The Apgar Score helped decrease the infant mortality rate | Hacker News Reader

The Apgar Score helped decrease the infant mortality rate

massivesci.com

172 pointsallthebest50 comments

> The newborn’s skin was blue and he wasn’t breathing. A few years earlier, the doctors would have documented the baby as stillborn, not believing there was anything they could do to help.

As someone who scored a 1/10 on the Apgar at birth, I'd like to thank Dr. Apgar for saving my life.

As a father whose 3 children were all born emeregency c section and blue I also want to thank Dr. Apgar for the joy they have brought into my life.

My mom was born at an Air Force base in the 1950s. She said she was born silent and unresponsive, and they put her in another room to die, but then she recovered several hours later. That story always struck me as very odd, and heat breaking, but now it makes sense.

Two close family members (twins) were born in the late 1950s. An emergency baptism was immediately administered, their mother was told "there is nothing we can do" and the twins were given to her. They both survived.

Having recently had a child, I learned about APGAR and marveled how the emotional "is my baby ok" was put into a super easy process. The chart from the article can be followed by absolutely anyone and babies can be sent to specialists as needed - or not. As the article mentions, it may not get everything 100% right, but it's useful enough - and more importantly easy enough - to save a lot of lives.

I can highly recommend anyone to read about the process of medical emergency triage in general. It drastically reduces the knowledge needed to solve complex situations and gives you something to hold on to when things get hot. Seeing these stressful problems reduced to if-else flows was very inspirational for me for designing ways to tackle urgent issues in other areas of life, e.g. tech support, service requests or HR.

> I can highly recommend anyone to read about the process of medical emergency triage in general

Any recommendations? I had a search about but didn't find anything much beyond basic explanations of the term.

Consider this chapter on assessment from the Trauma Nursing Core Course (1). The full provider manual may be hard to obtain, however.

(1) https://notendur.hi.is/thorsj/gogn/TNCC.pdf

Atul Gawande's Checklist Manifesto has some good discussions of complex care situations that are more or less driven by runbooks.

If you're in the US, a recommendation is to look up your local CERT[0] organization - they usually have free or low cost classes and other learning opportunities. Triage is an important part, as is preparing for disasters that are relevant for your community. Going further, a basic first aid and/or CPR class is good to get hands-on.

[0] https://www.ready.gov/cert

Isn't APGAR useful only for newborns?

Yes. It happens after birth. The paediatric nurse takes a look based on the checklist and ranks the baby out of 10. Our kid was an 8 but required NICU for the 2 they were missing. But if it's even lower they can immediately intervene, etc.

Indeed

It was great to hear him being 8/10 and soon up to 9/10. So comforting and removing all that unnecessary fear. Days and hours right before that moment were so exhausting that simple number was easy to process.

My father-in-law is a doctor and he jokingly told me when my daughter was born, that only the babies of doctors who work in the hospital get 10/10

The ABC's are helpful for just about any emergent medical situation. From first responders to paramedics, we are hammered to remember and implement the ABC's. You can do a lot with very basic knowledge.

Correcting problems with the systems associated with the ABC's is more knowledge and experienced based. A good basic first aid and CPR class will get you a lot of that knowledge. From there, staying calm and calling 911 is vital if you are US based.

A - Airway / B - Breathing / C - Circulation

After my daughter was born, my parents showed me the booklet containing the results of the routine examinations I had as a child (where I come from, this booklet has been standardized for decades, so it can be compared pretty easily). Interestingly, we both had the exact same Apgar scores 6 / 10 / 10 (scores are measured 1, 5 and 10 minutes after birth).

For the emotional "is my baby ok" aspect, before you are even interested in the Apgar scores, you automatically and instinctively do a quick "is everything there" check, even if you know that to be the case because of the ultrasound examinations.

That's a pretty typical score progression (it's very rare for a baby to be a 10 right right out of the gate).

https://www.newyorker.com/magazine/2006/10/09/the-score This is linked in OP, but gives very slightly more detail around how the score was actually popularized, and what Apgar's career looked like. (Plot twist, she wasn't "just" a practicing anesthesiologist, but the founder and head of a whole new Anesthesiology dept. at Columbia) I think the short version is that she published a paper in 1953, and managed to get obstetricians using the scale in a competitive spirit, but I am still curious about how it was marketed (just publishing a paper is rarely enough to get something publicized, afaik).

She also carried around a scalpel and tubing for giving passers-by emergency airways (tracheotomy?), and apparently did so over a dozen times.

> She also carried around a scalpel and tubing for giving passers-by emergency airways (tracheotomy?), and apparently did so over a dozen times.

My mother does the same (well did, she's retired. She was an ER doctor). Before seatbelts and other safety devices were common there were a lot of gruesome accidents on the roads and we would have to stop. I remember several episodes were my sister and I were bored and annoyed because my mother had departed in the ambulance and my dad would drive us to the hospital to wait for her. Kid's perspective.

I've been trained to do emergency procedures like a tracheotomy, move a patient with a back injury* et al and in my life have encountered zero situations where my so-called "skills" would be useful. I don't even drive past many car accidents any more, nor have I ever seen a diner choke to the point where they needed assistance. But as a child I knew several kids who'd been hit by cars or fallen out of trees and been hospitalized, not to mention kids who'd lost a parent. Has the world become safer?

* Obviously you only do this when the victim would be in even more and immediate danger where they are, else you leave 'em in place for the professionals.

The world is safer, kind of, but we also now heavily discourage activities deemed to be unsafe, and may have erred too far in that direction.

In the US, walking and biking to school has declined from nearly half in 1969 to 13% today. A Vancouver BC man recently won a lawsuit after he was taken through the child protective services wringer for letting his kids ride the bus unsupervised. While overall traffic deaths are down, the fatality rate for pedestrians is shooting up.

We have basically created a world where only car travel is safe, and where we explicitly and implicitly encourage driving and discourage walking to get anywhere.

This is, I think, a good contrast to the "management by metrics" article currently sharing the front page. Attempting to govern through massive data or singular narrow measures each seen like folly. A broad, even vague, "directionally correct" measure is an excellent tool for keeping an enterprise aligned.

I’ve been thinking about this since I started working at a metrics driven company.

One thing we often lose sight of is that metrics are coarse grained. Something like GDP for example is very good at telling you that the USA is a better place to live than Somalia. But it fails for more fine grained comparisons. We should refrain from doing micro optimizations on coarse grained metrics or ranking people on its basis unless the change is truly massive and validated.

Metrics also need counter metrics. For GDP growth it maybe things like inequality, pollution, stress levels and so on.

Metrics also need to continuously evolve as people understand their limitations.

Metrics are a tool of social coordination and one of the most powerful ones to exist.

My personal opinion is that metrics should be largely invisible, only becoming visible at the level of management where decisions are made. Anything else leads to exactly what you just said: misguided micro-optimizations and gamesmanship.

GDP is an excellent example, I think. Basically, it measures the total flow of wealth inside a country. If everyone behaves rationally this is a good proxy for wealth as a whole. But what happens if the government would setup a group of companies that trade immaterial or trivial products amongst each other at absurd prices? The faster that group trades, the higher the GDP. A metric has become a goal.

One issue with GDP: how do you define wealth? It's hard to incorporate more abstract assets like social trust or environmental conditions (latter can have direct impacts on things like tourism)

I think this might count as a "checklist" rather than a "metric", and crucially there aren't quite the same incentives to game the metric.

I know this score too well. Our second child scored a 2/10, as he was not breathing. My heart nearly stopped. But the nurses were quick to get to work, and all is well now, years later.

I think simple, quick assessment tools, allow fast, correct reactions - which in this scenario is an absolute must.

My daughter had the same score and experience two months ago. Scariest moment of my life -- But all is well now thanks to some amazing, fast moving doctors.

BigQuery has a sample table, natality, that has all recorded births in the US from 1969 to 2008. It includes apgar_1min and apgar_5min fields.

https://cloud.google.com/bigquery/public-data

(Fun fact: I was actually able to find myself in the table based on my birthday, my birth state, my parent's ages and their birth states.)

Thanks for mentioning that! I took your example and was able to find myself - there was only one record which matched the combination of birth day and state, parents’ ages, and mother’s birth state (which is different than mine). Add in birth weight if you know it, and I speculate you’re almost certain to be able to find yourself.

An interesting aggregation query would be how much information is needed to uniquely identify some large percentage of all births in the data set.

My wife is a pediatrician. She uses Apgar Scores in evaluating babies weeks and months after birth. From what I understand, it's often useful to know the 1-minute and 5-minute Apgar Scores of an infant or young child, and specifically why they were scored less than 9/10 or 10/10, because some of these issues are germane to that child's future development.

> "blue all over" = 0

> "blue at the extremities, body pink" = 1

> "no cyanosis" = 2

I wonder if they have updated guidance and training for scoring non-white babies. Brown and black babies probably don't turn blue in the same way white babies turn blue. In fact, a brown baby that's off color may appear to be a "healthy looking" - to the untrained eye - pink when in fact they should appear brown when healthy. I'd be curious to see mortality rate deviations for non-white babies vs. white babies (especially in non-metro areas that are more homogenous).

> One of the most important symptoms of low blood oxygen concentrations in the newborn (hypoxia) is a change in skin colour, known as cyanosis. This is where the skin has a bluish hue. In dark skinned babies, this can be more difficult to see. For this reason, always inspect the mucous membranes (inside the mouth and the tongue) to determine if cyanosis is present. If you discover the mucous membranes are blue, this is known as central cyanosis.

https://www.futurelearn.com/info/courses/neonatal-assessment...

> Brown and black babies probably don't turn blue in the same way white babies turn blue.

FYI: "Brown and black" babies are pretty pink at birth (or should be, when they have adequate oxygen).

Related: I don't know if you saw that there was a WAPO article posted 11 days ago to HN that covered that "mortality for black babies plummets when they are delivered by black doctors":

https://news.ycombinator.com/item?id=25716481

Gamification is nothing new, and can have big impacts

> Implementing the Apgar score introduced a spirit of competition because the doctors inherently wanted the newborns they delivered to have better scores.

Reading the responses of people here that survived with a score of 1/10 it really didn't matter what the score was. Only that it got doctors to compete to raise the score.

It's a bit sad though that doctors apparently just didn't try to do anything about it before.

One is really missing to me: how she convinced others to use the scoring system?

Is there a single list of such scores by different domains as well as how they are computed? e.g. for drought severity we use the Palmer Drought Index

First time I opened that link I got a full screen scam ad about "Someone is stealing your data"....

Here's an outline link:

https://outline.com/VZBnSL

Is there a list of such scores by domain anywhere on the net i.e. name of the domain and the metrics applicable to it? e.g. for agricultural drought there is the palmer drought index

And worsened maternal heath while deskilling obstetrics.

https://www.newyorker.com/magazine/2006/10/09/the-score

Blind Taylorism is dangerous. What we measure gets managed at the expense of unmeasured things.

You may want to read that article more attentively, because it does not support your claim at all.

Do I misread the concluding paragraphs?

"The skill required to bring a child in trouble safely through a vaginal delivery, however unevenly distributed, has been nurtured over centuries. In the medical mainstream, it will soon be lost."

"In a sense, there is a tyranny to the score. Against the score for a newborn child, the mother’s pain and blood loss and length of recovery seem to count for little. We have no score for how the mother does, beyond asking whether she lived or not—no measure to prod us to improve results for her, too. Yet this imbalance, at least, can surely be righted."

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