Feast your eyes on today’s excerpt… From Tokyo to toilette slippers....Please click on this link from author Wendy Tokunaga!
Welcome to my Friday Feature, in which my Quick Take Tuesday guests regale us with tasty and tantalizing morsels of their work.
Feast your eyes on today’s excerpt… From Tokyo to toilette slippers....Please click on this link from author Wendy Tokunaga!
This is my second interview with a pediatric specialist. In this case, the doctor is a neonatologist. That is a pediatrician who does an extra 3-year post-residency fellowship in order to specialize in the intensive care of newborns. Neonatologists care for newborns that are hospitalized due to complications of prematurity as well as full term babies needing critical care, such as those born with serious birth defects needing surgery, such as my son.
On delivering babies early:
Some percentage of babies born at any age will have problems. The more premature a baby is, the more likely the problems. The most common problem is respiratory distress syndrome (RDS). This is a condition where the lungs lack a chemical called surfactant. Near term babies (35+ weeks) with RDS can be some of the sickest babies we take care of. Many of these babies will need to go on a mechanical respirator and some of them will need extra-corporeal membrane oxygenation (ECMO), which is very similar to heart/lung bypass. Most hospitals don’t have the capability to take care of these patients. A typical community hospital has a level 1 neonatal intensive care unit (NICU), which probably does not even have a respirator for a baby and/or the people qualified to operate it.
Inducing a 44-year-old multipara woman carrying a 35-week Down syndrome fetus:
In order to justify an induction at 35 weeks, there has to be a significant risk to the mother’s or baby’s health. Down’s syndrome in itself is not such a reason. There are tests to evaluate lung maturity. They require an amniocentesis, which carries its own risks and are far from 100% accurate.
Sarah Palin states she began leaking amniotic fluid in Dallas 24 hours before she delivered and flew for 8 of those:
Aside from the mess associated with leaking amniotic fluid (was she wearing an adult diaper to catch the fluid? There can be a lot of it), medically, it makes no sense. The longer that the membranes are ruptured, the higher the risk of infection to the mother and fetus. The risk rises more rapidly after 24 hours and mothers ruptured that long should be monitored in a hospital and probably should be given IV antibiotics. Any doctor who tells her patient with ruptured membranes that it’s ok to travel for 10 hours better have good malpractice insurance. Once the membranes rupture, the onset of labor can happen at any time. A woman who has had several children will often have a shorter labor and can deliver shortly after labor begins. This is variable, of course, but who would want to take this risk?
What would happen to a baby born on an airplane:
If a baby was born on an airplane, the odds that someone knows what to do are fairly small and the equipment to handle a delivery will certainly not be available. Most doctors who aren’t in OB/Gyn or Pediatrics haven’t been to a delivery since medical school. They would probably do fine if the mother and baby had no real problems, but in the case of premature baby, possibly infected, possibly with a heart defect and known to have Down’s syndrome, many things could go wrong. At best, the plane would have to make an emergency landing and the mother/baby taken to the nearest hospital.
Delivering in small hospital without NICU:
For a full term baby with no known problems, this is fine because most babies and mothers do well. The equipment and personnel to resuscitate a baby would be there and the baby could be stabilized and transported to hospital with a higher level of care. However, when there are known problems with the baby, it makes no sense to take unnecessary risks that the baby will need immediate intervention that cannot be provided in community hospital.
Delivery of a Ds baby by a Family Practitioner:
This, I have no problem with. A family practitioner (FP) who routinely does deliveries can handle this, as long as there is an OB/GYN back up in case a C-section is needed. Keep in mind that an FP could also help with the resuscitation of a sick baby, but that would divert him/her from the care of the mother and someone’s care would be compromised. Often, there is a pediatrician on call, but they may not be immediately available and would likely get there after the baby had already delivered. Again, this is fine for most cases, but when there are known issues with the baby, it makes no sense.
Down syndrome heart defects :
About half of babies with Down’s syndrome will have a heart defect. Many of these do not cause immediate problems, but will usually need surgical correction in the first year of life and need to be watched closely in the hospital before discharge to determine the timing of follow-up. Of course, this is not true of all heart defects and some will need immediate intervention from a cardiologist and pediatric cardiac surgeon. Not all congenital heart defects can be detected on prenatal ultrasound and it is recommended that all babies with Down’s syndrome have an early evaluation by a pediatric cardiologist. While this can be done in some community hospitals, it isn’t always easy.
There is another condition that occurs more often in babies with Down’s syndrome called persistent pulmonary hypertension (PPHN). This cannot be predicted prenatally and can be very serious. In this condition, the blood vessels in the baby’s lungs are constricted and very little blood flows through the lungs. This means that the baby has a hard time getting oxygen into their blood even if they are breathing normally. The usual treatment ranges from small amounts of supplemental oxygen, above concentration of oxygen in the air, delivered via an oxygen tent or nasal canula, to a mechanical respirator, to ECMO (heart-lung bypass, described above). This is more often associated with premature babies, but can happen at any age.
Photo of Trig seemingly with a nasal canula for oxygen:
If Trig required a nasal canula, there are many possible reasons. The most common would be “delayed transition” where he simply needed some support while he cleared fluid from his lungs. This could be exaggerated in a baby with low muscle tone due to Down’s syndrome. This generally gets better over time, but this is care that is over and above the capability of a level 1 NICU in a community hospital. He could also have some PPHN as I described above or even some RDS due to prematurity.
Taking a 3-day-old newborn to work:
Babies in general are very susceptible to infection. A baby with a heart defect and/or lung disease could get very ill if they get an upper respiratory infection. It is not recommended that newborns be taken out where they could be exposed to people who are sick.
The feeding issues associated with Down’s syndrome are usually related to the low muscle tone. Swallowing and breathing are two things we take for granted in a baby. In a premature and/or Down’s syndrome baby, they may not be able to do this right away and may need a feeding tube for a period of time. Often, the cardiac surgeons want a baby to gain weight before they operate on a heart defect. The heart defect can also make it harder for the baby to gain weight with a normal food intake. Oral feedings are often supplemented by tube feedings in these babies.
Down’s syndrome can affect almost any system in the body. They have an increased incidence of intestinal blockages, needing surgery shortly after birth. They can also have abnormalities of the blood. They can have low platelet counts (platelets are the cells in the blood that are involved in forming clots) and have a higher incidence of neonatal leukemia.
The media and the “Spiral of Silence”:
This is out of my area of expertise, but I can say this: Until recently, there was a line of respect for public figures that the media was not willing to cross. A politician’s children were generally off-limits for criticism and that probably explains the silence. However, it seems like everything is fair game these days.
Trig and Trisomy G:
I have never heard Down’s syndrome called “Trisomy G”. A quick Google search tells me that the Merck Manual has that name, but I’ve never heard it mentioned by anyone. We either call it Down’s syndrome or Trisomy 21, as the baby will have three copies of chromosome 21, instead of the usual two.
What a parent names their child is their decision. I’ve seen some crazy names over the years and Trig (Trisomy G?) is no big deal. What would you do if your parents named you “Shi’thead” or “Chlamydia”? Once we had a teen mother try to name her baby “Diarrhea” but we convinced her it wasn’t a good idea. My favorite baby name was pronounced “An-yae” but it was spelled “Etienne”. Apparently, the mother took the wrong name off her Etienne-Aigner purse when filling out the birth certificate. As we often say, “You need a license to drive a car, but not to have a baby.”
Ruffled ear defect:
I don’t know much about this. Generally, when a ear is deformed by the baby’s position in the womb, it will return to a normal shape after a few weeks. Rarely, some splinting is needed to re-shape the ear. This is not the case for developmental abnormalities of the ear. When an ear is malformed, surgical correction is needed to give the ear a normal appearance.
Downs and age:
The incidence of giving birth to a baby with Down’s syndrome rises with the age of the mother. It can be as high as 1 in 60 for a mother in her mid-40s. However, any mother of any age can have a baby with Down’s syndrome. It does happen in teenage mothers, but their risk is more like 1 in 1250.
Has a mother ever hidden her teenage daughter’s pregnancy and birth? Of course, I’m sure this happens all the time. The daughter has the baby and they announce to the world that the mother had another baby. It saves them from difficult questions and possibly shame. I can imagine if a mother is a political figure and an advocate of abstinence-only education, she would not want her teenage daughter getting pregnant and having a baby in the public eye. It could be the end of her political career, or at least her credibility.
I remember hearing that Bristol Palin was out of school for about 6 months due to “mononucleosis”. While mono can make a teenager quite sick, the timing certainly is suspicious and the length of time out is much longer than most cases of mono would last.
In response to the first pediatric specialist interview I conducted about this mystery, I received two insightful, intelligent, and delightful comments from a reader named “V”. She agreed to share her math skills with us on a broader scale by allowing me to post her work here. As someone who can barely add, I am intrigued by V’s work. And as someone who wants to embrace all possibilities in this sordid tale, I welcome this wonderful way of analyzing the data. Take it away, V.:
One question that has come up several times, in one form or another, has been: what are the odds? I thought it might be interesting to look at various independent data points that we seem to have in Sarah’s story, and assign odds to them, and then apply a little math, in order to determine how likely her story actually is. This is going to be chock full of assumptions and I’m sure the rest of you will have plenty to contribute to make the math better.
Data point/assumption 1: Trig is a Down syndrome baby. As many have noted, an older woman is much more likely than a younger woman to have a DS baby. On the other hand, a younger woman is much more likely to produce a baby. 80% of all DS babies are born to women under 35. So we’ll give Sarah a 20% chance of being Trig’s mom here (I know that this could be refined, either using conditional probability, which for various reasons I don’t want to apply, or better data regarding the probabilities, which I don’t have). But I think it’s important to remember that it’s simply a lot harder for women in their forties to produce babies at all (especially when they may have had their tubes seared shut, or when they’re grown-ups who should really understand birth control).
Data point/assumption 2: Sarah did not appear pregnant until her 7th month (unlike her daughter Bristol, who not only looked pregnant in the one picture which I saw of her, but mysteriously disappeared for the relevant period). I think this is rather unlikely – but there seem to be instances of it happening, even with women who have been pregnant before. So I’m assigning a 10% chance here, which I actually think is rather generous to Sarah, given how extremely odd the photos are. We’re down to 0.2 x 0.1 = 0.02 – a 2% chance that the child is hers.
Data point/assumption 3: Sarah did not tell anyone she was pregnant before then. Well, if she were faking it, she certainly wouldn’t tell anyone. However, I can imagine other reasons for not telling anyone. First, she had an important position, and she might not want to reduce her work effectiveness with a pregnancy. Second, knowing that it was a DS baby makes it less of an occasion of joy, especially if there is a chance that the baby won’t survive. So I’m not going to count this either for her or against her. We’re still at 2%.
Data point/assumption 4: Sarah did not behave pregnant before then, being seen drinking coffee and with no evidence of going to the doctor for extra visits. It’s possible that with a baby with Ds, that she saw no point in taking care of her body for him. On the other hand I think it’s odd that no one ever mentioned any behavior that would make them think, at least retroactively – Of course! Preggers! Especially as her appointments would have been generally visible to everyone on her staff, or at least there would have been occasions when people would wonder, hey, where was she Friday afternoon? Whereas poor Bristol apparently had a car accident in front of an OBGYN office. So again, being very generous to Sarah (and rather hard on everyone around her) I’m going to say 75%. We go from 0.02 x 0.75 = 0.015, or 1.5%
Data point/assumption 5: The flight attendants during Sarah’s wild ride claim that they did not notice that she was pregnant. Not just not 8 months pregnant, but pregnant at all! Now, if she was showing as much as she was in the Gusty photo, this seems really unlikely. Or if she took off an empathy belly, of course she wouldn’t appear pregnant either. However, I feel compelled to suggest another possibility: they noticed that she was pregnant but let her fly anyway, and then later, to protect themselves, said they didn’t notice anything. So on this point I’m not quite sure what to think – how to assess the odds. I’ll give it 50%, but additional input would be appreciated. That gets us down to .015 x 0.5 = 0.0075 or 0.75% (not 75%, but one hundredth of that)
Data point/assumption 6: the rest of the wild ride. Although I think it’s extremely peculiar, I’ll listen to the medical opinion you’ve presented here, and not go up or down. Still 0.75
Data point/assumption 7: Internet scrubbing. Many folks have mentioned that after the selection of Sarah as McCain’s VP candidate, pictures of Sarah disappeared, and that even kids’ computers and Myspace accounts were scrubbed. Although I could believe that the kids probably had indiscreet remarks on drugs and drinking, I can’t understand deleting general photos of Sarah. Something to hide? Sure looks like it, especially when you think that the McCain campaign would generally be interested in showing more rather than less of the photogenic Sarah officiating as governor … we’ll reduce her probability of telling the truth here by 50%. So that’s 0.0075 x 0.5 = 0.00375 or 0.375%
Data point/assumption 8: the letter from CBJ. This is a difficult item to assess. CBJ’s letter certainly indicates that Sarah gave birth to Trig. So for Sarah’s story to be false, CBJ would have to have lied. How likely is that? I have no idea. There are strange aspects to CBJ’s letter and behavior. Why on earth would she have OK’d the ride back from Texas? Heck, I can’t understand why she OK’d the ride TO Texas! Why was CBJ’s letter released on the eve of the election and not well before? Is it possible that there was a great deal of pressure on her? I’m sure that the letter was scrutinized by the McCain-Palin team – was she forced to say something which wasn’t true? Why did she need a lawyer when responding to questions from the ADN? This is all extremely odd, and it’s not as if we’ve never heard of unethical doctors, so I have some real doubts about CBJ. On the other hand, I must say that if Sarah was not pregnant, and all CBJ did was to lie about it, I actually respect her more. She did no medical harm in this situation and actually protected her patient’s privacy – probably ethically to her more important than telling the truth to the public. However, because I want to give her all benefits of doubts, I will double the chances that Sarah is telling the truth. So now it’s 0.00375 x 2 = 0.0075 or 0.75%
Data point/assumption 9: no release of a birth certificate. This I can’t understand at all. If Sarah is the mother, releasing the birth certificate would effectively quash all rumors. The only reason not to release it, other than Sarah not being the mother, would be if Todd were not the father – which I think is really unlikely. So here I have to give Sarah a 25% of telling the truth (generous to Sarah on my part): 0.0075 x 0.25 = 0.001875, or 0.1875%.
This is all very rough, but it ends up with Sarah having a less than 2 out 1000 chance of being Trig’s biological mother.
An interesting exercise for an afternoon – thanks for reading! UPDATE: Gryphen reminds me that he did a post on The Odds last year. It's a great read, as always, and free of numbers, which means I can wrap my tiny brain around it! Check it out!
And thank YOU, “V” for sharing your skills and time with us. Math wizards, weigh in!
The French were right: The more things change, the more they stay the same. The “Spiral of Silence” that Professor Brad Scharlott wrote about in this draft of an academic paper examining the media and the Sarah Palin birth rumors, has begun to spiral again. Only it’s downward, and it’s not pretty.
This time, the media is not so much debunking the rumors and laying them to rest. Instead it is turning in on itself with outlets out-arguing and out-shaming themselves. Bloggers pressing for answers. Reporters turning on bloggers. Just when Professor Scharlott and I think we can forge ahead with our conversation about the actions of major news outlets in 2008, reports came out last week that reporters quaking in their shoes once saw the then governor’s pregnant belly.
The formidableAndrew Sullivan has weighed in on this new evidence. The incomparable Joe McGinnisshas as well. Both linked to my earlier interview with a specialist in the field of pediatrics (read the interview and figure out what he does. It’s not that hard. And they don’t get any more specialized than him.) I appreciate their guts and due diligence.
The immortal Immoral Minority’s Gryphen says the story still stinks like foul fish and I have to agree. So, Brad, let’s talk shop:
LN: “Make it stop,” cried one reporter who now says she thought the governor was pregnant, in part because her friends in another city saw Mrs. Palin sweating on a treadmill. And that’s what I say now because I’ve just read about a reporter swearing he shooed people out of her office and then begged her not to get mad at him. Tell me I am dreaming.
BS: You’re not dreaming. Well, that reporter is Wesley Loy, the one I praised in our last edition as having “a lot of guts” for writing in March 2008 that Palin “simply does not look pregnant.” The scene you describe above comes from his recovered memory, three years after the fact, in which Palin seemingly convinced him she was with child. So if a hard-nosed, call-it-like-it-is guy like Loy suggests he thought she was really preggers, that seals the deal, right?
But wait. I wrote to Juneau newsman Gregg Erickson in September 2008 asking about the alleged hoax. He wrote back that in the summer of 2008, he and his wife had offices next to Loy’s, and that they “especially enjoyed Wesley's accounts of his pursuit the ‘Grandma Governor fakes birth’ story.”
Huh? If Palin, by lifting her shirt and revealing her fabric-covered belly, convinced Loy sometime that spring that there was no hoax, why was he investigating the hoax that summer? After Loy took a buyout from the Anchorage Daily News, I understand he became a freelancer and a blogger.
And Julia O’Malley, still with the Anchorage Daily News, wrote the “Make.It.Stop.” story, in which she virtually called me an idiot. Indeed, everything coming out of the Daily News these days seems to have a strong pro-Palin spin. These are tough times, especially for newspapers, and the Daily News gets over half a million dollars a year from the state of Alaska for advertising and other services. And while Palin is no longer the governor, many of her friends, whom she put in high-level state positions, are still around.
So could the Palin crowd be orchestrating something like reporters’ recovered memories and attack-dog articles? Does a polar bear eat moose in the woods? I simply don’t know.
LN: I am stuck on this fact that a reporter is saying he actually apologized to Mrs. Palin behind closed doors asking her to not get mad at him, before she lifted her shirt to prove she was pregnant. Scrape me off the floor because not only can I not fathom a reporter ever doing this, I’d be too ashamed to ever admit it. And no matter what the truth in this whole ordeal, she had him right there. He was mincemeat. Am I right?
BS: I’ve never been a woman, but a couple of folks posting at blog sites have said that the above scenario sounds like a woman wrote it. I don’t know the first thing about Loy – maybe he is good at getting in touch with his feminine side. But my reaction as a journalist is like yours – it seems like a very strange scene.
But I don’t want to seem snarky. Palin was the governor. And she was also beautiful and charismatic. To be honest, I have no idea how I would have reacted when I was a young reporter faced with a situation like that – but I might have been every bit as deferential. I’m guessing the scene happened exactly as Loy described it, and he was just overawed by her presence. Loy should just be thankful it wasn’t her gender that was being questioned.
BS: Your turn Laura. Can you picture a circumstance where you would write a “Make.It.Stop.” piece like O’Malley’s, effectively telling journalists that further investigation of a potential presidential candidate should be off-limits, because you absolutely know the truth and have revealed it?
LN: Never. Yawn. Next question.
Seriously. Years ago, I worked with a very famous TV journalist in London and New York. Every time I went in to his office, he had his hands in his pants. Deep down. Fiddling with his shirt, I suppose, if I want to be charitable. Things like that happened often in the news business to young women. The sexism was rampant. So, had there been a weird story then that the man had no private parts, say, would I have said that no, that I was pretty sure there was something there to fiddle with? I’m sure I would have been discreet had that question been raised (he was a notorious philanderer.) Later, if someone asked, would I change my story about his fiddling with his pants and with other women? No. I experienced what I experienced. I wouldn’t adapt the story to fit the current agenda.
Same goes for my experience with Rush Limbaugh. We worked at the same all-news station in Sacramento. My experience was that he was a gentleman. He was always nice to me and had a good sense of humor. He’d often invite me on his show to debate issues. He called me a "flaming lib in the newsroom!" All these years later, with all that’s been said about him, would I change my story just because I disagree with his politics? No. I experienced Rush the way I did. It’s bogus to adapt to the current discussion rather than hold to our original truth.
BS: Joe McGinniss recently asked this in his blog: “Is it purely coincidence that so many are suddenly so intent on insisting that there are no legitimate questions to be asked?” What’s your answer?
LN: One must tread carefully, Obi Wan. Influence talks. Absolute influence talks absolutely. If reporters reported the story correctly, we wouldn’t be having this conversation.
Remember what you just said: Young reporters are more timid. They can be overwhelmed by the power brokers. I would probably have been as well, though to be honest, I overcame a lot of fear by compensating with fierce reporting. I could just get in their face!
But I want to point out one more thing. Powerful people have media people. Those media people do not, I repeat, do NOT leave the room because a green reporter tells them to. (again, scrape me off the floor). I’ve had them place their tape recorders next to mine for the interview. I’ve had them try to redirect the conversation. I’ve even had them sit directly behind me and click, click, click away on their laptops to log the entire interview, almost as if in an attempt to unnerve me! I’ve been pressured, leaned on, harassed, schmoozed and offered bribes.
Brad, anything is possible. Anything.
If you're just joining me, thank you for visiting. My posts about Sarah Palin are marked as such in the side bar. Several new ones are almost ready. And my interview with the doctor is a short scroll down.
Thank you to Andrew Sullivan and Joe McGinniss, two of the world's finest journalists, for linking to my interview with this MD.
To clarify an important point: "Pediatric specialist" is a term that the doctor wished to use in order to not further identify his sub-speciality. I agreed to do so. He is NOT a pediatrician. He is NOT an OB/GYN. With all the nut jobs out there in the world, I was content to let him choose the moniker "specialist". He actually has many, many more years of training than a medical doctor. If you read his words carefully, you can probably discern his speciality. It's not that hard!
If you never have to meet a doctor in his shoes, consider yourself very lucky. This man speaks from 30 years of experience in the trenches, treating horrific things in pediatrics that most people can't imagine (though I can because I volunteered in an inner-city NICU for five years and saw some pretty unspeakable things myself.) This doctor is eminently qualified to speak about Down syndrome, or I would never have asked his opinion. I've been a reporter for 25 years. I don't seek out unsound sources. Nor am I unfamiliar with pediatric medicine and its many sub-specialities: My son has endured 15 surgeries in all, one of them lasting seven full hours. He lived in neonatal intensive care for three months.
I admittedly interviewed the doctor with preconceptions. He answered me with no regard for what I, or anyone else, wants to hear. My job as a reporter was to listen to the doctor and print what he said. Whether or not I agreed.
Thank you for reading. And welcome to the conversation!
Quick Take Tuesday, a blog of tasteful, yet shameless, self-promotion involving an author or someone of equal social standing. I ask two questions, and then my guest turns the table and asks me two questions, as long as they don’t involve pounds or pant size.
Reporter, Author, Blogger, and Mother...