Tag Archives: Rant

Reply turned post, I reject your reality! style

OK for Mythbusters, not for health advocacy

I have been participating in the Facebook group VBAC Facts Community for a little while now, ever since meeting the wonderful community founder Jen Kamel at the VBAC Summit last year. It is a supportive group, and Jen runs the site well with the help of moderators and a good foundation of evidence.

This group, at times, can be a good example at how distorted internet microcosms can make uncommon opinions seem much more accepted. In this community, using midwives and having a home birth comes up in almost every thread, it seems. I have seen using a midwife treated like a hipster fashion choice recently on Jezebel and other sites. However, midwife attended births still make up less than 10% of births in the United States. Hardly a huge trend. Midwives are underutilized here compared to many other countries with better maternity and neonatal outcomes than we have. But, depending on your source, midwife attended and/or out of hospital births may seem to be common or even a glorified standard. However, in the circles I travel in my daily grind as a physician, choosing out of hospital birth is fringe, reckless behavior.

So, it’s like entering a portal in another world when I participate on a thread in the VBAC group, and the commenters have a heated argument about epidurals, and many participants did not get one. On our labor and delivery floor, it is a rare to never occurrence that someone wouldn’t get one. Because out of hospital birth, choosing not to have an epidural even if you deliver in a hospital, and VBAC are such rarely available, rarely supported choices, I am usually on the side of defending people who advocate for such choices as underdogs, not the holier than thou bullies that many paint them to be.

It’s also a really strange place for me to be in when I gently try to correct medical inaccuracies, and I sometimes get painted as a brainwashed surgico-technocrat physician. I correct fellow physicians when they say all VBAC is dangerous. For real, even my attending physicians. I also have corrected fellow physicians who state episiotomies are preferable to tearing. But, I also correct women in the VBAC group who state things that are medically inaccurate, like that worsening hypertension in pregnancy is not serious and does not warrant an induction or cesarean unless the fetus is in distress, or that leaving the hospital midlabor is a reasonable course of action if one is faced with unwanted interventions (in one particular thread in which I was painted as a typical brainwashed South Florida cesarean happy physician, the intervention that warranted attempting to leave midlabor was continuous external monitoring).

These are not the majority opinions even in this microcosm. But, they are often aggressively defended positions. One that has come up repeatedly, recently, is an insistence that tubal ligation is linked to “post tubal ligation syndrome”, which leads, according to some posters, to the majority of women needing hormonal interventions to control heavy menstrual bleeding, and / or hysterectomy to control intractable post procedure pain.

I think these communities are incredibly valuable, not just because of the sharing of strictly evidence based facts. I think a lot, even the majority of the benefit is the support and stories from other women who have experienced similar choices and situations, or share similar priorities and stories. I think in the VBAC community, and in pregnancy and mothering as a whole, there is so much value to support, empathy and stories. However, there is a big difference between asnwering an original poster who says “what was your experience with tubal ligation?” and someone answering “geez, I had pain and menstrual irregularity after” and an original poster saying “I am planning on a tubal ligation” and a slew of commenters saying “NO! This is PROVEN to cause a, b and c horrible side effects to the majority of women who get it!” and usually a touch of “Have you considered Natural Family Planning?”

Sigh.

I have reluctantly been the heavy in many of these conversations, but it is triggering a bunch of pet peeves of mine. 1. Medical inaccuracies masquerading as facts. 2. Ignoring the expressed informed choice and priorities of the woman posting and substituting the commenters’ own priorities and (often faulty or anecdotal at best) information

So, this coalesced into a recent thread, and here is the reply I posted:

“This is the best article I have found on post tubal ligation syndrome:

http://www.nejm.org/doi/full/10.1056/nejm200012073432303#t=articleResults

It is a good article because it compares women who have had tubals with women whose partners have had vasectomies. It is also a good study because it has an N number of over 9,000 subjects who had the tubal ligation. It is also authored by a group from the Centers of Disease Control (the CDC). There is no economic conflict, and the New England Journal of Medicine is about as high quality a publication as it gets. Here are the results:

“The original concern about sterilization involved the risk of heavy bleeding and intermenstrual bleeding, but we found no evidence of either problem. Furthermore, we found that women who underwent sterilization were likely to have decreases in the amount of bleeding, the number of days of bleeding, and the amount of menstrual pain and an increase in cycle irregularity. We know of no biologic explanation for these changes, most of which were beneficial, in women after tubal ligation.”

I don’t think there’s any evidence of widespread issues post tubal. In fact, this high quality study seems to indicate the opposite. I am not saying a tubal ligation is right for everybody, but I do think it is inappropriate for every thread on here in which tubal ligation is mentioned to devolve into a pronouncement that tubals are PROVEN to cause these problems, often with alarming figures like half of all women who get tubals end up with hysterectomies, etc.

As I have also said, it is inappropriate at best and borderline bullying at worst for women on here to disregard a woman’s stated informed choice and substitute their own priorities, especially if they are coming from a place of anecdote and questionable information. It is also inappropriate to ignore a woman’s expressed desire for a highly effective form of birth control (like a tubal or IUD) and to tell them to try NFP* instead, when it has a typical failure rate much higher. I hold a woman’s right to make informed decisions about her reproduction to include highly effective birth control if desired as well as safe options for trial of labor after cesarean.

I am not a surgery lovin’ medicoindustrial defending brainwashed doctor. I trained as a midwife, had both of my kids unmedicated** with midwives, and have never used hormonal birth control myself due to my own priorities and reasons. I support low intervention birth and VBAC for two main reasons which may seem contradictory, but are wonderfully not. 1. It’s a woman-centered approach and 2. It is an evidence based approach. Bullying women into avoiding their choice of safe contraception is neither.”

*I love this site for comparison of contraceptive methods: http://www.birth-control-comparison.info/
**The first labor was augmented with pitocin without my informed consent, but was otherwise unmedicated

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Reply turned post, Trisomy 18 and mental masturbation style

I can get really frustrated by people who enter into philosophical arguments about serious medical ethics questions online. Many of these people have a definite agenda, often controlling access to abortion, but try to couch it as some sort of intellectual exercise. Many of these commenters are men who toss around large words like “autonomy” and “qualitative determination.” This happens all over the interwebs, and I know better than to spend my time hunting down every blowhard that litters a comment section with his ideas on viability and fetal rights.

However, I clicked through a link on my Washington Post headline newsletter on Trisomy 18, since it is a topic that genuinely interests me. Presidential candidate and notorious crusader against contraception and abortion Rick Santorum has a daughter with Trisomy 18, one who is questionably lucky to have survived the few years she has, and has been hospitalized yet again. I was generally pleased with the accuracy and tone of the article. I hesitantly stumbled into the comments section, and then happened upon a perfect example of what I like to refer to as mental masturbation, from a commenter named “johnbmadwis”, which he wrote in response to a comment drawing the logical connection between the suffering and medical expense of Santorum’s daughter, and his position on the ability of other families to choose this road for themselves:

But haven’t you just made Santorum’s point and fueled the fire of the pro-life proponents? That is, the pro life advocate’s long held belief that abortion rights advocates are not really talking about rape and incest, but rather personal evaluations of the quality of life of the fetus or externalities such as heartache and expense. Regardless of the condition of the fetus, pro life advocates would say society has a moral interest, they’d say imperative, in preserving the life of such a fetus from individuals such as yourself, who may want to terminate that life due to such condition. At what point, if any, does that societal interest give way to individual autonomy? Would you truly advocate for the ability to terminate that life after birth? in the last weeks of pregnancy? 3rd trimester? viability? Whatever the point, what is the guiding principle? Individual autonomy? Quality of life? (determined, assuredly, by one other than the one whose life is at stake – so, whose individual autonomy?) at what point does one achieve individual autonomy? Does a fetus have individual autonomy At some point the life of the fetus does, presumably, outweigh the individual’s autonomy, right? When? Is individual autonomy equally valid if it were exercised for clearly base purposes such as mere inconvenience or desire, say, to have a boy instead of a girl? Who should make that qualitative determination? Society? The individual carrying the fetus. The affected fetus? The personal choice of a couple does affect the life of another human being in your scenario, so, it is reasonable to ask you when, if ever, do you believe that personal choice must give way to other principles or interests?

My reply, which was thankfully limited by a character limit, is here (I added a few hyperlinks to this version, but otherwise it is unchanged):

@johnbmadwis, these questions have been answered by courts and medical ethicists. There is an obvious glaring difference in autonomy between a child who is already born and a fetus, whose existence depends entirely on the mother, whose life is intimately affected and at risk by carrying a pregnancy. Late term abortions (post viability) are extremely rare, and most states have strict limits on the conditions under which such procedures can be performed.

If you are worried about a slippery slope, it is pretty obvious the slope has been tilting towards restrictive legislation limiting all abortion, not just the dramatic but rare cases you bring up. More than 400 bills have been proposed recently in state legislatures seeking to place barriers on access to abortion, from extended waiting periods for all terminations, overreaching excessive requirements for providers and facilities that don’t extend to other, riskier outpatient surgeries, to personhood bills for fertilized eggs.

Trisomy 18 is a serious condition that is considered mostly “incompatible with life.” Not only is the fetus likely to die in utero, but if it survives, it is likely to die as newborn. The article (mostly) covered this really well. (We do know the “cause” of most trisomy 18 – nondisjunction during meiosis II – which is much more common the longer the egg has been in a suspended state of meisosis, i.e. in older mothers).

Santorum’s daughter is lucky in some ways to be a 1% in more ways than one, but this is more than just some sort of ethical masturbation in a comment section of a blog. This issue involves the emotional and physical challenges to the mother. Have you ever carried a fetus, commenter with a male sounding handle? Have you ever had a stranger put their hand on your belly and ask when you were due, when you knew the fetus would most likely die before birth, or soon after? Then there’s the suffering of the baby if it survives, and the emotional toll such care takes on caregivers – do you have any idea what it is like to work in a NICU on suffering, terminal infants? With major cutbacks in personnel in public hospitals, too.

Not to mention the health care dollars arguably misproportioned here. I got to tell pregnant mothers with no insurance yesterday that they had to pay full price, cash up front for necessary basic lab tests. These are mothers who don’t have husbands flying around the country campaigning for president. These are mothers who may and do skip important labs, or prenatal visits, because they have to choose between knowing if they have hepatitis B or food for their existing children. We got to tell a mother who was having her fourth baby and desired a tubal ligation that there was no funding anymore for it. She could pay $1400 up front to the clinic then pay more in hospital fees. Maybe she could google birth control – oh, wait, she probably doesn’t have a computer.

Enjoy wringing your hands about the autonomy of a trisomy 18 fetus. It’s a luxury.

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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.

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Us vs. them (or a blog retrospective)

I cut down on my blogging a lot this past year. It was due to a combination of a different factors. It is harder to tell stories about clinical experiences without discussing my patients or attending physicians in a possibly sensitive way than it was to tell stories about studying or research. Also, I became a single mother, and blogging time is more negotiable than cooking dinner. Or cleaning muddy footprints up from the entire. fricking. house last night. After shower muddy trampolining and wooden sword fighting? Great idea!

But, another reason I stopped blogging has to do with the polarization and vilification that is so common in internet discussions of topics I find dear. Give me a nuanced discussion about breastfeeding, birth, contraception or abortion, please? Please?

I keep ending up writing posts like this one about the rhetoric surrounding “natural” birth, the how to present risks surrounding birth without freaking out post, the one about a death threat I got over a post about vaccination, abortion, fetal monitoring for chrissakes or posts one, two, three, four, five, six (OK that’s enough!) posts about polarizing breastfeeding if-you-can-call-it-conversation. I’m not going to start searching for my posts on race.

Let’s not forget Mommy Wars Bingo.

After one and two disappointing posts and comment sections on Skepchick about breastfeeding, I was tempted to post another plea on here. I want to like Skepchick because of posts like this about female genitalia self image, and a post about female body hair shaving that seems to have disappeared. I was going to beg, again, to please, please let a discussion of breastfeeding science go by without the “GUILT!!” hammer coming down, but I am starting to feel like I will be rating level five on the Professor Internet dick meter if I keep covering the same territory. Even though I’d rather fancy myself more like Jon Stewart preachin’ it on Crossfire.

Hell, I know I have “rant” as a tag on my blog, and I think I coined the term reply-turned-post, even though I hardly invented it. I replied on both Skepchick posts, but I didn’t even bother reposting it here. I am just tired of it. And, I have a sandwich, or a rank list, to get to.

By the way, this is apparently post #665. My next post will be from hell.

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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.

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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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And, partial birth abortion

I am feeling better enough to post a rant!

A friend posted a link on his Facebook page to this ridiculous distortion of an article on National Review Online, which accuses Supreme Court of the United States nominee Elena Kagan of distorting medical fact and the positions of ACOG regarding the so called “partial birth abortion” ban, when solicitor general for the Clinton administration.

He wrote “This is the woman who may have a lifetime seat on the most powerful Court in the United States” and linked to the article. Here is what I wrote in reply:

Thank goodness if she is appointed, which seems very likely.

She did not contradict the language in the ACOG draft at all. They said it was never the case that there was “no other option”. There are inferior procedures that are actually more dangerous to the mother, and more difficult for the practitioner. Yes, they were options, and are now the only option. She suggested language that said an intact D & X may still be the best option, which was obviously indicated by the rest of ACOG’s position. As a member of ACOG, I am completely comfortable with that.

I think it is disgusting that this rare and difficult procedure that was only used in the already most difficult of cases has been politicized like this. And, now is unavailable to doctors. Physcians can still perform later term abortions where (and when) it is legal and indicated; they just can’t use this safer procedure. This ban had nothing to do with gestational age, just technique.

In fact, a D & X is a procedure that is psychologically much kinder to the mother in this difficult circumstance, because she can hold the intact fetus, (or baby, if you use the vernacular), which was most likely incompatible with life on its own or with her ability to survive until it could be viable, and have a proper mourning period. Physicians are now forced to dismember the fetus in utero before removing it, making this impossible. I hope you realize this is the implications of the ban.

I am assuming, considering what I know of your other political leanings, you are not generally a fan of government telling physicians what procedures they should use, based on politics. ACOG clearly was opposed to the ban, and her language in NO WAY misrepresented their position at all.

This is completely ironic considering that science and medical opinion was completely usurped in many cases in the Bush administration. Look into the history of trying to get emergency contraception approved for over the counter use, for example. I hope you were as adamant about respecting ACOG’s positions then.

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