A Conflict of Interest in Anesthesia

I just returned home from a lecture given by the Chair of our OB Anesthesia Department which I found highly upsetting.

She opened the lecture with her overall purpose: "I want to prepare you for the fact that we are trying to provide care to patients who don't want us to care for them." She said she wanted us to have more preparation before "you are thrown into the lion's den."

Lion's Den? Laboring woman= lion? Really?

DISCLAIMERS
The lecturer gave no disclaimer of her personal opinions regarding labor and delivery management and pain relief but those became quickly evident as one can surmise from her opening statements. I have my own personal opinions, of course, and I have recently had experience with a natural childbirth approach that became surgical.  My biases will undoubtedly color what I'm about to write, but I would like to think that I have no personal agenda for other women.

What I wish for the laboring woman is for her to have confidence in her support system, for her to feel that her providers are there to help her, for her to be in a safe atmosphere with skilled, encouraging medical help, and for her baby to have a safe outcome. I think it also reasonable to wish for all of this to happen with very little drama.

Noticed I have said nothing about pain.

PAIN
I am aware that in a number of months I will be the provider who walks into a room to provide pain relief to a woman who may or may not want it. Insofar as my medical training will benefit, I will eagerly jump at the chance to perform epidurals on women who say yes. I will gladly answer their questions to the best of my ability. But if they say no, it won't really matter to me. I have no personal investment as long as the patient has been presented with the options.

My lecturer's approach to laboring pain was this: Why would you not treat it? "Would you do an appendectomy without anesthesia?" She implied it was cruel to NOT provide an epidural. She also cited a study that showed the newborns of natural births had mild alkylosis from their mother's hyperventilation (in an effort, I believe, to prove scientifically that pain is bad... and you can't dispute science, right?), yet she failed to prove that a transiently high pH would have any adverse outcome on a baby.

There is no dispute about laboring being a painful process, yet I think it is important to let women decide what is allowable for themselves. Some women go through it and feel more confident and proud of themselves for having "made it." Great. Some women have such relief from an epidural that their birthing is a more pleasant experience. Great.

The point, again, is that is is not for me to decide.

The odd thing is that in all of my other pain lectures, we have been taught to focus on the fact that pain is made worse by human suffering. We are advised to approach patients not with the intention of erasing their pain, but with the intent of helping them to manage the suffering (depressed mood, lack of sleep, anxiety) that accompanies pain and makes it worse. The new goal therefore, is to help a patient "pain better."

Why, then, are anesthesiologists only able to offer laboring women epidurals and spinals as the only tool in our pain-relief toolbox?

EPIDURALS-New data
Ok, the one helpful thing in the whole lecture what dispelling some myths about epidurals. It turns out we've gotten a lot better at them. In the last ten years, we've started to use a really light concentration of local anesthetic and we use a miniscule amount of fentanyl; basically, just enough to have an effect on the spinal cord without effecting the blood or the baby. The result is epidurals that don't totally numb the patient, making it easier to be strong and push. The is, of course, at the expense of getting complete pain relief. So, at best epidurals take the edge of off pain (and we're taking the contraction pain, not the pushing pain because epidurals don't even touch the perineal area at all).

Secondly, because of this decrease in the medication concentration it has now been shown, repeatedly, that epidurals do not slow labor and do not lead to more c-sections. In fact, many studies show that they decrease laboring time. (The same has also been proven for having a doula present in the room...hmm...) The lecturer's point was epidurals are safe in early labor and should therefore be placed in early labor. Why? Because it's more convenient for us. I'm sorry, but I'm really wary of doing anything just because it's more convenient for my work schedule. Unless a woman wants an early epidural, you won't find me pushing one on her...

WTF?
So, the lecture gave me some new factual data on epidurals. I'm sure that will come in handy at some point. But if the overall purpose of the lecture was to prepare us for "patients who don't want our care," I think it failed miserably because instead of placing us in the shoes of a laboring woman, she puts us at odds with them.

My lecturer seemed to think that women who refuse pain relief or women who desire a home-birth are not concerned about their health or what's best for their baby's health. She essentially implied that pregnant women can't even think logically. While there are, most likely, exceptions, I think most people would agree that mother's-- more than anyone-- want what's best for their babies.

So one must ask the question, Why are women so mistrustful of their birthing experience? If they are not thinking "logically" and listening to our "science," what is making them so emotional?

To even begin to discuss women's health and laboring health in particular, I think one has to acknowledge that is is political, just as much as it is personal (Note, the recent fall-out over the word "vagina" used on the congressional floor). Our current practices and beliefs are part of the legacy of medical care that came before us.

For example, during my medical education in the south, we talked a lot about race in the context of healthcare. How could we not? We worked in a hospital that some locals still call "The Gradys", plural, because Grady Hospital used to be segregated into two separate hospitals. One cannot even practice medicine there without knowing about the Tuskegee experiments (performed on African-American men with syphilis, during which a cure was found but withheld from the research participants) and how that contributed to a growing mistrust of the medical system.

Similarly, in the last century, women have also been the subjects of the medicalization of birthing. Don't get me wrong, I don't think medicine is the enemy. There have been fantastic advances in medicine that have made many birth situations, particularly for high risk moms and complicated babies, much safer than before. But I'm not convinced that the average experience of otherwise-healthy women has improved much. In our efforts to make women and babies safer, I think we have to acknowledge that a lot of women came to more harm than was necessary whether psychological (ether births) or physical (induced labors, unnecessary c-sections, unnecessary repeat c-sections).

There is a reason many women feel like they get bullied during their laboring experience.

And it's called "The Business of Being Born."

No, just kidding, I watched that video and while I don't think it's a 100% accurate depiction of the medical world's view towards birth, I like that it encouraged women to educate themselves about birthing options and advocate for their plans. Ultimately, though, it IS about preserving the health of a newborn and I don't think we should sacrifice that for our personal and political agendas (oops, now I'm referencing my own birthing experience!).

SUGGESTIONS
So what do I do now? For now, I slap a fake smile on my face while I work with this woman who seems like she wants to use science data to argue women out of decades of medical harm and hurt.

In the interim, I'll be dreaming of a birthing experience in which anesthesiologists offer more than needles and local anesthetic. Maybe we can be more involved in the prenatal education classes so we can dispel myths about epidurals so we aren't viewed as evil needle-pushers, stooping over contracting women, waiting for them to cave into our plans. Maybe we can partner more with doulas and promote massage and acupuncture and other methods to reduce stress and pain.

~~~

I have a feeling that when it comes to satisfaction with one's laboring experience (and yes, I am speaking from personal experience) that women care more about the kindness and comfort they received from their healthcare providers than the precision of their pain relief. We all know labor's going to hurt on some level, epidural or not. Maybe anesthesiologists, instead of rolling their eyes, can offer women words of moral support and encouragement when they choose to forgo an epidural.

Father's Day... an homage to my love

Today was just another day at work. A Sunday at work. Oh yes, Father's Day at work. You know, I spent Mother's Day at work too (and Memorial Day, and Easter...)

So for Father's Day I left Kyle behind at home, alone to care for Sam. He took Sam strawberry picking, then grocery shopping, then to the park, then nap-time, lunch and I came home at 5. Kyle made dinner.

Father's Day dinner.

Steak on the grill, braised carrots with rosemary, sauteed mushrooms, baked potatoes and a salad. And a glass of wine. While I cleaned the kitchen, he bathed Sam and read him a bedtime story ("Daddy and Me"). With the cleaning done, I joined them in Sam's room for the flourish of "Night-nights" and "I love yous."

It was an amazing feat of fatherhood. A heroic day for any parent.

And it was just another day in Kyle's life.

While I want to celebrate the work that Kyle does as a husband and father, I am aware of the evolving nature of the role of father's in the modern day. I read the book, Manhood for Amateurs by Michael Chabon in which Chabon described the following scene: He is standing in line at the grocery store with his 20 month old son when a complete stranger-- a woman-- turns to him and says, "You are such a great dad!" He looks down to discover his son is chewing on some wire-like twist-tie and has snot running down his face. In that moment, he realizes that dads are often congratulated just for "showing up" to the job of parenting. He wonders, what would a mother have to do to receive such praise from a complete stranger:


 "Perhaps perform an emergency tracheotomy with a Bic pen on her eldest child while simultaneously nursing her infant and buying two weeks' worth of healthy but appealing break-time snacks for the entire cast of 'Lion King, Jr.' "


Lets face it, even in this modern day, the bar is set extremely low for fathers. Just as Chabon expresses, the sentiment is insulting to many of us.


Our own family-style of parenting has been a work-in-progress. Before we had Sam, Kyle and I had the typical, stereo-typed, gendered-division of house-hold labor. I was the domestic dominant. Kyle the willing, but passive, chore submissive. As worked through nine months of pregnancy, I realized that I could not successfully be a do-it-all mother and a full-time physician. 


That was hard for me. 


Having grown up with a stay-at-home, completely-available mother, my model of motherhood was one that I could never emulate. Nor, it turns out, after months of contemplation, would I want to. I love my job with a passion and I am so proud to be (in the process of...) becoming the family's primary breadwinner.


Ok, this post is not about motherhood. And yet it is. During pregnancy, it dawned on me that I would have to give up "doing-it-all" and moreover, I would need to allow Kyle to do some-- and more-- of the parenting that would surely be needed.

Kyle now credits my difficult work schedule with making the task easier. "When you're not here, it's easy for me to step in and take the lead. I can just be the parent and do what makes sense." It's not perfect of course, and I'm still the default household queen. But Kyle, as ever, is receptive and responsive to a list of to-dos scratched out and left behind on the kitchen table.

Yet a major shift has clearly taken place. It was particularly notable when Kyle started giving me advice on mealtime preparedness and bedtime routine. HIM giving ME advice on parenting?

It was a shock. And a blow to my motherhood ego.

After 30 minutes of inner-reflection, I felt unbelievably lucky.

I realize that this model of parenting is not for everyone. Every family is different and the goals Kyle and I have as parents do not necessarily reflect those of other parents. I definitely do not think there are "right ways" and "wrong ways" to be a mom or to be a dad. But surely every couple, challenged with their first child (or second, or third), has experienced the growing-pains of shifting responsibilities and roles. Hopefully, most experience, as we have at times, a sweet-spot of balance...

With that, I end with a link to a great (European, of course!) commercial that celebrates the evolving role of Fathers. While criticized by Jezebel.com for perhaps focusing on Dad-themed aspects of child-rearing, it still made me and Kyle cry...

Happy Father's Day, Kyle!

http://www.youtube.com/watch?v=oeKuFs0KxO8&feature=youtu.be

Trains and Trucks Oh My

In early May, we took Sam to Snoqualmie Falls and the Northwest Railroad museum. The falls is 30 miles east of Seattle and is nearly 300ft. The hiking trails were closed but we got a good view of it (and a fair soaking too due to all of the mist in the air!)

Most of these trains came with descriptions about where they were made and how they were used. Most of them also had historic photos of the trains in action up to 110 years ago. This one had plants growing out of it!

 Sam enjoyed getting to climb inside one of the cars.

In June, Seattle held a free event, "Touch a Truck" for kids. A number of service vehicles parked in a parking lot where kids could investigate them, sit in the drivers seat and speak to servicemen and women. While we didn't wait in any of the lines to get inside the vehicles (Sam is too impatient for that stuff), we did have fun exploring!

Sam is currently obsessed with cement trucks, but he was quite apprehensive he saw this particular one.  Maybe he didn't trust it because it wasn't spinning...

On the city bus:

In the bucket of a backhoe:

And the bucket of a bulldozer:

Strapped into the back of an ambulance:

Exceling

Spending this lovely evening budgeting our family finances for the next 2-3 years. Oh yah. Good thing my husband knows his way around an excel spreadsheet.

(If that sounded sexy somehow, it was unintentional.)

What does an anesthesiologist do? (Part One)

I've been thinking about this post since I started the anesthesia portion of my residency last July. In part, I've been wondering myself what my career will look like; what will I do everyday? Who will I care for? But also because most people don't even know how to spell anesthesiologist let alone know what they do at work (It's okay, I still have trouble with ophthalmologist.)

It is obvious to most people that surgery is not a benign process. It is painful for one and can be very risky depending on the situation. Yet, surgery is often necessary and can in fact, make people feel better. What is not so clear to most patients and lay-people is that anesthesia is no less risky than surgery. For some, the anesthetic is actually more dangerous than the procedure.

That's where I come in.

I could tell you that anesthesiologists are "peri-operative physicians" or that we are experts in physiology and resuscitation. Yes, we put people to sleep, but more so, we keep them alive. "Vigilance" is the motto of our professional association.

Admittedly, it is sometimes easy. A young, healthy guy having an appendectomy is a walk in the park. The chances of having an adverse reaction are quite low, almost negligible, but bad things can and do happen.

Perhaps a better way to explain is with an example:

I was recently caring for a middle-aged, basically healthy male who was having a simple spine surgery (a 2 level "foramenotomy"). I noticed right away that he had a healthy low resting heart rate in the 50s before anesthesia started. After inducing anesthesia and placing a breathing tube, his heart rate sank and rested in the mid 40s. I gave a little medicine to try to pick it up some. It didn't really change. I gave a little more. His blood pressure was still stable and his oxygen levels were fine, so I wasn't too concerned, but I was aware of the pattern emerging.

The next step was for the surgeons to place a fixation device on his head to keep his spine aligned for surgery. This is a "stimulating" process (read: painful), so I gave the patient a little fast acting pain medicine as the surgeon did his work. My eyes were fixated on the EKG because I was expecting his heart rate to increase if he felt any pain.

Instead, the numbers started to go down... 40...38...35

I said to the nurse, "Call my attending back in the room!"

35...32...28

"Get him here immediately!"

25...10...0

What? 0?

I felt on his neck for a carotid pulse. Nothing. I turn to the surgical resident, "Do you feel a pulse?" He puts his hand on the neck and says nothing."

"Call a code! He's got no pulse. I'm starting chest compressions!"

I immediately go into CPR mode and try to instruct others to do the same, but it's like the other 4 people in the room are stuck in mud. No one moves.

Two other anestheiologists fly in the room. "What's going on Sara?"

"He brad-ied down and went asystolic just as they were pinning him. He lost his pulse and I started CPR. He needs epi."

My attending says, "Wait, wait I think he's got complexes, hold your compressions."

I stop and sure enough, the patient's heart rate is back. We place an arterial line, draw labs and all looks to be normal. Our diagnosis: profound bradycardia (slow heart rate) and hypotension due to anesthesia and pain medicine in a patient with an slow heart rate at baseline.

There was no adverse outcome in this particular case, which is what makes it a good example. I spoke with the patient's wife after the successful surgery and recommended that he have a cardiac evaluation for his slow heart rate.

The thing that impressed me the most was my reaction time. I'd been watching his heart rate, his physiology all along. I know what the side effects of anesthesia drugs are and how they can effect even healthy patients. I was additionally impressed when the surgical resident said to me,

"You know, I saw his heart rate dropping, but I just kept assuming that the equipment was malfunctioning. I had no idea it was real until you were doing chest compressions."

And that's what an anesthesiologist does.

My son is a genius

Ok, I know. I'm not the first parent ever to think that their child is perhaps the most gifted individual to ever toddle on two feet. But, since it's just you and me here in the space, I'm going to put down my completely unvarnished, unadulterated, incredibly biased praise for one Samuel Atticus Weisbrod for posterity so that when he goes on to cure cancer, solve the Israel/Palestine crisis, and fix the US political system before he's 30 years old I can say "I knew it when he was 18 months old." Also, you should stop now if people talking about how awesome their kid is makes you throw up a little in your mouth (seriously, this is where I would stop if this were someone else's blog). Don't say I didn't warn you.

And let me say now before I get to far into this that my measure of success as a parent has zero to do with his cognitive ability (as long as he can support himself as an adult) and everything to do with his enduring happiness and belief in himself. But let's let that go for one moment to bask in the brilliance of Samuel A.

So, from some quick online surveying it seems that the language milestones for 18 months include a vocabulary of 12 and 50 words and understanding around 200 words. In February we counted around 150 words that Sam speaks and by now I would estimate it is around 300. His vocabulary includes words like "triangle", "motorcycle", "helicopter," and "Target" (yes, the store. Sam has learned his very first brand).

Where Sam really excels is in his knowledge of birds. Tonight, at dinner Sam looks outside and says "chickadee." Sure enough, there were two little black-capped chickadees gathering nest materials on the ground outside the window. A minute passed with us looking at them and then they flew away. I told Sam "the chickadees flew away" and he said "flew away" (he often will immitate the last two words of a sentence, particularly if he doesn't know those words). I then asked him "What else flies?" I figured I'd be answering it myself but Sam processes for a minute and then says "Robin." Seriously. I was floored. I responded "yes! A robin flies. What else flies?" And Sam said "Cardinal." Now, I knew Sam knew those words and that he could identify those birds (once, when seeing a Cardinal, he made the beginning of it's call "Cheer Cheer Birdie") but to link that to the question "What else flies?" seems unbelievable. I then said "A plane flies." And his eyes widened. And then said "Does a helicopter fly?" and he broke in to a huge grin as he made the connection around things that fly. Awesome!

Sam is also in to nursery rhymes and can recite broken but recognizable and hilariously cute versions of "Bah Bah Black Sheep," "Row Row Row your boat", "the ABCs", "Ring around the Rosy", "Twinkle, Twinkle, Little Star," and "Rain Rain Go Away." When we pass the park on the way home he will occasionally say "Home again, home again, home again, pop!" (from the nursery rime Home Again, Home Again, Piggity Pop!). Sometimes the "home agains" will continue repeating which is pretty damn adorable. If you start him off counting with "1, 2, 3" he can count up to "10" (although he does miss numbers). That's crazy for an 18 month old, right?

He also understands the concepts of names. When asked what "Mom's" name is he says "Sara"and he does the same with "Dad" and "Kyle."

Unfortunately, when we start videoing Sam's emerging language development (mostly because it is super cute), all he wants to do is grab the camera. We'll have to keep working on it. I'll make it a goal for this weekend.

Ok, I should stop now. I know I'm going to look back at this post and regret it. I already do a little bit even though I haven't yet posted it yet so I went ahead and added the up front warnings. So if you read this far and now have to brush your teeth you have no one to blame but yourself.

Trip to Bainbridge Island

As many people who have/have had a toddler can understand, it can be challenging to go outside the house for more than a few hours. As my sisters can attest on their recent visit, Sam naps for 3 hours smack in the middle of the day. So unless I head out the door first thing in the morning, it's hard to get any adventures of significant duration. Add to that, the weather in Seattle and well, let's just say that our family has not made any outings since we moved here last July.

Enter Bainbridge Island, an idyllic, artsy, well-to-do community of about 20,000 people.

We decided to go, no matter what. Despite Sam's mid-day nap, despite the awful weather, we were going. And you know what? I think in the end, we felt all the more "Seattle" for it.

We drove our car onto the ferry and enjoyed the scenery. 

No, of course it didn't actually look like the above picture. That would be what it looks during the summer. My picture looked more like this:

                            

We headed first to the most amazing playground we've ever been to. Again, it looked nothing like this picture today. The silver lining, though, was that we had it all to ourselves on a rainy Saturday morning at 10am. The big key was bringing two sets of clothes for Sam, including waterproof shell pants. I forgot Sam's rain boots, so we lined his shoes in extra sandwich bags that were in his diaper bag. Resourcefulness!

After the park, we went to a kids museum. Sam tired himself out pushing a kids 

grocery cart around and pretending to drive this smart car:

Once Sam was napping in his stroller, Kyle and I enjoyed browsing the main drag. We had a great lunch and the walked along the waterfront nature trail.

While I don't exactly love the weather of the Pacific Northwest, I do appreciate how green everything is, even in the winter months. I think the keys to living here are being prepared for the bad weather (extra clothes, and rain shield for the stroller were key) and just getting out there no matter what.