultrasound results showed a normal pregnancy.
At 2 a.m. her water broke, and she was brought to her lying-in clinic where she had her check-up. Everything had been well until the baby’s heart rate was observed to be slowing down. They were advised to transfer to a hospital. Unfortunately, the funds they had saved up were not enough.
They moved to a total of five private hospitals in their locality and nearby cities until they found out at the sixth hospital that the mother had oligohydramnios (or severely decreased amniotic fluid) and no fetal movements. It took them four hours again to travel to PGH, and by the time they arrived, 28 hours after her bag of water ruptured, no fetal heart beat was observed. The baby was delivered vaginally that day, with the diagnosis—Fetal death in utero, and an autopsy referral was made.
Truth in a white-tiled morgue
I had a memory of me being eight years old, and I was with my late mother in a bus. My mother’s face was tear-strained. We were going home to our home town, my baby brother Tristan had died of measles. He was wrapped in a white sheet and my mother carried him inside a duffel bag on her arms, while I sat beside her. She stifledsobs the whole time during the trip, and the wind blew my fine hair as the bus sped through the highway.
That memory haunted me as I claimed the body from the clinician and transported it to the morgue.
I carried the body of the infant inside a Styrofoam container with ice. Placing it on the cool steel table, I opened it and carefully took out the body wrapped in white sheet. Doing autopsy on a baby is very different from an adult. More details needed to be taken in like distances of the inner and outer canthus, the philtrum, the inter-pupillary distance, and checking for facies or abnormalities like drawing an invisible line from the corner of the eye to the occipital prominence to check for low set ears.
Common causes of abortions and intrauterine deaths are malformations and chromosomal abnormalities which sometimes show distinct facies and morphologies, and those needed to be ruled out right away. But as I unwrapped the infant in the sheet, his face was that of a sleeping angel. The hair was straight and fine, eyes were almond shaped, and the lips shaped like a bow.
I started with the externals, and even then, one could already observe the slippage and peeling of the skin. Langley Maceration Grade of 1 implied that intrauterine demise happened more than eight hours already, and a small bulla on the skin suggested it might be within the recent 24 hours. There were meconium stains in the skin, and even the placental membranes were green tinged.
There were no cord coils, however there were numerous pale areas- infarcts in about 50 percent of the placenta. The organs were grossly normal, but examination of the skull and brain showed subgaleal and possibly subarachnoid hemorrhage. The cause of death was probably fetal hypoxia.
From a father to his son
I think I have understood myself why I was so especially fond of children- I’ve always wanted to have kids of my own. I once wrote a short poem on my blog:
“I’ve always wondered what it’d be like
To have a son who would ride a bike,
Stay in the sun and play all day.
Tell me, will he also like the bay?
What joy it would be,
To see a little guy who looks like me.
Will he like to paint?
Or write stories without restraint?
To see those tiny hands,
Clap and beat like marching bands.
To hear that laugh and squeals of delight,
Just before I tuck you in at night.
Sleep tight little tyke, and dream if you can,
You’ve turned your Dad into a better man.”
Until the day comes when I have children of my own, I will always look at each child and ask, what if that kid was my own? It was a heartbreaking task to tell the news of what caused the demise of their child, but I went ahead to the mother’s bedside to explain why their baby died. I touched her shoulder lightly to convey my sympathies and proceeded to explain to the family the sequence of events that led to fetal hypoxia in terms that they could comprehend, and made recommendations as to what they can do next time. I’ve read in some textbooks, an autopsy may help families get closure, finally knowing what had caused the death of their loved one; and to some extent, it offered some peace of mind to me as well.
Back at the morgue, the body of little Pedro was also covered in white sheet. I usually dread carrying the body to the table but his small frame was light as a feather. I unwrapped the sheet and he was nestled inside in his diapers, the tracheostomy site visible in his neck. His limbs sagged as I tried to support his back and slowly laid on the table. It was such a pitiful sight, I remember his mother told me Pedro was “makulit” (talkative) and all I could think of was how sorry I was to be doing his autopsy. Children belong on a playground filled with colorful rides and laughter, not on a whitetiled morgue.
I documented the externals and proceeded with the evisceration. As I examined each organ, I could have sworn something moved. I ignored it. Clamping the jejunum so I can localize and dissect the second part of the duodenum together with the gallbladder and pancreas, I cut it between the clamps and noted how strangely large the jejunum was in comparison to the ileum.
The Kelly forceps fell from my hand into the metal, and lo and behold, a tangle of giant round worms were bursting out of the jejunum, and then looking at the entire length- with the intestinal walls almost translucent and very thin and distended, the entire two or three feet of jejunum was filled with a mass of Ascaris lumbricoides adult worms. The child had intestinal obstruction from severe Ascariasis. That would explain the malnutrition, and the pulmonary symptoms could be explained by the heart-lung maturation of the larvae, causing asthma like symptoms called Loeffler’s syndrome.
As I was finally typing the report, I thought of how unfortunate a case of parasitism would be extreme enough to harm a child when we have government programs like mass deworming which should address those problems. Ascariasis is a disease of poverty. Usually in poor sanitary conditions where there may be open defecation and these children walk around barefooted, the life cycle of the parasites are perpetuated. The solution isn’t a quick dose of Mebendazole and sending them back to the place where they will catch the disease again. It is environmental sanitation, and educating people and advocating hygiene.
I was all alone then, even the mortician had gone home and the Funeral parlor had taken Pedro’s body earlier that afternoon. The morgue was clean and in order, my instruments neatly piled along with my notes, and the windows were closed and bathed in the dying rays of the sun.
“An autopsy may help families get closure, finally knowing what had caused the death of their loved one; and to some extent, it offered some peace of mind to me as well”
August 2017 Health and Lifestyle