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Posts Tagged ‘Doctoring’

Permission

Posted by MDViews on December 11, 2008

Mrs. Smith (fictitious name) comes in for her first prenatal visit at about 8 weeks. Our practice performs a routine ultrasound at the first visit. When the baby appears on the ultrasound monitor, I point out the parts that can be seen, especially the heart motion.

“Isn’t that wonderful?” I say. “That’s your baby, your son or daughter, growing inside you right now.” Then, the baby will move, as usually happens. The arm and leg buds wiggle, the torso moves back and forth. The obvious movement surprises and sometimes startles the soon-to-be mom and dad.

“The baby is moving!” she exclaims.

I look up and see tears forming in her eyes. The reality of this new life floods the room. I feel nothing but awe.

“So, have you felt the baby move?” I ask Mrs. Jones (fictitious name) matter-of-factly at her 20 week prenatal visit.

“Yes, I have. For about two weeks now, I think,” she replies.

I smile. “What do you think about that?” I ask.

“Oh,” she smiles back. “It’s wonderful. I always wondered what it would feel like. It’s nothing like I thought it would be.”

“Being a man, I have no idea what the feeling is,” I answer. “But I have to think it would be very special. To just know that there is a new life, a new person, a child who will possibly have you or your husband’s hair color, features, temperaments, eyes—all that. And there it is. Growing and moving inside you. You are a walking miracle.”

By now, I can see a thoughtful expression, often a smile and agreement.

For an obstetrician such as myself, prenatal care is a conversation about the medical and social aspects of pregnancy, all of which need to be covered and all of which need their appropriate attention. In fact, we have huge lists of what to cover each visit. Things like clinic procedures, HIV counseling and testing, nutrition, weight gain, seat belts, exercise, prenatal screening and diagnosis, smoking, alcohol, drugs, overheating, cats, raw meat, un-pasteurized milk—and that’s just the first trimester.

It’s an exam each visit, usually not involved, of weight, blood pressure, fetal heart tones, growth, position and edema.

It’s a phone call in the middle of the night, attention during labor, monitoring the patient and the baby, pushing, sweating, delivering, resuscitating, bleeding and repairing.

It’s a medical-legal risk, a worry, a burden and another day working sleep-deprived.

And that’s just the routine ones.

Most often for a woman (I have seen exceptions), pregnancy and childbirth culminate a life-long dream, a dream she’s had since she was 9 years old. She has listened attentively to pregnancy stories through her growing-up years. She’s ooh-ed and ahh-ed over newborns. She has looked at a boyfriend and wondered what her baby would look like if he were the father. She’s wondered if she would be fertile, what pregnancy would be like, if she would be able to handle labor and delivery and if she’d be a good mom.

In my 30+ years of attending pregnancies and childbirth, I’ve noticed a change. A not-so-subtle change. Society seems to pressure women into a view of marriage, pregnancy and family that stifles joy and excitement and honor. From a girl, a career for her dominates the conversation and teaching. One view holds sway—career fulfills and motherhood burdens. The adequacy, even superiority, of day-care compared to mom-care goes unquestioned. Statistics about the cost of children frighten the most well-to-do. Magazines write articles about tummy tucks and breast lifts for those sorry pregnancy and nursing changes in a woman’s form. Population experts proclaim a goal of none or one, two children at the max and upbraid those women who would add another carbon footprint to our world, an irresponsible act.

So, a woman presents for prenatal care with measured excitement, suppressed joy and worried happiness. But she carries the excitement, the joy and the happiness just beneath the surface; these feelings even, sometimes, a surprise to her. The heart beats on ultrasound—how wonderful! The tummy starts showing—has anyone noticed? The baby moves—what a bond you now have to the baby and to mothers everywhere who have felt the same. The birth is approaching—how are your preparations going at home? Did you take classes? How does your husband feel about being a father? What color hair do you think the baby will have? Uncomfortable toward the end—it means you are that much closer to motherhood, holding your baby, looking into your baby’s eyes, showing your baby to your own mom, a special moment.

Permission. That’s what I try to give to my pregnant patients. Permission to be joyful. Permission to realize the miracle occurring inside them. Permission to have awe over the heartbeat and ultrasound and movement and even the changing pregnant form. Permission to glory in the entire experience, the magnificent process of conceiving new life, nurturing new life, carrying new life, bringing forth new life and then holding, cuddling and loving that new life, that baby, that child.

It’s not hard. The feelings are already there. They just need permission to come out.

Pregnancy in 2008 is a 59400, a SUPERVIS NORMAL 1ST PREG[V.22], a 12-14 prenatal visits, two ultrasounds, one normal delivery and one routine postpartum visit event.

What is the ICD-9 (International Classification of Disease) code for “MIRACLE?”

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CPR

Posted by MDViews on December 10, 2008

Small town medicine is personal. A winter evening splashing and playing with my children at the Friday night YMCA open swim in Burlington, IA in about 1986 found me using my CPR skills on a 12 year old boy who nearly drown. The frantic shouts of a 17year old lifeguard tore my attention away from my children as he hauled the limp body of a young swimmer from the deep part of the pool. The other lifeguards quickly directed the multitude of other swimmers out of the pool area. I sent my children out, exited the water and approached the victim and his rescuer, identifying myself as a doctor. The stark fear and anxiety on the face of the young lifeguard, who couldn’t have been more than 16 years old, eased somewhat as he realized he had done his job and would not have to revive the child. I checked. The lifeless-appearing youngster had a pulse. A good pulse. Strong. But he was not breathing. I started mouth-to-mouth, thankful for his youth and the light breaths it took to ventilate him. He started to cough and sputter after about 45 seconds. Another minute and he opened his eyes and started to struggle. He did not yet know where he was or how close he had come to death. He looked dazed and confused, but sat as the ambulance crew arrived. The hospital ER looked him over and sent him home after a few hours of observation.
At church about a week later, a very shy young man said a weak ‘thank you’ and handed me a card as he stood close to his mother. His mother was a single mom, a minority woman on welfare who had two sons. I encountered her youngest at the pool, the shy young man who delivered the thank-you card. After several years, he and his family quit attending our church and I lost touch. But that winter evening will be one I’ll not forget.
About four years later, while jogging on the 15-laps-to-a-mile track at the same YMCA, a staff member caught my attention as I rounded near the door.
“A man collapsed in the hall downstairs. A nurse has started CPR. Could you help?” he asked urgently.
I ran down the stairs three at a time (I could do that back then), through the door and into the main hall. A large elderly man lay on the floor with a small crowd around him. He probably weighed 250lbs with a barrel chest and the type of clothing you would see on a retired farmer from our area. As I moved closer, I could see blood on his face, cheeks, mouth, nose and blood splatter marks on the floor. A nurse from the hospital where I worked pumped up and down on his chest, counting “One, two, three, four…” By that time, I was at his side. I could see the nurse was getting tired. She glanced at me with recognition and said he had collapsed, falling forward, which accounted for the blood splatters and blood on his face, mouth and nose. I volunteered to ventilate, getting two breaths for each of her five compressions. The 911 call went out, but no ambulance crew came for 20-30 minutes. We switched from ventilating to chest compressions and back again as our fatigue increased. Occasionally, we felt for a pulse, but found none. Prior to my arrival, my now CPR partner ripped open his shirt exposing a long vertical mid-line chest scar, obviously from previous open heart surgery. At that time in our history, a major source of HIV was contaminated blood from transfusion. Anyone who had undergone a coronary artery bypass procedure had been exposed to at least six units of banked blood. He had undergone two bypass procedures, his frail wife relayed to us as we kept working on him. We were exposed to banked blood, at least 12 units. Both of us. When the paramedics arrived, they were able to start a line, administer meds and defibrillate him with some success. He left the YMCA unconscious with the paramedic bagging him with oxygen. And he had a pulse.
Later, I learned that he lived through the night, but died the next day. His wife sent a thank-you for our efforts. Neither of us tested positive for HIV.
Two stories, both true. Two outcomes. The common thread, using the medical skills I possess in an emergency situation. Rare situations as I’m sure you know, but who can predict events of tomorrow? For you or me? I thank God for the training I’ve received, the skills I have and the privilege to practice this most satisfying profession of medicine.

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The Pain of the Uncommitted Male

Posted by MDViews on December 2, 2008

Since venturing on my medical career some 30 years ago, our culture has undergone a sea change in how marriage, fornication (sex outside of marriage) and infidelity are viewed and practiced.

In 1978, there was still some shame at conceiving an out-of-wedlock child. Couples shacking up were somewhat unusual and certainly far from mainstream. Having an affair often led to divorce.

Since that time, I first noticed, especially in the lower socio-economic patients (poor folks with weak family and social connections) that out-of-wedlock pregnancy became more commonplace and accepted. Then, living with boyfriends became more accepted. Now, the practice of shacking up is accepted by middle and high income people with good education. With no shame. It’s not just OK, it is often celebrated.

I often ask my pregnant patients or even gynecology patients if their live-in boyfriend is husband material. Many times, I get a smile and a “yes”, but then it is followed by a “but not now. We have to do xxxxx first.” Which is generally make more money, buy a house, pay for a car, finish school and on.

But I also get a response from many to the effect of “Why would we marry? Who cares?” Marriage is now so unknown to large segments of our population that the thought of marriage is not even entertained.

I explain that she will be the one hurt in the end by such a relationship. She will have given herself to a man with no attachment, meaning he can leave at any time without repercussions, except child support, if the state can find him. If he leaves, she is left with the shattered hopes and dreams, the risk of STD’s, the children, the poor job, the poverty while he goes on his merry way and shacks up with the next one.

I usually get the “but we aren’t breaking up. We are together.” response. It is heartbreakingly sad. I marvel at the denial. Truly, denial is not just a river in Egypt.

Just today, I talked with a patient who had been with her boyfriend for several years. When she pushed him slightly to get married, he said he just wasn’t sure. They were living together! So, she is now a bundle of tears and feels used, betrayed and cheated out of several years of her life. And for what? His selfishness.

When a couple shacks up, men are in the drivers seat, enjoying the ride. They get the companionship, the sex, the home comforts, the married lifestyle with the freedom to leave anytime the relationship gets sticky or uncomfortable or unsatisfying as all close relationships eventually do. They never have to do the hard work of relationship and reconciliation. They never have to pay an emotional or financial price for their misdeeds.

PMS? Hey, I’m outa here. No sex tonight? See ya later, baby. Not enough money for a motorcycle? Good luck on your own, sweetie, I just bought a Harley and need my whole paycheck. New baby has colic? Well, call your mom, because I met this girl at work and I’m moving in with her.

So women who choose this lifestyle end up hurt and hurting. My heart goes out to them. Shame on a man who would bed a woman and not have the courage to commit in marriage. Shame on a woman for allowing such behavior in a man. God help the children born of such a loose union.

I’ll post more on this in the future.

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Cervical Cancer Vaccine

Posted by MDViews on October 6, 2005

Gardasil.

That’s the name of the new HPV vaccine seeking FDA approval. It is expected to be approved as early as June 8. It’s a vaccine made by Merck and gives immunity to the two most virulent Human Papilloma Virus strains, 16 and 18. By virulent, I means capable of transforming the cells on a woman’s cervix into pre-cancer–and ultimately cervical cancer–if not detected and treated. That’s what the “Pap” or cervical smear is for. Detecting these abnormal cells early so they can be destroyed in the benign pre-cancer stage before they cause a life-threatening problem.

Merck hopes that the vaccine will be administered to pre-pubescent boys and girls to provide them this immunity. Merck touts this vaccine as the first cervical cancer vaccine to hit the market.

Hold it. What? Boys too? I thought you said this was to prevent cervical cancer in women?

Well, I did. But it’s not as straight-forward as that. The vaccine does not target cervical cancer, and in fact, if I read the news report correctly, it is not intended to. Instead, it targets the HPV virus and provides immunity to it. By extrapolation, then, it should help prevent cervical cancer, since HPV is the agent that causes the most common type of cervical cancer.

So why vaccinate boys? Because HPV is a sexually transmitted disease which is harbored by 50% of sexually active teens and young adults. One cannot get HPV unless one has sex with an infected partner. And sex means boys and girls–so, vaccinate the vector as well as the victim.

This vaccine opens the same can of worms as the Hepatitis B vaccine. Hepatitis B is a liver infection that one can only get by exchanging bodily fluids with an infected person (the same as HIV), ie., blood products, IV drug users sharing needles, inadvertent needle sticks to doctors and nurses (health care workers) or sexual activity. So, does everyone need Hepatitis B vaccine? Sure–if you do IV drugs, plan on getting an infected blood transfusion (very rare), plan to be a doctor or nurse or if you have sex with multiple partners and one is infected.

Does that sound like you? Does that sound like the person you want your child to become? Hepatitis B vaccine can be given to adults if they enter health care and it works just fine. Our blood supply is safe–very safe. Testing continues to improve. So that leaves IV drug use and promiscuous sex as the reasons to vaccinate your child.

Along comes Gardasil. Your child receives the vaccine, maybe at age 10 or 11 and is protected from the consequences of promiscuous sex–at least one of them, the HPV virus that causes cervical cancer.

No woman wants cervical cancer. And no man would want to spread the virus to women, I presume.

So where does that leave the wait-until-marriage-and-have-one-partner-for-life argument? Weakened, that’s where.

Obviously, some parents will not want their children vaccinated against a sexually transmitted disease for moral reasons. But no parent would deny his children protection against cancer. Doctors do not want their patients to get cervical cancer. Doctors will not want the parents of a 10 year old girl or boy to say, “No thanks. We’ll pass.” So if the doctor says, “This is a vaccine against cancer,” –and stops there, parents of boys and girls will likely say ‘yes’. But, if the doctor says, “This is a vaccine against an STD. By stopping the STD, your child is protected from cancer,” –some parents will decline.

What to do, what to do.

I presented this at a hospital meeting last week in the context of being “culturally sensitive” to those who may object, and to lobby for honesty when presenting the purpose of the vaccine.

Oh, my. Did I get a response.

Anger. Indignation. Loud voices. It appears “cultural sensitivity” does not apply if the group likely to object is Christian conservatives. One doctor flat out said it should be presented as a cancer vaccine, not an STD vaccine. Otherwise, we would have to tell patients that cervix cancer is an STD. To which I replied, “You don’t? I do. We have always known that as gynecologists and have not hesitated to inform patients of that. I do it every day.” He was surprised, I think, but remained adamant that this should be presented as a cancer vaccine and that no one should be allowed to refuse the vaccine. Another doctor said that the cancer part needed to be emphasized and the STD part minimized. No one in the meeting backed me. I was alone in my view.

So, what do you think, dear reader? Will you vaccinate your little ones?

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