Vacation IV

I'm still on vacation and still not creating new posts. Here's a couple of my favorite poems to (maybe) keep you entertained.

He Wishes For the Clothes of Heaven, by William Yeats

Had I the heavens' embroidered cloths,
Enwrought with golden and silver light,
The blue and the dim and the dark cloths
Of night and light and the half-light,
I would spread the cloths under your feet:
But I, being poor, have only my dreams;
I have spread my dreams under your feet;
Tread softly because you tread on my dreams.


The Termite, by Ogden Nash

A primal termite knocked on wood
and tasting it, found it good.
And that is why your cousin May
fell through the parlor floor today.

Vacation III

While on vacation, I'm not writing new posts. Here's a rerun of a post from February. The OB's at my hospital are still having fathers - and others - cut the cord, so I guess they're not reading my blog.

Fathers

I feel a little sorry for fathers in the delivery room, because let’s face it, they’re pretty useless there. At best, if they’ve been to a birthing class they can maybe count while their wife or girlfriend breathes or pushes, but any nurse could do that just as well, or perhaps they can give a small amount of emotional support to the mother. At worst, they can foul things up by fainting or needing to be led from the room because they can’t take it anymore. The fact that their wife or girlfriend is doing one of the most difficult human tasks in life – as the saying goes, there’s a reason they call it labor - can only emphasize their feeling of inadequacy. Mind you, I don’t blame the father for this. The delivery room is a new and scary situation for them, and that is compounded by the worry they have for their significant other and child.

Unfortunately, some genius many years ago came up with the idea of making the father feel useful by having them cut the umbilical cord. This has been the bane of neonatologists ever since. We’ll be called to a delivery because there is concern about the baby’s health, perhaps because of meconium stained fluid, maybe because the baby’s heart rate is low, only to have to wait to receive the baby while the father painstakingly cuts the cord. Give us a break, people! If you want us to be there for the baby, then give us the baby as soon as possible.

I’m not sure how cutting the cord is even symbolically important. Is it supposed to mean that now the baby is no longer dependent on the mother alone, but on both parents? If so, then why has the practice spread to include grandmothers, aunts, and other bystanders cutting the cord?

Dads, let the mother have all the attention and glory in the delivery room. They deserve it, and a puny thing like cutting the cord won’t begin to change that. Rest easy with the knowledge that there will be plenty for you to do, and plenty of rewards, in the years ahead. Stick around – too many fathers don’t – the real work of fatherhood is just beginning.

Vacation II

Instead of creating original posts while on vacation, I'm having fun with some other things. Today I'd like to quote some excerpts from actual court transcripts, as taken from Uncle John's Great Big Bathroom Reader. I think they're kind of funny, which is appropriate, since my experience with the the legal system is that it's much closer to theater of the absurd than cinema verite.

Q: "What did he say?"
A: "About that? All the way back he - I've never been called so many names."
Q: "You're not married, I take it."

Q: "What is the meaning of sperm being present?"
A: "It indicates intercourse. "
Q: "Male sperm?"
A: "That is the only kind I know."

Q: "And lastly, Gary, all your responses must be oral. Okay?"
A: "Oral."
Q: "How old are you?"
A: "Oral."

Vacation

Neonatal Doc is going on vacation. Yes! I'll be on vacation for about nine days. While on vacation, I don't plan to write any new posts. However, if I can find a working wi-fi spot in the burg we're going to, I'll still try to post something every couple of days. They might be reruns of old posts, from when no one was reading me, or maybe I'll just tell some jokes or something.

If I can't find a working wi-fi spot, then I'll see you in nine days. Have a great week!

Prematurity

A few days ago the Institute of Medicine released a report showing that there has been a 30% increase in the rate of premature birth in the U.S. since 1981. One of every eight babies born in the U.S. is born prematurely. The economic burden associated with it, that is, how much it costs to take care of these premies, is 26.2 billion dollars, or about $51,000 per premie. Obviously, the more premature you are, the greater the cost.

I haven't seen the actual report, just a news article about it, but for those of us who work in the field this is not a surprise. We've known for a number of years that the rate of prematurity is increasing. We've also known for a number of years that we don't know why the rate of prematurity is increasing, and we certainly don't know how to prevent it.

We know that certain infertility treatments increase the risk of multiple births, which increases the chance of premature delivery, but that accounts for just a small proportion of the increase. The report recommends that we take steps to decrease the number of multiple birth pregnancies - such as implanting only one or two embryos when doing in vitro fertilization - but that's just a drop in the bucket. For years, I've heard people saying we need more research into causes of prematurity, and we do. It just makes you feel a little impotent to be able to do nothing more about it besides call for more research.

Often reports like these are accompanied by hand wringing about how bad the U.S.'s infant mortality rate (IMR) is. We are far from first in the world in that measure of public health. I think we're around 20th, although I haven't looked it up recently. About now we will also likely hear statements meant to shame us that say the infant mortality rate in some of our inner cities is the same as that of some third world countries. These are bad things, but I'd like to point out one reason why our infant mortality rates will never be best in the world.

Blacks have a higher rate of premature birth than whites, 17.8% versus 11.5%. We don't know why that is, but it seems to be a biological phenomenon, and not just due to socioeconomic factors. Blacks of the same educational and economic levels as white counterparts still have more premature births. Since premature birth is one of the main contibutors to the infant mortality rate, countries that have more blacks are going to have a higher infant mortality rate. We are never going to be able to compete, in terms of infant mortality rate, with countries with more homogeneous populations like Japan (a perennial high achiever in IMR) and the Scandinavian countries.

I'm not saying we should be proud of our showing in the IMR rankings, or that we shouldn't try to improve it. I guess I'm just trying to point out that our high IMR is not a blanket indictment of our health system, as some would have it.

Pump

"Complete Health Care HMO. May I help you?"

"Yes, I'd like to order a hospital grade electric breast pump for a patient."

"I'm sorry, we don't cover those."

"But you're required to cover them...."

The above is a template of a common conversation I and several of our NICU nurses have had with various Medicaid HMO's in our state. Most of my patients have some type of Medicaid, and it is usually with a Medicaid HMO. (The state pays the HMO a monthly fee per person enrolled, and the HMO pays for that person's health care. The less the HMO pays out, the more profit it makes.) These Medicaid HMO's are required to cover hospital grade electric breast pumps, because straight Medicaid covers them and Medicaid HMO's by law have to cover everything straight Medicaid does, but getting them to provide them is like pulling teeth. I'm not sure if it's so hard just because many of the HMO employees are incompetent, or because the HMO wants to make it difficult, hoping people will give up, which they sometimes do, so they won't have to pay for the pump.

Most people reading this know that breast milk is the best food for an infant, but perhaps not all of you realize that it is even more important for a very premature baby. Necrotizing enterocolitis (NEC) - think of it as sort of a lethal infection of a baby's intestine, although it's a little more complicated than that - is a dreaded killer of premies. Babies who are fed breastmilk are less likely to get NEC. Also, a study in this month's Pediatrics reminds us that premies fed breast milk have higher intelligence scores when tested at age 18 months - the equivalent of about 5 I.Q. points higher. The advantages of breast milk are so great that when a tiny premie is born, I ask the mother to pump her breasts for milk for her baby even if she wasn't planning to breastfeed. Most of them do it, but it doesn't always last.

Which is where the hospital grade electric breast pump comes in. The easier it is for a woman to pump - and I'm told the hospital grade electric pumps are vastly superior to hand held pumps - the easier it is for her to maintain her milk supply. So when a Medicaid HMO makes it hard for us to get a good breast pump, as they almost invariably do, sometimes successfully, they are decreasing a baby's chance of survival, as well as decreasing his or her chance of an optimal I.Q. I'm not exaggerating. When HMO's make it hard to get a good breast pump through either planned or unplanned incompetence, they are toying with manslaughter.

There are many forms of health care insurance coverage, such as HMO's, fee for service, and single payor plans. Each has its advantages and disdvantages. But as long as a company's profit is enlarged by denying health care or health care equipment, as is the case with HMO's, needed care will sometimes be denied.


P.S. Check out the new pediatric grand rounds.

Shaken

I'm used to seeing young mothers with lots of children, but even I was taken aback when I went to the delivery of a mother having a scheduled repeat Caesarean section. At the age of twenty years, she was having her fourth C-section. I could only sigh.

Mom said she was putting this baby up for adoption, as she had her other three children, but she wanted the baby to stay in her room until she went home. This is not that unusual. It turned out, though, that her other three children were removed from her home by Protective Services because of abuse. Apparently mom had shaken one or more of her babies.

Many of you have probably heard of shaken baby syndrome. It occurs when someone holds an infant in front of them and shakes them to and fro, causing their head to flip repeatedly and rapidly from front to back. That shaking alone can cause bleeding into the baby's brain, in some cases causing significant brain damage. The baby's head doesn't have to hit anything, so there may be absolutely no external signs of abuse. A tell-tale sign, though, is the presence of retinal hemorrhages - patches of bleeding in the back of the eye that can be seen when a doctor examines the eye with an ophthalmoscope, that really bright light we shine into people's eyes.

Because of the Protective Services involvement, we kept the baby in our special care nursery until P.S. could check out the home again and determine whether this baby could go home with mom. The mother has been faithfully visiting her baby and feeding her. She acts like she really loves this baby, and I believe she does. I think she probably loves her other children too, even the one or more she shook. It's a bit paradoxical, but I think a lot of child abusers love the kids they abuse. They just can't help themselves, though, or their temper gets the best of them, and they harm their children anyway. They're not monsters - in fact, they are very much like you and me. They just get out of control sometimes.

It's sad to see kids taken away from parents who love them, but it is absolutely necessary in cases of abuse. It's too bad we haven't figured out a way to make that love all encompassing, so it overrides any fits of anger and abuse. I guess it's just another example of the imperfect world in which we live.

Misfortune

I long ago reconciled myself to the fact that I make my living off of other people's misfortune. I rationalize it to myself by saying that I don't really want babies to get sick; I just want them to come to me if they are sick. Yet, somewhere deep in my psyche, there is part of me that probably does want babies to get sick. Otherwise I wouldn't have a job.

I am reminded of the time in medical school when I listened to a very abnormal heart for the first time. The elderly patient had an artificial heart valve, and his heart wasn't working too well. When I put my stethescope on his chest, instead of hearing the usual "lub dup, lub dup" sound of a normal beating heart, I heard "whooosh pop click, whooosh pop click." I almost wanted to say out loud, "Wow, cool!", because that's how I felt. The elderly man's misfortune was an exciting moment for me, but he probably didn't think it was too cool to have that bad heart.

The other night on call I went to the labor and delivery area to see what was on "the board", a list of the women in labor, to see if there were any potential NICU patients. We were busy and didn't really need more patients. I scanned over the list and came across one who was premature. I started to frown, but wait, there was an IUFD sign on her spot. Before I could catch myself, I thought "Oh, good, it's an IUFD." I immediately felt bad, though, for thinking that, because IUFD stands for intrauterine fetal demise. She was going to have to deliver a stillborn child, a terrible thing for anybody, but not something that would involve me. It seemed like a sick thing for me to be glad about it, but I couldn't help it, because her IUFD meant an easier call night. If she had a live premature baby, it might have kept me up that night.

It can be a weird business sometimes.

Information

Any day now a new issue of the medical journal Pediatrics is going to arrive, and itwill be chock full of articles related to my specialty. I recently received my monthly copy of Journal of Pediatrics, another journal loaded with information relevant to me. Every three months I receive an issue of Clinics in Perinatology, containing a few hundred pages of usually neonatal information. The latest edition of the Neonatal Resuscitation Textbook just arrived - I'd better be up on that. And every week a new issue of the New England Journal of Medicine shows up in my mail slot. It doesn't have a lot of neonatal stuff, but plenty of other interesting medical information I'd like to know.

I like to keep up with what's new in neonatology and to some extent with medicine in general, but it can be really hard to do. The volume of information out there and available to read is astounding. I have to pick and choose the things most relevant; there is no way I can read everything related to neonatology. I find myself hoping that the new issue of Pediatrics or Journal of Pediatrics won't have many neonatal articles, just so there will be less to read that month.

And I'm in a subspecialty. People in broader fields, such as general pediatrics or internal medicine, have an even tougher time. A general pediatrician has to keep up with topics as varied as infant meningitis, school problems, and birth control. Then there's the family practitioner. Keeping up with everything in medicine seems just impossible.

In fact - and I'll probably take some criticism for this - I'm not sure that family practice as a specialty should continue to exist. Medicine is complicated, and it will only get more complicated. There's a huge explosion of information, and it's pretty important that a doctor knows the right information. I simply don't think one person, a family practitioner, can keep up with it well enough.

Instead of family practitioners, I think there should be family clinics. The kids could see a pediatrician there, the adults an internist or obstetrician, and so on. No offense to my family practice colleagues, but I think a pediatrician does a better job taking care of kids than they do, and the same is probably true for an internist regarding adults.

This could be a big topic, but I'd better stop here. Besides, I should probably be reading a journal instead of blogging....

Debacle

I hope you'll excuse me for writing a non-medical post with political overtones, but I can't not write about the debacle in Iraq any longer.

A couple of days ago National Public Radio had a story about the number of civilian casualties there have been in Iraq since the American invasion. Hard figures are difficult to come by, of course, but the estimate is that somewhere between 35,000 and 45,000 civilians have been killed in the violence. That number does not include deaths of soldiers or combatants on all sides, which would obviously inflate the figure. The Baghdad morgue handles 1400 to 1600 bodies a month. It is overflowing. These figures are both awesome and awful. Whoever is responsible for it should be ashamed.

And who is responsible for it? Certainly Al Qaeda and other insurgents have to take some blame. Clerics who foment ethnic violence and militants who practice it are guilty. Suicide bombers who think it's valiant to kill a dozen people along with themselves are despicable. But most of all, we have to blame the U.S. for this mess. We started it. We brought to Iraq at least three years of chaos and sectarian violence with no way to stop it. We started a cycle of violence that has already killed more than 35,000 civilians, with no realistic end in sight. Another sad fact is that well into the mess we re-elected as President the bonehead who started it. To make matters worse, we have lost any high moral ground we may have had by our hideous practices at Abu Graib and by ignoring the Geneva convention at Guantanamo.

If given the choice, I wonder if Iraqis would prefer to have the 35,000 to 45,000 civilians still living but with Saddam Hussein still in power, or whether they think the loss of life is worth it for the government they have now. I think I know what the answer of people who lost sons and daughters and spouses is.

P.S. What should we do about this mess? I say, let's divide the country into three parts already, Sunni, Shiite, and Kurdish, and be done with it.

P.S.S. Thanks for letting me get this off my chest.

Humanity

The NICU was crazy busy, one of those days when sick babies just kept on coming. Everyone was doing something, monitors were alarming, and staff were calling impatiently for help with this or that. Sitting on a stool in the middle of the commotion sat a woman alone, weeping. Her 27 week gestation baby had just died at two days of age. She was a heroine addict, thin and cachectic, with no friend or family around for support. After I told her about her baby's death, I unfortunately had to leave her alone to care for one of the living, and now she looked about as alone as anyone could be. Finally one of the nurse practitioners had a moment to put her arm around her and move her a little out of the way of the busy aisle she was in.

This happened twenty years ago, during my fellowship training in neonatology, and I will never forget her. It struck me that she was about as different a person from me as there could be in the U.S. She was black, lower class, jobless, and probably without enough food. Her days were dominated by the need to find drugs, and many would consider her one of the dregs of society. On the other hand, I was middle class, not black, had never in my life lacked for food, and was well on my way towards a respectable career.

Yet looking at her then, I realized how very similar we really were. Stripped to the core of our humanity, as we are in times of extreme emotion, she was just like me. She grieved for the death and loss of her baby just as I or a middle class mother would grieve. At that moment in time, her place in society didn't matter. She was a devastated mother, just as women in all places and from all times are when their child dies.

I sometimes wonder what happened to her. She might not be alive anymore; heroin addicts don't have a terribly long life expectancy. If she is, though, I'm guessing she still thinks of that baby every day.

News

I have good news and bad news.

The good news, which you may have already heard, is that there is a new vaccine effective against the human papilloma viruses (HPV) that cause 70% of cervical cancer. It also provides immunity to two of the viruses that cause genital warts. It has the potential to save thousands of lives in the U.S. each year and should have an even greater impact in developing countries, where pap smears are not obtained as regularly and more cervical cancer presents at a later stage, resulting in a higher death rate.

The bad news is that some people don't want to give it to their kids because they think it will make them go out and have sex. I find this slightly unbelievable, although I really shouldn't be surprised, because I know full well that the efforts of such people have really hampered sex education in the U.S.

The general principle of these naysayers seems to be that any discussion of ways to make sex safer or have fewer consequences will automatically make it more likely that young people will have sex. I don't think that's true, nor do I think there is any data to support that view. (Unfortunately, this subject is more often discussed with emotion as the foundation rather than data.) Plus, it stands to reason that what is learned in the child's home and upbringing will influence them much more than any sex education in the schools.

Don't get me wrong. I don't mind if people want to teach abstinence as a way to avoid pregnancy and sexually transmitted diseases. It's a free country, and people can believe what they want. Also, I happen to think that abstinence followed by monogamy has a lot of advantages. I personally don't mind if that is taught in schools, and it certainly can be taught in the home. But we can't teach only abstinence; we have to also teach birth control and use measures like the HPV vaccine to prevent some bad consequences of sex. I think that kids are sophisticated enough to hear the twin messages of abstinence being a good thing, but that if you are not abstinent, use some protection - please! To teach only abstinence is to deny a basic reality of our world: lots of people have sex (and lots of people have venereal diseases, unintended pregnancies, and cervical cancer.)

I feel sorry for the kids of people who will deny their kids the HPV vaccine. In essence, they are increasing the chances that their children will get cancer. That just doesn't sound like good parenting to me.

Special

I went to the delivery of a full term baby yesterday whose mother's water had broken 24 hours before delivery. That's longer than usual and increases the chances that the mother and baby might get infections. In fact, this mother had some chills prior to delivery, and the baby's heart rate was fast, both signs of possible infection. After the baby was born she breathed more rapidly than she should, which bought her a trip to our special care nursery for some antibiotics and observation.

This was a pretty easy case for us. It's a fairly common situation, the baby wasn't very sick, and we weren't too excited about it. In fact, I wanted to get the orders done right away so I could finish my rounds. I'm always a little on edge until I can get those rounds done and the NICU babies' care, especially that of the critically ill ones, settled for the day.

For the parents, though, this was far from a routine thing. This was their first baby; the possibilility of a serious infection was a major worry. Also, they naturally wanted the baby in mother's room so she could breast feed. They had a million questions, and it was all I could do to remain patient and answer all of them.

This is a bit of a problem for health care workers. A huge, special event in people's lives - for example, the birth of a baby - is a routine thing for us. If that baby turns out to have a problem, it's an even bigger deal for the family - but still might be sort of a ho-hum thing for us, and it can be hard to treat it like the big deal the family expects it to be treated as. If we don't act like it's a major thing, we can come off as seeming cavalier to the family.

When I left the parents of the smelly baby in the delivery room, taking their baby with me, they seemed a little shell shocked. Fortunately, I was able to speak to them at more length later in the day, after I had finished my rounds, and we had a great conversation. They were an extremely nice family; it was a pleasure to play a part in the birth and well being of their child. It's just hard to remember sometimes what a privilege it is to have my job and take part in so many special moments.


P.S. A new grand rounds is up at Dr. Rangel's blog.

Introspection

I can't begin to count how many times this has happened to me. I go to a delivery and while waiting for the baby to deliver try to find some history on the mother and fill out our delivery room consult form. Besides looking for basic things like the mother's age and number of pregnancies, we also want to know some of her lab results, such as blood type and tests for hepatitis, syphilis, and HIV status. However, in this case I can find practically nothing about the mother. Why? It's not because the mother didn't have them done; it's because the obstetrician's office didn't communicate the results to the hospital.

Women who have prenatal care have these tests usually done in early or mid pregnancy. Obstetricians, whether at our clinic or in private practice, are supposed to send these results to the Labor and Delivery area of our hospital when the mother is about 34 weeks along, so we will have them when the mother comes in to deliver. This is a common arrangement, but at our hospital obstetricians only do this in about 60% of pregnancies. For some obstetricians the percentage is much lower. There is no good reason why some of them don't send them in; rather, it usually occurs because of laziness or inefficiency on the part of the obstetrician or his or her staff. When the results have not been forwarded to the hospital, the labs are drawn again when the woman is admitted in labor. Tests, sometimes expensive ones, are repeated. It might not seem like a large amount of money per patient, but when you multiply the cost per patient by several hundred - the number of times per year we need to duplicate tests unnecessarily - it adds up to a significant chunk of change.

I write this post in response to Dr. Rangel's request for ideas about what's wrong with the U.S healthcare system for this week's Grand Rounds. I'm sure there will be many fine posts about things like malpractice and tort reform, access issues, payor and insurance reform, or simply about getting rid of as many administrative layers as possible. But too often we doctors are unwilling to look at ourselves and at what we can do right now to improve healthcare. I'm not saying that improving the rate at which OB's send in their prenatal labs is a huge thing, but I bet that in every specialty other doctors could come up with similar examples of wasted or duplicate tests, wasted simply because we are unwilling to make our offices or clinics as efficient as they could be. There are other examples of waste due to our own laziness, too. I hear internists in our hospital complaining that they have to keep patients in the hospital an extra day because an X-ray result is not back yet. It's not back yet? Well, then go down to radiology and find the film and a radiologist to read it. And the lax job we physicians do in getting rid of bad doctors is a whole other topic.

There are lots of people we can blame for problems in healthcare, but physician friends, we have to fix our own problems before we can expect others to fix theirs. And by the way, although I recognize there are many problems with U.S. healthcare, I still think it's the best in the world.


P.S. A new Pediatric Grand Rounds is up.