Wednesday, April 29, 2015

Dr. Rebecca Kukla on Ultrasound Laws: a Rebuttal

Recently, Dr. Rebecca Kukla visited the university with which my college of medicine is associated. Sponsored by the departments of philosophy and humanities (and probably women's studies), she lectured on mandatory ultrasound laws regulating abortion. Her thesis: even those who favor restricted access to abortion should reject these laws, since they are bad for women and bad for clinicians.

Bad for women. Dr. Kukla argues that because the first ultrasound has become a very ritualized event (indicated by the prevalence of ultrasound pictures as the baby's first picture, the anthropomorphic language of ultrasound techs, the industry of cute-to-kitchsy merchandise to display the photos) which people use to transform themselves into fathers, mothers, families, siblings, etc. To subject a woman contemplating abortion to this ritual is traumatic and may make her choice more difficult.

Bad for clinicians. Law should not govern medicine, especially about disclosing information; the attempt to do this preoperatively (while noble) has resulted in uselessly long forms that don't demonstrably benefit patient autonomy. Realistically, physicians cannot present all possible information to their patients, nor should they, since this can be unhelpful, overwhelming, and unwanted in some cases. Physicians have the right and duty to select what kind of information is most helpful to the patient; these laws make this impossible by mandating a one-size-fits-all approach.

But it's actually Dr. Kukla's position which is bad for women and their healthcare providers.

Bad for women. I encourage us to look to the reason rituals develop. The first ultrasound has become ritualized because of the power of ultrasound to reveal what the fetus is--it allows us to sense the body and movement that we couldn't see or feel before. An ultrasound reveals a reality that already exists: an autonomous, immature organism of the human species. I agree that parents use it as an announcement tool, but they're not being transformed in any true way. Instead, they're seeing the cause of that transformation for the first time.

This part of the rebuttal relies on a premise that Dr. Kukla would probably reject--the premise that pregnancy = motherhood, that embryo/fetus = child. But even without this premise, I still have something to say, because another fundamental error in this argument is consequentialism.

To subject a woman contemplating abortion to revelation about her condition will inform her choice. I agree that this may be traumatic for her, and make her choice more difficult. But we should not base our decisions on the emotional consequences they incur; we should make decisions based on whether they are right or wrong. We don't avoid invasive procedures, chemotherapy, or psychotherapy because they are painful. We give family members of ICU patients all information about very dismal prognoses, even though that may make their decision to continue or withdraw treatment difficult. Information does not endanger freedom, although it may endanger the likelihood of someone choosing a particular option (such as to abort).

Dr. Kukla or others rightly point out that post-abortive women who are conflicted or wavering about her decision to abort have more symptoms of PTSD. They argue that we should not do anything to cause ambivalence, because this could contribute to a higher incidence of PTSD. I would repeat that we cannot make decisions (such as to perform ultrasound or not) based solely on their consequences. Instead, we should be open about risk of mental health problems and the risk factors that increase them. So, we should counsel patients about the importance of confidence in her decision, to promote her mental health. If she cannot be confident at the time of the clinical encounter, I would encourage her to take some time to consider her choice, and schedule a follow-up visit with her. This ensures that I am truly serving the patient to make the choice she can be comfortable with, not rush into the choice I want her to make.                              

Bad for clinicians. I agree that law should not govern medical practice. Medicine should govern medical practice. Protocols for ultrasound before abortion should come as "standard of care" recommendations from a professional organization, not as a regulation from lawmakers. This stems from the duty of physicians and healthcare providers to provide best practice for their patients.

But one of the duties of lawmakers is to protect citizens from injustice. When "injustice" and "failure in best practice" coincide, lawmakers must be act when physicians do not.

This argument depends on premises that Dr. Kukla would not accept, premises such as the gravity of abortion for a woman and a fetus. Without acknowledgement of the gravity of abortion, it is difficult to argue that "failure in best practice" is occurring in abortion without ultrasound. It is almost impossible to see how "injustice" applies at all.

An enormous inflamed appendix. (Want to see a gallbladder?)
So what would I say to Dr. Kukla? I did raise my hand and speak. I said nothing about being pro-life, nothing about fetuses. I also didn't start an argument about what ultrasounds are. I didn't get to finish, but here's what I wish I could've said, in full:

"I wish this policy had come from ACOG. The practice itself makes sense, because it makes terminations like other minor surgical procedures--you know, for gallbladders and appendices. They do ultrasounds for those, and good docs go over scans with their patients before elective surgeries."

Friday, April 17, 2015

24-Hour Call on L&D: A Breath of Fresh Air

This post conforms to the blog rules.This minipost started during an away and was never written. It's the story of two 24-hour L&D shifts in the middle of a urogynecology rotation. The attending belittled me and taught me nothing, and I missed obstetrics. So when I heard that "acting interns usually take the Thursday 24-hour shifts," I was ecstatic. So, as an escape from my attending (and away to see more of the residency program, because this was an audition rotation), I took call. It was wonderful to be with laboring women, L&D nurses, infants, and fathers. I saw a D&C for retained placenta, a sacral dystocia (yeah, weird), and a few sections (at one of which I legitimately impressed the resident with my running subcuticular, which I have been perfecting since the summer after M1). It was wonderful.

Sunday, April 12, 2015

Stories from the ER: Bedbugs

This post conforms to the blog rules.In college, I devoured books written by medical trainees. I read Singular Intimacies, Complications, and A Not Entirely Benign Procedure (and others) as a college student. Having read these, I think I could've said about medical school what St. Therese said about the convent: I went in with my eyes open, and I was right.

When I read Danielle Ofri's story of a homeless, bug-covered man who came in through Bellevue's emergency department, I thought, "I know med school is an experience, but that's too crazy to happen to anyone but people who write books." Crazy books about crazy NYC hospitals.


A disclaimer: this story contains a few nasty things, including bedbugs and elder abuse. There will be no exaggeration. There's a happy ending.

During my ER rotation, a woman was brought in covered in bedbugs. The attending sent me in to see her and I went into the room at my usual busy pace. One of the EMTs, still packing up his stretcher, halted my progress with a few words. "You might want to...." the EMT started, then tried again: "She's sort of...covered."

Then my eyes registered the hundreds of mini-M&M sized insects swarming in and out of her clothes, around her arms and legs and fingers, on her neck, and on her sheets. I stopped short, my shoes almost squeaking on the lineoleum with the abruptness of my deceleration.

The woman herself was moaning.

"What's the story?" I asked the EMT.

"She called about pain. We had to break the door down. Found her in a chair, in feces and urine and--" he gestured to the insects "--those. Vitals were stable in transport."

With that, he left. From a safe distance, I took a history as best as I could. (I was a little disgusted.) The woman lived alone. She was unable to get out of her chair. She didn't eat or drink. Everyone once in a while a neighbor brought a sandwich. The last time he'd come was three days ago. The neighbor doesn't get too close. Nobody cleans her. Nobody cleans her house. She had home health, but they didn't come too close. She had had pain "in her seat" for a while, but didn't talk to anyone about it. She called 911 about it today.

I left the room without doing a physical exam, as the ER nurse was posting a "DECONTAMINATION" sign on the door. I was angry; elder abuse is something I feel very strongly about. I went to my attending and told him the situation.

"Someone's going to get sued," he said, meaning the home health organization.

"I'd like to help decontaminate," I said.

"Be my guest," he replied.

Outside her door, nurses were gowning up as if the patient had Ebola. I joined in: boots, cap, two gowns (the flimsy ones that only cover half of you; one for each half), and mask with face shield. None of us were wanting to take bedbugs home. We were already itchy.

I turned my anger into zeal and worked alongside the nurses, overcoming my disgust and turning myself into Love to this woman. We brought in large trash bags and a dozen packets of moist skin towelettes. Then we took off and threw away the woman's clothing and all the sheet's she'd touched. We wiped bugs and bug carcasses off her body. I cleaned where the nurses didn't. It turned out she had two decubitus ulcers from sitting so long.

It was a terrible day (that patient, plus a death, plus family troubles). That night I told Jesus all about it. "What was Your day like?" I asked, in a slightly complainy tone. And He answered, in my imagination. (This is the happy ending.)

"Someone cleaned Me."

Tuesday, April 7, 2015

Stories from the ER: Motherhood

This post conforms to the blog rules.While working in the ER last semester, I met a woman who surprised me by her reverence for motherhood. Because there was real concern that she might have colon cancer (like classic-history, I-was-actually-scared-for-her concern), a CT scan was being ordered.

But one of the CT scanners was broken, so there was a long line for the other one. Worse, trauma cases kept rolling in that night. This woman had been in the ER for seven hours, and she was still awaiting her scan. She threatened to leave. The attending talked to her and came back. The nurse returned twenty minutes later. "She says she's gonna go," the nurse said. Her (perfectly acceptable) facial expression said, "And I'm resigned about it."

"I'll talk to her," I said. Talking to upset people is one of my favorite things to do, ever since I deescalated a potential emotional explosion in the psych ER waiting room and someone told me I was good at it. My theory is: it can't get any worse, and you can only make it better!

The attending was busy, so he let me. I went in and sat down, preparing for a long haul. My intention was to sit with that woman and talk with her until a radiology tech came to take her to the CT scanner. It was something I was uniquely poised to do, because I didn't have true clinical responsibility and I could be functionally absent for whole hours, if necessary. It would be good for this patient and our ER if she stayed--she'd know more about her colon (cancer?) and the ER wouldn't have her back in two months with inoperable disease. So the attending let me go, and I plopped down at her bedside, hoping to distract her.

It worked beautifully.

After a few minutes of expressing her displeasure about the wait, I got her talking about all kinds of things. TV shows, her day, traffic, weather, her old jobs, her family. Her favorite topic was her grandchildren. Her voice changed from unpleasant to soft and full of fondness. When she started talking about when she first became a mother, something peculiar happened.

Alfred Gilbert: Mother Teaching Child
"Oh," she said, looking at me with something between mischievousness and envy, "when you find your man and have a baby...! There ain't nothing like it, no where in this world. Nothing like giving birth, it's--tch!--can't be described a'tall. Miraculous."

Our roles suddenly reversed. I was no longer in power, pinning her down as one who knew better. She was instantly a queen, telling a little girl about magic.

"Really?" I asked.

"People say it's painful. I say 'ha!' Pain is nothin' compared to what you have. Your baby growin' inside you, then your baby in your hands. Just you wait, you're gonna be a good one. Now," she said, pragmatically, "how long I gotta wait for this CT?"

I grinned enormously. She'd taken me off my guard and my silver-tongued attempts to keep her in bed were suddenly exposed. I have a feeling she knew what I was up to the entire time, and was letting me win.

"I'm being honest," she said. "I still want to go."

"I'll ask," I said. I found out she was third in line and went back to her. "Number three!" I said, like we'd both won the lottery.

"Three?" she said, smiling. "Guess I'll stay, then."

I have no idea what the results of the CT were (it was read after my shift was over), but I got her to stay until she was in the scanner. She stands out in my mind as someone who values motherhood; even if she knew what I was up to, she was serious when she described how marvelous it is. I think of her frequently now and I try to have that esteem for motherhood, too.

Saturday, April 4, 2015

Stories from the ER: Elder Neglect

This post conforms to the blog rules.The ER rotation was four weeks of shifts during interview season, during which I saw the entire spectrum of urgent to extremely-emergent care. I inserted IVs and foleys, I did ultrasounds, I put on splints, and I stitched up lacerations (the highlights of which were a flap closure on a woman's nose and an 11-centimeter arm lac). I also saw patients and attendings work their way through crises, deaths, and long waits for the CT machine. Here are a few of the stories that had the strongest impact on me.

An elderly man with COPD on oxygen came in with vague complaints. He had been to the ER (brought by EMS) several times in the past for similar things. He was cachectic, his lips were terribly chapped, and his saliva was thick and white. As I took his history, it became clear that this was a case of elder neglect: his children didn't visit and he was alone all day. He said he didn't drink much water, because his oxygen tubing wasn't long enough for him to get to the bathroom in time. His teeth were caked in plaque and tartar because of his dehydration. I saw in the medical record that he'd declined home health nursing before, and I knew I had to do something to change his mind.

It was a long history-taking session. I knew my attending would be wondering what took so long, but for once, I decided not to care. This man needed someone to sit down and be quiet, to appreciate his loneliness and change it. At the end of a long monologue of truly tragic complaints, I said. "I'm sorry."

"It's not your fault," he said.

"But it feels terrible to be isolated."

His eyes stayed on me for half a second, because he saw that I'd understood. "Yes," he whispered.

I asked him about his previous decisions on home health. He didn't like that home health nurses made such quick, business-like visits. We talked about more prolonged companions. As I left he squeezed my hand. "Thank you," he said. I smiled, and I went back to my attending and with a very short presentation. "This is an 89-year old white gentleman with COPD who is suffering from a very lonely home situation, and needs a social work consult for an in-home companion." As I moved onto the next patient, social work was arranging something.

I wish we took care of our elderly in our homes. When interviewing out of state, I stayed with one Catholic family who gave me the best example of this I've ever seen. They had emptied their front living room of furniture so that their elderly, demented mother could have a hospital bed and a lift chair there. This woman was nonverbal and could not move by herself, but her daughter kept her at home. The room opened onto the kitchen so that this elderly mother could join in family meals and engage with her grandchildren doing homework at the table, in the very limited way that she could. She could be heard if she moaned, and she could be checked on easily. 

In this case, both spouses were physicians (one a retired, stay-at-home parent), so I know they were competent to do this. But in many situations, competence in caring for an elderly parent is easy to gain from a few weeks of home health visits. It's not competence, but generosity that is frequently lacking. Most don't realize how isolating and miserable life becomes for someone so rich in life experience and so used to social interaction. It takes generosity to place yourself in the position of an elderly person, and further generosity to improve that position by opening your home.

This patient could certainly be cared for in a son or daughter's home, provided that someone was at home for at least half a day. I ask any young professionals or young married couples reading to please remember to care for your parents!