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.
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…
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.
As I look back over my 10 year career in obstetrics and gynecology, I am sometimes struck at how many things have been discovered in this time period. When I started the origin of pre-eclampsia was unknown, and now we know that it likely originates in an overabundance of a molecule called Soluble FMS-Like Tyrosine Kinase, a competitive inhibitor to natural angiogenesis in the placenta. Ten years ago the origins of cervical dysplasia were still being developed, and now we know that the majority if not the entirety of cervical dysplasia and cancer is due to an infection of Human Papillomavirus, and for all intents and purposes cervical cancer is actually a sexually transmitted disease. We have developed this idea even further, allowing us to use HPV virus detection as part of a screening program for cervical dysplasia and cancer, and even to immunize for HPV infection in young women yet to be exposed.
All of these things amaze me. But to be honest, they also make the practice of obstetrics and gynecology more difficult. We have advanced our understanding to level that is impossible to explain to patients who lack a strong background in science, forcing us to accept simplistic explanations over explanations of how it really works. Let’s use HPV as an example.
I recently had the opportunity to go to the anatomy lab and help the first years go through the pelvic anatomy. What a blast! There is nothing like dissecting a cadaver to tune up one’s surgical anatomy skills, and helping young eager medical students through it is a great experience.
Prior to going into the lab, I spent many hours going through Netter’s atlas to brush up on the anatomy so I could accurately help the medical students. Its amazing what one can learn reviewing what one used to know. Here’s a few examples:
1. The small vessels we like to cut at cesarean have names, and we can avoid them.
Everybody that does cesarean deliveries knows that there are small vessels in the path of entry that sometimes get cut, but not everyone knows what they are called. So for the record, the small vessels in the subcutaneous fat that get cut are superficial epigastrics (most people know this one) and the vessels that sometimes go during the lateral extension of the fascial incision are ascending branches of the deep circumflex iliac artery. One can see that these ascending branches lie between above the transversalis muscle but beneath the obliques, which explains why sometimes taking the fascial layers separately allows one to miss them. I’ve always felt that the routine sacrificing of these vessels was a surgical faux pas, and knowing this anatomy helps one to avoid it.
Junes’s Green Journal had an interesting article on vertical versus transverse skin incisions for emergent cesarean deliveries that seemed worth some comment.
The point of the article was to look at a large retrospective cohort of emergent cesarean deliveries, stratify them by vertical or transverse skin incision, and then look at operative times and patient and fetal outcomes. This dataset was drawn from recorded data from many different centers, as part of the MFMU Network system of studies.
For the last 12 months, I have worked for a federally funded hospital. When I came to this hospital, I immediately noticed that the GYN surgical equipment was very outdated, most likely because the primary focus of the hospital until fairly recently had been the care of men. Wanting to bring hospital up to snuff, I requested about $100,000 worth of new equipment, including a hysteroresectoscope, new hysterectomy clamps, uterine ablation equipment, a laparoscopic morcellator, and a modern laparoscopic power source. When I put in the order for these things I was assured that we could get these things in short order, as the hospital had upgrading GYN surgery on its priority list.
As time went on, the equipment never arrived. It was held up in committee. It needed further approval. We needed more competitive bids. After further investigation, it seemed that the hospital just didn’t have enough money to do anything non-critical.
27 year old woman with 2 years of intermittent left lower quadrant pain, presenting with sudden increase of pain and nausea. Ultrasound showed a 7 cm cystic lesion in the left adnexal area.
I had the opportunity to do an abdominal cerclage with one of my MFM colleagues this week, which was fantastic. This is a procedure that is rarely done, and for me is something pretty new. I had the opportunity to do a few of these in residency, but hadn’t done one for over 5 years and never in a pregnant woman, so that was a great envelope-pushing experience for me.
For my colleagues that haven’t had the opportunity to do one of these procedures, I want to lay out how its done. In short, the goal is to place a cerclage between the ascending and descending branches of the uterine arteries, at the connection of the lower uterine segment and internal cervical os. When you’re done it should look something like this -
RT @brainygirlnyc: "The social media world is a bit like quicksand - once you put a foot in...you're not getting out" - John Partilla, D ... 4 months ago
NPR: Bahrain To Execute Protester For Killing Policeman. - doctors and nurses being prosecuted for helping. Sick-More at http://n.pr/rpYekz4 months ago
If anyone within the sound of my tweets is a member at East Lake and would like to have me out as a guest please msg! RT pls 4 months ago
