Archive for the ‘OBGYN dreamin’’ category

Response to Dr Val

June 10, 2009

I was reading Dr Val’s blog over at the Better Health Network. She has linked to an essay by a third year medical student discussing why she will perform abortions as a physician.

She voices her own opinion on the subject. I highly recommend going over and reading it yourself, I suspect I could not pick a quote that is a good summary, or summarize it myself without losing the nuance of her position.

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Cervical Cancer Alt-Med Tragedy (an anecdote)

June 9, 2009

In tragically ironic timing with the AP finally doing decent work on any alt-med, yesterday I saw another victim of alt-med.  Our patient was a woman with cervical cancer who opted against conventional therapies. She’s now paying the price.

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What Operation Rescue Doesn’t Understand About Abortion.

June 5, 2009

This is not a political blog. This is a medical, and sometimes a science blog. Mostly it’s a blog about combating willful ignorance. So as I write the rest of this post, set aside your party affiliation, your rhetoric, and just be a human being for a few minutes.

I’ve been pondering George Tiller’s murder over the past few days, it’s left a bitter taste in my mouth. Abortion is a complicated issue, everyone carries their own baggage of beliefs to the conversation.

 What is indisputable is that someone murdered George Tiller, for practicing medicine. Yet people are primarily discussing his death in terms of how it helps or hurts their movement. Worse, they caricature Tiller as a villain, and then characterize abortion as “Murder”.

The decision to abort is never a simple one. It’s even more complicated in the case of late term abortions. Characterizing a doctor who decides to do this procedure as a “murderer” is beyond ridiculous. It’s disingenuous. And like all things I discuss here, it’s all about ignorance.

 Lets have a little respect for a man whose job involved more difficult decisions, and more heart-breaking stories in a day than most of us have to make in a life time.

It’s never easy to make the decision to abort. This is especially true for late term abortions. How do I know?

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Bittersweet

May 10, 2009

Please note that some of the language in this piece is coarse. If you find that offensive, read my science posts instead.  We shall begin our story in media res.

“Is the heart still beating?” whispers Dr Sanders, my attending for today.

“Of course the heart’s still beating, what do you take me for, an intern?” Dr Rike snarks back quietly. We stand at the foot of a patient’s bed. We’re attempting a cephalocentesis, transabdominally. Using ultrasound Dr Rike placed the needle in a fluid filled space in the skull. We drain almost half a liter – a quarter of a big coke bottle. We’ve removed enough fluid for our patient to deliver her baby vaginally. That’s the only thing the patient wants. She doesn’t want a C-section, because she understands that this won’t help, and her religious convictions tell her that a vaginal birth is what she should do. Early in her pregnancy she didn’t want to terminate for the same reasons. Her fetus had severe holoprosencephaly, and won’t likely survive long after birth.

 She wants to at least, say hello to her baby. She also wants to say goodbye.
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Holoprosencephaly and Cephalocentesis: an Overview

May 10, 2009

ResearchBlogging.org
This is a very brief discussion of Holoprosencephaly, and a similarly brief discussion on cephalocentesis, and it’s role in OBGYN. Both holoprosencephaly and cephalocentesis could be considered disturbing, if your sensibilities are easily offended, don’t read this post.

 It’s hard to call Holoprosencephaly one defect. It’s a spectrum of congenital defects in midline structures of the brain and face. That means that it effects structures that form on the line you’d get if you split your body into left and right halves.

It can be caused by almost anything, sometimes it’s genetic, or chromosomal. It is often caused by Trisomy 13. It can be associated with environmental factors, material overdose on salicylates, maternal diabetes, infection with a specific virus (CMV) while in the womb.

What I found most suprising while reading about holoprosencephaly is how wide a spectrum we’re talking about. In it’s mildest form, holoprosencephaly can be just having one midline incisor, instead of 2, on either side of the midline. In it’s more severe forms, it is not compatible with life. Defects can include cyclopia (having one, midline eye), having no nose, having a tubelike structure called a proboscis instead of a  nose. More importantly, and devastatingly, it can have midline brain malformations, the most severe being called alobar holoprosencephaly – basically not having much brain over the brainstem. The brainstem is the part of the brain that controls many automatic functions – unconcious breathing is among those functions. Some of these patients develop hydrocephalus, and have increased skull size.

About 10 percent of patients will have severe brain malformations, without other defects. In this case the infant will have severe neurologic issues. Generally, they do not live long, even if they outwardly look normal.

With very severe holoprosencephaly, many children are stillborn. Those that are born often don’t live long. A day, a few days, a week would be long.

Cephalocentesis is a procedure used to drain fluid from the skull of a fetus with hydrocephalus. It is a very rarely done procedure. Chasen suggests that it should be offered to mothers when the expectation is that the child will be stillborn, or will not survive very long outside the womb, and a vaginal delivery could be attempted if the fetal skull was smaller. 

The procedure uses ultrasound guidance to put a needle in the uterus, much like amniocentesis. Instead of withdrawing amniotic fluid, the needle is further inserted, into the CSF space, to drain excess fluid. The idea is to make the skull small enough to allow a vaginal delivery. In doing so, the hope is to prevent the mother from having to undergo a C-section, which is significantly more dangerous to the mother. The procedure shouldn’t be used if the fetus could likely survive outside the womb long term – it’s considered a destructive procedure.

 I hope that this post answers a few of the medical questions related to my other post from tonight, Bittersweet. After reading either or both posts, please post any scientific questions in the comments of this post.

Chasen, S. (2001). The role of cephalocentesis in modern obstetrics American Journal of Obstetrics and Gynecology, 185(3), 734-736 DOI: 10.1067/mob.2001.117487

Olsen, C., Hughes, J., Youngblood, L., & Sharpe-Stimac, M. (1997). Epidemiology of holoprosencephaly and phenotypic characteristics of affected children: New York state, 1984–1989 American Journal of Medical Genetics, 73(2), 217-226 DOI: 10.1002/(SICI)1096-8628(19971212)73:23.0.CO;2-S

Later tonight

May 10, 2009

Those who have been following OBGYN dreamin’ will know that one of my goals this rotation was to deliver a baby. I did get a delivery, but it wasn’t exactly how I imagined. For myself, as much as for you guys, I’m blogging about it. If possible, it will go up later tonight – depending on how obsessive I get about trying to get it right before posting.

In an effort to focus better, I’m blogging about this in two posts. One will isolate the science, not of birth, but of a specific medical condition. The other will be my experience. By doing this I’m hoping to keep the science from interfering with the broader questions we’re interested in, and keep the broader questions from interfering with the science education.

As you read,  I’d like you to think about a some of the questions that we’ve been starting to talk about, and a few questions I’ve been wanting to talk about.  How and why do doctors act jaded? Are even major events like birth are “just another procedure” to those in the medical field? How does one cope with the responsbility of effectively having someones life in your hands? How do you balance giving people the best care with educating doctors and nurses for the future?

OBGYN: First Cuts

May 6, 2009

I’m two days into Labor and Delivery and haven’t had time to really process any of it. The thing about OBGYN is that it’s a surgical speciality. This is less than stellar for a couple of reasons. 

  • Early mornings: We round on our (more than 20) patients no later than 5:30, of course this means that I need to be there significantly earlier than 5:30 to spend more than 3 minutes with my patients, and not look like an idiot on rounds.
  • Late nights: We get out pretty late, and after I go home I still need to study.
  • I haven’t really had a ton of time to think, so my thoughts here aren’t particularly deep.
  • Unlike Orac I am not a surgeon. Anyone who has seen me in an operating room would never ever mistake me for a surgeon.
  • I’m very tall. Most OBGYN’s at my institution (35 of 40 residents) are female. Most of them are short. That means that I’m spending 3-8 hours a day killing my poor back, holding the bladder blade.
  • Did I mention holding the bladder blade? The bladder blade is the implement used to keep the bladder, and part of the body wall, out of the operating field. This allows the surgeon to perform the C-section. I’m told this makes me an important member of the surgical team…

On the other hand. This is the only service I’ve been on where people are so happy! I love that about this rotation. Sure the women are angry and screaming when they’re in labor, but that is to be expected. These are the only patients I’ve seen happy to be woken up at 5 in the morning and asked if they’ve passed gas yet. Don’t look at me funny! Flatus is very important to surgeons – you can’t go home til we know your gut works.

Heck, today I asked a patient that and they said “Nope, but look at the baby isn’t she cute?!”

You just don’t get that on surgical oncology, no one says “Nope but look at that tumor!”

On a completely different note, I still have not achieved my goal for the rotation. What’s my goal? Well I’m going into emergency medicine. I won’t do C-sections as an EM doctor. But I will occasionally have to deliver a baby. I really want to be ready to do that when the time comes. So my goal this rotation? Catch a baby. More officially, “deliver” a baby. I hope that you’ll all wish me luck in my quest to help bring a bundle of joy into the world.

Moving on to general meta-blogging.

I’m having a tough time focusing on specific blog posts right now so I’ve been simultaneously half working on far too many posts right now, including:

  • Last post on Swine Flu: One more research article on the subject, it’s really more on flu in general, to clear up alot of myths I’ve been hearing repeated.
  • Post on Jadedness in physicians: wherein I discuss apparent jadedness as a coping mechanism, among other things. It’s also kind of  a segue into a series of posts (in the very very long run) about the bad parts of medical training.
  • Parts 4 and 5 of HC:Vaccines and Autism. I can guarantee these won’t come before the weekend. The HC posts are really satisfying for me to write, but the research takes time, and I work hard to get the science right.
  • My first actual, thought out reactions on OBGYN, with some answers for the readers who took the time to comment on OBGYN dreamin’.
  • Two completely random posts that are more for me than all of you, but posts that hopefully some people will enjoy anyway.

Feel free to vote for which of those posts you want to come out first in the comments. No guarantees, but I’ll try to take into account what my readers actually want to read rather than my own randomness alone.