Never fear, an account of Saturday night's events will be posted soon, once the appropriate documentation has been gathered. In the meantime, back to medical school...
Here are some things I've been reading that you should read, too.
With a heart back from the brink, Southern Indiana man faces recovery and a new lifestyle
Eric's heart surgery story. Damn, he's a good writer
The Score
I read this article at the beginning of my Ob/Gyn rotation and found it really interesting. The other night, at the end of my rotation, I read it again, from a new perspective after seven weeks of actually doing this stuff. More detailed than the average article published for the lay audience, but it is the New Yorker. I hadn't heard of Dr. Gawande before, not being a regular New Yorker reader, but two of my friends say he is the best, so I might have to find some more of his stuff.
Ah Yes, Medical School
This blog by a just-graduated medical student had apparently gained some notoriety by the time he graduated in May. I was passed the link by a really awesome attending who thought I would enjoy it, but in typical doctor CYA mentality, warned me that it contained curse words. I hate that CYA mentality. Some of the guy's entries are graphic, a lot contain curse words, but it's also pretty damn funny. I started at the beginning and read through halfway into his third year the other night at 2 am while NO babies were being born, and here are the best of the entries I saw (he doesn't provide individual entry links, but you can search within his blog for them):
-Hypertalkers, Sept. 13, 2003 -- Apparently my med school class isn't the only one with this problem
-The Interview Day, Nov. 3, 2003 -- Good advice for all interviewing pre-meds
-If Darwin Only Knew, Dec. 3, 2003 -- An expansion on the Hypertalkers issue
-Holy Fucking Shit, Feb. 3, 2004 -- Obey the disclaimer at the top of the post and don't read if you can't handle very graphic medical stories. It's kind of weird to think about all the stuff I and every other doctor-in-training has gone through that most of the public just absolutely would not want to know about
-It Could Have Been Worse. I Think, Sept. 23, 2004 -- This made me glad we exclusively use standardized patients for our physical exam skills
-Taking A Trip Down Hershey Drive, Oct. 14, 2004 -- I'll tell you right now, this is about rectal exams
-The FIHTTTU Status Exam, Feb. 27, 2005 -- Thank goodness Step 1 is behind me, but in case you didn't get a sense of how crazy I was in May, this will give you another glimpse of it.
-Faking It, April 16 2005 -- For the first two years, I, too, faked physical exams. I aced my OSCE by simply going through the correct motions of physical exam techniques. I have never, ever seen a retina, but I know how to use the ophthalmoscope to make it look like I can! Well guess what, now I can't fake it anymore. Dammit.
-Tales From The... Ah Fuck It, May 20, 2005 -- Another glimpse into Step 1 studying. Wow, I cannot believe that just three months ago, that is what my life was like. With some minor edits, of course
-Tales From The Crypt VI: Yes, This Actually Happened, June 24, 2005 -- This story is 100% hilarious, and has nothing to do with medicine
-Oh, The Places You'll go, June 27, 2005 -- A description of this kid's lecture hall, complete with diagram, is amazingly similar to our own lecture hall and its inhabitants. Our Question Girl was instead named the Grand Inquisitor, but sat in almost the exact same spot!
-Glory, August 8, 2005 -- You think 3rd-year medical students are important? Think again.
-A Special Guide to Laryngoscopy, August 17, 2005 -- Hilarious, but sexual in nature, so don't read if you don't like the humor of the average 24-year-old male.
-NSWTHAIGTDWML-O-Meter, Sept. 2005 -- A great story of why he can't be an anesthesiologist, with the same magazine-reading observation Eric had.
-Eagle Eyes, August 27, 2005 -- Yeah, third year med students are pretty stupid, me included.
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6 comments:
I never did get your take on that childbirth-going-industrial article after you sent it my way. What did you think? What do you bring to that topic after your ob/gyn rotation?
I guess it's a good thing to hear from other people going through the same thing - forewarned is forearmed. I have the New Yorker - I'll have to look up that article.
A lot of childbirth is definitely pretty industrial, and it's definitely a balance of desires. Birth plans are great if you've had a totally normal, healthy pregnancy. If you haven't, then there are a million legitimate reasons to induce a pregnancy when medically necessary. If you can't stand the pain of even a single contraction, then go ahead and get the epidural; you may not be able to feel your bottom half well enough to push that great, but even women who don't have epidurals need coaches to help push, and as my private practice preceptor said, you don't get a brick of gold from Ft. Knox for not getting an epidural, just conversation fodder.
And even with a birth plan, you have to be willing to face reality during labor. We had a woman come in who refused to recognize that her labor had stalled to a dangerous point after nearly 48 hours (you can only have your membranes ruptured for so long until massive infection will set in), so those conversations between the doctor and patient were not pleasant. You can't cling to the idea of natural childbirth if nature is saying she'd rather kill you or the baby or both instead of succumbing to modern medicine. The problem is that totally normal pregnancies can go bad at any moment, and totally normal labors can go south REALLY quick. I saw that a lot. Sure, external fetal monitoring may catch odd heart rhythms that would otherwise correct themselves and not cause any harm, but who's going to be the one to perform that experiment?
As for forceps vs C-section, that's an interesting issue that I hadn't thought about prior to reading the article. My reaction to the idea of forceps was just that they were bad, being a U.S. citizen born in the 80s. But I guess I have to believe what the article said, that it's an art that works great when used well, but it's hard to teach art. We have three attendings here that do forceps, so if they're on for the shift, then the residents will do them when appropriate. But C-section is still the method of choice. The only time I saw someone almost have a forceps-assisted delivery was a woman who breathes through a tracheostomy who couldn't stand to be lying down for a regular vaginal delivery or for a C-section, so they were going to let her labor as long as she could, then apply the forceps to help the baby out. Except she deteriorated much worse than we all expected, so she got a C-section under general anesthesia (instead of a spinal) anyway. But I've seen them demonstrate forceps, and I'm sure under the right hands, they work much better than C-sections. C-sections ARE tough, they are absolutely not benign procedures. Some residents chose the UofL program in part because they still teach forceps when forceps are applicable, and I think I would probably view that as a perk to a residency program as well. But it's definitely a dying art. My personal opinion is that PCJ did it right, going to a midwife located right next to a hospital, and using midwives who don't want anything to do with non-healthy pregnancies. Some states have midwives who advocate home birthing, and that is just way too dangerous. But if you have a healthy pregnancy, why not use a midwife or a doula and get in a hot tub and be one with nature? Just do it close to a hospital so the abruptions and the shoulder dystocias can be managed if necessary.
This wasn't in the article, but my other big OB question for the rotation was episiotomies. I knew they were once done routinely, then fell out of favor, and I wasn't sure what the protocol was now. The answer is that they are only done when necessary, and it's pretty obvious when it's necessary. Otherwise, we let women tear, to a certain degree, without our help. Given the choice between an episiotomy and a 4th-degree tear, I'd choose the epis, but between an epis and a superficial periurethral tear, I'd probably take the tear.
I don't know much about the specific dangers of forceps, since neither the midwives or the OBs at the adjacent hospital really ever used them anymore. But I do have to say that I find the 30ish% c-section rate to be alarmingly high, especially because it's so much lower in lots of other nations with even lower infant mortality than the U.S. I just can't wrap my head around the notion that major abdominal surgery is the safest bet for one out of three women, ya know? It does seem to point to some element of convenience, in my estimation.
Anyway, I don't have super strong feelings about the epidural or episiotomy, either, and it makes me crazy when some natural-childbirth-devotees tsk-tsking anyone who'd consider these relatively minor interventions. Sure, there are stats that say going with the epi tends to slow down early attempts at breastfeeding, and that's a big reason I went without one, but: early difficulties can usually be overcome, and I do believe that there are many cases where it is absolutely in the best interest of both mother and baby for the laboring mother to get pain relief if she needs it. I only have a problem if a woman is continually pressured to get the epidural, or if a care provider is so accustomed to women getting them, s/he is unprepared to offer other kinds of support/relief to a woman who chooses not to get one.
I guess my strongest feeling is that it seems very easy for one medical intervention to lead to another, to another, to another, so I'm uncomfortable with any of these interventions being considered totally risk-free, or a no-brainer, or something every woman should go for without a second thought. Which, judging from things I hear from other moms, is the way much of it is presented throughout prenatal care and L&D.
Something else I plan to learn more about is the legal aspect of midwifery. In many states, midwives are specifically banned by state laws from attending hospital births (or running facilities similar to The Birth Center where I went). So if you want to have a midwife deliver your baby, your only option is to do it at home. I can understand seeing that option as a reasonable one when you have no middle ground available.
You have to be careful how you compare rates across countries. Some countries have lower C-section rates because they don't have the training, physicians, or facilities to do C-sections. Some have lower infant mortality rates because they don't regularly deliver periviable infants at 24 or 25 weeks (which we do in the U.S. regularly), so a 24-week delivery is a stillborn, not a viable infant that may later succumb to any of a number of things and die, counting toward the mortality rate. Our infant mortality rate is high in part because half of our population doesn't get proper prenatal care or take care of themselves or their babies -- 90% of my patients the last 4 weeks smoked, and at best they've "cut down" for the pregnancy. But those babies, and the crack babies, and fetal alcohol syndrome babies will all be born and have a chance at survival, but who's to say what will happen within the first year.
The other thing to consider is maternal mortality; the risk of dying in childbirth in the U.S. is 17 in 100,000; there has only been 1 maternal death in Louisville in the last five years, and that was a woman with a known aorta problem who was aware of the risks and told not to get pregnant but chose to do so anyway, in an informed manner, and ended up dying. In lots of other countries, women still die in childbirth. C-sections here save lots of women from that, and still often allow the babies to live as well.
C-sections also allow us to handle serious cases that other countries can't. On the labor and delivery floor, I took care of or attended five sections. One was a term woman who stalled at 4 cm overnight with ruptured membranes; once you've been ruptured for 18 hours, the risk of chorioamnionitis skyrockets, meaning danger for both mom and baby, and you need to get baby out. One was the breech 28-week old; if the baby had been head-down, she would have delivered vaginally, but breech in surprise active labor doesn't leave much time. One was the placental abruption at 35 weeks; if we had taken one more minute to cut the baby out it would have been dead, and if we had waited much longer than that the mom would have bled to death as well. Another was the woman with the tracheostomy whose lungs couldn't take the stress of laboring on her own no matter what; forceps were the first option, but C-section became the only choice. And the last one was a 4-peat C-section; once you've had 2, you can't go back to a vaginal delivery. For none of those women was a vaginal delivery even an option; 40 years ago some of them might have been good forceps candidates, but now C-section is really the best way to get a baby out if either baby or mom is in trouble. In private practice, I saw two scheduled C-sections, the indication for both of which was previous C-section.
I've never heard of a purely elective C-section in the regular world; Hollywood and New York are probably the only places you could find boutique doctors willing to do such a thing. So I wouldn't even begin to suspect that the 30% C-section rate is due to elective procedures; it's due instead to our ability to care for women and infants who would have died even 50 years ago with bad labor outcomes. Every textbook and attending will tell you that a vaginal delivery is safer than a C-section, with a much better recovery rate. Heck, if you've only had 1 C-section, the data say that having a VBAC is still safer than a repeat C-section (but once you hit 2 C-sections, you can't go back). No one that knows anything about this advocates for elective C-sections. In fact, the only placed I've heard of that offers regular elective C-sections is someplace in southeast Asia where there are so few practitioners they can't guarantee anyone will be present at all times to attend the birth. So I totally agree with you that elective C-sections are bad, but I don't think they are accounting for the overall C-section rate.
I understand the plight of the midwife and the nurse practitioner and the physician's assistant, but the best thing to do is to change the laws. Home delivery just isn't safe. Louisville's birthing center shut down a few years ago even though it was popular because it was on Broadway, just about in between our apartment and the hospital, and enough ambulances had to be called for women with prolonged shoulder dystocias, prolapsed cords, or prolonged rupture of membranes that it just wasn't safe anymore. And that was just down the street from the hospital. It's a tough balance between making medical pregnancies medical and benign pregnancies benign, but they unfortunately can go from benign to medical very quickly.
Good points. Just to clarify one thing, I wasn't talking about elective c-sections necessarily when I mentioned the convenience factor (of many factors, of course). I know that's mostly urban myth. I'm talking about things like inducing the minute a woman hits 40 weeks, or pushing for an epidural because a non-medicated woman is a challenge, or any other intervention that will then necessitate staying in bed, which does increase the incidence of a labor so stalled that a c-section becomes necessary. When c-section rates go up with the introduction of almost every other intervention, I would just hope that those other interventions would be used with great discretion. Hypervigilant discretion. Gear every aspect of care to the goal of giving every woman the best chance at a vaginal delivery, you know? Don't induce for being a few days post-dates unless fluid levels are low or something else indicates it's time to get things going. But I know so many women who faced induction simply because their OB's practice decided that 40w5d or whatever is the absolute deadline. And her body is just not ready and the induction doesn't work, and she finds herself in surgery.
Anecdotal, of course. Just some things I think about. If hospitals could, across the board, eliminate some of the assembly-line feeling many women get in a standard OB practice, almost nobody would even consider a home birth. But there's a reason (or lots of reasons, I guess) that many women are going to feel like they can get superior care from a home birth midwife, even if they are not reasons most people would find medically advisable. It points to something being amiss in routine obstetrics, no?
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