To Bare Or Not To Bare

Topless sunbathing is widely accepted in France, where we've spent a lovely vacation visiting my husband's family. Our recent day trip to a beach on the northern coast sparked interesting conversations between my daughter and me and between my husband and me.

On one hand, I think the relative absence of Puritanical sexual repression in Europe, as compared to the United States, has provided some advantages. People are accustomed to seeing bare breasts on billboards and other media from a young age. Breasts therefore need not be objects of shock value or secret, horny fascination. Women are allowed to be comfortable with their own bodies - as they should be - and men allowed to be comfortable with women's bodies in multiple ways without having to be so obsessively titillated by the one aspect of them, their sexuality.

On the other hand, I value modesty. I think there's something to be said for being feminine and even sexy without needing to bare all, for keeping private parts private (and thus in some way sacred, and meant for reverent care) and preserving the meaning of intimacy. My husband pointed out, though, that two-piece bathing suits are already immodest; what's the big deal with doing away with the top piece? (He is, of course, half European.) My young daughter, on the cusp of womanhood, sounds torn between two cultures; she was a little shocked at how easily modesty was abandoned here in France, but also admired young women for their confidence in their bodies regardless of body type.

Not long after our trip to the beach I read the current National Geographic article about child brides in India and Yemen. So much in that article dredged up a lot of anger in me - at how girls and women are still seen around the world as possessions or goods for use, whose worth is directly associated with the integrity of their hymens, whose appearance or even presence is often blamed for what is really the uncontrolled lasciviousness and misogyny of the males around them. Are men all over the world really so incapable of controlling their basest tendencies? Really? Can't the rape just STOP already? What is WRONG with people?

In my mind the jury's still out on topless sunbathing. Where it's commonplace and culturally comfortable, there doesn't appear to be a down side, and there may even be many positives. Women's efforts at extreme modesty elsewhere don't seem to quell the animal frenzy that leads to their victimization by stupid, irresponsible, and worthless men. Perhaps if the whole world would just relax about the human body we could all just step back, appreciate it, and take good care of it.

Why I Hate Birth Plans

Recently on a physicians' forum I came across a tragic story about a home birth gone bad. The doctors on the forum were mercilessly critical of the individuals involved, but I couldn't disagree with them. Their tone may have crossed the line from anger over the tragedy into disrespect or even cruelty, but I can't say I blame them entirely - there's a part of every conscientious physician that does get enraged over what's perceived to be preventable catastrophe, and sometimes venting the outrage in private (which this forum was supposed to be), among others who understand, can release some of the tension raised by the story.

There seems to be a wide chasm between expectant women who distrust or perhaps even hate doctors and doctors who see themselves as the protectors of human safety and life and who thus sometimes see such mothers-to-be as close-minded, willfully uninformed, and even selfish. From the physician's point of view, a) "natural" isn't synonymous with "safer;" b) pregnancy causes physiologic changes that can sometimes pose real dangers to mother and infant - DANGERS, not just inconveniences or discomfort; and c) a rigid "plan" for birth is nonsensical in light of the possibility of unplanned concerns necessitating prompt and sometimes life-saving intervention.

Don't get me wrong; I firmly believe in women's right to express PREFERENCES and to have those preferences respected as closely as possible when safety allows. Of COURSE I would never insist on placing an epidural in a woman who preferred to give birth without one. But I resent the kind of pseudo-feminist culture that creates guilt or a sense of "failure" in women who feel they would like an epidural to relieve childbirth pain. I've heard it so many times; a tearful woman saying "I'm a failure" because natural childbirth became medically assisted childbirth. No woman should ever feel BAD about bringing a new life into the world. That, and the social signals that engender it, I definitely resent.

And despite the title of this post, I don't actually hate birth plans. I had one myself. I scrapped it in the end and decided to just trust in the process, and take things a step at a time, and actually have face-to-face conversations with my caregivers, but I did draft one. A birth plan that is meant to clarify preferences is a good thing. A birth plan, written or spoken or just held in one's mind, that is meant to be a binding contract for a physician, come hell or high water, is stupid and ultimately, in my opinion, wrong. The priority should be the baby's and mother's SAFETY, not the parents' "birth experience." If the so-called birth "plan" interferes with safety, it has to go, and any parent who insists on adhering to it under such circumstances doesn't deserve to be a parent. What I hate about certain birth plans is the unspoken attitude or culture behind them that seems to declare that nothing is more important than the mother's "birth experience." This is irresponsible and wrong.

So when a screaming doula verbally abused an obstetrician colleague of mine recently for going to stimulate a baby who was cyanotic and was making no respiratory effort - and when I say screaming, I mean I was three doors down attending to someone else and I could hear her yelling at my colleague at the top of her lungs - I felt the same anger that the physicians on the forum were feeling over the home birth disaster. My colleague was doing her JOB, protecting the baby's life and ensuring the mother's safety, according to standards that have been carefully studied, and here was this medically untrained woman interfering with this physician's care and potentially threatening the life of the child by screaming at the doctor that clamping the cord and stimulating the baby were against the parents' wishes. The baby's safety didn't seem to matter; it was all about the parents' wishes. THAT kind of ignorant, selfish "care" is completely inexcusable, yet in certain circles is glorified and touted as advocacy of women's rights and empowerment of mothers. There's nothing empowering about medical ignorance, stubbornness, or selfish adherence to a dream of a birth experience contributing to a child's death.

Here's what I would want all expectant mothers to know about giving birth at our hospital. Pregnancy may be natural, but it can also be dangerous. If you show up at our door, we're going to bend over backward to protect you and your baby, but we're going to do so according to the high standards of safety to which we've been trained to adhere. Please tell us what you prefer, by all means - we do want to create as wonderful a birth experience for everyone as we can - but we also have to put safety above EVERYTHING. We would be bad doctors, and morally culpable people, if we did any less.

_________________________________________________________
ADDENDUM:
See also this well-articulated critique by an ob/gyn:
BIRTH PLANS: WORSE THAN USELESS.

Anesthesia v. The Joint Commission, Part II

Yesterday's post mentioned that the leaders of this country's most important anesthesia organizations had sent a letter protesting several inane mandates that were being imposed or about to be imposed on anesthesia providers by the JCAHO.

This letter, requesting written confirmation that we anesthesiologists and anesthetists could keep our current, safe practices rather than switching to the suggested idiotic, less safe practices, was sent last December.

Now...let the back-pedaling begin!

JCAHO's response arrived at the American Society of Anesthesiologists' desk just about a month ago, and our anesthesia group has been abuzz about it this week.

The highlights:

"Dear Anesthesia Providers:

...Your letter points out that if specially designed processes are followed to accomplish [the task of pre-labeling syringes], labeling a syringe first and later filling that syringe can be accomplished in a consistently safe manner. [REALLY?! YOU DON'T SAY...?! Is that why we've managed to do this for the last several DECADES?! Imagine that!]

...After discussions with the Joint Commission staff, it was decided that it is beyond the scope of this NPSG [National Patient Safety Goals] to detail all of the various safe and unsafe processes in which a syringe could be filled and labeled. The Joint Commission decided to leave the current NPSG as is, which requires all filled syringes to be labeled, and to remove from the FAQ the prohibition against prelabeling...

As a follow-up to the previous discussion, one exception does exist to the requirement that all syringes be labeled...As long as there is no break in the process, labeling is not required during the administration of spinal and epidural anesthetics and analgesics. [Why THANK you! But we already KNEW that, because to require something so USELESS and intrusive would be completely STUPID.]

...The issue of anesthesia professionals (or anyone for that matter) carrying a medication is left to the individual health care organization."

Thank you, JCAHO, for taking our concerns seriously and realizing the idiocy and lack of groundedness-in-reality of so many of your requirements. Keep up the good work. Maybe if you keep paying attention to what you described in your response as "a number of concerns" voiced by many medical practitioners from many different fields, you can make up for your deficiencies in clinical knowledge and practical imagination with responsiveness to those who actually live and work in the real world every single day.

[Photo source here.]

Anesthesia v. The Joint Commission

The following was written by a colleague who wishes to remain anonymous but whose permission I have to reprint it here. I think it expresses what a lot of people are thinking but can only admit in private.




Dear JCAHO (Joint Commission on Accreditation of Healthcare Organizations, a.k.a. "Jay-Co" to clinicians talking about you or, most commonly, complaining about you):


Over the years I have dealt with your incessant nitpicking by reminding myself that the regulation of institutions responsible for human lives is, in principle, a GOOD THING. I believe in safeguards. I believe in holding organizations to high safety standards. I believe accountability is important.


But over the years I have also wondered how it is that the bureaucrats that come to survey our hospitals can be so unimaginably clueless about the practicalities of patient care. Yes, perhaps they have had clinical experience in the past, are highly qualified (according to you), and have an alphabet soup of degrees after their names that purportedly validate their authority. Yet why do they seem unable to belie the stereotype of the out-of-touch, small-minded bean counter who has absolutely no idea how the real world of caring for patients really works?


You've already received a missive about this from representatives of all the major anesthesia organizations in the U.S., but I feel that their diplomacy diminished the forcefulness their words could have had.


I've gritted my teeth and had to accept the locked anesthesia cart you mandated in the obstetric O.R. despite the fact that if a pregnant woman were hemorrhaging TO DEATH and needed a true STAT C-section, the delay caused by having to retrieve the key to open the cart might actually KILL her AND her baby.


I've rolled my eyes at the various little rules you add each year, with the determination and scrupulousness of people whose mission in life is to add at least ONE new rule each year come hell or high water, even if on occasion one of your commands might, for example, be to get rid of the very form you made us adopt the LAST time you came.


But I cannot, cannot, CANNOT wrap my mind around the completely ASININE prohibition against pre-labeling my medication syringes and against the transport of medicines on my person for the sake of patient safety / emergencies, and the criticism of anesthesia practitioners for not labeling the STERILE syringes of a spinal kit when there is absolutely no discontinuity in the opening of the kit, drawing up of the medication, and injection of the medication into a SHARP OBJECT STABBED INTO SOMEONE's BACK which needs to be done as swiftly as possible once the patient's cerebrospinal fluid is observed leaking out of his or her spinal canal.


You would rather, as I understand it, INTERRUPT a procedure for the sake of a literally USELESS step, CONTAMINATE a sterile kit with a nonsterile label, and risk the injurious complication of arachnoiditis from the ink on a labeling pen, than have a spinal anesthetic performed cleanly, efficiently, and above all, SAFELY.


You would rather I draw medication up into an UNLABELED syringe, leaving it unrecognizable for a few seconds or its contents potentially forgotten, than allow me the opportunity to SAFEGUARD the drawing-up process by making sure my label and my medication vial MATCH. Pre-labeling, by the way, is an EVIDENCE-BASED safety practice, unlike your nonsensical and over-intrusive prohibition.


Most egregiously, you would rather a patient CODE AND DIE during transport than have me carrying with me the very interventions that might save that patient's life. And for what? For the sake of making sure pharmaceuticals are locked away, locked away, locked away? Who is protected by this kind of imbecilic medical tyranny?


The above satirical cartoon sums up in a few seconds why you appear to be almost universally despised by the medical community. Arguably no one is more obsessed with patient safety than an anesthesiologist, and we certainly know intimately the day-to-day practices that safeguard it. Perhaps, then, YOU should take a few mandates from US. You might subsequently find your recommendations and regulations actually having some lasting positive impact and earning something with which you might be unfamiliar: respect.


Sincerely,


An anesthesiologist somewhere in the U.S. who cares deeply about patients and their safety.

How I Spent "Judgment Day" 2011

If you knew, or thought you knew, when the world was going to end, would you change the way you live your life?

Would you spend your life savings and forego career plans? Would you take one last trip to see some places you'd always wanted to see?

I never believed in preacher Harold Camping's prediction that the Rapture would occur today. Even if Jesus himself hadn't said plainly that no one can know the day or the hour, Camping's calculations would still have held no merit, based as they were on a) a literal interpretation of the Bible and b) a calendar that failed to take Dionysus Exiguus into account. But I did follow some of the media coverage around this phenomenon with interest. It generated questions like, "What makes people willing to take such risky actions for the sake of one fallible man's ideas?" and "What would you change about your life if you knew it was ending - SOON?"

I was pleased to realize that the answer to the latter was "not much." I'd still go to work and do my job - but keep it part-time, or make it even MORE part-time. I'd still spend as much time enjoying my family's company as I could. And if today had really been our last day, I would have been truly happy to have spent it as we did today.

My husband and I had a long, relaxing lunch outdoors. The weather was perfect - sunny, breezy, dry, in the 70's. The food was delicious. Later in the day we went to a fair two towns over. I love small town fairs; they evoke simpler times, happy families, and friendly communities with something to celebrate. The best thing about this particular fair was the presence of a book tent, where my husband and I spent contented hours browsing through tables laden with used books while the kids enjoyed the games and rides outside. Back home I concocted some Thai-spiced burgers for a late dinner, and they were yummy. It was a day full of all the things I enjoy and the people I love most. If the world had actually ended, I would have counted myself blessed to have known such lovely moments.

Blog Anniversary - It Kinda Snuck Up On Me!

I can't believe this blog has been around for four years!

I know it's been much quieter lately, but that's been working for me. Not that there's anything too extraordinary going on in the rest of my life right now - other than the usual extraordinariness of my ordinary life. One day I am running to the emergency room to help with a potential difficult airway, anesthetizing a patient for abdominal surgery, or putting epidurals in expectant moms; the next day I have a cake decorating class, or a post office errand, or a movie night with spouse and kids. Life's got stresses, life's got joys, and I'm finding that this kind of balanced, un-remarkable existence is just what the doctor ordered (so to speak!).

It seems fitting, then, that I should celebrate with...

Berry-Basil Guacamole. An ordinary treat with an extraordinary twist.

This is my latest obsession. I had some at my in-laws' and fell head-over-heels for it. I really enjoy this kind of food adventure: take something rather ordinary (mashed avocado), and make it a little special with the unexpected ingredient, a not-your-usual combination of flavors. The strawberry-basil combo is, I must admit, kinda old news; it's been done a lot, as a salad, an ice cream, and even a cupcake. But I still consider it somewhat special.

Let me know if you develop (or have) a good version. Mine is just what you see above: avocados, strawberries, fresh basil, a little diced cherry tomato and onion, and whatever sprinkling of seasoning and citrus juice happens to be on hand and palatable at the moment. Best with my other latest obsession: Tostitos brand Artisan Recipe roasted-garlic-and-black-bean whole grain tortilla chips.

Happy Berry-Basil Blogiversary!

On Advocating For Patients

The following is based on an actual conversation from an evening on call. Some details have been changed.

Situation: Emergency surgery for a patient whose vital signs were unstable and whose mental status was deteriorating.

Doctor: "I have some quick questions before we enter the operating room, and I'll also need signed consent for the anesthesia."

Family Member #1: "Oh, I'm his health care proxy. I can sign that."

Doctor: "All right. Can you tell me about his medical history?"

Family Member #2: "You mean why we're here?"

Doctor: "No, I know that part, but I was hoping you could tell me about his major medical problems. Does..."

Family Member #1: "Oh, I don't know any of that. I'm just the health care proxy."

Questions:

What does the average person understand to be the role of a health care proxy?

What should that role consist of?

Can people really advocate for others whose situation they either are in denial about or don't understand fully?

Family Member #1: "My brother knows some of that stuff, though."

Doctor: "I was reading through some old records. He has high blood pressure?"

Family Member #2: "Oh, no, he doesn't have that."

Family Member #1: "No. Not that."

Doctor: glances at listed hypertension medication in the record

Family Member #1: "He's actually really healthy."

Doctor (puzzled, glancing once again at list of medical issues from previous hospitalizations): "Oh? I thought I saw..."

Family Member #2: "Yeah, he's healthy."

Pause.

Family Member #2: "He just has a little congestive heart failure and some emphysema."

Processing...

The physician ran down a list of specific questions, asking about recent hospitalizations, heart symptoms, frequency of inhaler use, mental status changes, and other medical information felt to be germane to the patient's care. In this situation, however, time was short - surgery needed to be performed as soon as possible. Not only was the information not readily available, but also the sources of information were largely unreliable. Such circumstances can have a significant impact on patient care. The doctor here is responsible for efficient and thorough information gathering and the performance of a proper focused physical exam, but time and available sources can be very limited in situations like these.

Plea: Please know your own medical history, and if advocating for another, know that person's issues as well as his or her medical management preferences. The best care is provided when clinicians have the best information available, especially during emergencies, and sometimes loved ones / proxies / advocates are our only source.