Hypnos

Late afternoon my lover starts to beckon me.

As I finish up with my last set of patients trying to give gravitas to their various complaints, the painful nodule on their left arm which their other doctor says is fine, the cyst on their right labia which comes and goes every three months and is not there at the moment, or the weird smell of their urine, I start dreaming of her soft embrace. Despite the emotional importance of my patient’s complaints as their medical significance diminishes, my interest wanes. In the morning I can put up a good show and feel their pain but late in the afternoon, my lover’s siren call becomes almost deafening.

This is not a new love for me. We have been seeing each other since I first started residency. We used hook up in the resident call room on Fletcher 3. We had an occasional rendezvous in the nurses station on Labor and Delivery. We would meet during grand rounds in the dark old auditorium with the uncomfortable wooden chairs with built-in ashtrays from when all doctors still smoked cigarettes.

My lover followed me to New York. We snuck off late at night in small rooms tucked away at Mount Sinai and Beth Israel and Elmhurst Hospitals. She visited me in my over-prized studio apartment on the Upper West Side. She also followed me to the West Coast when I decided Portland had more to offer both in life and in medicine than Manhattan.

In fact, I have been with my lover longer than I have been with anyone else. It is the most uncomplicated relationship I have ever had, purely physical. We slip away to the dressing room at family weddings. We meet at my house in the early afternoon. Sometimes we share a glass of wine at the restaurant around the corner where the manager knows my name. No one knows about our affair. I have not shared the existence of my lover with anyone, but everyone knows her.

Some can can do without her for days it seems, some battle her, some yearn for her, but everyone suffers if she is not present.

Bird Watching Or The Devil Is In The Details

My friends Gerry Ellis and Jennifer Loren go bird watching every Sunday in the Ridgefield Wildlife Refuge and keep a lovely blog about their sightings: http://ridgefieldnwr.wordpress.com.   Gerry is a former National Geographic photographer and he can identify a red-breasted nuthatch by its song.  Jenny sees the difference between a flock of Brandt’s cormorants and a flock of geese flying high over our heads in a V-formation.   These people are real birders. 

I tagged along with Jenn and Gerry twice before I left for Ethiopia and I was still struggling to tell the difference between a blue jay and a Stellars’ jay.   Gerry and Jenn are light years ahead of me. But birding with them made me realize what you need in order to be a good birder, and it is not just experience and patience and an eye for detail.   What you need is a love of nature, a deep enduring love of nature.

I am in Ethiopia with a group of photographers for the Prints for Prints project: www.printsforprints.com  None of my fellow travelers are birders and we are spending most of our time in Addis Ababa and Bahir Dar.   I decided to bring my small binoculars and Ber van Perlo’s  ‘Birds of Eastern Africa’ to see what I birds I would be able to identify on this trip.   So far I have already identified seventy-one birds, of which six are endemic to Ethiopia.   This is a testament to the amazing birdlife found here, even in the cities.  I did go rambling in the Simien Mountains in Northern Ethiopia for three days last week where I met Maarten.   Maarten is a Dutch sailor and has lived in Dubai the past 40 years skippering the sailboats of the Royal Family of Dubai. 

He loves birds and he loves nature.  He has watched Dubai change from a sleepy fishing town to a collection of skyscrapers, and watched the Red sea slowly die.    The corals and the fish he used to see are gone.   Maarten helped me identify numerous raptors and swallows that circle the cliffs around the Simien Lodge.   He taught me how to recognize a harrier and how to tell the difference between a male and a female falcon. 

Except for three days with Maarten I have done all my birding by myself in the garden of our hotel in Addis Ababa and the garden of our hotel In Bahir Dar and from the car.  This picture that I took in the garden of the Abay Minch hotel in Bahir Dar was captured with my cell phone.  It’s a White Cheeked Turaco, my favorite bird of this trip. 

My next trip I am bringing Gerry Ellis and Jennifer Loren and a good camera and we will see what we find beyond the hotel gardens in the big cities of Ethiopia.

 

There is nothing like a drunk woman…

Another cycle Oregon has passed and I already miss it.   Last night my sleep was not disturbed by fellow bicyclists chatting, snoring, and un-zipping their tents or coyotes howling.    This morning I did not have to put layers of clothing on to protect against the early morning chill and walk a quarter mile to stand in line to use a bathroom that another cyclist has already left a malodorous deposit.   

I miss meeting people like Mary Otley, who says she is a nicer person now than she was ten years ago.   Mary is 92 years old and still hays the fields and orders the cattle and does the books on her fourteen thousand acre ranch in Diamond, Oregon.  She hates it when Quicken comes out with new software.   She was born in Independence, Oregon on a dairy farm and went to University of Oregon to escape farm life.  After college she joined the WAVES in 1943 and was appointment barrack supervisor based on her stellar test results.  Mary Otley said of the women who signed up for this specially created branch of the US Navy:“Many joined just to be close to the sailors.”  She said she had to carry many a WAVE  to her bed at night so she would make curfew.  “Let me tell you, there is nothing like a drunk woman” After the war ended, she was assigned a teaching job in Burns and fell in love with Harold Otley.

I miss the boy riding by on his horse as we pull up in Frenchglen.   Our bus driver, Connie, tell us that is Colton.   Connie teaches science at the Oregon’s only public boarding high school in Crane, which is an hour away from Frenchglen. Colton is one of her 60 students this year.  Connie also drives the bus for tours up the Steens Mountain and is an archeology technician in the summer helping to record and collect Native American artifacts on BLM lands before they disappear.

I miss seeing Cassiopeia in the Milky Way on my way to the Port-a-potty at 2 AM.  I miss the smell of sagebrush and juniper as I am trying to make it up a hill on the hottest time of the day, 3 PM

I even miss my fellow cyclists asking me as they pass me up the hill: “Sweetpea… was that bike named after you?”   After the tenth time, I came up with the perfect answer for this rhetorical question: “No, because then it would be called Royal Bitch.”

I miss thinking there is no way I can make it up one more hill in this heat and doing it any way.  I miss dreaming of sitting in the shade of a tree and thinking I will never see another tree and then finding a tree..

I even miss the well-endowed gentleman of a certain age, who we have dubbed ‘Tan Man’.  He is a participant of Cycle Oregon every year and struts around in his Speedo without a shirt like a peacock looking from side to side making sure everyone is noticing him without his shirt.

I miss my brother educating us all at the dinner table about Jared Diamond’s theory on Homo Sapiens’ penile size.  Diamond believes there is no evolutionary advantage to having a large penis other than competing with other men.   At which point all the men at the table said it was because women preferred men with larger penises and the women at the table said that penile size was not an important factor in choosing a mate, thereby proving Diamond’s point. 

Maybe Tan Man needs to read Jared Diamond’s ‘The Third Chimpazee.’

 

 

Home Delivery, Out of hospital delivery in Portland (Previously published in the Scribe, the magazine of the Medical Society of Metropolitan Portland

Portland with its backyard chicken coops, front yard vegetable gardens and roof top beehives has a very active home delivery community. A growing number of pregnant women feel that those of us who work in a hospital have lost the connection to the essence of the birth experience, the amazing fact that a woman can grow a healthy human being in her belly and deliver it vaginally most of the time. Women who seek home delivery feel that hospital based obstetrical care “medicalizes” pregnancy and delivery. Critics of hospital birth point out that needless medical interventions have driven the cesarean section rate up to the 30% range, whereas cerebral palsy rates are unchanged.

In 2008, 3.3% of births were planned, out of hospital births in Multnomah County. The preliminary data from the Oregon Bureau of Vital Statistics indicate that this number went up to 5.2% in 2012. Most of those births are attended by certified nurse midwives or licensed direct enter midwives. In 2010, 7.2% of the out of hospital births were attended to by unlicensed direct entry midwives. Oregon and Utah are the only states that allow unlicensed midwives to attend births. The Board of Direct Entry Midwifery sets training requirements, defines the scope of practice for midwives, and it also conducts investigations and imposes disciplinary action. It functions very similarly to the Oregon Medical Board, but it has no jurisdiction over unlicensed midwives.

The Dutch System

Advocates for out of hospital birth tend to point to the example of The Netherlands where up to 30% of women deliver at home and even the professional society of Obstetricians, the NVOG, actively supports home delivery by licensed and certified midwives. All midwives in Holland have to complete an accredited four-year program and have to be licensed to practice. A Dutch pregnant woman enters the healthcare system by first seeing a midwife. The midwife takes a thorough medical history and determines whether the patient has an indication for a hospital delivery. She is guided by a checklist of indications developed by Dr. Kloosterman, the Chief of Obstetrics at The University of Amsterdam. This list is still called the Kloosterman List and a committee of midwives and obstetricians updates the checklist every ten years based upon outcome data. If the patient does not have an indication, she stays in the care of the midwife and delivers at home or a birthing center. If she develops an indication for hospital birth during the course of her pregnancy, she gets transferred to an obstetrician. A practitioner planning to attend a birth at home with a hospital indication is subject to prosecution and could be jailed or fined, depending upon the outcome.

Is home delivery safe in Portland?

Many practicing obstetricians and midwives have deep concerns about the safety of home delivery in Oregon. Not just because the state of Oregon allows an unlicensed midwife to attend a planned home delivery, but also because the scope of practice of licensed direct entry midwives in Oregon includes home delivery of twins, home delivery of patients with previous cesarean sections and home delivery of a breech baby, all indications for a hospital birth in The Netherlands.

In the 1990s, most obstetricians stopped delivering breech babies vaginally in Oregon and many hospitals stopped allowing patients a trial of labor after cesarean section. Direct entry midwives were the only ones who offered to attend those births. A group of direct entry midwives in Oregon successfully lobbied the legislature to increase their scope of practice to include patients with previous cesarean sections and breech vaginal deliveries because of patient demands.

Many of the more experienced direct entry midwives do not feel comfortable delivering twins or breech babies at home or in a birthing center and do not feel comfortable letting pregnancies progress beyond 42 weeks. However, they also face a public that truly does not understand the potential complications of childbirth and views any mention of hospital based obstetrical care with skepticism.

The response of the medical establishment

“Home birth is like the rain”, says Dr. Duncan Neilson, Chief of Obstetrics at Gynecology at Legacy Emanuel Hospital. “You can get mad at it, but it is still going to happen.” Emanuel’s policy of accepting patients that were planning an out of hospital birth without judging their choice, makes patients and their midwives feel welcome in the hospital. By lowering the threshold to transfer a patient to the hospital some of the complications associated with home birth can be avoided. Oregon house bill 2380, which passed in 2011, protects both physicians and hospitals from legal liability if an injury occurred as a result of care provided from a direct entry midwife.

The hospital policies are also changing in other ways to actively try to lower our cesarean section rate. Last year, Oregon Health & Sciences University started allowing breech vaginal deliveries again in select patients and Legacy Emanuel may follow suit. The hospital based obstetrician model is gaining acceptance in Portland, which will allow more patients a trial of labor after cesarean section and will allow more twin patients to deliver vaginally. Most hospitals in the area have restricted elective inductions, which many believe have contributed to our increased cesarean section rate.

 

Our Dilemma

Whether or not home delivery is a safe option for delivery in Portland at all is a big question and one that cannot be answered without assumptions and conjecture at the present time. While the Oregon Board of Vital Statistics has been collecting data on home birth and freestanding birth centers since 2008, is it difficult to draw conclusions about the safety of out of hospital birth, because the report only records the final method and place of delivery and the outcome. As a result, a fetal death in labor occurring while a patient is being transferred to a hospital is accounted for as a fetal death that occurs in the hospital. This should change with the above mentioned Oregon House Bill 2380, which will require the Oregon Public Health Division to add two questions to the Oregon Birth Certificate to determine planned place of birth and birth attendant, and to report annually on birth outcomes, including death, by location and attendant type.

 

More information will also be gleaned from a report to be released in the summer of 2013 based on a perinatal fatality case review of term births intended to occur out-of-hospital conducted by the Oregon Public Health Division in 2012. This report will cover key findings of live term births by planned place of birth and planned birth attendant, term fetal and neonatal deaths by planned place of birth and planned birth attendant, and maternal characteristics of births by planned place of birth.

 

We have a duty to our patients to understand their choices and needs, but we also have a duty to protect the lives of mothers and babies. Armed with data, we can educate women about the possible risks of out of hospital birth. However, unless the hospital based obstetrical community starts to celebrate the joy of birth while managing the risks, we will continue to lose patients who will choose a home delivery over a hospital birth. Any complications associated with these deliveries are best handled in the hospital than at home.

 

 

 

Special treatment

For those of you who have not caught up with Downton Abbey, do not read any further for I don’t wish to spoil things for you.  I just can’t resist writing about it. 

Lady Sybill Crawley is in labor and Lord Grantham has decided to have Sir Philip, the obstetrician to the aristocracy, attend her birth rather than Dr. Clarkson, the general practitioner.  Lady Sybill develops preeclampsia and Dr. Clarkson recognizes the signs and Sir Philip pooh poohs him.  A battle of the egos ensues and Lord Grantham sides with Sir Philip.  Lady Sybill delivers a healthy baby girl and all seems well until the night after the delivery when Lady Sybill develops eclampsia and dies. Had Lord Grantham not ordered Sir Philip to attend Lady Sybill’s birth and had Dr. Clarkson been able to deliver her sooner via a cesarean section she may have died from an infection but may not have developed eclampsia. 

As an obstetrician I had many thoughts about this episode.  Delivering Lady Sybill a day sooner might have prevented an eclamptic seizure but it might not have.  A Cesarean section is not a decision to take lightly in a low resource setting. Doctor Clarkson would really have to be sure of his diagnosis. But if Dr. Clarkson was so sure why did Sir Philip not recognize it?  The thought that struck me the most was the thought that Lady Sybill might have lived had her father not insisted on VIP treament.

I was a medical student at the New York Hospital six months after Andy Warhol died.  He died after a routine gallbladder operation.  He had checked in under an alias and had not wanted to have residents or medical students involved in his care. He went into cardiac arrest the morning after surgery because he was hyperkalemic and he developed an arrhythmia. High blood potassium levels are well known to cause heart irregularity. By the time the code team made it up the stairs of the Baker tower to his VIP suite he was dead. He was otherwise perfectly healthy and might not have died if he had not insisted on special treatment. If he had medical students and residents in the OR, his potassium level might have been checked post operatively and he might have received an intravenous fluid infusion without potassium post operatively.  If he hadn’t insisted on the VIP suite his room would have been closer to the residents call room and the code team might have reached his room in time to resuscitate him.

When patients insist on special treatment they believe they will be getting better care.  However special care is not always better care. As a physician, I never want anyone to give me the VIP treatment in the hospital. And as a physician, I would never seek care from a physician who attends only to the rich and famous. I have seen the care they receive and I prefer the care the Hoi Polloi receive.

 

 

Thinking about the election or in search of a race neutral narrative

I just saw a play by Christina Anderson, an African American playwright. It is called ‘Hollow Roots.’ It’s a monologue and the protagonist is in search of a race neutral narrative. She walks all over the city, talking to over a 100 people in search of brown person with a race neutral narrative and she never finds such a person. At the end of the play she looks at the mirror and thinks hers is race neutral narrative, but at the same time she realizes she has forgotten her own name and who she is.
After the play there was a discussion between the actress and an African American poet, about identity and race based identity and how there isn’t such a thing as a race neutral narrative. The poet argued that all our identities, stories, narratives are defined by race.. As I was listening to their discussion I was thinking: “I don’t think about race when I think about my life story or my work. “ But then suddenly I realized that the reason I do not think about race is because I am white and no one is reminding me, every day, of my race.

On Tuesday night Obama was reelected President of The United States of America and Romney had to concede. The newspapers said Romney never considered losing a possibility. In fact he didn’t even write a concession speech. As he was giving his concession speech I looked at his audience and saw that everyone was white.
On my way home from the play tonight I realized Romney did not anticipate his loss for the same reason I thought my narrative was race neutral. We are both white. When you are white in the USA, you are not conscious of race, unless some one makes you conscious of it.
Romney thought he was race neutral, because no one reminded him of his skin color on a daily basis. Romney never realized that people look at him and see a white person surrounded by a lot of white people. He never realized how those who are not white may see him and how that may affect their vote.
By the time the next census is performed whites may not be the majority in the United States. Maybe then the protagonist in ‘Hollow Roots” will find a race neutral narrative.

Marvin

I meet Marvin in the lobby of the Mimosa Hotel. He looks like he has just stepped off the set of a Clint Eastwood movie. Military haircut, weathered face, pressed collarless shirts, handmade cowboy boots and a Stetson hat.
What on earth is he doing in Addis Ababa?
The Mimosa is crowded. There is an entire French family including grandparents staying at the hotel for the wedding of their son. One night the kitchen closed for business so they could prepare the large quantities of Kitfo, the raw beef that every wedding quest expects in Ethiopia. There is a United Airlines flight attendant /photographer with his assistants staying here. He flies to Addis every two months for fashion shoots. There are some Yemeni businessmen staying here who stand outside the door chain smoking cigarettes while fingering their prayer beads.
There are always interesting characters mulling about the lobby of the Mimosa Hotel. It is the only place where the wireless internet works, so I get to meet most of them during my stay.
Marvin, however, is not just interesting. He is downright mysterious.
He used to work a ranch in Eastern Oregon in the eighties and would seem more at home in that setting than under the fluorescent lights of the lobby of Mimosa Hotel.
Marvin hasn’t lived in the US for sixteen years. He has had cattle operations in Ecuador, Yemen and Argentina and traveled all over North Africa. He first visited Ethiopia seven years ago. He took the bus from Bahir Dar to Addis Ababa and he knew, he would be back
“There is more cattle here than anywhere else and the soil is more degraded than anywhere else” he says. He has never seen a piece of land he cannot improve. He used to work with a real-estate agent in Oregon to find him the worst piece of property. Erosion, compaction, weeds, you name it, the worse the land, the cheaper the land. He would terrace the land and build ponds. He would throw lots of seed on the ground and plant trees before the rains came and then he would order his cattle. So many heads of cattle at this exact weight. Then he would rotate his cattle every twelve hours. Leaving his cattle on each piece of land long enough so they could only eat the top two inches of grass, never letting them eat the grass to the ground. Why? Because the longer the grass, the longer the roots. The longer the roots, the less erosion, leeching and compaction, and the greater the forage yield. The longer the grass is the less parasites there are, because bugs live either in the soil or the two inches just above the soil.
‘The main product is the forage, not the meat or the dairy or the fruit” Marvin says. Sure, the quality of the meat improves if the cattle only eat the tastiest bits of the plants within the top two inches. And yes, your milk yield increases as the parasite count goes down. And yes the trees yield more fruit the more moisture the soil retains.
The cattle and the tress are just a tool with which you manage the sward. The dung fertilizes the forage, the grazing challenges the grass to grow,the hooves press the seed into the soil and the trees over shade.
In eight years, Marvin can take compressed rock hard dirt and turn it into loose soil with his rotational grazing method. He has done it all over the world.
Joel Salatin’s, a farmer whose rotational farming practices Michael Pollan describes in ‘Omnivore’s Dilemma,’ has a Wikipedia entry. A Google search of Marvin E Hegge, shows an old US addres and nothing else. Unlike Joel Salatin, Marvin is not a writer, nor has philosophy been described in a best seller. But like Joel Salatin he is a believer in sustainable holistic farming practices and the ability of this type of farming to enrich the soil and repair the damage of conventional commercial farming. Like Joel Salatin, Marvin sees himself as a crusader against ‘common practice.’ “Common practice” is not sustainable in Ethiopia. They will run out of soil.
Marvin is not working with one of the many NGOs trying to improve land management in Ethiopia. Ethiopia’s population has quadrupled in seventy years. Every scrap of land is being tilled or grazed. Most of the forests that once covered this land are gone and there are huge gashes in the land from erosion.
Despite having more cattle than per square mile than any other country, despite ample sunshine and ample rainfall, Ethiopia has to import milk and the majority of the population eats one meal a day.
Marvin’s ranch will be a commercial operation, backed by Yemeni businessmen. The land is leased from the Ethiopian government and will start as an fruit orchard. There is no private land ownership in Ethiopia and all companies need to lease land from the government and have a permit to run a business. The orchard fruit and the meat will be sold to fancy restaurants in Addis Ababa.
If Marvin succeeds and the surrounding farmers see the difference in his forage yield they will want to copy his methods and rotational grazing will make Ethiopia a milk producing country. The Netherlands is more densely populated than Ethiopia and it is a milk producing country.
Marvin’s grazing operation could have an enormous impact on the development of Ethiopia.
“Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.”
Chinese proverb

Marvin

You….You

Boy running by Joni Kabana

The cities are busier, new buildings have sprouted up where goats roamed last visit. The contrasts are starker. Shiny new Hummers are weaving through traffic avoiding street vendors, donkeys, beggars, but still there are no functioning traffic lights and the roundabouts are still free for all. Dogs still roam the unpaved side roads and there are cow bones lying between the weeds.
“Look Dr. P, here are the rich people living next to the poor people. It’s crazy, my city,” Dani, our driver, points to the slums across the street from McMansions near the airport in Addis Ababa. Fancy cars parked in front of high walls fringed with broken glass and bougainvillea on the left of the road and grey hovels built of mud and sheet metal on the right. He considers this a good thing because it shows how the rich and poor get along.
The upper and middleclass in the city is doing better. Even in two years’ time, things have changed. I can tell just by how many restaurants have popped up and how many Ethiopians are eating in them.
The rural poor are exactly were they have been since biblical times, except there is more of them. The industrial revolution has passed them by and none of the economic progress has trickled down. The majority of Ethiopians are still subsistence farmers.
The country is blanketed with signs of international aid organizations, but other than leaving their name on a rusty signs in every hamlet in Ethiopia, they seem to have had little impact on the daily lives of rural poor.
If only they would have used the metal for the signs to build donkey carts and plows. If only they would have spent the money the pay the CEO of the NGO in his office in Addis Ababa to dig some wells instead.
Other legacies from forty years of aid: every time you walk in the countryside as a white person you are surrounded by little kids in rags chasing you saying “You, You” and everywhere in the countryside you can find Toyota parts. The Toyota Land Cruiser is the most popular brand for both the nongovernmental and governmental aid agencies. ‘You…You” comes from when the UN relief workers used to point to the skinniest kids while handing out food relief packets from the back of pickup trucks. ‘You and you: come here.’

Choice #2

And we choose to do this...

I have been too busy to blog. Funny in Motta I was busy but my downtime wasn’t filled with errands, engagements and entertainment and I had time to blog. I am riding Cycle Oregon this week, which brings me back to my favorite topic choice.
We have too much choices in urban USA and western Europe. So many choices that we pack our days to a point where we have to grab our day planner to schedule time with our loved ones. It’s crazy and it’s exhausting.
My friend Vincent Tamariz, who is a pediatric emergency room physician posted a link to a recent New York Times article about ‘decision fatigue’, http://www.nytimes.com/2011/08/21/magazine/do-you-suffer-from-decision-fatigue. The article describes a study of decision made by Israeli Parole Board Judges. The presumption was that Arab Israeli prisoners may be less likely to be considered for parole than Israeli Jewish prisoners that have served the same amount of time for similar offenses. It turns out race is immaterial. The most important factor in determining whether a prisoner was granted parole was the time of day the judge decided on the prisoner’s case.
Prisoners whose cases were reviewed early in the day, were twice as likely to get paroled than prisoners whose cases were reviewed at the end of the day.
By the end of the day the judges were too tired to decide anything and not granting parole was a safer choice. It was a ‘non-decision’ so to speak. After making decisions all day long they couldn’t make decisions any more.
Having a lot of choices becomes difficult at a certain point because we all get too tired of making decisions about everything. So when we get to the super market we can’t even decide about something as simple as breakfast cereal.

It’s one of the reasons I love being in Motta. Life is easier with less choices in some regards. It’s why 2000 doctors, nurses, lawyers, TV producers and financial advisers sign up every year to bicycle 500 miles in one week and sleep in tents, eat bad food and use portable toilets. It’s pretty simple living for a week.
The only decision to make in the morning is how many clothes to wear.
In the evening it’s:”Which of the 4 flavors of beer should we try tonight?”
Aw, choice, it’s a blessing and a curse.

Better

Every morning I wake up with a dream about Mota. There is a delivery I am needed for. There is a baby that needs to be resuscitated. There is something that went wrong. By the time I wake up, I have forgotten what it is.
I love Atul Gawande, who inspired this blog. He is a surgeon and writer. He writes in his book ‘Better’:
“I used to think that the hardest struggle of doctoring is learning the skills. But it is not, although just when you begin to feel confident that you know what you are doing, failure knocks you down. It is not the strain of the work, either, though sometimes you are worn to your ragged edge. No, the hardest part about being a doctor, I have found, is to know what you have power over and what you don’t.”
Every morning I am figuring out what I had power over and what I didn’t while in Mota.
I was only in Mota for three weeks, a very short time period, in retrospect. While I was there, it seemed like ages, because every day was filled with so many new experiences.
Medicine is universal. People get sick and women have complications in labor all over the world. The diseases and the complications differ from place to place, but not as much as you think. What is different is how much resources are available to cure the diseases and tackle the complications.
In the US, we monitor a baby’s heart rate in labor because we have the resources to deliver the baby quickly if the heart rate goes down. In Mota government hospital, it takes an hour to get a patient ready for a cesarean section, and by that time the baby is either dead or the heart rate has recovered.
We had some babies die during labor in Mota. Their ghosts haunt me at night into the morning. The part of me that practices medicine in the USA with seemingly unlimited resources thinks I should have done more to save those babies. The part of me that realizes that we did not have the resources to predict which babies were going die in labor in Mota has made peace with those baby souls. I had no way to diagnose fetal distress in labor and no way to respond to fetal distress quickly enough to save babies. I know that, but boy is it hard to accept that I had no power over something that is such a part of every obstetrician’s fiber in the USA.
The biggest financial payouts in malpractice cases are for neurologically damaged babies. John Edwards, the presidential candidate, made most of his money prosecuting obstetricians who failed to recognize signs of fetal distress and failed to do timely cesarean sections. Many of my hospital’s labor protocols address what to do in cases of fetal distress.
Fetal distress is one of the reasons our cesarean section rate is 30 % in the USA. Because our tools to diagnose fetal distress are not very accurate, we often over diagnose fetal distress. We think a baby is going to have difficulty, but it’s fine. We don’t know and we err on the side of safety, because cerebral palsy is permanent and debilitating. I am trained to look for signs of distress and act on it. And I am well trained. As far as I know, I have never delivered a baby in my career that died in labor or that had severe neurological consequences as a result of the delivery.
So accepting that I had no power to save babies was hard, very hard. Delivering dead babies or babies that died right after delivery was hard, very hard.
And every morning when I wake up, I realize that I still do not accept that I couldn’t have done more to save some of those babies. It is why I will always feel some sorrow when I think back of my three weeks in Mota despite how many mothers we saved.
That brings me back to Atul Gawande, because in the last chapter of ‘Better’, he gives advice on how to grow in medicine, and any profession for that matter. He extols you to change, to obsess over your outcomes, and to change.
He also recommends that you don’t complain, that you count something, that you ask a random question every day. And that you write for yourself and for others.
I am writing

Photo by Joni Kabana

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