177. Mission Accomplished

I like to know something about patients, more than just the "what can I do for you today." I asked Yolanda, age 39, about her family. She said she had two teenagers and a 20 year old.  Is the 20 yr old still at home?  No, he’s serving a mission for our church in Florida.  Well, I replied, that’s what I did many years ago in Brazil.  

She had come to the office after experiencing some abnormal bleeding for about 9 months; I assumed hormonal imbalance, but to exclude the much less likely uterine cancer recommended a routine endometrial (uterine) biopsy.  But the exam expectedly suggested cervical cancer. She’s not had a Pap smear in 10 years--no insurance. Regular Pap smears would have picked up an earlier and easily treatable “pre-cancer.”

Two days later I have the results: cervical cancer confirmed. I don’t normally have patients return for just a discussion of results ($20+ copay and a half day missing work just to be told, “everything is normal”).  So I call her with the news; silence then some crying as I explain and try to reassure.

So whenever an anti-Obamacare guy starts complaining about the surfer who expects free health care for his chronic ear infection, I’d like to direct the conversation back to Yolanda and her missed Pap smears.

176. Decision-Maker

Several years ago Myra delivered a healthy 7 pound girl; a couple of days ago she presented at one week after her due date with spontaneous rupture of membranes.  Labor progressed slowly, augmented by the contraction-stimulating hormone oxytocin (Pitocin).  Fetal heart monitoring was abnormal with several episodes of bradycardia (heart rate less than 110 for more than three minutes). Bradycardia prevents inhibits normal delivery of oxygen to vital organs.

Each episode resolved spontaneously, but the concern remained that the next bradycardia might persist, causing permanent damage.  Severe bradycardia (less than 60) cannot be tolerated for long; even a fetal heart of 100 or so can result in fetal harm if continues more than 30 minutes. So we faced the decision whether to interrupt labor by performing a cesarean delivery.

We hesitated because between the bradycardia episodes the heart monitoring was reassuring (no subtle signs of fetal distress) and because labor was progressing. We became hopeful when she made it to complete dilation but the first push triggered another bradycardia. At about 8 minutes into this episode, we recommended and Myra accepted cesarean delivery.  The baby was vigorous at birth, with no explanation for the bradycardia. 

Based on the exam (the baby’s heady was well descended into the birth canal), and her prior delivery (proving an adequate birth canal), I estimated that a vaginal delivery was only 10-20 minutes away. If she had requested a continued trial of labor, I would not have objected.  But she didn’t. It’s a joint decision--in the current parlance, “shared decision-making," and that 10-20 minutes could be devastating.

175. No Doc Call

Amy’s new partner not only donated sperm but also herpes virus, which became manifest when she entered labor, requiring a cesarean delivery (by a covering doctor she’d never met) to protect the newborn--neonatal herpetic encephalitis can be devastating if not deadly.  Too bad after 6 prior vaginal births.  But that was just the start of her problems.

First, postpartum hemorrhage, requiring a return to OR to control bleeding. Six units of blood transfused.  Then a blood clot in her ovarian vein, extending into the inferior vena cava. Hospitalized 10 days for anti-coagulation (blood thinners).  Sent home still bleeding.  Returned in two days when bleeding increased.

This is where I come in.  The same doctor who delivered her is again covering for her doctor, but she refuses to see him, so the ER calls me as the doc assigned to see patients without local doctors (aka community call, aka “no doc” call).  

She receives another two units of blood and responds to “uterotonics” (drugs that make the uterus contract; her overused uterus just can’t do the job on its own), meaning we don’t have to take her off the blood thinners, which would be a risky venture. Nor does she have to return to the OR for a hysterectomy, another risky option.

And yes, she did get a tubal ligation at the cesarean delivery.