185. OPS

78 year old Mildred presented with an abnormal vaginal discharge. Premenopausal vaginal glands are active,yielding a white mucoid discharge, but after the menopause these glands become less active, so the normal would be a scant discharge or none at all. The malodor bothered Mildred the most.  The exam was normal as were the lab evaluation of obtained samples.

When I advised her of these results by email, she replied:

"Thank you for the follow up. I guess I will continue to be a water waster and enjoy lots of showers and baths. I wish there was something else to do. I've been comfortable with my body most of my life. This whole adventure has been miserable, embarrassing and depressing."

Although science appears to support an "old people smell," this is unlikely to be what's happening here.  After all, OPS exists in the nose of the beholder, not the beholden.

184. Ivan the Terrible

I meet 40 year old Mariya for the first time just a week before her scheduled repeat cesarean (she's has three prior cesarean deliveries, a number that puts her at risk for significant intraoperative complications).  

I note that there have been previous discussions regarding a tubal ligation, but as I try to confirm that, it is clear that Mariya wants a tubal ligation but her husband Anatoly does not. We've doing okay up to now he says, a generous use of "we." I suggest that a final decision can be made the day of surgery.

Delivery date arrives, no tubal ligation he says.  She's silent.  Surgery went well but post-op there's another difference of opinion.  He wants to name the newborn Peter, but Mariya and her 17 year old daughter prefer Luke.   

When I see her the next morning, Anatoly tells me, I think we'll end up with Peter.

183. What Would Cicero Do?

Understandably, my exam room explanations have undergone countless iterations and though perhaps smooth, may sound a little too polished, too rote.

For example, today 66 year old Sandra expresses concern about painful intercourse, and I explain that this is common due to menopausal changes: decreased estrogen leaves the vaginal surface dry, irritable, and less flexible.  I start to encourage her to consider a vaginal estrogen preparation, when she starts to interrupt me, but I won't let her, my prepared speech is too near it's conclusion to allow distractions, and concludes with the observation that the estrogen has no systemic side effects because it doesn't enter the circulation 

When I finish she resumes her objection.  It seems that a few years ago she tried a vaginal estrogen and within a few hours experienced breast tenderness, a clear indication of systemic absorption.  Furthermore her mother died of breast cancer, increasing her wariness about any form of estrogen.

I quickly backtrack, learning again that my primary role is not to provide fluent, persuasive explanations, but to listen, to guide the discussion with questions such as, is there a family history of beast or cancer, or have you used any hormone preparations in the past?

182. Pardon me for asking

Randy has scheduled a vasectomy 3 days before his wife's scheduled cesarean delivery.  When a prior provider suggested that the time may be not be optimal, Randy, a trial lawyer, said he had a six week trial starting in January and just couldn't take time off.

But I'll have to give him credit: in the same setting, most dudes would tell their wives, you're having surgery anyway, you do it.  Which attitude aside, does have it's point, a cesarean tubal ligation has fewer complications than a vasectomy, and does not make the cesarean recovery any more difficult.

181. Proactive

52 year old Lisa, on the other hand, has decided to learn from history, so as not to repeat it, as they say. During a recent exam, I thought I felt an abdominal mass, until I realized I was just feeling her abs.  I noted my observations and she said, yeah, I do core exercises all the time.  My mother had ovarian cancer, and she broke her hips just getting out of her chair. She just sat in the chair all the time. Go Lisa.

180. Fate

Theresa is 38 years old, never pregnant and not sexually active.  She is overweight, hypertensive, and pre-diabetic, without much evidence from the clinical records of much progress in managing these issues, but she did come in for cervical cancer screening ("Pap smear"), which was abnormal, prompting an office procedure called colposcopy--that's where I come in.

Pap smears screen; colposcopies confirm. 

The colposcopy begins with application of acetic acid (aka vinegar), which causes proteins to denature/precipitate, forming small particles that reflect light straight back to its source instead of scattering the light.  The examiner thus sees white, which is biopsied (a small--about 1/16th inch--sample is removed for microscopic evaluation). This contains more cells than the brushings of a Pap smear.  More cells = more information = more accurate diagnosis.

Theresa's biopsy showed cancer, early enough for successful treatment--she will do well. I was struck by her attitude with the news; as if she totally expected cancer; just one more health problem that fate has decreed for her.

179. Please, Mommy?

When I came on call Friday I looked at my schedule and saw a D&C (dilation and curettage) added to my schedule for 1:30, a miscarriage.  I looked up the chart and saw that Emilia also underwent D&Cs for miscarriages in 2013 and 2011.  

All told she has experienced 6 miscarriages and one life birth. The most recent miscarriages may be related to her age, 42, but there may be some other factors to explain so many.

She tells me that she didn't really want to try another pregnancy, but her daughter keeps pleading for a brother or sister. But this is it, she tells me, not again. I want to believe her.

178. Dead Poets Society

28 year old Samantha is about two thirds the way through her first pregnancy.  I always ask about work issues that may impact antepartum care; she told me she loves her job as a high school language arts/creative writing teacher, a career she attributes to an inspirational high school teacher.  

We also talk about two other issues noted on her problem list. She has had problems with "substance abuse" in the past, but is not shy to tell me that she will be two years sober in October.

And there is a history of depression, a subject which when raised brings tears and a choked admission that, "I'm having a real hard time with Robin William's death."  She's not alone.

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. 

174. Primum Non Nocere, Part Two

Well, we made it to Singapore.  By arrival, his blood pressure had decreased slightly, to about 219/118, and his oxygen saturation level remained at 100%.

A medical team was waiting for us, but initially couldn't even make it up the aisle because the minute the plane stopped, passengers filled the aisle, pulling down suitcases, ignoring the flight attendant's timid request to remain seated.  So I stood up and very loudly (but not to the yelling state) said, "Everyone please sit down to make room for the medical team. This is a medical emergency."  That did the trick.

The medical team had three people, with a stretcher and a medical bag. A young man in an impressively neat, tailored white shirt and tie, presumably the equivalent of a paramedic, was clearly in charge.  I told him what I knew, and he proceeded with an initial assessment of heart and lungs then quickly inserted an IV (just like in the movies). 

Then he opened up the defibrillator kit (which can provide an electric shock to convert arrhythmic heart patterns to normal rhythms, arrhythmia a common consequence and/or cause of cardiac arrest).  But wait: he has a normal pulse, is breathing regularly, and is fully oxygenated (so clearly the heart and lungs are doing their jobs).  So why the defib? The defib routine begins with electrodes that are placed on the chest to provide an analysis of the heart's rhythm. Though skeptical of the need for this (why delay the transport?), I grant that uncommonly an arrhythmia might be present but undetected by a stethoscope exam (not that he asked for my opinion).

If the defib machine were to pick up an arrhythmia, it would verbally prompt the medical attendant to push a button to administer a shock.  In this case, with a normal heart rhythm demonstrated, the verbal prompt instead said, "begin chest compressions." Having just confirmed a normal heart beat, why would the machine's algorithm do that? Anyway, the paramedic knew more than the machine--that the patient's oxygen levels were normal. But he followed the machine's instructions and started chest compressions. Chest compressions are not harmless since ribs can be broken, and of course the continued delay.

Fortunately, he soon gave up on this and the patient was put on a stretcher and taken to a hospital, where he probably received a head MRI--when I later talked to an ER doc in my clinic, asking what he would have done, he just said, a head MRI, as soon as possible.

I headed for the terminal, wondering, as is my nature, if I could have done anything different.

173. Primum Non Nocere, Part One

First work, then play, right? Maybe not. 

We thought play as we left Bagio for Bali, flying over the South China Sea, with anticipation of tropical waterfalls and coral reef snorkeling, when the an overhead announcement asked if there were any medical personnel on board. Though not eager to volunteer--unless of course a baby has decided that time's up--I did catch the eye of an attendant.  A Filipino nurse also raised her hand. No one else.

An elderly Filipino man had become unconscious.  I noted normal respirations and a strong, steady pulse in the 80's.  Family members thought he took medicine for high blood pressure, but did not think he was diabetic.  He was already being given oxygen through nasal tubes.  The plane's medical kit produced a pulse oximeter which attaches to a finger and measures oxygen levels (anything over 90% is okay).  His level was 100%. 

We also found a wrist blood pressure cuff: 220/119, suggesting an hypertensive crisis which could cause a rupture of cerebral blood vessels, aka hemorrhagic stroke, leading to unconsciousness. Concerned about the accuracy of the blood pressure, I measured my own: 140/90, more than my usual, but considering the stress of the moment, it seemed to confirm the accuracy of the device.  I remeasured his BP: 228/122.  A normal variation or an accelerating, possibly deadly hypertensive crisis?


Other common causes of unconsciousness: drug overdose, seizure, cardiac arrest, and either hyper- or hypoglycemia.  Hyperglycemia from uncontrolled diabetes, hypoglycemia from accidental insulin overdose.  The history, setting, and elevated BP all point to stroke. 

The nurse knew how to use the glucometer also found in the medical kit; it showed a normal blood sugar level. I didn't really think he had blood sugar issues, either extreme value would not likely be associated with increased BP.

The kit also contained a number of medications, including some that could be used for hypertension; many with unfamiliar (non-American) names, but I did recognized one: nifedipine, occasionally used for gestational hypertension.  He can't swallow and I didn't have the resources to monitor intravenous medications, but nifedipine can be given sublingually

We were 90 minutes from the nearest airport: Singapore, which was the destination of the flight. Attempts were being made to contact an ER in Singapore, but no immediate response.

Should I give him an hypertensive agent, possibly preventing further stroke damage, but risking a sudden drop in BP which could lead to cardiac and cerebral ischemia as the body becomes unable to deliver oxygen to vital organs?  

First do no harm.

172. Final Baguio Post

Most fibroids grow within the wall of the uterus.
This "pedunculated" fibroid grew from the top,
 attached to the uterus by a narrow stalk

The dense, gnarled nature of a fibroid
appreciated when it is bisected.

That's the cervix underneath the bulky uterus fundus,
which had to be removed first to gain access to the cervix

Inside, it looks like multiple, not a single, fibroids

Again, multiple fibroids, this time apparent from the outside

That's just $13.50 per day for hospital room, but a hospital and doctor costs for a hysterectomy would add up to P60,000, or over $1300, we were told.  That's over $30,000 of gynecologic surgical care.
Assume an equal amount or more for the general surgeons and $2500 expenses for each of the 25 volunteers.
The result: an investment of $60,000+ for $60,000+ medical care plus some teaching along the way.
All in all, a pretty good return on that investment

171. Baguio Stats

9 -Day of Surgery:

large fibroid uterus

Twenty-four major gynecologic procedures.

• 10 abdominal hyst (8 fibroids, one unanticipated cancer, one ovarian cyst)

• 11 vaginal hyst (8 prolapse, two fibroid, and one hyperplasia with atypia (“pre- cancer”)
• and three exploratory surgeries, one for the removal of just the fibroid and one for a suspected cyst.

And two minor procedures, both tubal ligations (one open, one laparoscopic)

Multiple fibroids totally distort anatomy

It would take me about a year at home to do as many hysterectomies; more than double what I’ve done on any other mission.

The two general surgeons had a few more cases (one only could stay a week), mostly gall bladder, hernias with a few thyroidectomies and one breast lumpectomy.

170. Baguio Day 10: Wipeout

On day ten we started the first case shortly after the start of the Superbowl, time zones and international datelines being what they are.  Four team members live in the Puget Sound area, ranging from lukewarm to energetic Seahawks supporters.  One of the latter tried and failed to find online Superbowl streaming, but did manage to pick up running commentaries.  He kept the operating room staff informed by periodically appearing in the glass OR door with an updated score.  

169. Baguio Days 6, 7, 8, 10: Ovarian "Accidents"

Ovaries produce and secrete (release) hormones and fluids that help prepare an immature ovum (egg cell) for its big meeting with Mr Sperm;  the same hormones have systemic effects as well, including but not limited to skin, joints, gastrointestinal, central nervous system.  Most of these secretions take place within the monthly ovulatory (aka follicular) cyst. But there are also abnormal cysts, what we used to call ovarian accidents.

Sometimes the ovary thinks it can reproduce without the help of a sperm, resulting in a dermoid cyst, which does grow and differentiate—mainly into nerve, cartilage, hair, and fat cells. But that’s about it; no virgin birth here. These cysts can become quite large and can rupture (very painful as the contents irritate the lining of the abdominal cavity), twist (also painful), or mask cancer.  So totally worthy of surgical excision.

endometrioma on left with swollen left fallopian tube;
uterus is normal as is the opposite ovary and tube.

Less dramatic are the cysts that just secrete fluids, such as Remerlita’s, or the almost as large cyst of 31 year old Ailyn.  Though suspicious for malignancy because of nodules on the lining of the cyst, her age, and normal screening blood tests suggested otherwise, so we proceeded with removal without assistance of a gynecologic  oncologist.  Lolita’s “ovarian accident” was an endometrioma, where cells from the uterine lining migrate from the uterus and form an ovarian cyst.  These "endometrioma" cysts are vascular and bleed, forming blood-filled cysts. 

Then came an ER consult: 33 yr old Emma with acute pain and an ultrasound showing an ovarian cyst, possible torsion (twisting, which would explain the sudden onset of pain), and also a fibroid.  She wanted to maintain fertility so our goal was to remove the cyst and the fibroid.  As soon as we entered the abdominal cavity we encountered adhesions between the uterus and bowels.  These were carefully dissected, separating the two organs.  Then a relatively simple removal of an anterior fibroid (about 2 x 3 inches).

But no cyst and no visible ovaries (obscured by adhesions which were left in place; the risk of removing greater than any benefit.  Best explanation: the ultrasound mistook an immobile segment of bowel for a cyst. The usually constant moving bowels are easy to differentiate from immobile ovarian cysts, but when part of the bowel  is stuck to the uterus, it can look like a cyst.

168. Baguio Day 6: Pain

In America, post-op hysterectomy patients are started on intravenous narcotics from just about the minute they reach the recovery room, the goal being to “stay ahead” of the pain. Narcotics are difficult to purchase, manage, and distribute on these missions. So most patients just received an acetaminophen suppository at the end of the surgery, then 1000mg acetominophen (two extra-strength Tylenol) and 400mg ibuprofen (two Advil) every 6 hours.  In Cambodia we added ice packs, but in the temperate climate of 5000ft Baguio, I didn't seen that approach.

Most postop patients cope well.  Except for Olivia, who couldn’t tolerate even the brush of a finger on her abdomen.  So she got some Vicodin, a moderate narcotic that I brought and was much appreciated. Out of 26 patients just 4 (two of whom had ibuprofen allergies) needed narcotics, each receiving 4-8 Vicodin tablets.

No privacy on an open ward, with beds only 12-18 inches apart, but observing others manage postop issues may benefit all.

167. Baguio Day 5: There's a Cyst in Your Bucket

Being prepped for abdominal surgery, Remerlita looks like she’s about to undergo a cesarean, but at 51 that seems unlikely, and in fact, she’s never been pregnant. She has a huge ovarian cyst that we were able to remove without rupture, important since if it were cancer, such rupture within the abdominal cavity could spead the cancer.  Too big for any specimen container, this 6 x 9 inch cyst had to be carried out in a utility bucket.  By pre-op testing, probably not malignant, final path report pending, won’t be available before we leave

 

166. Baguio Day 4: TVH

top: me, flanked by residents; bottom: student nurses 

Nancy, 48, was scheduled for an abdominal hysterectomy (TAH) because of a fibroid that had prolapsed (think “deli vered”) though the cer vix and into the vagina, still attached to the uterine lining by a half-inch diameter stalk.  With four vaginal deliveries and an otherwise normal uterus, I rescheduled her for a vaginal hysterectomy (TVH).

This is a teaching hospital, student nurses everywhere, and 12 ob-gyn residents--all women; the last male was 2 years ago. When I asked why there are no male residents and answer was predictable: “women want women for their doctors.”  So I’m working with 3^rd and 4^th year residents, who are quite competent with TAH, but have little experience with a vaginal approach.  One told me that the preop diagnosis of a fibroid automatically excludes a TVH. Most of them have assisted a couple but never performed a TVH.

So while I may be demonstrating just alternative techniques or short-cuts TAH, with Nancy the residents are learning a new procedure.  Is one experience enough to make for a long-term learning experience?  I’ve adopted new techniques from single observations (I’m taking home a few things I picked up here); I trust they can also.

165. Baguio Day 3: Thirty Thousand Pesos

49 year old Virginia presented to an outlying clinic with an abdominal mass that she had first noted about three months ago. A local ultrasound showed an enlarged uterus due to a 6-7cm fibroid and she was referred to Baguio General Hospital, and scheduled as my first patient. Had we not been here, she still would have had surgery, but perhaps weeks or months later.

After securing the upper uterine blood supply I decided to cut into the uterus to remove the bulky fibroid from the uterus, the better to see surrounding anatomy. But it was cancer we found, not a benign fibroid.  Endometrial cancer starts at the inner endometrial lining and then invades the uterine wall, eventually encountering blood vessels, which allows spread anywhere, and then through the surface of the uterus (as with the Riobamba patient in previous post). This tumor had not yet broken through, though so close that metastasis is presumed and chemotherapy recommended.

Our free care stops once she leaves the hospital; if she cannot she come up with the 30,000 pesos ($650) needed for minimal chemotherapy, her prognosis is dismal.

164. Baguio Day 2: Go-Med

Magandang Umaga.

One of my call day routines takes me to recycling bins on L&D, and occasionally the main OR.  Once a sterile pack has been opened, the contents can no longer be used, even if not contaminated,the hospital figuring that it is cheaper to buy new than to re-pack and re-sterilize. But these supplies are not trashed, instead they are saved for overseas missions.

Last October I stopped by the OR on a Saturday morning, and seeing me, someone asked, hey Dr H. do you have [an emergency] case for us? No I said, just looking for supplies to take overseas.  Hearing this, RN S.M. said, do you want to go to the Philippines? When? Late January. Sure, I said. And here I am, a member of the Go-Med surgical team to Baguio City, Philippines.

Arrived Manilla Saturday, then 6 hr drive to Baguio City, over 300,000 at 5,000 ft, spread over several mountain ridges; today, Sunday interviewed and examined pre-op patients for Monday.

note: all patients gave explicit, written consent to be photographed before, during and after surgery.

163. Victory!

Remember Ronda, from a month ago (post #161)--gestational diabetic, nutritional contrarian?  She was admitted to the hospital a few days ago for a medical tune-up, her blood pressure and blood glucose levels both needing attention.  Well, at some point she pointed out to a nurse that she was drinking a diet soda, even though it "doesn't taste very good," because "some doctor told me to."

Okay, so I didn't get personal credit; it still counts.

162. Grumpy

From 59-yr old Teresa, when asked the usual screening questions about depression and safety at home: "I feel safe at home and I don't feel in any danger.  I know that he's not in good health, and he's just getting grumpier and becoming more stubborn as he gets older."

Old age?  His depression perhaps secondary to illness? Early Alzheimer's?  Or perhaps not a change at all, but rather the continued manifestation of a lifelong personality disorder that Teresa is just tired of putting up with.

161. Faaast Food

At over 6ft, Ronda carries her 240 pounds reasonably well, but still not surprising that in this fourth pregnancy, she screens positive for diabetes.  Her other pregnancies have gone well, so she finds it hard to get serious about this.  Not well controlled on a moderate dose of insulin, I ask her to keep a diet diary--everything she eats over three days.

She must have found a smart phone ap because she brings in a computer print-out, initially impressive though short on details (more of what she ate than how much):

1. Fast food ("I don't have time, I work, I take care of my family, I get up at 4 to drive my boyfriend to work.").  Okay, grant a hectic schedule. leaving  little time for food preparation.

2. No fruits or vegetables ("I don't like salads; maybe broccoli with cheese; or if I have my thousand island dressing").


3. Sugar soda ("I hate diet drinks--all of them").

Any suggestion I made was immediately countered--she's been through this discussion before.  Best I could do was an agreement to mix regular with diet soda, slowly increasing the ratio of diet to regular.

160. Cancer Phobia

A few months ago Helen's mother passed away from ovarian cancer; several years ago the mother had undergone surgery for breast cancer.  Most breast cancer is not hereditary, but the BRCA1 and BRCA2 mutations dramatically increase the risk of breast cancer, hence Angelina Jolee's decision to undergo bilateral mastectomy.  That Helen's mother tested negative for BRCA1/2 provided little reassurance: "There's breast cancer in my father's family as well."

So she wants to "take it all out," meaning removal of uterus, ovaries, and fallopian tubes.  Our offer to frequently screen with ultrasounds and not-that-accurate blood tests.  For now she's satisfied with waiting for the BRCA1/2 testing that her family practice doctor agreed to order (pending approval by a genetic counselor or will talk with her in a few weeks).

Even if this test is negative, I expect Helen to return with her request.  I don't think I could justify a hysterectomy, or even the safer laparoscopic removal of ovaries.  But first there needs to be more time between her mother's death and a final decision about surgery.

159. To BF or not to BF, that is the Question.

Breastfeeding--either directly or by pumping ("induced lactation")--has a list of benefits that grow with every review.  Breast milk components change as the baby's nutritional needs evolve; it contains antibodies that enhance the newborn immune system. It's easier to digest, and breast-fed babies are less likely to develop asthma and diabetes, or become obese.  And they have a decreased risk of Sudden Infant Death Syndrome.

But some babies just do better with a bottle, and filling a bottle with pumped milk is easier said than done for some women. Forget the psychological second-guessing; formula just works better for both Mom and baby
.

Kelly tried nursing, then the pump, but now just wants to formula feed. She denies depression, but feels stressed out by the pressure exerted by her family who want her to continue pumping. Do these people not know what it means to support a new mom? The difference between encouragement and badgering? Apparently not.

158. Stream of Consciousness

40-something Cynthia came in to talk about pelvic pain, but the usual questions about pain (exactly where, what triggers, how long, how disruptive) were soon sidelined by the following:

I'm unemployed... I just found out he's addicted to pain killers... I'm impatient with my daughter... He's kind of abusive... I don't want to go to hell.

157. Update on Helena: a tough call.

Looked good for a few days, with baby now head first, mom could look forward to a vaginal delivery (she has enough problems without having to recover from an operation).  But the baby turned around, and the doctor on call that day was concerned that another "external cephalic version" (the process of apply gentle pressure on the abdomen to turn the baby) could disrupt some uterine-placental vessels, allowing mom's HIV to transfer to the baby.  Helena's viral load (the technical term for the amount of HIV in her blood) was very low, her HIV well controlled by medications.  Low but not zero, so the doc's concern was justified.  So he recommended and performed a cesarean.  A tough call.

156. Tour de France

What do you think when you see a cyclist, football player or other athlete with an oxygen mask (not illegal since oxygen is natural, though some may object that 21% atmospheric oxygen is natural but 100% tank oxygen is not natural)?  The more the better, right?

Well, that's what neonatologists thought a few decades ago who gave premature babies continuous 100% oxygen. It turns out though, that high oxygen levels stimulate blood vessel formation--normally a good thing, but not in the retina, which such proliferation can cause blindness.

Enter Helena, who was born premature 34 years ago, given 100% oxygen and blood transfusions as well (premature babies are often severely anemic).  Fast forward: Helena is blind, HIV positive, and pregnant.  Oh, and as another consequence of prematurity, her cerebrospinal fluid doesn't circulate so she has a plastic shunt draining excess fluid away from her brain into the regular vascular system.  A couple of hours hard pushing could disrupt the shunt.  And did I mention she's breech?

Well, the baby was turned by one of my colleagues, and we are now waiting for spontaneous labor.

155. Mary Jane

58 year old Margaret has lost 25 pounds in the past 4 months.  Just don't have an appetite she explains, I prepare meals for my husband and start to eat, but then feel nauseated and can't continue.  She never vomits and has no history of recent trauma or depression, though today she appears depression (but of course what part is antecedent depression, or depression from uncertainty about her weight loss, or simply weakness from malnutrition?)

In the midst of an extensive work-up for this, I was consulted because of an incidental finding on an abdominal CT--the uterus looked a little funny.  The  uterus was fine, I decided, so my services were no longer needed.

But I thought I'd throw in my two bits: for example, protein shakes, sipped every hour or so throughout the day, with no expectations of sitting down and eating a full meal.  I thought about, but decided against discussing marijuana, known for it's anti-nausea effects for patients with chronic illnesses such as AIDs or cancer or who are undergoing chemotherapy.  

Her evaluation needs to be completed first, and then such a suggestion should come from her primary care team who knows her best and has her trust and confidence.  Still, though, what if no one else suggests what could be a significant, even life-changing treatment?

154. Time to Move On

The recent quarterly report of actions taken by the state medical license commission noted the license revocation for a doctor under whose care a mother and her twin babies all died from complications of preeclampsia (the same condition that led to the death of Lady Whatshername in Downton Abbey).  License numbers are issued sequentially so seeing that his license number is lower than mine, I can assume that his license was first issued well before 1982 when I first became licensed in this state.

Cut to the chase: did his age (60 or more) contribute to the mistakes he made in not preventing this tragedy, or did he just not know what to do (seems unlikely, this not being a rare condition) or was it unavoidable?  The commission did not go into details but clearly thought it was time for him to move on.

At a recent meeting, a 64 yr old colleague expressed uncertainty with a chart note, "patient needs TOC for CT."  Everyone else in the room knew that it meant Test Of Cure for Chlamdyia Trachomatis, i.e., the patient needs a follow-up test to see if her chlamydia infection was adequately treated.  I think this guy focussed on "CT" as in the xray procedure computerized tomography and was trying to figure out why someone need to be retested for an xray.

Does this cognitive inflexibility suggest an aging process, or just an off moment?  When I forget a scheduled meeting, I think, is this early dementia? When a younger colleague doesn't show, we say, oh that's just Bob again.

How do I know when it will be time to stop working, time to move on?  Hopefully before I tell a woman carrying twins, oh, your blood pressure's a little high, rest more and see me back in a week.

153. Breech

Worried about an after-coming entrapped head, we generally don't recommend breech (butt or feet first) deliveries. The head can be the biggest part of the newborn, and if it gets stuck with legs and trunk already outside, the results can be catastrophic.

Sandy is near term with breech presentation, being seen by a lay midwife (which means a home or other non-hospital delivery).  The latter recommended that she see us to discuss possible version (trying to turn the baby around before labor) and/or a CS.  

She failed to answer our attempts to call to make an appointment, and when I called the midwife to find out her current status, was informed that Sandy now may be seeing an unlicensed lay midwife known to attempt home breech deliveries.  The new lay midwife once had a license, but it was withdrawn after a couple of deliveries with negative outcomes and serious questions about her ability to provide appropriate care.

152. Floodgates

Early in his career, one my colleagues remembers greeting with mother-in-law with the standard, Hello, how are doing,"  expecting a return, fine, and how are you?

Instead, she replied, "the floodgates have opened," leaving him a little confused.  He later realized--perhaps with the help of his wife, that she was referring to the onset of a heavy period.

Like most phenomenon, menses follows a bell curve.  So though most women may describe a 4-5 day flow, a small group may experience 2 days of light bleeding, and an equal group on the other end of the curve may have 7 days of heavy flow, enough sometimes to keep them home for a day or so.

Lindsay has been bleeding for three weeks, never like this before and with no apparent reason.  She has lost about half of her blood supply. As a healthy 23 year old, she is able to tolerate this loss to a degree.  She can walk around but has a strong headache and could not deal with her job where she stands most of the day

If the bleeding stops and she tolerates iron supplements, her level could be back to normal within a couple of weeks.  But she has been offered a blood transfusion because another few days of heavy bleeding could lead to a life-threatening level. That would allow her to return to work. A temp worker now, she wants a full-time position and is worried that taking time off now (which she would have to do for a several days if she does not received a transfusion) would jeopardize this advancement. She says yes to a transfusion.

So we stopped the bleeding with intravenous estrogen and gave her two units pints of blood. The average adult has 10-12 pints of blood, so while two units will not put her pack to normal, it will take her out of the danger zone.

151. Judge Not

Cathy has been pregnant nine times: one child and 7 abortions.  Today she is in tears because she is pregnant again and an early ultrasound showed a small fibroid which she misinterpreted as meaning an inevitable miscarriage.  She really wants a second child.

150. Sticks and Stones

At 19, Ericka did not plan this pregnancy with her live-in, unemployed boyfriend, but she says she is okay with it.  At least until she became ill at six weeks (just a month after conception), with nausea, vomiting, diarrhea, and abdominal pain.  A little early for morning sickness, perhaps just a prolonged viral gastroenteritis ("stomach flu"). Or a combination of the two.

I met her for the first time this morning, her 4th day in the hospital.  Talking with a couple of the nurses, it appears that she has not had any visitors during these four days. With a couple of intravenous anti-emetics (she refuses to take pills), she was able to eat for the first time this morning. She wanted a burrito but a nurse limited her to some applesauce and similar soft foods.  A few hours later, she was throwing up again.  

I need to talk with her, but she hides her face in the pillow and complains about the light when I open the door to her room.  I don't want to talk, she says, I just want to sleep.  I tell her that I need to have a serious discussion about other treatments. Because she talks so softly, I bend on my knees (no chair available) to get close enough to hear her responses.

"You're creepy, staring at me like that." 

Accepting my dismissal, I told her I'd be back in a few hours when she might be feeling better.  As I left I could hear dry heaving in the background.

149. Insurance

Usually when we consider the non-insured, the non- or under-employed come to mind.  But not always.

At 37, Trish and her husband have no insurance for delivery and only high-deductable for non-pregnancy care. She is an attorney and her husband a family practice doctor.  If they were employed by a large system, say a hospital or a large legal firm, they'd have insurance, but as solo providers, they have opted for a high-deductable individual plan.  

Anything else would be very expensive even for this double-employed couple.  Remember that not all lawyers are millionaires and family doctors are at the low end of doctors income scales.

"She is very concerned about the cost of everything," notes the midwife she sees, explaining why she is having blood drawn at her husband's office.  She will not ask for extra (but not necessarily indicated) ultrasounds and she's hoping for a less expensie vaginal delivery (first child was cesarean).  

We feel uncomfortable with patients or doctors making decisions based on financial reasons, but maybe that's the only way to control medical costs.

148. Mother and Child

At 79, Ellen has a prolapsed bladder (see post 107).  Won't shorten her life, but uncomfortable, irritating her bladder, preventing normal activity.

There is a surgical fix and a pessary, the latter a silicone ring placed in the vagina, acting as a dam holding back the bladder and/or uterus.

Size is important.  A pessary too small falls out; too big and it becomes more uncomfortable than the prolapse.  Sometimes we just can't find the right size and turn to surgery.  And so it is with Ellen.

We plan surgery, and in the course of discussing postop care, I told her that for a month or so, she will have to avoid heavy lifting.  That may be difficult she replied. My 60 yr old son lives with me; he has mental problems and sometimes puts the recycling in the regular can and the other way around, so I have to go and make it right, which means bending and lifting

147. Momentum

In the final month of her pregnancy, 26-yr old Dolly experienced a "loss of vision" while driving. She managed to pull over and call the consulting nurse who told her to go to the urgent care clinic (instead of labor and delivery?). Urgent care called me, noting normal vision and normal blood pressure (one of the complications of the auto-immune disease involves hypertension). Send to L&D, I recommended, which they did.

I opened her chart: 4 prior pregnancies, all uncomplicated, moderate anemia (low blood count), and a recent diagnosis of an auto-immune disease, based on lab tests but not on actual symptoms.  Symptomatic auto-immune conditions increase risks of pregnancy complications.

L&D called me in my office, said the baby looked fine, normal blood pressure; OK, I’ll be there in about 15 minutes. Five minutes later, I got a call saying we need you right away, the baby’s heart rate has dropped. I was there in ten and found Dolly in the OR being prepared for an emergency cesarean, a decision made by another obstetrician who had been consulted in my brief absence.  He thought there might be a placental abruption (premature separation of the placenta, which leaves the baby without oxygen).

The baby’s heart rate was 80-100.  Normal is 110 or above, with rates in the 90-110 range considered tolerable for the short-term.  So no immediate crisis.  I put a hold on the proceeding, waiting for her to receive a full liter of intravenous fluid, which can revive a compromised baby. Waiting with me in the OR were two neonatal intensive care nurses, the anesthesiologist, two labor and delivery nurses, the OR technician, and the midwife who assists me with cesarean deliveries.  And of course the patient, who is freaking out. With the baby’s heart remaining low, but not critical, I decided to proceed with operative delivery. Too many unknowns--the visual thing, the prior diagnoses, the uncertain meaning of the fetal heart rate--and of course the momentum of a process set in motion 10-15 minutes earlier.

A vigorous baby with no sign of placental abruption or other problem, but over the next hour was noted to have a resting heart rate of 90-110 instead of the expected newborn rate of 110+. Add hypoglycemia (the patient had not eaten for about 10 hours at the time of the surgery) and her even lower blood count (blood drawn at arrival to L&D but not available until after the surgery).

So a combination of hypoglycemia, low blood level, and the baby’s naturally but not abnormal low resting heart rate contributed to what seemed like an emergency.  An unnecessary cesarean?  Maybe, maybe not.  But given the uncertainty and the momentum, pretty much unavoidable.

146. Second Sleep

At the end of the visit, Tim nudged Svetlana.  Go ahead, he said, ask about it. Fatigue, she said, I'm tired all day.

Okay, good question.  Experts tell us that 35% of the US population sleep less than 7 hours per night, and that falling asleep at the wheel accounts for up to 20% of all traffic accidents.

So I ask, how many hours do you sleep at night. 

"5-6"

Tim works swing shift, getting home around midnight.  She stays up for him; they have a meal, the she sleeps from about 1-6am, getting up at 6 because, basically she's a morning person.

5 to 6 hours sleep per night is not enough.  Forget about this celebrity or that who thrives on 4 hours per night. Most of us need at least 7, probably would do better with 8.

It's okay to break up sleep, I said; sleep from 10 to midnight, or nap during the day.  Find what's best for you.  Before electricity many societies pracrticed a second sleep: going to bed with dark, then waking again for a few hours around midnight before returning to sleep.

145. Oh, Yeah

Svetlana and Tim came in to talk about infertility.  They have both had children from prior relationships; sexually active without contraception; she has regular menses suggesting ovulation; no history of pelvic infection that would block fallopian tubes. So far so good. Anything else, I ask?

Oh, yeah, Tim just had a vasectomy reversal.

What?

The average couple, with no health problems, takes about 7 months to conceive.  If seven is the average, then even a year or so of trying without conception does not imply an infertility problem. Umm, come back in a year, I suggest.

But not a wasted visit.  We talked about timing of intercourse.  Generally, a woman is fertile three days a month (since both sperm and egg are viable for about a day; do the math), so a worthwhile discussion.

Although there are various ways to determine ovulation, it's not exact. So assuming a 28-30 day cycle, I recommend that starting on day 10 of cycle (first day of bleeding is day #1), have sex every 2-3 days for 10 days. Every day would be depleting; four days of abstinence might miss the three day window.  Actually to keep it simple, I usually just say, every other day. At which point Svetlana winced.

144. Not in My Lifetime

At a conference the other day, an expert (he's written a book!!) on medical economics, was asked what he thought about the potential for a single-payer medical system for the United States.

His reply, "Not in my lifetime," appears on the surface a dramatic but safe prediction, though on further reflection might ought to be avoided especially given its association with predictions about integration, marriage equality, and the election of a black president. In general, one ought to be careful with predictions about health care.

The largest medical plan in the country (Medicare/Medicaid) is already single-payer.

The country most like us (Canada) is single-payer.

And one state (Vermont) has made major steps towards a single-payer plan.

Is this dude planning an early departure from the world?

143. Burnout

So... you're in a doctor's waiting room reading a handout introducing you to the practice, where the doctor went to medical school, his or her special interests, and finally the observation that the doctor has lost his/her enthusiasm for medicine, feeling cynical and unaccomplished. How would you feel? Like leaving and finding another doctor?

If your visit is in an ER, an ICU, or a family practice or ob/gyn office, chances are about 50/50 that your doctor would report at least one of these signs of burnout. These four specialties top the list; least likely to have burnout are pathologists and psychiatrists (though still over 30%).

We know the effects of burnout on the doctor: increased rates of suicide and divorce, for example, but what about the effects on the care that they provide? Worse because they just don't care enough to go the extra mile; or better because they are better able to empathize with patient who are experiencing similar feelings?

Many experts fear the former, as the American health care system is strained by increasing patient loads with Obamacare and the difficulty that medical schools face in replacing retiring physicians

142. Cybermedicine

"I didn't go to school until 30 to be a typist."

"I spend an extra hour every night because of EPIC."

"The only people who like electronic medical records are those who sell them."

Luddites notwithstanding, electronic records such as EPIC promote better care for a number of reasons. Hand written records are easy to lose or are unintelligible. Computer systems allow for data collection and alerts (if a provider attempts to prescribe a medicine to an elderly patient whose age places her at higher risk for side effects, the screen flashes, "Are you sure....?")

Yesterday: a patient has an X-ray, the radiologists dictates the report, which takes a few days to transcribe, and a few more days to make it to the patient chart.  

Today, the radiologist uses voice recognition software, so that by the time the patient has walked from the xray room into my exam room, I have already read the report.

the legend is fuzzy, but the states in dark blue (Hawaii, Washington, Oregon, Utah, etc), have a "significantly higher" use of electronic medical records; as for Florida, Louisiana, Kentucky--well, what can I say?