My first job after residency was in a neighborhood health center in the city. We provided care for a large, relatively discrete ethnic population. Most of my patients did not speak English, but I was never without one of our excellent translators. My patients came from a culture where children’s futures were considered paramount. They heeded any and all medical advice about pregnancy and birth.
There were down-sides to the job, of course. I admired many things about the culture of my patients, but there were some I found difficult to accept. The clearly inferior position of women and the way that many of my patients greeted the birth of a daughter with obvious and profound disappointment bothered me.
One spring Friday, I met Mrs. W. She had come to the US only 3 weeks before and believed herself to be about 8 months pregnant. She had two healthy girls and no history of medical problems. However, on exam, her uterus was larger than expected and I ordered an ultrasound to see if she was closer to her due date than she thought. The patient smiled brightly when the translator explained the ultrasound and the translator reported that Mrs. W was happy to have an ultrasound. She and her husband wanted to know if this was the son they both prayed for.
The ultrasound report arrived in my office midmorning on Tuesday. Mrs. W was carrying twins, 8 months along, and both girls. One of the twins appeared to have a heart problem of some kind, with clear evidence of serious illness. The twin was swollen (probable heart failure) and there was other evidence of severe compromise.
I was furious. The ultrasonographer should have called me immediately. The information was extremely time sensitive. The patient should have been evaluated promptly by me and a battery of specialists to determine whether the babies should be delivered early and to arrange special care for the ill twin. The office called Mrs. W and advised her to come to the hospital right away.
At the hospital I found that the situation was worse than I feared. The nurses could find only one heartbeat. I pulled out a portable ultrasound machine and did a quick scan. The ill baby was dead. She had died, and based on her appearance, almost certainly from congenital heart disease.
The second baby looked healthy and vigorous. The situation still remained precarious, because it was unlikely that a pregnancy with a dead twin would continue to term, and it was 8 weeks before the expected due date. A baby born that early would have a good chance of survival, but far from assured. Mrs. W was admitted to the hospital and given medication to speed maturation of the baby’s lungs in advance of the inevitable premature delivery.
Sure enough, despite intensive medical efforts to prevent delivery, Mrs. W ruptured her membranes approximately 1 week later in the middle of the night. My partner on call delivered the babies. Baby girl 1 was sent to the morgue. Baby girl 2 went directly to the neonatal intensive care unit. We were optimistic that the extra week of pregnancy, and the medication for lung maturation had improved her chances for an excellent outcome.
The parents did not express any disappointment that this baby was girl. Indeed, they seemed to have bonded to her fiercely, visiting her in the NICU at all hours and willing her to live. Baby girl W had a surprisingly rocky course. She required prolonged ventilator assistance to breathe, developed gastrointestinal problems and other complications of prematurity as well.
Gradually, the Baby W began to improve and after several weeks it became clear that she would survive. Almost 2 months after her mother was admitted, Baby W went home with her parents.
Several weeks later I arrived at my office to start a day of seeing patients. Before I crossed the threshold, I knew that something was wrong. The translators had red rimmed eyes. Our patient educator was crying.
I looked around the room. “What happened?” I asked, dreading the reply.
“Baby girl W died last night,” one of the women replied. “The director of the health center wants to talk to you about it.”
I was stunned. Premature babies are at much higher risk of sudden infant death, but she had seemed so healthy when she left the hospital. I sought out the director and we ducked into an empty exam room to talk. I was still in shock and she looked grim faced. What had happened? What had caused the baby’s death?
Baby girl W’s mother had found her lifeless in her crib the previous night. She called an ambulance, which brought the baby to another hospital closer to home than our hospital. The pediatricians at the other hospital tried to resuscitate Baby W but it was far too late. Compounding the tragedy, no one could communicate with Baby W’s parents because they did not speak English. They waited for a translator to arrive.
The pediatrician, who had no knowledge of the complicated history of Baby W, proceeded as if this were any other unexplained infant death. He sent the baby’s body to radiology for a full body X-ray. By the time the translator arrived, he knew why Baby W had died.
The director looked anguished.
“Baby W died of a skull fracture. The x-ray also showed that she had multiple broken ribs, and a broken leg. Baby W was beaten to death.”
I was dumbfounded. The director recognized my confusion.
“The father has already confessed. He killed the baby because he did not want another daughter.”
I went back to my office and told my staff. They were equally stunned, and over the next few days we agonized over whether any one of us could have seen this coming. Child abuse is not uncommon in any community, and we had all been trained to look for the warning signs, but none of use had seen any.
Sometimes tragedies leave us with valuable lessons, but sometimes they leave us with nothing but grief and pain. Even after 20 years, I still cannot make sense of what happened. Baby girl W’s life had been threatened by the death of her twin, by the negligence of the ultrasonographer, and by a whole host of additional complications of prematurity. We all worked so hard to save her, and then, unwittingly, we sent her home with the man who would kill her. Baby girl W’s life and death must mean something, but, I confess, I cannot conjure anything positive from her story of illness, struggle and the ultimate betrayal.
