The Dreaded Moment

[Guest Biochem10]

I just wanted to add a comment that I can see both sides of the argument. I've met many babies/kids with Down's Syndrome at the Transplant unit in the hospital I was volunteering at and I think there's much more to this disability than the mental retardation aspect. I don't think anyone's life is worthless, but seeing what some of these kids and parents go through made me realize that testing for a disability in-utero is a personal choice. The kids I've met have undergone several surgeries, some with serious complications and i can see how a future parent might want to avoid having to go through that and avoid having their child go through that. I'm sure it would take a lot away (time, energy etc.) from the whole family to have a child who is constantly hospitalized (some parents may feel that these sacrifices are worth it or may feel like "this is God's way", if they are religious--I totally respect those positions) As far as I can see no one here agrees with eugenics and we all believe that you have to draw the line somewhere-- allowing only severe disabilities to be considered for testing and not things like choosing sex, eye colour etc. I truly believe that many people with disabilities live fulfilling and long lives, however, that's not to say that having a choice to abort when there is a serious disability is wrong, it's just a matter of how much the mother/family can handle and whether the child will be happy and not suffer as a consequence of being conceived.

 

I also believe it's important to have an open mind, you'll probably encounter people with opinions on both extremes of the spectrum when practicing medicine.

[Guest not rex morgan]

As for gross, I'm not too worried about that, although being vomited on by an adult may be a bit disgusting. I have done digital rectal exams, pelvics, seen people in the burn unit, assisted in an abortion, etc. The one thing that worries me the most at this point in time (possibly b/c I'm cramming psyc) is dealing with people with major personality disorders, especially the cluster B's, as they can be really dangerous. Narcissists, histrionics, borderlines...all somewhat stable when you first meet them, then as time goes by, you don't know how to help them, treat them, or help others who live with them. It must be very scary to have a major psychiatric disorder (if you can recognise it, yourself). As it's one of the last uncharted fields, it scares me.

[Guest Ian Wong]

Draining abscesses (large collections of whitish/yellow/green/use your imagination pus) is pretty disgusting. Cool and neat, but also nasty. The smell can be downright putrid.

 

Getting your shoes and legs soaked in amniotic fluid, blood and feces while doing a delivery ranks right up there in the "ugly" factor too.

 

Ian

[Guest MayFlower1]

Notrexmorgan...

 

...I strongly suggest reading the book "I hate you...don't leave me." I'll try to dig up the reference for you. I lived with a borderline (ex wife)...this was a very helpful book. As most "good" borderlines are very intelligent I would recommend, at your discretion of course, giving them the reference too...

 

Unfortunately, dealing with borderline behaviour is really trying and difficult...you have to be firm, establish clear boundaries...and stick by them...easier said than done. The hardest thing, in my opinion, is that they have a way of taking your weaknesses and using them against you by in very subtle and manipulative ways...often in very passive/aggressive ways as I'm sure you can appreciate. I found my ex often projected her issues onto me...very difficult to deal with.

 

Sorry...the psych guy in me came out there for a minute...darn!

 

Peter

[Guest MayFlower1]

Ian,

 

That's the one smell that actually does get me a bit...especially, subaceous cysts...yuccky!

 

The amniotic fluid, etc., from birth isn't exactly pretty...but, for some reason, that one doesn't bother me that much...although the only time I've been "sprayed" was when watching my children being born...probably a different experience when you don't know the woman...

 

Peter

[Guest not rex morgan]

Hey Peter. Thanks for the reference. I think part of the nervousness in dealing with people with personality disorders is that interactions are not logical, and I, quite frankly, don't know much more about them than what Toronto Notes has told me. I don't think I'll be reading the book before the exam, but it sounds like a worthy read when I have more time. As for the amniotic fluid thing, yeah it can be a little gross. I watched my friend's baby being born. I think I was more in horror of the pain and distortion than anything. The baby was huge and therefore probably not the first birth to watch for someone who could potentially give birth. C-sections were looking pretty good...adoption even better. :eek

[Guest jmh2005]

A delivery definately ranks up there...it is totally a beautiful and special moment (and I actually still get tears in my eyes...), but one with many fluids. In my first delivery, I got literally drenched from the waist up (thankfully I was wearing my glasses!) with amniotic fluid and vermis (must have been trapped inside when the membranes were ruptured, ie. putting your finger on the garden hose when its running if you know what I mean...??)...the Doc I was working with was moritfied, but i totally tried not to react and just kept doing my thing (which wasn't all that much other than holding the mom-to-be's leg and coaching her to continue pushing...)...after the birth, I quickly trotted to the locker room (trying to avoid the 'what happened to you??', which I got about 3x along the way...) and had a sponge bath...I'll never forget that day!!

[Guest everyoneloveschem]

I know this is off topic from the beginning idea, but since we seem to be discussing birth, is it possible for a woman to carry her baby say past 10 months (i.e. if no physician were monitoring her, so no one would induce her after being a week late)? If so, how long can a woman carry a child (is there a record)?

 

I read this article about C-sections vs vaginal deliveries and they described a woman having a vaginal delivery au naturel, and that she sounded like an animal screaming. I thought that was pretty vivid. What percentage of women opt for drug-free deliveries? WHY?

[Guest Akane200]

There isn't any specific procedures or things that I see that I find scary/particularly gross (they all are in some way...). I've seen the "needle in the eye" on optho, really advanced cellulitis, patient who slit her wrists down to the bone, etc. What I'm most afraid of is contracting something from my patients (be it blood borne, and now air borne as well).

 

I remember my first needle stick injury in the OR. It was at the beginning of my first rotation too. I just kept looking at my ripped glove and bleeding hand. And it just kept running through my mind, the potential danger that I have just been exposed to. (But I was lucky that the patient didn't have anything either, but it was pretty scary)

 

At least now with SARS, precautions for TB and other infectious diseases have improved. I don't mind wearing all that gear if can mean that it's safer for everyone.

[Guest UWOMED2005]

Actually, not rex morgan, I have the same wariness you do of personality disorders. Same goes for schizophrenia. The idea of not being able to believe a patient when taking a history is somewhat frightening. . . what are you then supposed to believe? Are you to make assumptions without any fact? I've seen this done with mental patients before. What if they're telling the truth and you think it's just a delusion?

[Guest Ian Wong]

Most women will spontaneously begin labour between 37-42 weeks. A large proportion of those who go beyond 42 weeks likely had their dates miscalculated (but how can you really check that?).

 

The thing is that the placenta (which is the transfer point for oxygen, nutrients, and waste between mom and the baby) can't keep going indefinitely, and it starts to break down in its function. Of course, the baby is also getting progressively larger and demanding ever more nutrients, so you can see a potentially huge problem on the horizon.

 

I don't know much about Obs, but I assume the body will at some point begin labour spontaneously. In the very rare event that it doesn't occur, I assume the fetus will die at whichever point the placenta becomes unable to sustain it. You might also run into problems with cord compression, with the baby essentially squeezing against the vessels which would also risk its death.

 

On the other topic, I've seen an au naturel birth, and it looked like the most excruciating thing, probably like getting kicked in the crotch, except repeatedly for hours on end (kind of like regular contractions)... Why indeed.

 

That's the thing with delusional patients. When the history you get from them becomes unreliable, you are really up a creek in a very big way. I still remember one of my patients who had schizophrenia complaining about an excruciating pain in her belly. Trouble is, all the standard questions you ask about pain don't work any more. (the mnemonic is OPQRST) ie. when was the Onset of the pain?; in what Position does it hurt?; what's the Quality of the pain like?; is it Radiating anywhere?; on a Scale of 1-10, how bad is it?; are there Times when it's better or worse?

 

And without knowing the answers to the above questions, it's impossible to tell what this patient really might have without ordering a whole schwack of blood tests, imaging studies. Sure, you could do a physical exam, but the patient can fake their way through parts of that too, or perhaps they don't react in the "usual" fashion even if they truly do have genuine pathology. And sure, you could say "the heck with the costs, and the trauma of sticking this patient with a needle/exposing them to radiation for imaging", and order the tests, but what if they are normal, and a week later, the patient comes back with a similar complaint.

 

Just because they didn't have an appendicitis or something last week doesn't mean they might not have one this week. And so on...

 

Ian

[Guest peachy]

On the other topic, I've seen an au naturel birth, and it looked like the most excruciating thing, probably like getting kicked in the crotch, except repeatedly for hours on end (kind of like regular contractions)... Why indeed.

Are there any risks to an epidural at all? Does any of the medicine go to the baby?

[Guest Ian Wong]

Topic drift again. Here's a couple sources of info re: epidurals. The conventional belief is that they are superior to IV opioids for pain relief during labour, and the rationale is that the anesthetic is delivered locally to the epidural space, and not intravascularly where it can distribute throughout the circulatory systems of both the mom and the fetus.

 

There will certainly be a small fraction of local anesthetic which gets absorbed into the intravascular compartment, and can then get transmitted into the fetal circulation, but the drug concentration will be markedly less, and that decreased drug concentration makes all the difference in the world.

 

Anyway, here's a set of clinical guidelines by the American Society of Anesthesiology:

 

www.asahq.org/publicationsAndServices/obguide.html

 

And for contrast, here's a link to the Epidural FAQ, a document put together by some motivated folks on the internet:

 

www.fensende.com/Users/swnymph/Epidural.html

 

Ian

[Guest mying]

Back to the original question here...

 

"Digital Disempaction"

 

I don't know why it does, but it right gives me the willies. Especially for something that really seems trivial in the grand scheme of things.

 

Though I do love the heebie-jeebie dance I get out of my system administrator friends when I suggest their mailservers need disempacting -- and explain what it is. It's a perfect analogy for when extra large email file continuously fails to download to user's computer because it's so big the connection times out -- thus preventing any further emails in the queue from being sent as well -- and the sysadmin needs to go in and either change some settings or move/delete the overly large email file from the queue.

 

But seriously. There's no glory in a digital disempaction. I'm bitter about glory this week. One of my friends made his first movie credit. In the Matrix: Reloaded. I'm jealous.

[Guest MayFlower1]

mying,

 

I don't know why it does, but it right gives me the willies. Especially for something that really seems trivial in the grand scheme of things.

 

I must admit, I forgot about this one...this is one of the things my wife really finds challenging...and I must admit...her graphic description is quite disgusting...it kinda presents itself in "smell-o-rama" if you get my drift. About 6 months ago, she had a patient with what she described as a several inch diameter "bowling ball" empacted...mmmm...yummy...anyway I hear ya about this one.

 

But seriously. There's no glory in a digital disempaction. I'm bitter about glory this week. One of my friends made his first movie credit. In the Matrix: Reloaded. I'm jealous.

 

Wow...a credit in the Matrix: Reloaded...very impressive. But don't lose sight of how much better someone feels when they are disempacted! A very nice thing to do for someone...

 

Peter

[Guest MayFlower1]

This is another great worry. Physicians are exposed to all the really nasty stuff that nobody else wants nor is able to deal with on their own. It's actually amazing you all don't get sick more often than you do. During flu season, it's really difficult to keep our house "safe". It makes me wonder what other kind of fun things one could get during clerkship, residency and once practicing.

 

Speaking about needle stick injuries...my wife had a needle stick injury during residency...it was really scary for her as well. It was during a delivery (she did an obs/gyne residency for 2 years prior to switching to family)...it was a freak accident...but it happened. At that point she felt almost completely helpless...praying the person was not infected with something life threatening or life affecting. Very scary. Anyway, thankfully, in her case, the individual was healthy in every possible way.

 

Peter

[Guest everyoneloveschem]

Okay, so now that I'm starting to fret about needle sticks, how often does this happen, why (is it because people are leaving needles around, or because everyone is moving too fast, etc?), does it happen more in surgery, do you know when you are doing a procedure on someone that they are say HIV positive or have some sort of other blood born disease? Ugh.

[Guest MayFlower1]

everyoneloveschem,

 

I think this is quite infrequent...but accidents do happen. My wife has only had the one incident...it occurred in a hospital setting during an operation...as a needle was being passed from one physician to another.

 

Peter

[Guest macMDstudent]

Couple of comments about birth again. I have only witnessed 2 births (my own children) so far. My wife had midwives for both. We had the first baby at home and the second one in a birthing unit at a hospital only because of some abnormal bloodwork on my wife's part, otherwise our second baby would have been born at home too. Both births were completely drug free and "natural."

 

My wife was mentally prepared before both births, in that she knew may be painful, she also knew childbirth is a natural process, not an illness, and her body was made to it. She had several methods of dealing with the discomfort, and did not ever feel the pain was unbearable. In fact, her body's sensations kept her aware of the progress of labour and she was very well in touch with when to push. Maybe it was luck, but both labours were short and uncomplicated.

 

It was a beautiful experience with midwives in the end and she recalls it fondly to this day. Our babies were born alert and started sucking within minutes. I feel this fear of birth pain is highly a suggestible phenomenon and MD's propagate it (generally speaking in my experience) while midwives (in my limited experience) help women prepare for it mentally and give a lot of support to women through labour. Without IV lines and a fetal monitor on, my wife was free to change position and move around which helped a lot for the pain.

 

Maybe I need more experience in OBS/GYN to see many more births but my wife and I certainly felt the "medicalization" of a normal birth was something we wanted to avoid. Before deciding on home birth I did a literature review and found the outcomes were at least as safe, if not safer than hospital birth for normal, full term pregancy. It was suggested in some studies that this may be due to one medical intervention being done leading to another intervention with a higher risk (i.e. epidural leads to not as good pushing by woman, leads to fetal distress leads to C-section). I no longer have this information at my fingertips, but it was interesting to think about. This work was mostly European since home birth seems to be viewed as inappropriate in North America to a large degree (although it is gaining some ground again).

 

Bad smells/gross things: death. Autopsies are a world of their own for that, I think. I have only seen a normal one and I won't forget those smells for a long time. Floaters (drowning victims), and people discovered after some time after death I've heard takes a certain kind of person to get used to that and do that kind of work! I found even pictures of children's autopsies that I've been exposed to at school are disturbing for me because I can't help but think of my own kids.

[Guest UWOMED2005]

I think needle stick injuries are quite infrequent, but considering the high volume of procedures involving needles in medicine, but it's been suggested to be that almost every med student can expect at least one needlestick injury in their career, no matter how careful they are and no matter how slow they work. Of course, if you've accumulated 5 in your first month of clerkship, you probably want to be more careful! :eek

 

Fortunately, often the needle hasn't been in a patient when the injury occurs, the chances of that needlestick injury occurring with an HIV, Hep C, or Jakob-Creutzfeld (make sure you are immunized for Hep B!!!) patient is small. Even then, the chance of a needlestick injury transmitting the disease is small as well. I'm not sure if any North American health care workers have ever contracted HIV from a needle stick injury, and if so, the number is small.

 

But yeah, it's something that can freak you out when it happens (not spoken from personal experience yet.)

[Guest MayFlower1]

UWOMEDS2005,

 

...it's been suggested to be that almost every med student can expect at least one needlestick injury in their career, no matter how careful they are and no matter how slow they work.

 

I've heard this statistic as well...I think it's just a fact of life. On the more positive side, I believe, even with a needle stick, the chances of getting HIV or some other uncurable disease are about the same as being hit by a car...common...possible...but quite unlikely. Even if one does get stuck with an infected needle...assuming quick treatment is implemented...I think the chances of actually getting sick are quite low.

 

Of course, if you've accumulated 5 in your first month of clerkship, you probably want to be more careful!

 

Probably some good advice....

 

Peter

[Guest MayFlower1]

Hey macMDstudent,

 

Many of our friends have had births at home or births with a doula or midwife. I must admit, my ex and I opted for a traditional birth...well, maybe not quite traditional...we did use a birthing room vs. an operatory. Anyway, while the idea of a home birth does seem nice, one of the things that worried me (and ultimately convinced me and my ex to go with a hospital birth) was...what if something went horribly wrong? What would I do if a complication arose and because we were doing home birth...we couldn't get medical help in time...and something drastically negative (possibly even death) resulted for the baby, mother, or both. What is your opinion on this issue and how did you guys deal with it? I must admit, if something happened to my wife or my child because I (perhaps selfishly?) wanted a home birth for comfort, etc., I'm not sure how I could live with myself.

 

On another note...I agree with you with respect to the "medicalization" of births these days. As you may have read in other posts, I recently conducted a national study focussed on maternity experiences of recent Canadian mothers. Some of the medical stuff they reported that was done...was quite shocking to me...just out of interest...what do you think the medical community could do to "demedicalize" hospital births to the point where you would opt for one? What "stuff" would you not want...what "stuff" would you want?

 

Thanks in advance for your perspectives...it's quite enlightening to have people like yourselves articulate points of view which are totally out of my grasp.

 

Peter

[Guest macMDstudent]

Thing can and do go wrong with normal births all the time, no matter where they take place. But also keep in mind that many a cab driver has delivered a healthy baby. Most low risk pregnancies usually go very well on their own.

 

Midwives are very well trained and are regulated by law to refer medium to high risk pregnant women to an obstetrician. The list of conditions that they MUST refer is very detailed and extensive. So people with any risk factors would not be allowed to consider a home birth or even a midwife birth in the first place.

 

Midwives recognize that even the most routine and low risk pregnancy may have something go wrong in labour and delivery. The have a doppler US unit to check the fetal heart beat on a regular and frequent basis. They are highly qualified with neonatal resusitation. They have oxygen and manual respirator "bags" they bring to the home. They also have a suction machine. They do have oxytocin that they can inject to stop maternal bleeding. They can inject vitamin K to stop neonate's bleeding. They are skilled at suturing. They check the placenta thoroughly to ensure it was all expelled. They also make sure that clearly posted by the telephone at the home there is a sheet with the address, phone number, parents names (of the infant) and blood types, drug allergies etc.

 

An important thing was pre-registering at the local hospital even though we planned a home birth. The hospital is aware that a home birth will be happening in a certain time frame. We live in an urban area that the local ambulance response times are supposed to be under 5 minutes. My wife/child could have been at the hospital in 10-15 minutes. I recognize that may have been too long, but don't forget if there was a problem, the first phone call would be to the ambulance, the second phone call would be to the hospital to assemble the obstetical unit on call. At the best of times in a community hospital this may take 10-15 minutes to get the obs team ready and in the OR. So by the time we got to the hospital the team would be ready and waiting.

 

My wife and I decided from a risk/benefit analyis that there was only a minimally (if any) increased risk with a great benefit. My wife was so relaxed and comfortable at home, I'm sure it helped the labour. Not to mention how much rest she could get at home after the birth, and continuous access to her favourite drinks or food.

 

We would not have had a home birth if we lived in a very rural area with a longer response time by ambulance.

 

The "medical" things that my wife did not want the most was being hooked up to an IV and fetal monitoring machine constantly. The ability to get up, move around or even labour in different positons on the bed was useful. Labouring on an big exercise ball or getting in the shower were all helpful, rather then just lying in bed. Our second child was born at a birthing unit, which wasn't too bad at all. The midwives were still the only caregivers, but the facilities had a jacuzzi tub, shower and lots of space to move around. The good thing about the birthing room was that my wife laboured and delivered in the same room. Having to move to a surgical suite just as things are getting intense would have been frustrating.

 

One of the best things about midwife care is you know who is going to be at your birth. You meet the different midwives during your pregnancy, and one of them guarantees that they will be there as your primary midwife for the birth. The second midwife, to care for the child, will be one of the other ones you've met. One of the worst things I have heard from traditional hospital births that our friends had is that the OBS/GYN on call the night of labour is rarely one you've met before. Likewise, the nurses are total strangers and when their shift ends, they are gone and then a new one comes in just before the birth. The high level of personal contact with the midwives and having familiar faces around you at this joyous but still stressful time, is very reassuring.

[Guest MayFlower1]

macMDstudent,

 

WOW...you have completely opened my eyes with respect to what midwives are capable of doing. In my ignorance, I thought they only did essentially what a very knowledgeable layperson/first aider would do. I had no idea they did suturing, injections, etc. Funny, we have a friend studying to be a midwife and I've always just assumed I knew what she was learning...once again, it's great to have this forum to learn new stuff...thanks.

 

Our hospital experience was actually quite excellent. The birthing room made it much more comfortable...the only reason we would have had to leave would have been for a crash c-section. I must admit, I was somewhat annoyed that the poor resident who was with us for the entire labour was just pushed aside literally at the last second by the obs/gyn on call so she could get her hands on our baby. I felt bad for the resident in that she was giving us excellent care and was really into delivering the baby. The obs/gyn staff running in and literally throwing on gloves as our daughter was being delivered was inappropriate in my opinion...it kinda ruined the whole calm atmosphere and continuity of care from my perspective. What even annoyed me more was once our daughter was born...seconds after...the obs/gyn disappeared, never to be seen again, leaving the resident to clean up...stitches, etc.

 

The next person we saw was the neonatologist who discharged us from the hospital.

 

Anyway, thanks again for your insight.

 

Peter

[Guest ploughboy]

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To answer the original poster, I'm with all the folks who answered "childbirth". To quote a buddy of mine: "If a pregnant lady gets on an elevator with me - I get off!" The thought just scares the livin' daylights out of me. Obviously I'm going to have to get over it, but I'm definitely not planning on doing an obs/gyn residency. It's just not my thing. I keep picturing scenes from "Alien".

 

 

Mying: It took me a minute to puzzle out what Digital Disempaction could possibly be. I've got it now, and I'm having horrible mental images. Thanks...

 

 

To branch the thread slightly and turn serious: one thing that isn't a procedure, but definitely falls in the category of "Things I don't want to do but will sometimes have to when/if I'm a doc" - going to my patient's funerals. Not looking forward to that at all. It's selfish of me, but that's something that I'm *really* going to have a hard time dealing with.

 

 

And on that cheery note...

 

 

pb

 

 

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