This month I started a fellowship that predominantly involves taking care of women with cancer. Through surgery, chemotherapy, and other medications we do our best to cure or hold back malignancies of many kinds. In these past weeks, I have taken care of several patients who are Jehovah Witnesses, an experience that has been quite interesting.
In most cases, what religion a person subscribes to has little to no impact on their clinical outcome. We have an exception, however, when it comes to a Jehovah’s Witness with cancer. JHW patients to a rule will not accept blood products of any kind, which greatly limits their ability to be effectively treated for cancer. In some cases they cannot have surgery the surgery they need is unsafe without the possibility of blood transfusion. In some cases they cannot take chemotherapy because blood transfusion is required to survive the associated myelosuppression. As surgery and chemotherapy are our two best treatment, they are at a major disadvantage.
When I was a resident, I had a pretty hard opinion about this. I heard a lot of different view on the topic, but the position of one of my attendings resonated best with me. He felt that his job as a physician was to protect the health of his patients, and that if a JHW was dying in front of him he was going to transfuse them whether they liked it or not. He was quite clear about this upfront, and told JHW patients that if they were not happy about this they should find another doctor. He even arranged for attending coverage for emergent issues if need be. He felt that the preventable death of a patient was an emotional trauma he didn’t want to be exposed to, almost as if the patient, through refusal of blood, was exposing him to unnecessary emotional violence. While this was a very hard line, I respected the boldness of it, and that he was being true to his internal values. I held a similar feeling for the first few years of my attendinghood, though I never had to test it until my third year out of residency.
I wish I could say that when I’m done doing a little impromptu lecture on pelvic anatomy that there is something on paper worth saving, but well, there isn’t. Wish you could have been there.
Drs Browne and Fogelson discuss Cesarean Delivery Rates, VBAC Guidelines, Placenta Accreta, and the critical role of Flash the Cat in the Academic OB/GYN Podcast.
Today I had the pleasure of talking shop with my brother’s mother in law, Joni Dawning, a very experienced direct entry midwife in Eugene, OR. Joni has been attending births for over twenty years, and she has been a great resource to me over the years I have known her. I hold her in great respect, as she is the kind of midwife that I think is a great resource to her community. She provides a service to her clients that is greatly desired, but at the same time sees herself as a part of a larger system of birth service provision that includes hospitals and obstetricians. Unlike some direct entry midwives (or CPMs in some communities), she respects the limits of what she can offer, and does not see a hospital transfer as a failure in any way.
Recently in Oregon there have been some deaths during attempted breech deliveries at home, all attended by various home midwives of varying skill. Following this there was a discussion in the legislature about whether or not licensed midwives should be completely banned from intentionally attending breech births at home. Joanie wrote a passionate letter about the topic. She shared this letter with me, and to my surprise the letter was not in support of breech birth at home, but rather a plea that the legislature ban breech homebirth. She felt that too may midwives believed that they understood how to deliver breeches, not because they had experience, but because they were just ignorant of the potential risks and the techniques required to succeed. I some cases they just “believed in birth” and felt that the baby would deliver if one would just stand by and watch. Read more…
Academic OB/GYN, and I, Nicholas Fogelson, are honored to have so many great twitter followers. Over time it has come to pass that there are two populations of followers – 1) people that are interested in the Academic OB/GYN blog, podcast, and related educational materials and 2) people that are interested in the unrelated musings of myself. At present, @academicobgyn is a combination of those two things.
So things are getting separated:
If you want to hear about things related to the blog, the podcast, and other things of medical interest, continue to follow @academicobgyn.
If you want to hear from me on a more personal level, follow @nickfogelson.
Academic OB/GYN has now found its third home in Atlanta, GA. The blog got its grew up in Honolulu, HI, spent its teen years in Columbia, SC, and now has moved on and is ready for its first real date in Atlanta, GA.
In all this moving, there hasn’t been a lot of time to write blog posts or do podcasts, but I’ll be coming back soon with lots of good stuff. Atlanta is perhaps the best city I have ever lived in. I’ve been here a week and love it already. If any fans or friends live in ATL please let me know so we can meet up!
My move to Atlanta comes as a sabbatical from attendinghood, returning to the learning side of it all in an Advanced Pelvic Surgery Fellowship in the department of Gynecologic Oncology at Emory University. I hope to get some great material for surgical videos, though Emory’s policies for posting may be a bit restrictive – more research is warranted.
One of the great things about Atlanta is the incredible music scene. Every big act plays here. I just saw Idina Menzel tonight – just awesome. She played Chastain Amphitheater and there was daylight for the first 2/3 of the show. She kept saying it was making her nervous seeing all the audience watching her. Even virtuosos get nervous.
Today I saw a patient for a preoperative visit and went through the ritual of “informed consent” and the signing of the surgical permit. We had decided to do a hysterectomy to treat her problematic fibroids, and she very much wanted to proceed. Having discussed the alternatives, we now had to go through the legal ritual of the surgical consent.
As usual, I discussed what we could expect to gain from the hysterectomy. There was a 100% chance that she would no longer have any bleeding, and a very strong chance that any pain that originated in her central pelvis would get entirely or mostly better. Anemia that resulted from the bleeding would improve. Other symptoms, like urinary pressure and frequency, and lateralized pelvic pain, would likely improve though it is not as strong a likelihood as the other symptoms.
We also discussed the risks. “You could have bleeding during the surgery, potentially enough to need a blood transfusion before or after surgery. You could get a communicable disease from a blood transfusion. You could develop a wound infection or abscess, which sometimes is easy to treat and other times quite complicated. Anything in the abdomen could be damaged during the surgery, such as the bowel, bladder, ureters (“which carry urine from the kidneys to the bladder” I always say), blood vessels, or other structures. Anything damaged can be fixed at the time by myself or a consultant. There is a possibility something could be damaged but we do not recognize it at the time, or that there is a delayed injury. If this occurs you might need further surgery, antibiotics, or hospitalization. Though extremely rare, you could die or be injured from an unforeseen surgical complication or complication of anesthesia.”
At this point she looked white as a sheet, as usual, and then I tempered with “but all of this is extremely unlikely, less than 1% of cases for major issues, and I have to explain it all for legal reasons. I am well trained to do this surgery and will do my absolute best for you.” I answered her questions, the consent is signed, and we had our pre-op. Read more…
Robotics is an exciting new area of surgery, and is of great use in gynecologic surgery. Robotics can be used in most any laparoscopic surgery, and makes many minimally invasive cases possible that otherwise would have to be open cases.
I have the pleasure of working with our resident GYN team for several weeks every few months, rounding on their patients and teaching each morning. One of the best parts of this is hearing our medical students present their cases.
Presenting patients is a skill that takes a great deal of time to master. Each student is taught the basic form of a medical presentation at an early ‘age’ – Subjective, Objective, Assessment, and Plan. Each of these bits can be broken down into many subareas, such a Past Medical History or Social History (part of the subjective usually), Chest Exam or Labs (parts of the objective), or individually listed problems (each parts of the assessment and plan.)
This sort of structure is both an aid to great presenting and a hinderance. It helps because it gives the presentation a structure that is easy to follow, and over the years of hearing such presentations the listener has created little boxes in their mind, and had developed the expectation that these boxes will be filled in a specific order. By following this structure, the student fills those boxes and thus creates a structured narrative that fits the listener’s expectations. This can be very functional and efficient. The downside is that if the student follows that structure too tightly, the presentation sounds stilted, like a person reading a spreadsheet. This creates a presentation that is technically correct, but lacks grace.
Drs Browne and Fogelson discuss articles from April and May of 2011. Antibiotics in Obesity (use more), Inpatient vs Outpatient Hysterectomy (hospital beds are nice), Homebirth Ethics a la Chervenak (not so much), Generalists in Academics (shrinking), MOC vs CME (MOC winning), Duration of Hot Flashes (long time).
Seeing @ceelogreen at #nolajazzfest. Sure looks like he is doing a great job. The mixer on the other hand sucks, as Ceelo cannot be heard 2 weeks ago
RT @olamedmac: @academicobgyn Interesting paper on delayed cord clamping and umbilical cord banking from the angle of Sociology: http:// ... 4 weeks ago
RT @olamedmac: @academicobgyn Interesting paper on delayed cord clamping and umbilical cord banking from the angle of Sociology: http:// ... 4 weeks ago
