Monday, January 19, 2009

What's in a pill?

Today was a holiday of sorts and I made it home in time to watch the evening news learning something that will help me in the future.

In for her annual exam, I was reviewing the list of medications with a patient this afternoon. "Well, I am on something for my cholesterol but I just can't remember the name," Mrs. S said with a puzzled look. "At first I was taking that one with the guy rowing on the lake. You know him, he invented the artificial heart."

Yes, I had seen the commercials for her old medication but tonight I figured out what medication she is currently on. "But I am not on that one anymore," she had continued. "It caused some problems so now I take the one with the young African American woman in the commercial." Got it. I saw the commercial. Now I can record the correct medication in her chart.

In medical school and residency I frequently learned to recognize a medication and the dosage based on the color of the tablet or capsule. Generics changed all that as it is impossible to keep up with appearance of even oral contraceptive packaging. Now with direct to consumer advertising the television commercial is often a point of reference for the patient.

I just wonder if a change we can believe in is a lowering of medication cost by removing some of this direct to consumer advertising. Then perhaps patients will begin to believe that a pill recommended by anyone other than Sally Fields might be effective to treat their osteoporosis.
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Saturday, January 17, 2009


Current medical culture encourages physicians to confront their mistakes and apologize to patients. This has not always been the case. In the culture of my medical training denial was the norm. I remember the first time I witnessed an apology from a physician. I was an intern and the remorseful physician was a second year resident. If you have the time, here is the story.

Shortly before shift change one morning an exhausted patient had been pushing for two hours trying to deliver her first child. The patient, Mandy, was sixteen years old and unmarried. One of the clinic patients who came from a small town nearby for her care, she was accompanied by her mother. The father of the baby had abrogated any role in Mandy's life shortly after her pregnancy was diagnosed. From all appearances Mandy's own father had done the same. She had been raised by her mother, Brenda, who had never married and worked as a cook in the local school cafeteria. Brenda was present in the labor room as Mandy's support person. I remember thinking that this grandmother to be did not seem much older than I which caused me to wondered if she had been even younger than her daughter when she gave birth.

Living on the economic margins while raising Mandy by herself were possibly factors that led Brenda to talk with Mandy about placing this baby for adoption. They sought help through a local agency and a family had been chosen for placement. There had been no exchange of information between the birth and adoptive families, so while the adoptive parents probably knew of the labor they were not present at the hospital. Mandy's bag of waters broke the day before and she spent the night in an exhausting labor. When I arrived she had been pushing to deliver the baby for almost two hours.

Rob, the second year resident was already a skilled and knowledgeable physician. I admired his abilities. He made the decision to delivery the baby with forceps due to Mandy's exhaustion. As a rotating intern this was only my second month on obstetrics since I was required to also spend time on medicine, in the coronary care unit, the emergency room and doing anesthesia. Rob would do the delivery and I would assist. The two of us and two nurses along with Brenda, dressed in a scrub suit like the rest of us took Mandy to the delivery room.

Once Mandy was on the delivery table I was allowed to place a spinal anesthetic for anesthesia during the delivery. With Mandy comfortable and all the monitors in place, I emptied Mandy's bladder and checked the baby's head for position. It felt irregular or assynclitic. Rob also noted this but stated that he felt he could rotate it once the forceps were applied. Mandy was prepped, draped and Rob slipped the forceps on, the first blade going on easily, the second a more difficult application. With the next contraction Mandy pushed, Rob pulled and nothing happened. The baby's heart rate remained stable but there was not decent of the fetal head.

At this point Rob removed the forceps and reexamined Mandy determining that he could rotate the head with his hand before reapplying the forceps. The baby's heart rate was still stable and Mandy was almost dosing, exhausted and now comfortable with the spinal anesthesia. To effectively rotate the baby's head Rob must have elevated it enough to allow the umbilical cord to slip down and prolapse through the vaginal opening.

Noticing the cord Rob's reflex action was to elevate the fetal head even further to take the pressure off of it during the next contraction. Panic set in the form of a scream, "Get some help. We need to do a STAT C-section!"

One of the nurses pulled the emergency code cord and the room filled with medical staff. Rob began to order us to prepare for surgery. I quickly tested Mandy's abdomen by pinching her only have her wake up and say, "Stop that! It hurts." I knew that we needed more than just my spinal anesthesia to deliver this baby. I called for anesthesia and one of the anesthesiologist was in the room with in seconds. He began lining up the drugs and telling Mandy she would soon be asleep. A veteran of obstetrical anesthesia, his voice remained calm. Mine was not and neither was Rob's.

"Get the C-section instruments open," Rob screamed at the nurses while ordering me to gown and glove without scrubbing so I could drape the patient. "The heart rate is only sixty. We have got to go."

"Not so fast," came the anesthesiologist's measured words. "The mother is a patient too and she has to have adequate anesthesia." While he was pushing medication into Mandy's IV a nurse was holding pressure on Mandy's neck to prevent aspiration while she was intubated.

Now gowned and gloved, I watched as another nurse splashed antiseptic on Mandy's abdomen. Before I covered her with a surgical drape Rob had to allow a nurse to elevated the baby's head in his place. I was too inexperience and could not do the C-section unassisted.

The anesthesiologist intubated Mandy while Rob gowned and gloved. From skin incision to delivery was less than a minute. Yet it had been ten minutes since we had first seen the umbilical cord, like a piece of purple and grey rope falling through the vaginal opening. The baby was equally purple as he appeared through the incision in Mandy's abdomen. As soon as I cut the umbilical cord, I placed him in arms of a pediatrician that began the resuscitation. Rob had cut a segment of umbilical cord for a later blood gas determination, delivered the placenta and we began the task of closing the incisions in Mandy's uterus, fascia and skin.

Over the twenty minutes or so that it took to close Mandy's abdomen the NICU team hovered over the baby first intubating him, then starting an IV and giving him medications. At one point I thought they were doing chest compressions because his heart had stopped but as it turned out, John, the name that Mandy later chose for him, always had a heart rate. He was not however breathing on his own when they placed him in the isolet to move him to the neonatal intensive care nursery.

As I taped the bandage to her abdomen, Mandy began to move and the nurse anaesthetist that had been left in the room with me began to suction the secretions from her mouth in order to remove the endotracheal tube. She was coughing and complaining about her sore abdomen as we moved her to the recovery bed in preparation for leaving the operating room. It was my job to write post operative orders and a note describing the surgery in the chart. Just as I was finishing, Rob brought his own note in and placed it in the chart. He also had the baby's umbilical cord blood gases showing hypoxia and acidosis. Rob's face looked grim.

Mandy was now awake enough to have her mother in the recovery room. Rob explained to them both that the baby was in the neonatal intensive care where they were breathing for him and assessing the situation. Probably within thirty minutes the neonatologist, a specialist who would be caring for the baby would come and speak with them.

Actually the neonatalogist came and spoke with us first. The baby, an eight pound five ounce male, was now being given medication for his seizures. His urine output would have to be monitor closely as kidney failure was another sign of hypoxic injury. Things would probably get worse before they got better. Looking at the clock I realized that it was nine a.m. I had been at the hospital for just a little over three hours. I was exhausted and my shift of twenty four hours had barely begun.

It was a week before John was ready to go home. On the day that he was to be discharged, Rob and I went up to the room where Mandy and Brenda has been allowed to "room in" with him for the night. John was no longer on the ventilator. In Mandy's arms he looked like a normal baby. Yet he had been born after having very little oxygen for at least ten minutes. He was on a medication to prevent seizures because he had already had one. The adoptive parents had decided that this was not the baby of their dreams. The adoption agency had agreed to take the baby into foster care but Brenda and Mandy had decided that John should stay with them.

Rob and I both had stayed in contact with Brenda and Mandy at least twice a day since the morning of John's birth. Rob looked as if he had not slept since the night before Mandy went into labor. He looked at the floor and cleared his throat. "There is something that I need to say to you both," he began looking first at Mandy and then at Brenda.

"I did my very best to deliver John in what I believed was the safest way possible. I feel that I made the wrong decision to do a forceps delivery. I was concerned about your health Mandy, how exhausted you had become. If I could go back I would do things differently but we can not go back. I hope that you will be able to forgive me. I will certainly do things differently in the future." With that Rob wrote his name and the hospital page operator's phone number on a piece of paper and handed it to Brenda. "If you have any questions, please call me. I will also be in the clinic when you come in for your check ups."

I saw Mandy about six weeks later. The baby was growing and she was able to begin some night classes to work on her GED. Brenda was still working in the school cafeteria. I have often wondered how John is doing. Was he brain damaged? I know there was never a lawsuit. I would have surely be deposed. Rob has done countless good practicing in a small town for the last twenty-five years. I would go to him or recommend him to family members who needed a doctor. None of us is perfect but how many of us apologize.

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Wednesday, January 14, 2009


"Life shrinks or expands in proportion to one's courage." Anais Nin

Reading the quote this morning has caused me to reflect on courage. I have chosen two patients who I believe have responded to a situations in different ways and each response required much courage.

I have known both these women for most of their adult lives. The first is now a forty five year old executive with a large local firm. Her husband works from home to be with their three children full time. The youngest son, now nine, was born with Down's syndrome or trisomy 21, an extra twenty-first chromosome. Andy is the light of this family's life. He has brought humor and happiness in to the family. They feature him prominently in their family photos. It is easy to that tell he has the love and respect of his older brothers.

The assurance with which this family deals with Andy's disability was not always a given. It has come from nine years of learning everything about Down's syndrome. I know that there were times they have had to advocate with health care services, the school district and other agencies to get the care that Andy needs. It took courage to choose to have a child after Pam reached what we in the medical community call "advanced maternal age." I am sure that there was some magical thinking own their part at that point. "It won't happen to us. We have two healthy children. Pam is healthy."

I always spend longer talking with these couples, making sure that they truly understand the risk without trying to push them into testing they do not want. If they are committed to the pregnancy and would not terminate, are they sure that finding out earlier would not help them prepare? Pam and her husband were committed. They were heart broken when baby Allen was born but their love for him never wavered. Gathering their courage, they immediately began collecting information and enlisting help for their son.

My other patient was also over age thirty-five and pregnant with her third child. She and her husband quickly accepted diagnostic testing when I offered it. I had delivered their two daughters and I felt I knew them well. Yet, when the test results return and I called to ask the couple to come to my office to discuss them, they wanted to come immediately with Tom leaving his work as an attorney in the middle of a deposition. Sandra is a wonderful mother who does not work outside her home. She cherishes her children and you can see the love and hard work that goes into her mothering.

When I revealed the fact that their son had Down's syndrome both of them cried, hugged each other and ask for some time alone. When I return to my office fifteen minutes later, Tom spoke first. "Before Sandra had the amniocentesis we discussed this and decided that we would terminate the pregnancy if the baby had Down's syndrome." I again felt the need to discuss the fact that this was not a lethal condition. Again Tom spoke about their decision and how they had made it, weighing the effects of either choice on their family as a whole. Sandra held his hand and nodded. "We have reviewed our options and we feel that this is the right action for our family.

Eighteen months after terminating that pregnancy, Sandra gave birth to a healthy, chromosomally normal son. Many times during the course of both pregnancies I thought about this couple's courage to choose the course that they believed to be right for their family. Now as I see Sandra and look at her family photos I detect a sense of loss for the son who had Down's syndrome but I do not detect any regret about the decision she and Tom made.

Both of these families met a challenge in different ways. Each way required courage. Their lives have expanded with the courage to live into the decision they made.
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Monday, January 12, 2009

Time travel

Returning to the past is attractive. There are several moments, hours and even days within my own life that I would return to in the hope of doing them better if given a second chance. For this reason I am ever a student of history to learn from others while living by the motto "the best is yet to come" which keeps me firmly gounded in the present and yearning for the future.
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Friday, January 9, 2009


A Susan Ertz quote goes something like "Millions who long for immortality do not know what to do with a rainy Sunday afternoon." For me this statement is the perfect illustration of the problems with time. It runs through our figures like tiny grains of sand while we sit stewing about not having enough of it. Time is precious. In 2009 I welcome the challenge to spend more of it exposing my thoughts.
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