Monthly Archives: July 2010

Friday music selection

I don’t do this very often, but I am going to post some music today. I have been really busy and bogged down with more drama than I need, and I think a little musical interlude would do me some good. And hey, who knows, maybe someone else will like one or a few of the tunes I put up.

OKGo’s “This Too Shall Pass”. Not only is it a great song, but it’s an awesome video. And, a message I need to repeat to myself.

I can’t figure out how to embed this, but HERE is a link to Babe the Blue Ox’s “Stand By Your Man”. It’s not my absolute favorite song of theirs, but it’s a great one that shows their balance between sweet ballads and rockin indieness, and it may be their only official video. I wish “King of the Rain” had a video. I was triggered into a Babe the Blue Ox fest last night when a website asked what band deserved more success than it got.

And, “No Children” by Mountain Goats. I can listen to this without crying now.

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Happy birthday, ADA

Today is the twentieth anniversary of the Americans with Disabilities Act! *blows party horn*

I didn’t know that earlier today. But, I did a little personal ally work in support of accommodation, so I am proud of myself.

The student who is sharing the surgery rotation with me is disabled. She was in a terrible car accident about five years ago, and shattered her ankle and heel. She has some difficulties walking and standing for long periods of time. She has been very successful when assisting on alternating surgeries, but she has asked our attending if she can sit when it’s my turn to scrub in at assist. My attending is fine with her sitting, but occasionally, the OR staff gives her a hard time.

Today, a nurse anesthetist started making really sarcastic comments to her when she sat before the procedure started. “Do you want me to get you a pipe and a smoking jacket?” he sniped. He turned to the one of the other people in the room and said “Is that what it was like when you were in medical school?” He made a few more rude comments. My classmate just glared at him from behind her mask, and didn’t say anything. She feels really put on the spot when those sorts of things happen, and doesn’t choose to make excuses.

After the procedure was mostly over, the surgeon took my classmate to go to pathology to check to see if the sentinel lymph nodes that were removed were negative, and the assistant and I remained to close the mastectomy. Once the incision was closed, and we knew the nodes were negative, I told the whole OR team that was assembled that I had something to say.

“I heard someone saying something to (classmate) earlier about her sitting down. I wanted to let you know that she is disabled. She was in a really bad car accident and her ankle was shattered. She has trouble standing for long periods of time. She has asked to be able to sit in the OR if she is not assisting, and Dr. (Attending) has told her it’s OK. She’s really self-conscious about it, and won’t say anything to anyone who asks her about it. I just thought it was important for you all to know.”

There were some mumbles and grumbles, but no other comments. There were two anesthetists and one anesthetist student there when the comments were made in the beginning of the procedure, and they all kind of look the same with their caps and masks on. One of the anesthetists left before the procedure. I am not sure if the one who made the comments heard what I said, but I hope his buddies go back and tell him what I said if he was the one who left. I wasn’t necessarily trying to teach him a lesson in particular, but I wanted to let everyone on the staff to know that people may sit because they need a disability accommodation, since this isn’t the first time someone has given her a hard time.

Maybe the next time someone sits down, they won’t automatically assume they are being lazy.

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Reply turned post, conjecture about home birth mortality

I think that the more swagger and sarcasm involved is present in an argument, the less evidence there usually is to back it up. I find this post particularly disturbing in its tone, and its lack of real obstetrical knowledge to back up the assumptions mixed among the insults.

I am not happy with the extreme bias and apparent interest in just supporting a world view (while criticizing the same in others, ironically) as opposed to actual truth finding in the few posts I read at this site, and I don’t think this site is going to be worth much investment of my time and limited stress reserve. I was pointed at this post, which discusses a recent, flawed meta-analysis of home births that includes unplanned, precipitous births at home in its analysis, instead of using an “intent to treat” model. I felt the need to answer this particular post, which simply assumes at the end that precipitous, unplanned home births only happen in snow storms, and would have no confounders associated with poor neonatal outcomes. With no discussion of the pathology or etiology of precipitous delivery or neonatal morbidity, of course, and no citations.

“The Pang study, for example, contributed a large chunk of the population analyzed for neonatal deaths, but has been widely debated and criticized for including unplanned home births in its analysis of neonatal death at home birth.”

How could this possibly make a difference? It was limited to near or full-term deliveries. People simply don’t have many near full term at home accidentally. These have to be things like getting snowed in.

Do you have any data about what percentage this is? Did you know you can calculate how big the effect would have to be to shift the results. (hint: if it is huge, than it can’t make a difference) Have you done that? If you haven’t why do bring this up?

Here is my reply:

(Reposted with the html fixed)

I can tell you how it could make a difference, even at full term delivery.

First of all, especially if there is no trained attendant at the delivery, and/or if a labor is precipitous, it would be very unlikely that a GBS colonized mother would receive antibiotics, as per protocol. Strep pneumonia is the “leading infectious cause of neonatal morbidity and mortality in the United States”. This is an issue regardless of term.

The next few points are all taken from Gabbe’s Obstetrics. 2% of labors in the United States are precipitous. This is not just an issue during snow storms.

Another way a precipitous labor may be associated with poor outcomes? Maternal cocaine use is a risk factor for precipitous labor, and is independently linked with poor neonatal outcomes. And, it’s linked with not having adequate prenatal care or a trained attendant at the delivery.

Also, placental abruption is associated with precipitous delivery. Also independently associated with poor neonatal outcomes, including hypoxia. According to Mahon’s retrospective analysis of TERM precipitous deliveries, it is the ones that are really abrupt (above the 95%) that are associated with neonatal mortality. You know, the ones that come so fast you can’t make it to the hospital, and end up being unintended home births.

Also according to Gabbe, precipitous labor is also associated with uterine tetany, which may cause intrapartum fetal hypoxia or fetal distress, which are related to poor outcomes.

I would rather see citations than insults and conjecture.

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Putting it in persepctive

I had a rough week, to say the least. My tumor board presentation went fairly well, but I was called out by my attending for a mistake on my epidemiology slide. It was a minor point about the prevalence of a less common type of thyroid cancer than the type I was talking about, but it still wasn’t fun being corrected at the podium.

Earlier this week, I found out that a Friday night social event at a good friend’s house is not open to me anymore if I have my kids with me. I understand the concept of wanting a childfree space, especially since many of the regular attendants are childless, but it still really stung, especially after the week I’ve had.

The status conference over the custody of my younger son went better in some ways than I expected, and worse in some ways than I expected. I got to sit with my soon-to-be-exhusband in a waiting room for an eternity, and he spent the entire time doing the Dr. Jeckyll / Mr. Hyde routine that made my life miserable when I was with him. “I hope you’re enjoying your rotations…Being a medical student means you’re a bad mother…I hope you find happiness…Have fun at residency when you’ll never get to see your children…I just want us both to be able to spend time with Z…You never loved me, and just used me as someone to watch your kids when you went to school…(Sorry, can’t come up with another positive quote)…My next wife will make lunches for me to take to work; you didn’t and that means you didn’t love me…” and it went on, up and down (mostly down) the roller coaster while we waited for our paperwork. I left and sobbed in my car, and considered dropping out.

I drove hundreds of miles this week in my car (and my piriformis and sciatic nerve are not forgiving me for that, yet). My rotation site is about 30 miles from my house on the highway, which is fine with me, and I put my older son in a camp at which I was a former counselor. It is near his dad’s work and my mom’s house, which is even farther from my house, and on ground roads (ugh). I also had to pick up Z from my ex’s house, which is even farther away. Yesterday, after picking up Z at the ex’s, then driving the opposite direction to S’s camp, I turned around again and drove 70 miles from my house to go to the viewing for my classmate who died recently.

My sons came with me to the viewing. She is being buried in her white coat, and we were asked to wear ours. The kids were very understanding about going. We only stayed for a short while, and sat in the back of the room. I briefly paid my respects at the coffin and to her family up front. Z crawled into my lap when I came back to our seats, and I held him and kissed his head. As I sat there and listened to my classmate’s mother wail with pain, and thought of her baby in the NICU, I thought how lucky I really am. Danielle wanted nothing more than to be a mother, to hold and nurse her baby, and to be a doctor. She never even got to meet her baby, and now her family is reeling from the sudden, heartbreakingly unfair loss.

In a few years, this shitty week will be a distant memory. I can still hold my sons and kiss their soft hair. I am still (so far) going to achieve my dream of becoming a physician. I still have a strong social support system with loving friends, even though, sometimes, it can be more piecemeal than I would like. I am trying to keep it all in perspective.

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Wish me luck today

I have a status conference in front of the judge to lay the groundwork for my divorce and custody proceedings.

Ugh.

Send good luck wishes, please!

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Reply turned post, what a doula can do

Well, Rixa wrote an entire post about the physician who trashed birth plans and doulas on her blog. I tried to write a reply to it, but I was got an error message that said it was too long. So, I have published it here. I guess that’s how the reply – turned – post was born.

Aha! Here it is. Well, I answered this travesty of a comment on my blog.

I have a few other things to add. The grammar and spelling are irritating to me, but irrelevant. Don’t even bother expecting good grammar. I see spelling errors everywhere in the hospital where I am training right now. Worst of all, I see meds misspelled in charts! If there’s anything you want to spell right, it should be the name of a med! I see right and left mixed up all the time also. I am doing a tumor board presentation tomorrow, and the pathology report mixed up the right and the left. Scary.

I also wanted to add that one major purpose of a doula attending a hospital birth, at least when I am a doula, is to inform the woman what to expect when she is traiged and admitted to the hospital. Also, to give informed consent, hopefully prior to labor, on typical labor interventions, and to help the woman decide where her priorities are before she is in labor, and what she may want to discuss with her practitioner. If the practitioner doesn’t show up until the end of the labor, how is she supposed to discuss an order given over the phone to break her water and give her pitocin when she’s at 4 cm? I was clueless about what would happen to me, and most women are not informed at all about what it is really like.

Many women don’t know that your doctor most likely won’t be there until you are completely dilated (that is the standard of care in my area – not sure if it is in all areas, but it is something the woman can ask her practitioner about once the doula brings it up.)

Many women don’t know that they will need to have labs drawn when they show up – they think they are “preadmitted”. They will be asked the same questions about their history over and over again by multiple hospital employees. They will be asked invasive questions about their sexual histories, drugs, smoking, prior abortions, including exact dates. In front of their partner, mother, doula, whoever is there. Even women who want an epidural immediately will not be able to get one (see below), and will be asked these questions during contractions, regardless of if there is an issue that is concerning her about the way her labor is progressing (such as the baby being premature, there being blood, her blood pressure being high, etc.) No one will reassure her or care that she was just asked all the same questions, or that she is scared, or in the middle of a contraction, or doesn’t want to answer a question about an abortion in front of her mother. It may be a good idea to inform her doula or partner the answer to some of these questions, such as if she has ever had a reaction to anesthesia, or if she has false teeth, etc.

Nurses may be brusque and insist that she removes all of her jewelry and not wear any of her own clothing, and tell her it will risk her and her baby’s life if she doesn’t remove them. (Seen it).

If they are planning on an epidural, they WILL NOT GET IT RIGHT AWAY. This is a HUGE issue. Many women seem to think the anesthesiologist will meet them in the parking lot. My cousin Susan was told by her obstetrician that she “didn’t deserve to feel any pain.” Well, she needed to have labs drawn, and run, and then needed to have 2 liters of IV fluid infused before they would even consider giving her an epidural. Considering her entire labor was 4 hours long, she felt the pain for half of it the first time. The second time, the epidural only took on one side. Was she only half as deserving? Did she even know that epidurals don’t always “take”?

I have seen epidural informed consent that consisted of “it won’t effect your baby”, and then the baby crashed immediately after, since the woman already had low blood pressure and was flat on her back. I got the honor of explaining to them what happened. I have seen an anesthesiologist storm off angrily when another couple asked about the blood pressure drops associated with epidural and spinal anesthesia (she was there on a birth center transfer and was most likely getting a spinal and a cesarean) – again, I was left to reassure them.

I have seen women told that stadol will “take the edge of and help you relax a little” as the entire informed consent. This poor women effectively missed her delivery because she was too busy hallucinating, moaning, and drooling on herself. The baby was born depressed and had to be given narcan to cancel out the effects of the drug. I have learned from these experiences to inform all women, regardless of their professed desire to avoid meds, what the pros, cons and side effects are BEFORE we are there and someone tries to talk her into it.

Also, I didn’t know, and many women don’t know, that their baby is likely to be whisked away immediately following the birth, and most likely will not be returned to her until after a four hour “observation”. I was simply devastated when that happened, and cried until they returned the baby. Even women I have warned about that have cried with me while the baby is gone.

Anyway, this went on longer than I planned, but needless to say, doulas can provide information in a way that tends to be seriously lacking in standard hospital labor and delivery.

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Reply turned post: birth plan, doulas and episiotomy nonsense

Rixa has an excellent post up at her blog Stand and Deliver. She wrote about yet another obstetrics practice that is refusing to allow their clients to bring a doula, but is forcing them to sign a birth plan that says episiotomies may be used to prevent tears, among other evidence free ridiculousness.

What is even worse, two commenters defend this position, with unsubstantiated statements that assume that doulas are somehow dangerous, and these interventions are what ensure a healthy baby and healthy mom. One of these commenters claims to be a physician!

I wrote a reply:

Argh, this is so frustrating. Rixa, excellent post. I have some points in response to the actions of the Kingsdale Gynecologic Group, their birth plan, and the replies from “B” and the anonymous physician.

First, I’d like to point out that using a doula as they currently exist, with their current level of training and lack of licensure, has been rated as one of the most effective labor interventions for improving birth outcomes, based on excellent evidence. Here is the article by Berghella et al on Evidence Based Labor and Delivery Management that covers this intervention (along with many of the other interventions mentioned in the original post and the comment thread.) It states that having a doula is one of the most effective interventions available. How a physician could criticize this practice, which has an evidence rating of A, but defends analgesia, which has no positive effect on birth outcomes, is beyond me.

Doulas are not immune from liability. They can be sued just like any other individual. They do not provide medical treatment, so do not need to carry malpractice insurance. I think that is a bizarre idea. Nurses, including labor nurses, do not carry malpractice insurance. Why should doulas, who simply provide emotional support and information?

Also, how does it make medico-legal sense to deny women the choice of an evidence based intervention that improves outcomes (doulas), but support interventions that are shown by copious evidence to be harmful (episiotomy) or are non-evidence based and have even been questioned in recent editorials in ACOG’s Green Journal (depriving oral nutrition during labor)? Who needs to “get their priorities straight”? If “[t]he important thing is a safe and healthy delivery for both the infant and mother”, why not support the evidence based interventions like doulas, especially if it is what the woman wants, instead of insisting on harmful or questionable interventions? (Sources: JAMA’s Outcomes of routine episiotomy: a systematic review, which says episiotomy is more harmful than helpful, and should be “avoided at all costs”, and the Cochrane Review on Restricting oral fluid and food intake during labour, which concludes that “women should be free to eat and drink in labour, or not, as they wish.”)

And, how are ALL birth plans nonsense? With obstetricians refusing access to doulas, encouraging episiotomies, and restricting food and fluids, what are we classifying as nonsense? How about when obstetricians induce women who are 39 weeks gestational age (if they wait that long!), with no medical indication for induction, and have a low Bishop’s score? Then, they are put in the hospital, told they cannot ingest anything but ice chips, and their induction takes several days (due to the unfavorable cervix). Let’s say they have only lactated ringer’s solution in their IV, so they are not receiving any glucose for 48 hours. If the woman has no glucose, her blood sugar will plummet and she may get an altered mental state. That, plus pitocin augmentation, may lead to the frequent request for analgesia in patients that originally intend to try to avoid unnecessary medication. I wish this was uncommon. Are you really suggesting that a birth plan is nonsense here? Or the current standard of care? The Listening to Mothers survey indicates that these interventions are all too common.

I find it really disheartening that people, including a physician and a gynecologic group, will defend harmful and baseless interventions, simply to bolster a paternalistic model of care, instead of an evidence based practice such as hiring a doula.

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