Awesome free resource!

I am so thrilled with the free books available at Herperian.org. They are designed for ease of use and medical accuracy, and take into account limited resources in remote locations. Each of the books is available in multiple languages.

I downloaded “Where There Is No Doctor”, “Where Women Have No Doctor”, and “Book for Midwives.” I haven’t had time to read them completely. Each one is more than 500 pages! I glanced through the midwifery book first, and was thrilled with what I saw. The section on the second stage of labor discourages frequent cervical checks, for example. It also has illustrations of alternative pushing positions, or in this case, physiologic pushing positions. The section on breastfeeding has accurate, non alarmist but very true information that formula can be harmful, including an illustration of an emaciated baby with diarrhea, warnings about unclean water sources, and the valid point that formula companies use predatory advertising practices to sell their product.

“Where Women Have No Doctor” has some overlap. There is a great section on abortion, with nonjudgmental language, and emphasis on safe abortion and management of complications. the chapter begins with reasons why some women choose abortion, and the first one is “She already has all the children she can care for.” Many people ignore the fact that most women who choose abortion are already mothers, and in developing countries with high maternal mortality rates, there is real danger to their already living children if their mother has an unwanted pregnancy. The midwifery book has a training chapter on manual vacuum aspiration.

Both books have good sections on family planning. Even though they are designed for practitioners in remote areas and perhaps minimal training, there is a good balance between necessary actions and not overstepping and perhaps causing harm by doing interventions with a lack of training. For example, the section on IUD insertion states that insertion can cause injury or infection, and should be inserted only by someone who is trained, but does not have alarmist contraindications. And, the book warns against putting in IUDs without permission, and the right to refuse an IUD.

The women’s health book also has a nonjudgmental section on sex workers, with information on risk reduction and negotiating condom use. It also has a section on women with disabilities.

I downloaded the Spanish version of the women’s health book. I figure I can read it to improve my medical Spanish, and I may be able to use it as a translation tool.

OK, I have gushed about the books enough. Go check them out!

Thanks, KK!

My post on reporting abuse on KevinMD

My recent post on mandatory reporting of intimate partner abuse being possibly more of an emotional response for the caregiver rather than good care for the victim has been republished at KevinMD:

Should every case of domestic abuse be reported?

Go check it out. There are some great comments there, as there were here.

When good care isn’t emotionally driven care

Hello, folks! I am slowly getting over not matching. Slowly. I am trying to strategize for the next match. And, I’m trying to take care of myself, emotionally and physically, in the aftermath.

In the meantime, I am on my last rotation for medical school. It is a “rural selective”, which is a required elective at a rural or underserved location. I am fulfilling it at a local community health center in the women’s health department. Fun!

I am taking part in a day long orientation today. In one of the presentations, the speaker had a point on one of the slides about mandatory reporting, and included all domestic violence as falling under that category. I rose my hand and suggested that we had been trained that elder abuse and child abuse fell under that category, but other domestic violence did not. I couched that statement by saying it was controversial and I didn’t say I necessarily agreed (although I do).

One of the other attendees got very perturbed by my correction, and said I was wrong. I said I disagreed, politely. The speaker and several other attendees said they thought I was correct, and one pointed out that other vulnerable adults, such as someone with a disability, also fell under the mandatory reporting group. At the end of the speaker’s presentation, the offended woman called me out specifically, and again told me I was incorrect, but again, had nothing to back herself up other than her strong emotional response. Since this was a training on legal requirements of the job and privacy, and this population definitely would include adult victims of domestic violence, I decided to look up the law.

When I located the appropriate information, I read it out loud to the group. This nursing CEU was the first good site I found, and it had very complete information. I read this part:

Intimate Partner Abuse

Florida statute 790.24 requires healthcare providers to report gunshot or life-threatening wounds or injuries. Obviously, this does not cover the majority of injuries sustained in IPV. However, reporting suspected domestic violence without the informed consent of the victim is unethical and may cause the abuser to retaliate.

She interrupted me and said “SEE? You have to report gunshot wounds!” and I continued to read the rest of the quote. Then she angrily said “Well OF COURSE you need their informed consent!”, and I countered “Well, then that’s not mandatory reporting, is it?” She got more agitated, and started pacing the room, telling me I am saying to send these women home to get killed. I said no, and tried to explain, again, the rationale of establishing trust with the patient, many of whom are not at a place where they are ready to leave or press charges. She said she would definitely report ANY case she saw of suspected intimate partner violence, and said she didn’t want these women killed. I said that they may not press charges, and then may not trust health care practitioners again, and still get killed.

I know that IPV is a sensitive, triggering topic for many, including me. I was in a relationship with verbal and emotional abuse, and trust me, if people came on too strong about me leaving him when I wasn’t ready to, I avoided them in the future. I would not come to them when there was an incident, because I didn’t want a lecture of how it was my fault for staying. When we went over this in medical school (and I was still in my abusive relationship), one member of my small group said she was a victim of physical violence in a past relationship, and she would absolutely never press charges, she would lie to any health care practitioner or official about it, and defend him under any circumstances, when she was still in the relationship.

These victims already feel an enormous lack of control. It is not our job to control them or act for them. It is our job to be there for them on their terms. Even if it gets us emotional.

Hands on in the boondocks

Howdy. I have been busy, as usual. Not only working at a new rotation site, which has been wonderful, but driving more than three hours a day to get to and from this site.

Our medical school requires that we do three months of rural rotations. I am doing two at a community health center in the middle of the state. The surrounding town is a farming town, with a large migrant population.

I am absolutely loving it. I am starting off with the ob/gyn, and we do gynecology, family planning and obstetrics. It is a very hands on rotation with an attending physician who is eager to teach. I have done many pap smears, STD tests, contraception counseling, cervical checks on full term pregnant women, and I GOT TO INSERT AN IUD. That plus a journal club, a training on human trafficking and a training on contraception compliance. Not bad for the first week and a half!

Our first two days consisted of orientation, and the longest time slot was given to the lactation consultant, who I love. She is working on a “Men and Women’s Health Day.” When I gently pointed out to the Medical Coordinator of the site that it was trans exclusive, they took me seriously. I am going to be the point person for any individuals identifying as trans (or anyone else who has questions in that area) the day of the health fair. Apparently they had some there last year and were at a loss. I am going to start with the resources linked to by Rachel at Women’s Health News and go from there.

I’ll try to check in again. If I could type while I drove, I’d have a ton of posts. Instead I am listening to board review materials. And looking at the swamp wildlife. And trying to avoid a speeding ticket.

I can easily see myself working at a community health center. This is totally my bag.

Birth for sexual assault survivors

I want to thank Amy Romano for linking to this beautifully written article, the first in a series of three, on sexual assault survivors giving birth. I definitely learned from it.

I Will Survive (Thoughts on Survivors Giving Birth)

I think one of the best ways to learn how to be a caregiver is to listen to people’s stories. After hearing about this particular author’s fears and experience, I feel like I can empathize better. I especially like the recommendations she gives on how to speak to a caregiver about birth. I think it has applicability in other areas of medical care:

Perhaps the most important thing we can do as survivors preparing to give birth is to tell our story. Working with a midwife or a very compassionate doctor who will take the time to listen is especially important for survivors. You may choose to have your partner join you for the conversation and focus on the facts: “I’d like you to know this about me. You don’t have to fix anything, but here are some things that I need you to do. Tell me before you do anything physically to my body, so I can be prepared for what to expect. Avoid the following words: ‘Trust me,’ ‘relax,’ etc.” If you are closer to your care provider, you might choose to really let them into your story, to open yourself to their healing words and experience.

As an abuse survivor, I bristle when I am told to “relax”. I don’t identify as a sexual assault victim, although perhaps I should. But, I do identify as a verbal and emotional abuse survivor, and there is some overlap there.

As for me, I started a new rotation today. Pediatrics outpatient. It was a lot of coughing, earaches, runny noses, physicals, and crying, which is what I expected. I liked it more than I thought I would. I hope I continue to be pleasantly surprised with my rotations.

Who knew closing the gender and race gap could be so easy?

I thought this article on a 15 minute writing exercise that improved the performance of women in physics and students of color in high school was beautiful in its simplicity.

Think about the things that are important to you. Perhaps you care about creativity, family relationships, your career, or having a sense of humour. Pick two or three of these values and write a few sentences about why they are important to you. You have fifteen minutes. It could change your life.

This simple writing exercise may not seem like anything ground-breaking, but its effects speak for themselves. In a university physics class, Akira Miyake from the University of Colorado used it to close the gap between male and female performance. In the university’s physics course, men typically do better than women but Miyake’s study shows that this has nothing to do with innate ability. With nothing but his fifteen-minute exercise, performed twice at the beginning of the year, he virtually abolished the gender divide and allowed the female physicists to challenge their male peers.

The exercise is designed to affirm a person’s values, boosting their sense of self-worth and integrity, and reinforcing their belief in themselves. For people who suffer from negative stereotypes, this can make all the difference between success and failure.

People who are in the minority (and I mean a power minority, not a numerical one) – people of color, women in science classes, disabled people, etc. – often feel that their values and needs are invisible in an academic situation. This exercise simply affirms that this is not necessarily true.

I want to go into academics one day. I may need to do this exercise in my classes.

“Doulas” is now a MeSH term

I am a proud research nerd, which involves being a PubMed nerd. PubMed tries to organize its articles by keywords called MeSH terms. Well, they just added the term “doulas”!

Doulas received an “A” evidence rating from the US Preventative Services Task Force and a favorable Cochrane database review. But, if you go to the Cochrane Database and enter in the keyword “doula” into their search, you come up with zero results. Its doula review is labelled “continuous labor support”. Let’s hope the addition of “doulas” as a MeSH term normalizes its use.

Also, other Mesh terms were added, including:

Airway Management; Bleaching Agents; Bullying; Carbon footprint; Catheters; Counterfeit drugs; Drug-Seeking Behavior; Epigenomics; Exsanguination; Examination Tables; Food, Organic; Gestational Sac; Hair Bleaching Agents; Gynecological Examination; Lost to Follow-Up; Nasal Sprays; Pets; Recyling; Sex Reassignment Procedures; Sex Reassignment Surgery; Social Stigma; Watchful Waiting; Wireless Technology.

Thanks, Rachel, for the blog post about the new MeSH terms, and the rabble rousing to get the MeSH term added. (Ha, I just noticed I am mentioned in the original post she wrote on this topic.)

Resources in Spanish for patients

The Agency for Health Care Research and Quality (a group of which I am a fan) has released Spanish language guides for patients. I am happy about this for a few reasons. Selfishly, I need to learn more Spanish, especially medical Spanish. I am hoping I can read over these guides and learn how to discuss these conditions more effectively. Of course, that doesn’t help me when a patient asks me a question outside my very limited scope of Spanish proficiency. But, it’s a start.

I was also happy because I thought these guides could be a good resource for the attending physicians at my rotation site. For example, one is A guide to breast biopsies (PDF) (non PDF versions are available at the first link). I just finished a surgery rotation with a team of surgeons who do a lot of breast biopsies, many of which are on women who only speak Spanish. However, it’s 12 pages long. I think it may be nice to put a copy out in the waiting room instead of a magazine, but it is too long to pass out to all the patients.

The are also a few guides specific to pregnancy:
Induction of labor
Gestational Diabetes

I haven’t read them, and my understanding of Spanish isn’t great, so I may not be able to offer a decent critique of their quality. However, this quote from the induction of labor guide troubled me:

Las investigaciones no determinan si la probabilidad de que una mujer tenga una cesárea es diferente si ella elije la inducción en lugar de esperar a que el parto comience espontáneamente.

Unless I am mistaken, it says studies have not determined whether the probability of having a cesarean is higher if one has an induction, rather than a spontaneous labor. That has been researched, and the ACOG Practice Bulletin #107 states that there is a twofold risk of cesarean in a nulliparous (first time birthing) patient than one who has a spontaneous delivery. Also, the chance of vaginal delivery with induction is strongly association with the patient’s Bishop’s score. A Bishop score is easy for a health care practitioner to determine in an office visit, and is not that difficult to explain, at least in general terms, to a pregnant person. I am disappointed in how few people who are induced even know what the Bishop score is, or what theirs was. Of course, if it is a medically indicated induction, it will most likely be attempted even with a low Bishop’s score. But, it is an elective induction, and the pregnancy is only 39 weeks gestation, and the Bishop’s score is low, especially in a nulliparous mom, an induction is very likely to be protracted, and end in a cesarean.

(Hat tip Women’s Health News, Catching Up Edition, which, ironically, I was catching up on)

I’ll tell you what I regret, and what conclusions I am jumping to

*Trigger warnings for discussions of sexual assault*

I don’t want to go into a lot of details about this, because I don’t want to violate HIPAA or trash any of my peers or future peers specifically. Suffice to say, I find it very disappointing that people in the medical community, including people who should really know better, don’t realize that someone who is severely intoxicated cannot consent to sex. It’s not “next day regret”, and I am not “jumping to conclusions” for following that theory. It’s sexual assault. End of story.

We are supposed to be advocates for our patients. It’s bad enough that people in the community don’t understand that rape isn’t just some scary dude jumping out of the bushes and clubbing some demurely dressed virgin over the head, and dragging her off to violently violate her. When physicians and future physicians dismiss (or worse, joke about!) sexual assault on intoxicated individuals, or even worse than that, discourage a peer from following that line of questioning with a patient because it would be “jumping to conclusions” because “we weren’t there and we can’t say if she consented”, it absolutely infuriates me. Especially if such a person has a history and physical strongly suggesting that this is a likely scenario.

OK, rant over.

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.