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Book Review: Small

Thursday, December 5, 2019  
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Book Review: Small: Life and Death on the Front Lines of Pediatric Surgery by Catherine Musemeche

Before heading out on vacation, I always try to find some new books to read, usually by looking through the book reviews on AWS or through Amazon. My choice to read this book, however, started with my mentor in medical school who is a pediatric surgeon. I aspire to follow in her footsteps one day, which led me to searching for books about pediatric surgery, which led me to Small by Catherine Musemeche. I highly recommend this engaging work to anyone interested in pediatric surgery, pediatrics, or medicine in general. It finds an easy balance and pace from the intermingling of history and personal anecdotes. The author states in the introduction that she aimed to "bring the reader into the operating room, neonatal intensive care unit, emergency room, and bedside" along with bringing to life "stories of individuals who achieved milestones in the field." She accomplished this goal, while making the book accessible for those both inside and outside of medicine.

Before reading this book, I did not realize that pediatric surgery could be considered a relatively young field. The prevailing attitude around World War II was that operating on children was a scaled down version of operating on adults. No special skills were thought to be required. In 1954, Dr. Willis Potts, the head of pediatric surgery at Children's Memorial Hospital in Chicago, stated that "out of the 45 existing children's hospitals in the country, all were staffed by first class pediatricians, but only eight had surgical services headed by full time pediatric surgeons." I was astounded by this fact. Surgeons that had experience working with children were able to recognize the warning signs of sick children and congenital anomalies more readily than adult surgeons, which lead to more rapid care and better outcomes. It wasn't until 1970 that that American Pediatric Surgical Association was formed in Chicago, with 24 pediatric surgeons coming together to form the organization.

I found the story of Dr. Barbara Barlow incredibly inspiring. She was the first full-time pediatric surgeon in Harlem Hospital in New York City in 1975. She witnessed all manners of trauma that she did not feel she had been prepared for during her fellowship, which focused on congenital anomalies and childhood cancer. For context, during the 1970s, Harlem had the highest death rate in New York City due to homicide, suicide, and alcoholism. The infant mortality rate, which was above the national average in the 1960s, rose again in the 1970s to over twice the national average. Dr. Barlow knew from a young age she would be a doctor. During her training, women only went into three acceptable specialties: pediatrics, obstetrics, or internal medicine. She chose internal medicine, and during her fourth year, she participated in a surgical externship to hone her diagnostic skills. Something unexpected happened though. She fell in love with surgery. Barlow had never even seen a woman surgeon. She went to the head of surgery at the medical school, and he said, "women should not be surgeons." She was not even allowed in the operating room of one hospital in the Bronx because the chief of surgery forbade females other than nurses to work there. She reached a compromise with the head of surgery. If the chairman would let her start the program, if she could not keep up, she would agree to leave. She spent the next six years living in the hospital, but at the end of residency, she chose pediatric surgery because "what happens to children isn't their fault." Barlow interviewed at New York-Presbyterian Babies Hospital where there had never been a female chief resident in any specialty. She did not believe she would be chosen, but after the preferred male candidate walked away from the fellowship, she got the job.

After fellowship, she decided to work at Harlem Hospital because it had no full-time pediatric surgeons. There were a few part-time surgeons covering the hospital, which left a 500 patient waiting list for elective operations. Barlow soon started the "Children Can't Fly Campaign" to get the word out that windows needed to include measures to prevent children from falling out. Within a year, window falls in New York City decreased by 96%. This started her on her further journey into public health. She made major contributions over her career to make neighborhoods safer and playgrounds to be repaired. She overcame many barriers to become a surgeon, pediatric surgeon, and leading public health figure in New York City. I found this chapter a very compelling read.

The last chapter covers incredibly moving stories of dealing with death in this population. The author shares her personal experience of trying to save a newborn that developed necrotizing enterocolitis after being diagnosed with truncus arteriosus. The bowel was completely necrotic at the time of the operation on Christmas night. I am sure it is never easy to have this conversation, let alone to have it with a father on Christmas night with his firstborn son dead in the operating room. Dr. Musemeche's writing style makes this story and all of the stories in the book so palpable that you can find yourself lost within the pages of the book. I really enjoyed this book, and I highly recommend it.


Alyssa Brown grew up in Chattanooga, Tennessee. She went to Centre College for a B.S. in Biology and minor in History. She fell in love with surgery after seeing her mentor perform an anoplasty during the first year of medical school. She finished her third year of medical school in 2018 and wandered off the beaten path to get a PhD before finishing her MD. She is receiving her MD degree from the University of Louisville School of Medicine, and her PhD in Biomedical Engineering and Physiology at Mayo Clinic School of Biomedical Sciences. She is currently working on research projects involving pediatric ulcer disease, diaphragm sarcopenia, and benign breast disease. She currently works as part of the AWS Blog Subcommittee and AWS Instagram Subcommittee. When she is not buried in lab work, you will probably find her in the pediatric surgery OR, baking pastries, or bowling. You can find her on Instagram @alyssabrown1013 and Twitter @Alyssa_B_MDPhD.