Lost… in an ER?

There is an incident which resurfaced in the news recently that has both embarrassed and outraged me: the inquest into a death. Five years ago, a double amputee in a wheelchair died in an Emergency Room after being overlooked -and neglected- for 34 hours! ( http://www.huffingtonpost.ca/2013/08/06/brian-sinclair-inquest-waiting-room-death_n_3711355.html?utm_hp_ref=email_share ) No, this is not a woman’s issue -although it might as easily have been a woman- it is an everybody issue; it could happen to anybody… Or could it? Would it?

Imagine showing up in a hospital emergency room needing help and then being forgotten. Forgotten -or ignored? Avoided? Scorned..? I’m trying to find a word that describes it best. Maybe discounted… You see, the person was aboriginal and apparently had been there before: he struggled with substance abuse -as if that were an excuse to discount any pressing need to address his presence in the ER. As if he could be dropped to the bottom of the list before his needs had been properly ascertained… No, not dropped to the bottom of some arbitrary list – dropped from the list: a man crying wolf! Sometimes I am embarrassed to be identified with the Health Care system, or to call myself a doctor.

The lawyer for the Regional Health Authority -I suppose as a way of deflecting accusations of the obvious (the patient was aboriginal, homeless, prone to substance abuse, and probably known as such to the staff in the Emergency Department)- was quoted as saying “These events could have happened to anyone.” Oh really? Does he honestly think that if he had showed up in Emerg in a wheelchair -especially as a double amputee- he would have been overlooked? Expecting more, he would have demanded more. He might have had to wait -a hospital ER is a busy place and triage of patients according to the urgency of their conditions is both necessary and appropriate. But 34 hours? Only someone used to being ignored would not put up a fuss -even if they were dying…

Oh, and there are the video surveillance tapes of a man, alone, in a wheelchair, not causing a disturbance, patiently waiting his turn! Here’s a sample (with commentary) from the CBC news site: http://www.cbc.ca/news/canada/manitoba/story/2013/08/26/mb-er-video-sinclair-inquest-winnipeg.html Or, how about this one: http://www.cbc.ca/news/canada/manitoba/story/2013/08/28/mb-brian-sinclair-inquest-security-guard-winnipeg.html  Apparently the Emergency Department was not even terribly busy that night. My god how can this happen? How can someone disappear in plain sight?

Could it be that we see what we expect? Or maybe we don’t see anything? Triage is the assignation of priorities according to need, but might it also be a selection based on other characteristics at times: appearance, behaviour, demeanour… race? And in the case of this unfortunate man, I find it hard to believe that his past did not influence the assessment as well. We -all of us- drag our histories with us like shadows; heavy clouds that obscure the reality of who we are and what we need. Past and present look all too much alike if we are being judged through a glass darkly. We all see the world with heavily laden eyes. And it is only apparent when it is us who are being evaluated -or should I say interpreted.

But is there any wonder why minorities -be they cultural, social, or economic- have come to mistrust the pretense of equality proffered by those in power? An offer with conditions so tightly attached to appearance and normative expectations that many have chosen not even to seek help, fearful they will be treated differently. Disparagingly. Begrudgingly. Or not at all…

Midwifery… Deja vu all over again?

Well, I see that midwifery is back in the news again, so I thought I’d revisit the issue -my last look at it  was in November, 2012. Its not that I’ve changed my opinions -I haven’t; nor that I have since discovered something new and compelling about the role of midwives in pregnancy -I continue to support them as I always have. Its more that I am surprised that there should still be any lingering doubt as to their value; that we should still be treating midwifery as if it were an Alternative Medicine -you know, like Huckleberry leaves for indigestion, or something. Midwives have proven their worth over millennia; their extensive and practical experience has helped countless women over the centuries -especially those who couldn’t afford, or even access doctors with their often unhelpful and sometimes misguided medical beliefs and practices -some dating back to Aristotle… It occurs to me that perhaps I am  being too harsh, too revisionist -too reductive- in my recollection of Medical History, but until quite recently there didn’t seem to be much advantage accruing to the involvement of a doctor in the care of a woman in labour.

A predictably Canadian stimulus -the CBC News- got me thinking about midwives again. They reported on a recent issue of the Cochrane Database of Systemic Reviews which looked at 13 studies that included more than 16,000 women comparing various models of obstetrical care with midwife-led care. This model is different from what has traditionally been known as the Medical Model in which a doctor is in charge and a midwife is (maybe) part of the team, but not the leader. In it, she was a useful accessory perhaps, but really just a doctor’s helper: someone who could see the simple and uncomplicated cases and therefore ease the doctor’s burden. I almost said ‘was allowed to see’ these, but I caught myself.

So the meta-analysis tried to put midwife-led care into perspective: was it as good as doctor-led care? Was it merely a niche product serving women with unusual needs and attitudes, or more mainstream in its goals and aspirations? Were they just two Majesteria staring at each other from afar, as incapable of comparison as the proverbial apple and orange?  Well it turns out that one can compare them, and after allowing for the more complex and sicker women that are more likely to find themselves assigned to the medical camp, it seems that there are definite benefits to seeing a midwife… Surprise!

Of course one could argue about some of the touted advantages of midwife-led care mentioned in the article: the use of fewer epidurals for pain relief in labour, for example. I’m not sure I understand why a procedure that truly does relieve pain -and which, if used in a timely and appropriate fashion, has minimal effects on the outcome of labour – can not be judged to have a positive effect on the experience. Labour doesn’t need to equate to running a gauntlet; there are no prizes for enduring the most punishment; no moral or societal penalties for actually enjoying it -in other words, being open to pain relief without a sense of guilt or failure. Or at least cherishing the opportunity to choose. Epidurals aren’t for everyone, but its nice when they’re available. Options are good. Maybe its the man in me wondering what all the fuss is about natural labours; can any labour that results in the birth of a baby -perhaps apart from circumventing it entirely with a Caesarian Section- really be unnatural? Unplanned, maybe; not living up to expectations or desires, perhaps; requiring interventions one would rather have avoided, possibly -things happen… All of us -doctors included- would like to see events unfurling as the mother had hoped, and honestly try our best to achieve this. But above all, we want a satisfying, but safe delivery of a healthy infant.

Fewer episiotomies is another benefit to midwife-led care apparently… Uhmm, I’m trying to remember the last time I -or my colleagues- had to resort to one of these! But I understand the point: there are some things doctors may do that could be construed as unnecessary intervention.  I take exception to a comment the CBC reported from a Guelph, Ontario midwife, though. She apparently felt that the fewer midwife interventions noted in the studies made sense “given how midwives view birth as normal.”  [italics are mine]. However, she does go on to say that “There’s more time in the visit to really address their concerns, so my expectation is we would really care for the whole person, address problems early, refer problems early and that allows women to be healthy.”  No Us and Them in that follow-up statement;  no aspersions cast there. Indeed, she’s managed to encapsulate just why I feel so comfortable with midwives. But I would like to suggest that even doctors are capable of considering the whole continuum of conception-pregnancy-birth as normal, too.

Choice in pregnancy care is the important issue, I think. Midwives, like general practitioners, refer to specialists when there is a need. Some pregnancies are known to be at higher risk than others right from the start -an older woman with hypertension, or diabetes, for example- but even there, as long as the midwife, mother, and specialist are comfortable with each other and with the probability of more intensive and perhaps more frequent testing, shared care between them is still an option if the patient wishes to continue with the midwife. Its a beautiful compromise that dips a toe in both rivers without being swept away by either.

Hope springs Ephemeral?

I sometimes wander through medical journals like a tourist, stopping here to gaze admiringly at a headline, pausing there to read a letter or two. Occasionally, I stumble upon a piece of information tucked away like a child under a quilt on a winter bed -interesting stuff that would still not likely find its way onto the six o’clock news even in summer.

Maybe it has something to do with my own personal epigenetics, but there was a piece in the July Canadian Medical Association Journal that intrigued me. The article was entitled Stanford researcher contends most medical research results are exaggerated and came from a keynote address by Dr. J. P. A Ioannidis at the World Congress on Research Integrity in Montreal in May. Now at first blush, that smells of a pot calling its researcher-colleague-kettle dirty, but think about the ramifications if true.

To quote from the article: ‘Empirical studies suggest that most of the claimed statistically significant effects in traditional medical research are false positives or substantially exaggerated.’ Indeed, ‘Even the pharmaceutical industry is now trying to replicate well-regarded studies before they invest in developing particular drugs.’ In fact, the speaker went on to note that ‘researchers at Amgen, a biopharmaceutical company, could replicate only 6 of 53 studies’ [in one project]… So, ‘Most of the time, clinicians should not jump on the results of a single study, even if it came out in a prestigious journal and was widely covered… Bias and random error are the chief reasons research findings often lack credibility.’

And why do I find that so fascinating, one might ask? Well, for one thing, the stuff I see tends only to be published if there is some positive effect, and seldom -if ever- when there is no effect. It’s like everybody I encounter in a journal is correct; things work. But in real life where the patients are not highly selected (or rejected) to satisfy the needs of an experiment -i.e. my practice, or that of my colleagues- there’s more of a Bell Curve effect.

I can live with that; I believe in the Scientific Method: make a theory, gather data to test it, and then see if it can be replicated or predict the results of similar future tests. It should always be subject to revision or even rejection if a better theory or explanation comes along. Science is always a work in progress, an unfinished sandwich…

So its nice to confirm that we shouldn’t always rely on conclusions drawn from one set of data -however large and convincing. They could be the result of a poor -or at least unfortunate-choice of candidates to study, or the results could simply be too good to be true. Ioannidis again: ‘Big discoveries do happen… but most of the effects that are floating around to be discovered are probably pretty small. When we see large effects, probably we should adjust them downward.’

We see things that seem like good ideas being tested all the time in Medicine; sometimes they appear so intuitively correct that minimal sober second thought seems to have been expended before their adoption into mainstream practice -minimal Scientific Method? Without benighting a now-accepted device in obstetrics -the fetal heart monitor and its use in labour and antenatal testing- let me say that there was initially a surge of what can only be politely termed prophylactic Caesarian Sections. It was, at least at first, a classic failure to disprove the Null Hypothesis. And yet, in its early use, if you accepted an almost unconscionably high rate of Caesarian Sections, it seemed very effective at preventing fetal damage in labour…  until it was realized that not every fetal heart rate deceleration, not every bout of fetal tachycardia, not every episode of decreased fetal heart rate variability necessitated immediate operative delivery.

Or how about the IUD -the intrauterine device? Stones worked in camels (at least apocryphally), so what the heck. And surrogate plastic stones were very effective at preventing pregnancies in humans as well. Only later did we find that they resulted in a fairly high rate of infection and even sterility… Admittedly, after reconsidering their design and choosing a patient population that would be at a lesser risk, we have shown them to be an asset. But they had more liabilities than benefits at first… More than we had predicted; more than we had planned for.

We can see the Hope in both these cases -and indeed Hope in the cases to which Dr. Ioannidis refers: the hope for a significant breakthrough in treatment or surveillance. Sometimes it just takes perseverance in the face of adversity: knowing (hoping?) you are on to something. But at what stage should one back off -or at least step back far enough to see if the road leads anywhere? It’s easy enough to look back in time and judge that they were never going to succeed with forceps that could be manually tightened around the baby’s head (so they wouldn’t come off if there was a need for a greater pull), or that the use of sterilized string -instead of a hard monofilament nylon line- on the end of an IUD (so it wouldn’t injure a penis) would act as a kind of wick to draw bacteria from the vagina into the uterus… Even the idea of over-the-counter (and therefore inevitably indiscriminate) availability of antibiotics for gonorrhea in some countries where infections were high and medical help unaffordable seemed like a forward-thinking idea at the time. I mean, who would have thought that gonorrhea would be so good at developing resistance to them?

So I suppose the observation that research results can be exaggerated shouldn’t come as a surprise. We’ve often let hope -belief- lead the way; looking for a path is what takes us somewhere else, somewhere we’ve never been, or have only glimpsed darkly in the night. But we must always be willing to retrace our steps, or at least listen when others are shouting to us from another trail.

Postpartum Depression -Just words?

Postpartum depression -I know these are only words, medical words, I suppose: descriptors. Language. But for all we’ve done with these particular words, what little attention we seem to have paid to them, they are still only words. And yet they describe a condition that has dogged us for millennia: the darkness that follows pregnancies like a silent shadow.  Creeping quietly in the background, it bides its time, stalks its prey. Camouflaged, it is visible only if you look carefully along the trail, study the  subtle indentations where it hides, part the branches of its lair. It’s always there. Lurking. Waiting.  And given the opportunity -a gift of circumstance perhaps, a melange of genes, a naivety of observation-  as the brilliant light of birth is slowly extinguished, it rises suddenly from the shade and pounces like a hungry cat.

It bothers me that we pay it so little heed until it strikes; that we read the cover of its book so well and then, seduced by the play of colours on the top, miss the message written clearly not so deep within. We act as if it were a surprise that things are not always as they seem; that we all have shadows if we dare to look behind.

There are quite a few tools -questionnaires, by and large- that have been designed to help doctors and midwives anticipate most perinatal problems long in advance. The problem, of course, is in according depression sufficient importance. We are too often focused on measurements in pregnancy: weight, blood pressure, the amount of protein in the urine sample, fetal heart rate, growth of fetus, position of baby –real things, objective things. Important things to be sure. Most of us feel more comfortable in writing numbers and words in their proper columns and following the trend; understanding and charting the ongoing fetal development: Ontogeny recapitulates Phylogeny as they taught us in medical school. There’s a certain comfort in the dispassionate assessment of what we take to be an objective, measurable reality. There are rules.

Emotions on the other hand are mysterious; we hardly understand ourselves, let alone the vagaries and vicissitudes of the moods, coping mechanisms, or even guiltily-expressed thoughts of our patients -their words on exhibit, but weeks apart on consecutive visits. On some of those occasions they’ve had a hard time at work, or have argued -are maybe even arguing in the office- with their partners; they’re polite, but only on the surface. Other times they’re all smiles -or all questions… Sometimes they never even get a chance to speak- just the partner. But I think that these are clues to an observant midwife, or doctor -even if the various screening strategies (such as the Edinburgh Postnatal Depression Scale, for example) have not been utilized. They are certainly helpful in gauging the amount of anxiety the woman is feeling, the attitude she has to her partner -or vice versa- and the amount of support she is receiving at home… all contributors to possible future problems.

Some of the clues -the postpartum ones at any rate- are revealed by simply asking the mother if she has been feeling down, depressed or hopeless of late, or if she has been finding that she is losing interest or pleasure in doing things. If she answers yes to either, then does she want or need help in dealing with it? The questions are asked sensitively, casually, and with no hint of prejudice or blame. They are not traps to assign the stigma of mental illness, nor to criticize her ability as a mother.

I am fortunate in my center to have a Reproductive Psychiatry program that is interested in assessing pregnant women and their risks for developing adverse postpartum mental health issues. They come up with strategies -not necessarily medication- to help, apprise her of facilities available in the community and ensure that the mother is in the system should there be problems. The woman knows where to go for help if she needs it.

I try to identify the risks both from history, observation, and direct questions as to whether they feel they might benefit from someone as well as me to talk to. I usually stress that it is better to be prepared beforehand than caught unawares. I try help them to understand that it is as much for the baby’s well-being as their own. Once the patient realizes that the referral does not mean that I think they already have mental problems, and that they won’t be pressured into taking antidepressant medications with their possible -yet controversial- effects on the fetus, they usually accede to my concerns. Caring for a person, means more than entering their data in a chart… Words, even in the correct columns, only go so far.

Words are signs, signals in the void that separates us all: little lights… and sometimes they’re really all we have. They’re among the few things that touch us deeper than skin; they often tell us more than we can take in with our eyes. But only if we listen.

Words

Are more than billboard signs,

Lined up

Along the road;

More than pictures

Hanging

On a wall.

Although

They can be pretty

As a group,

Perhaps

It is an accident of birth

That any one of them

Alone

Has more than a passing flair.

But

Each one

Is a suitcase,

Opening…

The Wrong Idols

I guess we’ve always needed idols: things beyond our ken or ability to achieve; things for which we strive but are just out of reach. They’re more than goals; they’re so desirable we almost worship them. They are what we are not -or at least not any more- but because they are so prized, they assume a disproportionate worth.

And the surprising thing about these idols is that they are more subjective than objective, more evanescent than real. They are often societally engendered, and culturally perpetuated. And there are temporal (and maybe geographic) boundaries beyond which they lose their meaning. Fashion is perhaps the most obvious and pervasive of these: despite its obvious, albeit transient importance, time strips it of significance fairly quickly. We all know this, expect this, accept this.

We are fickle and easily besotted creatures and our tastes are subject to random currents that tangle us together and carry us en masse to ever changing shores. You’d think we’d learn -or at least step back occasionally to wonder where we’re going. Or why. Insight is a gift that most of us leave unwrapped.

Beauty, like fashion, is built on shifting sands. Things that even a moment’s reflection would forever embed in the camp of the sacred are sometimes ignored, seldom mentioned -or worse: denigrated. I’ve always felt that the post partum abdomen is one of these. So I was pleasantly surprised to find an article about it in the BBC News in an article entitled Are Women’s Bodies Still Beautiful After Pregnancy?  http://www.bbc.co.uk/news/magazine-23276432

The idea that stretch marks are more like wrinkles than merit badges has always rankled me. The very notion of a need to hide them rather than celebrate them is anathema. Counterintuitive. They are earned credits to be displayed proudly.

Perhaps what may be distressing is the thought that the changes herald a phase-shift; that the abdomen will forevermore advertise a loss of innocence, a recognition for all (maybe) to  see that the bearer is no longer inter regnum in society. A different stratum has been enjoined.

Change is fraught with anxiety and inlaid with traps for the unwary. It is a new dress that looked good in the store, but in a later mirror, arouses doubts as to how or when to wear it -whether it was even a good choice. But a moment’s breath, and the beauty surfaces again. And again. There is nothing that unfolds from that recognition but awe; I suspect that little stays the same in life that is truly worthwhile. We are not the creatures even we remember…

I wrote a poem about this once -it captures some of what I mean in metaphor:

There was a time,

I think,

When colours splashed me

As I walked along the street-

Not playfully

But in earnest

As colours are when they dance among the leaves

Flirting lightly with the wind.

I thought

I heard some whispers from the grass

Where dark things stretched

And shopped for light

Like tiny bathers on a cloudy beach.

I even listened to the summer waves

Breaking,

Falling exhausted on the shore

With messages from somewhere

That wished them well on every tide.

I suppose it once made sense

To worship everything that moved-

Or might-

And find divinity in a tree;

Those were days when people laughed

Not once

But often in the night

With no one near.

It doesn’t matter any more,

Of course:

The world was different

Then

And so was I,

I guess.

But sometimes

When the shadow of a cloud

Consumes the footsteps that I follow,

I wonder

Where do all the colours go

When I close my eyes?