Christmas Eve Can Kill You

Time is the Enemy

"Language is the cake with the file in it."

Photo by Tim Ellis

The title of this post is a quote by  B. Blanton sent to me by my ever-clever father-in-law with the byline "a quote to get us through the day." And it did just that.  It also got me thinking about language and how it tricks us, often without our even knowing it. So I thought I'd apply this idea to the area of medicine with which I am most familiar by laying out a few of the phrases I would like to expunge from the obstetric lexicon. So, here goes nothing:

1. Incompetent cervix
- There is nothing incompetent about any part of woman's pregnant body. Period.

2. Low pain tolerance / low pain threshold
- First, why is pain, especially labor pain, not inherently valuable? Why is it an experience that needs to be tolerated? Why is it a problem for a person to have a physical or emotional reaction when the intensity of pain has exceeded a certain magnitude? And if a woman wants pain relief at this juncture, isn't there some serious paternalistic behavior being exhibited if she doesn't get it? Finally, how in the hell can we objectively judge what the patient is experiencing? But all of this is yesterday's news.

3. Terrible pusher
- What can I say about this? Really nothing except that our patients aren't freshman linebackers.... or novice drug dealers.

4. Dysfunctional uterus / dysfunctional contraction pattern 
- Dysfunction implies impairment, something that is flawed, decayed, defective - a deviation from the norm.  So we should ask, who is defining the normal?

5.  Failure to progress
- Failure: collapse, defeat, fiasco. As in "I'm sorry Ma'am, but your labor has failed.  Now you get a cesarean section. And all because you made no progress."

6. Elderly primigravida / Advanced maternal age
- Up until the 1960s, women were often having children well into their 40s.  Modernity does not necessarily equate with progress. And I think even my teenage son will agree that thirty-five is certainly not elderly even if he categorizes The Smiths as "classic rock".

7. Stalled labor 
- The body is not a '64 Impala.

8. Late to care 
- I am pretty sure that most of these women care.  They may have been late to medical oversight, late to obstetric assistance, but they are not late to care.

9. Failed homebirth
- Again with the failure.  It's a homebirth transfer.  Let's say it aloud: no one is a failure in this scenario.

... and, for the all time most heinous of our many articulations:

10. Give the woman a tubal, already! (or) Please tell me she's signed her tubal papers.
- This is one for future scrutiny in the form of an academic paper. And I am totally on it. All I can say for now is that I know Americans are terrible with history, but our collective memory cannot possibly be that short-term.  Ever heard of sterilzation? If not, follow the link for an easy primer.  We need to think about these not-so-distant days of yore, and think hard, before uttering these words ever again.


So, as the good Mr. Blanton says, language is indeed the cake with the file in it.  The question is, does that file set us free or does it cut our throats?  You decide.

The Problem of Pain

Pain.  Pain is something that, as health care providers, we learn is subjective.  Subjective: meaning belonging to the subject (patient) rather than the object (the “objective” practitioner).  Subjective pain: pain that is perceived by the patient and not by the provider.  Pain: an area of healthcare where the objective practitioner can have the ability to, and often does, perhaps unconsciously, objectify his or her subject.  This may be doubly true in assessing laboring women who all present differently at different stages and who may or may not meet certain clinical expectations in response to the pain of childbirth.

I won’t talk about patriarchy and women’s experiences of their bodies.  I won’t talk about how women punish one another into utilizing or forgoing modern pain relief methods for some weird feminist ideal of woman/motherhood.  I won’t even talk about language such as “low pain threshold” or “no pain tolerance” in discussing another person's pain.  No. Just for today, I won’t. Instead, I will give you this anecdote.

A patient is admitted for intractable pain, not in labor.  This intractable pain is accompanied by some intermittent vomiting… and a suspicion by providers that this patient might be drug seeking. It is never totally clear why. She is poor.  She is a minority.  So there are two strikes against her from the get go.  She is perceived as something before she is anything in the clinical realm... before she is even a patient. “What makes you think that? About the drug seeking?” someone asks in team meeting.  “Well,” responds the attending provider, “Her pain seems very out of proportion to her early labor status and no one has ever witnessed her vomiting.  Also, we were going to perform a tox screen but she can’t seem to void, which I find very suspicious.”  Suspicious.  Not concerning but suspicious. A good practitioner should, right about now, have counted at least five symptoms that could be used to rule out a host of issues other than drug seeking behavior. But this is where we are.  So a wise doctor seated beside me addresses the pain issue by asking, “And have you given her anything for this pain?”  “No,” responds his colleague, “Nothing but an antiemetic for the supposed vomiting.” 

The inquiring doctor rolls his eyes and turns to me, sotto voce, “Drug seeking for ondansetron. Now that’s a problem.”

*The Problem of Pain is a very brief and worthy little book written by C.S. Lewis and Virginia Woolf touches on the subject in her essay On Being Ill.  For a little non-medical perspective to inform practice, you can also read some Heidegger and Nietzsche among others. 

As Dear to Life As Breathing*

One of the doctors from our hospital spoke on a local radio program last evening, albeit briefly, on the issue of Licensed Midwives in California having the right to practice without supervision by a physician.  You can hear the piece on the KALW program Crosscurrents. I posted the piece to Facebook with the request for people to share opinions, a wildly regrettable move on my part, always, because that forum appears to be for a  large majority of people who peruse (i.e. express impressionistic reactions) and who do not read.  But the great thing about radio is that if you're not a reader you can be a listener and you can do that here.

The crux of the story is one that lays out all of the apparent advantages of legislation known as AB 1308 (which also requires reading).  Admittedly, the proposal was explained fairly accurately in the Crosscurrents piece.  The big omission was the differentiation between Licensed Midwives and Certified Nurse Midwives and the conflation of CNMs with Obstetricians who practice inside the hospital.  That and the rather big assumption that all pregnancies and births are low risk and therefore all women are, by default, candidates for home birth. These issues definitely remain firmly stuck in my craw. Every day. It is irresponsible for us, as healthcare providers in obstetrics and women's health, to let women believe that prevention is akin intervention.  It is equally irresponsible to guilt women into thinking there is a "right" way to experience birth and to become a mother.  Childbirth and motherhood are hard enough.

But what we're talking about here is AB1308.  Current legislation allows Licensed Midwives at alternative birth centers to practice under a Physician or a Certified Nurse Midwife.  This distinction was not clear in the Crosscurrents piece.  In 2010, there were 1,500 Certified Nurse Midwives in practice in the state of California, many of whom practice homebirth exclusively.  Very few, in fact, are hospital-based providers. CNMs are educated and trained under a medical model, equipping them with strong clinical skills by way of training as advanced practice nurses.  CNMs must be registered nurses and must receive a master's degree in a nurse-midwifery program that is accredited by the American College of Nurse-Midwives in order to practice legally. These midwives can treat patients throughout their pregnancies, attend births, prescribe medication and are highly trained in the pathology and physiology of childbirth to be able to recognize a women or baby who may be in distress and in need medical intervention, a real and unfortunately common occurrence.  (Consider maternal and neonatal mortality rates in parts of the world where medical intervention is *not* accessible).  Licensed midwives, on the other hand, may or may not have a bachelor’s degree and their training varies depending upon length of apprenticeship, mentorship and at home study.  I think making this distinction is central to a conversation about the role of midwives in the community and what AB1308 means for the profession of Midwifery as a whole.

Of the responses I received to this post, most didn't even address the point of the radio piece.  Many made the fallacious argument that a midwife-attended "homebirth is (statistically proven to be) more  safe than a hosptial-based birth" -- an argument I can't deny (not unrelated, I am sure, to the fact that it was the basis of my senior thesis as an undergraduate.) But it's a poor logical argument, a base rate fallacy.  Statistically, outcomes for homebirths are quite positive.  This is true.  Personally, I fully support and advocate for homebirth with a Certified Nurse Midwife under the condition that both mom and baby are in good health.  But the statistics of it are somewhat confounding.  I am hesitant to embrace statistics comparing midwifery to hosptial-based care because it is fraught with problems - in that there are certain variables for which there is no control. For example, high risk patients are treated in hospitals and have "worse" outcomes (higher rates of epidural use, episiotomy, vacuum or forcep extraction, neonatal admission to the NICU, maternal blood transfusion, cesarean section).  All because hospitals have access to these interventions and treat sicker patients.  This is fact.  Providers in medical settings have the tools and the knowledge to manage extremely difficult situations and to keep babies and mother's alive.

I guess the question always lurking in the back of my mind is "how many bad outcomes would I, as a practitioner, accept?" (A bad outcome, in my mind being a maternal or neonatal death, not a cesarean section).  For me, personally, the answer is zero.  I wish I had, in my lifetime, seen zero.

The confusion between high and low risk birth, maternal right and choice, information and knowledge, security and safety is complicated.  It is complicated by history, complicated by access, complicated by perceived understanding, complicated by stories like these and specifically by women who stake claim over what is right for other women in the name of liberation.  I have said this before and will say it again: Prevention of poor maternal and neonatal outcomes, or death, should never be mistaken for unnecessary medical intervention.  It is so disheartening to me that obstetrics has become this strange and difficult place for feminist convergence and collision and thus is the ONE area of healthcare in this country where preventative medicine is shunned as counter to choice.  When the outcomes are poor, it is also the most litigious area of healthcare.  And in these cases it is the most heartbreaking because it is here that we have the most to lose.

If women lose the right to say where and how they birth their children, then we will have lost something that's as dear to life as breathing. - Amy McKay, The Birth House 

Out of the Marvellous

Lightenings viii

The annals say: when the monks of Clonmacnoise
Were all at prayers inside the oratory
A ship appeared above them in the air.

The anchor dragged along behind so deep
It hooked itself into the altar rails
And then, as the big hull rocked to a standstill,

A crewman shinned and grappled down the rope
And struggled to release it. But in vain.
'This man can't bear our life here and will drown,'

The abbot said, 'unless we help him.' So
They did, the freed ship sailed, and the man climbed back
Out of the marvellous as he had known it.

“If you have the words, there’s always a chance that you’ll find the way.”

   ~ Seamus Heaney (1939-2013)

There is No Them

2013 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
Persons in family/household	Poverty guideline
For families/households with more than 8 persons, add $4,020 for each additional person.
1	$11,490
2	15,510
3	19,530
4	23,550
5	27,570
6	31,590
7	35,610
8	39,630

This week in the break room a few of the nurses were asking one another, "If you had the power and the resources to take on one cause, what would it be?"  I remembered reading the night before a mind boggling statistic about poverty in the United States:  more than 35 million Americans now live below the poverty line - which is saying quite a lot given than the poverty guideline for a four person household is a measly $23,550 per year. To put that in perspective, imagine a family of two parents and two children with the primary wage earner* making about $12.25 per hour over a 40 hour work week.  The current federal minimum wage is $7.25 per hour. Needless to say, the standards set by our government are ridiculously and embarrassingly low. 

And then there's the Affordable Care Act.  Apparently drafted in an effort to insure all, under the ACA, many of those working poor who make a wage above poverty line are not eligible for coverage.  Because the government made Medicaid optional, and 27 states opted out, those individuals and their families who make between the poverty line (but not below) and four times that amount are ineligible for both government subsidies under ACA for private insurance and Medicaid benefits.  Which states opted out?  Those with the highest number of families living just at the poverty line.   

As a nurse in a public hospital in a large urban setting, this really strikes a cord.  Every day we are the eyes and the ears of the war on the poor in this country, from the front lines.  But how many times are there grumblings from both nurses and doctors about patients who have not sought out preventative care, who's BMI is "too high", with uncontrolled, underlying conditions, who have had multiple pregnancies, abortions, losses, births, addictions. And how many times are these people blamed for their "lack of initiative" in caring for themselves.  Every day there is someone blaming a patient for poor health outcomes -- or for being overweight or impoverished or having multiple prior pregnancies or for being addicted -- and every day I wonder how these people can care for themselves when we can't - not even for 24 hours - suspend our judgement to simply care for them.  As we should without doubt and without question, as this is the root of our profession.

You aren't cared for because you care for yourself.  You're cared for because others care for you. 

*No the second parent doesn't work because they can't afford childcare.  

For Every Field There's A Mole

Because I am back with my anonymity no longer in tact, I will be writing less about what happens in the hospital in a detailed manner.  That is to say, it is of the utmost importance to me to protect my patients. Of course, I am confident that many anecdotes of this crazy business will find their way through.

I have been an (employed!) nurse for three years since I last posted here.  Yes, I still see this job as my true calling.  But I am often frustrated and disappointed in the system and I am daily looking for a way to articulate: to reverse the ethnography, so to speak. I have to demonstrate the transition from critic to cog in the wheel, which is very hard.

From the moment I stepped into the role of clinician, I have struggled not to speak too loudly, but I often fail.  I have tried to be fair and to equally, quietly bear witness to all of our patients.  I have tried to burn the injustices that I see and hear every day on my brain so that I can one day, in some small way, try to right them.  I hope that this forum will be the jumping off point for me to eventually do that in a larger way.  I hope that there are eyes here to bear this with me.

All of my life I have watched the masses of the world 

suffering from the same disease for which 

the cure is readily available to them 

but they cannot see it.  

We are all born to take a little share of 

the abundance of this earth. 

When you see that, there will be 

tremendous change. 

You only have to open your eyes to open your mind. 

Where You Going Riding, Boy?

After three long years, I'm back in the saddle.
There is a lot to say.
Maybe someone is listening.