Friday, February 26, 2010


In addition to having a special vocabulary, medicine has its own set of acronyms. PERRLA stands for "pupils equal round reactive to light and accommodation." All medical students learn this when doing the first year course in physical diagnosis. Medical students also learn the importance of preforming both the reaction to light AND to accommodation. The reaction to light is when the doctor pulls that little penlight out of her pocket, darkens the room and points the light directly in first one eye and then the other. In the darkness, your pupils should get bigger. The bright light will make them smaller. Accommodation is where you are ask to focus on an object, say the physician's finger held out in front of your face, and watch it as he moves it closer to your nose. With this your pupils should also grow smaller.

As every medical students learns, neurosyphilis reduces the pupils ability to accommodate. Back when medical school classes were made up of mostly male medical students taught by male professors, the way to remember this bit of information came in a story about prostitutes who have neurosyphilis and will "accommodate but they will not respond."

As an intern long ago, I carried a spiral notebook in my pocket with just such a list of acronyms. This was in a time when husbands were confined to the waiting room while their wives were in labor unless they had gone to childbirth classes. This was carried out with such seriousness that certificates were given to the couple and the labor nurse was required to put this certificate on the patient's chart before the father was allowed in the delivery room.

I remember my first solo delivery. As the nurse anesthetist and I pushed the patient's bed to the delivery room, she kept asking me, "Is this an FID?" I had no idea what an FID was and I panicked. Did this woman have a condition which had escaped my attention? Could it affect her health or safe delivery of this baby? Looking in my notebook, I could not find FID. Finally, as we were moving her over on to the delivery table and I realized I would not have time to look through her chart again before the birth of the baby, I whispered to the nurse, "What is an FID?" "FATHER IN DELIVERY!" she shouted back. "No," the nurse replied. "He didn't go to childbirth classes, so he can't come in."

Well, now we have FOBs. FOBs are related to FIDs. Now, instead of pushing the patient down the hall to a delivery room, we have labor, delivery, and recovery rooms or LDRs so everyone gets to come in, at least for the labor and some patients choose to have several people present for the actual delivery. One obstetrician pointed out there was only one thing missing from the LDRs - the bleachers.

But back to FOBs. This is the term which is now quite common for the father of the baby. It is usually used when the patient and the FOB are not married. In private practice thirty five percent of my patients were not married at the time of their first OB visit, however, many did marry before the baby was born. In my current job, many not only don't marry but the FOB is the father of several other babies born to other girls.

In my continuing search for why this state has the highest teen repeat pregnancy rate, I believe accountability of these FOBs is an essential step to reducing our teen pregnancy rate. Accountability? Yes, the FOB's name on the birth certificate. Then they would be required to do more than swagger around the hospital room and brag to all their friends in the hallway. With the FOB's name on the birth certificate, the FOB could be made to pay child support. And if the FOBs are out working and paying child support they would have less time available for repeat preformances.
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Thursday, February 25, 2010

Speaking of hope and change

There is a reason I am a physician, not an attorney or clergy. I have often wondered but I believe it is because my vocation best fits my personality. I am usually too outspoken to be the latter and not enough to be the former. Thinking about my chosen profession on a day when the leaders of our country are trying come to some type of consensus on an equatable way to deliver health care in this country has caused me to reflect on the words: "hope" and "change."

This has also given me pause to reflect on the two words I believe are most critical in this health care debate: "greed" and "apathy."

Two years ago I had a great deal of hope that we would see change in the way health care is delivered in this country. My passion for this has pitted me against many of my colleagues. One of the biggest reasons I left private practice was the unmitigated greed I saw medical practice. This included everything from unnecessary testing to generate income for the profit centers in the practice to poor medical practice in allowing minimally certified office staff to preform triage functions including ordering and reviewing medical tests when the physician was not present, allowing that physician to bill for services preformed when he/she was out of the office. The reasoning given for doing this was the same one I use with my mother when I was in junior high school. "Everyone else it doing it."

Lest you think physicians are the only greedy ones, hospitals and insurance companies are right there and they make a bigger impact on health care costs than physicians. Without naming names I challenge you to look at some of the publicly traded health care companies from health insurance, physician groups, and hospital corporations. Or better yet, go and look at how your local nonprofit hospital is set up. You may find many for profit arms protruding from the altruistic body. These for profit connections receive money from the non profit base and they are owned by the officers, board members, and physicians, who are employed by or practice at these institutions.

Like the cardiologist once explained to my father, then in his 70s and only taking a baby aspirin daily, "We have a huge industrial-medical complex here and we need to get you to participate more to keep it running."

Which brings me to apathy. The employed and retired American public that by and large has health insurance is very apathetic when it comes to helping those who do not. If you are over 65, you probably have Medicare and many in this age group also have gap policies provided by their former employers. (Look at your TEA Party groups and you will find those who maybe taxed enough already but they are also happily getting their health care from a younger generation's tax dollars while many in that younger group are going without health care coverage.) Those who are too sick to work, disabled, or self employed know how difficult and expensive it is to obtain health insurance. Having always been self employed, I have always been aware of the cost of health insurance. With tort reform, I now pay more for health insurance than I do for liability coverage.

And there is patient apathy. For example we all want heart health achieved by prescription drugs, brand name at that, not the self care and work which is required to eat a healthy diet and participate in daily exercise.

I could go on but I will stop here. I remember as a child being told the only person I have the power to change is myself. I continue to work on this and yes, even my attitude after a year of this health care debate. I will also keep on talking with patients about contraception, diet, exercise, and sexually transmitted diseases because I have hope that some will listen and begin to change.
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Tuesday, February 23, 2010

Risky business

The most common cause of maternal death is hemorrhage. Massive bleeding which is uncontrollable and often times the severity of which goes unrecognized until it is too late. I had a close call recently with a situation where the bleeding was uncontrollable.

The patient had a condition call placenta increta. The placenta grew through her old Cesarean section scar. The odds of this increase with the age of the mother and the number of C-sections. In her cause these numbers were 23 and 1. That's right. She is twenty three years old and she has had one other pregnancy, a now two year old.

The other terrible part of this case history is the baby. She has a cardiac abnormality. That fact and the placental problem put both mother and baby at high risk which is why she was transferred to a major medical center for delivery.

Outcomes: The mother lost her uterus. While better than losing her life, a hysterectomy was not the outcome I had hoped for going in to the C-section. Realizing the baby may not live caused me to delay longer trying conservative measures before I began the hysterectomy. This resulted in enough blood loss to warrant the transfusion of several units of blood and blood products.

The baby is very sick. One surgery has been done and another is planned. I know one baby cannot replace another but thoughts of harvesting eggs and IVF with a surrogate donor have already crossed my mind. At best this couple has a long road of treatment for this baby's heart defects.

This is the type of scenario I think of when someone says to me, "Delivering babies, what a wonderful job!" I would agree. I have a wonderful job but most of the people who say that have no idea how dangerous pregnancy can be.
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Tuesday, February 16, 2010

Watch out!

Over the course of the past eleven months I have composed a new list of dangers. This list goes beyond the normal one I present to the residents when trying to raise their awareness of the likelihood of complications such as a shoulder dystocia or post partum hemorrhage. These dangers are more common on certain days.

Rainy days would be one type of day for which I have gained a new appreciation. I will almost always end up seeing at least one pregnant woman who has been injured in a motor vehicle collision. And I will never forget the woman brought in at term, a full code in progress. Neither she nor her baby survived despite the emergency Cesarean section in the emergency room.

Having treated a severely hypothermic expectant mother, I am more aware of cold days but carbon monoxide poisoning was not on my radar until recently. After a bout of extremely cold weather combined with prolonged power outages, a pregnant woman arrived with symptoms of carbon monoxide poisoning. I am happy to report that she and her fetus both did well after a trip to the hyperbaric oxygen chamber.

Holidays are also a time I worry. As I have tried to explain to my teenagers, even though you aren't the one drinking, if you are out and someone is drinking and driving, you may end up being casualty of their short sightedness. Stay off the roads, especially when it gets late, is my advice. I have seen too many victims.

Imagine my surprise when I walk in to the labor board check out at 7 AM to find someone already wearing Mardi Gras beads. Today is one of those days where I will worry a little more than usual about what might show up in the emergency room. I hope I am wrong. I hope everyone stays home to finish up that last piece of chocholate cake.
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Thursday, February 11, 2010

A new diagnosis

I was ill last week. Originally, I believed my illness was food poisoning. As I heard of more people having a similar illness, I decided it was just something going around. My case was unusually severe, requiring a full day in bed and then another five or six days before I could eat normally. In talking with one of my colleagues about the fact that I was almost unable to get out of bed for an entire 24 hour period, he said "You know, I think you may have had 'man flu'."

"Man flu," I cried, "What in the world is that?"

"Actually I learned about it from one of my patients," he told me. "She said that when she has the flu, she is somehow able to get up and care for the kids, do some cooking, and keep the house straight. When her husband has the flu however, it is so severe he is not able to rise from bed except to go to the bathroom."

Man flu. I hope no one else at my house gets it.
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Friday, February 5, 2010

Baby for adoption

By noon on a recent call day I was ready not to be so entertained by this job. After a morning full of teenagers having their second or even third baby, a 23 year old woman with limited prenatal care arrived in obvious labor. By limited care, I mean two brief visits to a free clinic. The patient’s fundal height (measurement of the pregnant uterus) was so small, at first I believed the due date she gave of 3 and 1/2 months from now. Her cervix was 4 centimeters dilated on arrival to labor and delivery. I did not have much hope of stopping her labor but I ordered the tocolytic, magnesium sulfate before I doing a sonogram. There is now some literature to suggest that premature infants whose mother receive magnesium sulfate to stall or stop preterm labor also have a better neurological prognosis, so I figured it could not hurt.

On doing my sonogram, I discovered this woman was very close to a term due date. In fact, her other two babies, which were 28 and 14 months old, weighed 6 and 6 1/2 pounds. This one fell right in that range on sonogram. The patient got her epidural and we began to have a less frantic conversation. Her other two children were with her mother in law in a small town an hour east. The patient and her husband could barely support themselves and these two children. They were placing this baby for adoption. Or at least that was the plan they made at the free clinic. And no, they had not made any arrangements with an adoption agency or and attorney nor had they even called one of the phone numbers given them.

So the baby arrived weighing just over six pounds. A girl with a very good set of lungs. She was screaming and pink within a minute of arrival. She left for the nursery after the 5 minute apgar with the pediatrician's approval for the newborn nursery. Mom never held her. Dad didn't even look at her. He was gathering up his jacket to go to work when I left the room.

Of all the babies I delivered this morning, these parents seemed the best equipped to raise a child. In fact they were raising two. The same situation, no health insurance, which landed this woman in my care, has contributed to her getting pregnant three times in as many years. And yes, she would qualify for Medicaid at least for the pregnancy. It is complicated, these issues of access to medical care.

Now I wonder if this free clinic provided birth control, would she have gone after her first child? I wonder if she kept this baby girl, would her chances be any better than her mother's? This last is the question I have about almost every baby I deliver. What I do know is this problem of unintended pregnancy is not getting any better. Cheap, easily obtainable contraception, and the motivation to use it needs to be a societal priority. No matter what you believe about the rest of health care, on this we cannot afford to wait.
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