Birthdays remind me of childbirth; fascinating!

Childbirth is fascinating to me.

So on this day when two of my own children were born on the same day four years apart (and yes, the older one, my daughter, is still upset about sharing her birthday!) I sit with a cup of tea and think about something we all must go through one way or another......you were born, right?

I am not a particularly religious person, but when I do ultrasounds on those very early fetuses where the arm and leg buds are barely visible waving in the breeze, I wonder how something that starts out as only a glob of cells divides and grows and further divides and specializes into a complicated human being. A person, that at the end of one year after birth, can walk and talk and think and learn and explore and be a little people.  In my view, I imagine a force setting the wheels into motion, sitting back with their own cup of tea, and beaming with pride every time one of these little creatures comes out into the light.

Each of my own birth experiences was very different from each other as most are.
Ok, there are those people who get to schedule their own c-section, but most of us do not.

1) Seth was born when I was only 18 years old.  My mother couldn't understand why Ron   would want to be present for an event that is so private to the mother.  He was born in the day when we were still wheeled to the delivery suite without an epidural yelling at everyone that "I HAVE TO PUSH!!!"  And push I did; the blood went right up backward in my IV.  The day after, when I was holding him, I listened to another young mother sobbing in her room as she had made the decision to give her child up for adoption.  I have never regretted going against my mother's advice to me to do the same.

2)Danielle was the easiest delivery I had. Being a medical student at the time, I bugged my obstetrician with some of the craziest and most obscure questions that he had ever heard from a patient i.e. "I've been exposed to CMV sepsis in the ICU, is that bad for my baby?"
I'm sure he would have rather me asked about my swelling ankles.  For her labor, I used visualization to get me through, and even though labor pain sucks (see #3 below), she came quickly and smoothly.

3)CJ is the reason that you should never give birth after you have passed your specialty board exams.  His giant melon head became stuck in the wrong position, and after a horrible labor, yelling "I HAVE TO PUSH," begging for a cesarean, loud wailing, not letting my poor overwhelmed husband step out for a break, CJ responding with steeply dipping heart tones, a vacuum extractor buried to the hilt, and a broken umbilical cord he was born.

With everyone of these three deliveries, immediately I was beaming with pride.
I also can't help but beam with pride during virtually all of the many hundreds of deliveries I have been involved in as a physician as that wrinkled red (bald or hairy) head emerges into the light for the very first time.

Childbirth truly is fascinating!
Happy Birthday Danielle and CJ! 
Happy half Birthday Seth (born 7/16)!
I love you all!  

P.S.  See Aline beam  :)

Human Behavior and the Electronic Health Record

There has been a lot of jibber-jabbering going on at work in the past couple of weeks.  We are getting ready to go to a new electronic health record (note EHR) in January, and everyone is getting their panties into various stages of a wad over the whole thing. And for good reason.....change sucks!
It seems that this move to yet another computer program brings out the best and worst in human behavior.....

1) There is the cheerleader (and one of our fearless leaders) who has the job of telling us all how it is going to be and then spends lots of time jumping up and down in e-mails encouraging us and yelling "Go Team!!!"  as we all sit in our offices and grumble about how tough this is, threatening to throw spit wads at our computer screens.

2) There are those of us who are overwhelmed in our jobs, who have taken too much call in the past couple of weeks, who are seeing too many patients and trying desperately to negotiate the old EHR, who haven't been to the gym in over a week, who've been looking for extra help for two years, who are flatly replying to the cheerleader's e-mails;  "I have too much to do."

3) There is a large group of us who are forced to work 60-100 hours per week in a desperate attempt to cram our heads with all the medical knowledge currently available in three short years and now being asked to do "one more thing," but who are so overwhelmed by it all that we can't even complain in a loud voice.  How can the promise of pizza and beer on a rare weekend off be so well received?  Because it allows us to bond!

4) There is the one who simply says "I'm not talking right now."

5) There are very many patients out there who are probably trying to understand just why they suddenly are being told that they have to wait approximately six months before they can see any of their regular providers.  So, en masse they troop through the ER in an attempt to get a follow-up appointment that may be only three months away.

6) There is the staff that shall remain unnamed that is working diligently away at all odd hours of the day and night to move the project along and have us ready by the middle of January.

There is nothing like "change sucks!"  to stress all of us out in an already busy and stressful holiday/cold and flu season. 

But overall,  I think we're going to come out on the other side A-ok.

At least we'll have enjoyed some good pizza and beer.

The Maternity Ward

What I do for work is always interesting; mainly because the stories behind the people are so interesting.
Today, Monday, I arrived to work to round on the babies that had been born over the weekend.  The mix of mommas and babies included the following;

1) Three mothers who had just given birth to their seventh and eighth children.  None of the women was terribly interested in permanent birth control, although one of the couples was considering a vasectomy for the father.  I grew up in a household of seven children; a loud chaotic childhood that I would not trade for the world.  In my family, children are a gift from God, and every one is loved equally and fully.  My parents did not have the ability to give us material goods, we got toys from Salvation Army at Christmas, and ate more than our fair share of soup.  But the toys were loved the same, and my mother is a wonderful cook who never let us feel we were going without, and always had on hand one scoop of ice cream each for dessert.  Despite our social rantings that people need to practice more effective birth control; perhaps the children in these large households would not trade their upbringing for anything, either.

2) One lesbian couple dressed a bit like gangsters with a new baby boy.  This child was apparently conceived in the natural way, but is going to be raised by both of the women in the room.  A young couple starting out much like any other couple with a new baby, but will certainly face many different challenges than most of us have faced as either parents or as children of heterosexual couples.  It is so easy to slip into the language of  "daddy and mommy,"  but in this case, you have to think twice when you enter that room.

3)  One 17 year old on her second baby.  That means that she probably had the first one when she was 15 and very possibly got pregnant the first time when she was 14.  How much time did we spend with her asking her about her support at home, the relationship with the father(s?).  Does she go out like most teenagers to the movies and to her favorite restaurants?  Does her mother spend most of the time with the children while she does go out?  Is she still in school?  Is school a priority?  Once again, the demands of our medical days are not conducive to sitting down and really talking with this young woman.

4)  One mother who lost one of her children to child abuse.  That one is almost too difficult for words and too difficult to even think about. 

Each one of these six or seven babies has now been born into circumstances and environments they cannot control.  They lay in their bassinets wearing white t-shirts and wrapped in standard hospital issue blankets.  Each one of them has a pink and blue knit hat on it's head.  Their eyes are perhaps open, trying to adjust to the new bright lights that have been thrust upon them.  They look so similar in these first few days of life.  They are clothed in garments of hope and joy.

What will be the interesting stories of their lives twenty years from now?

The Daily Vignette

 I often compress my workday into a vignette involving a patient that has given me pause and made me think.  Here is a scene from several years ago......

The room was dark and full of shadows.  The man lay in the large ICU bed, turned half way onto his left side, eyes closed, the plastic oxygen mask covering the lower half of his face.  His body looked much smaller from the last time I had seen him as if something had come along and deflated him.  The monitor above the bed was quiet, but gave a running update of his vitals.  The curtains at the window were drawn so the winter light could not enter the room.  The overhead lights were dark and the only light there was came from the doorway that faced into the hall.  We stood as a group around the bed, two nurses and two physicians, discussing various aspects of his care including his persistently low blood pressure, the feeding tube, and the fact that he was too sick to withstand surgery for his ischemic gut.  The distal 20cm of this man’s colon was dying and as a result, he was unable to control the stool that leaked slowly out.  A rectal tube was inserted to try and contain the mess.  A smaller Dobhoff tube snaked out of the man’s nose, filled with the brown liquid that would drip into his duodenum and give him nourishment.  The conversation revolved around trying to keep his blood pressure up so he could maintain an adequate blood supply to the ischemic colon in the hopes the damaged bowel would not get any worse.  The decision was made to restart the second agent to keep his blood pressure in an acceptable range.  This same vasopressor had been discontinued only less than twenty-four hours before. 

            During the conversation at the bedside, the man never moved, never changed his expression, never made any indication that he heard or understood the words that were being said in his presence.  He had Down’s syndrome and had already lived beyond his expected years.  Not many people with Down’s live into their fifties.  How much of the conversation would he understand even if he was completely well?

            The room was devoid of any personal objects and trinkets that often accumulate from family and friends while one is in the hospital.  He has no family; his only guardian having passed away several months ago.  He is a ward of the state.  It will be a judge who will make the decisions regarding this man’s care.  Someone completely unknown to him who will simply follow the letter of the law in prescribing what will and won’t be done with his medical care and his life.  Would the judge ever consider coming to visit the man as he lay in his white hospital bed, blue gown covering his thin arms?  Would the judge stand at the bedside, take the man’s hand into his, and squeeze it?  Would the decisions made be any different if he did?  Would a look at the rectal tube change his thinking?

            The four professionals standing around the bed paused in the conversation at the same time, almost as if on cue.  The one nurse remarked that she was afraid he would have to be intubated again at the rate the day was going.  The others nodded in agreement.  They decided to restart the second medication again to correct the low blood pressure.  They decided to suction him if needed, probably disturbing his sleep.  The four of them slowly drifted toward the doorway and out into the lighted hall.  The man remained laying in his bed, quietly breathing, not moving.

I don't remember the ending of this story, except that I think the patient eventually died from his illness.  Many people are lucky enough to have family and friends surrounding them during their illnesses, but many more do not.   As physicians, I wish we were more comfortable going in and simply holding a patient's hand for a few moments, but we are often taught to separate ourselves from our patients.  This message is conveyed to us throughout our training, often simply by the means that we are too busy trying to get the next patient seen, the next lab ordered, the next dictation done, the next family member out of our hair.

A wise physician once said to me;  "Listen carefully to your patients, for 99% of the time, they will tell you what is wrong with them."  What do you suppose the man with Down's Syndrome in the ICU bed was trying to tell us?  And why did we all drift away from him so quickly?