Pregnancy in Fiction

I’ve read a couple of novels recently that took fiction to a whole new level with regard to pregnancy and delivery. In one, a “neonatal nurse” flipped a breach baby during delivery, in another, a 6-week pregnant woman had an audible fetal heart rate, a traditional abdominal ultrasound, and had difficulty with her pants becoming tight and her bra no longer fitting. So I thought perhaps some ground rules were in order…

First, pregnancy is caused by…yeah, I’m skipping this part. One of my romance-writer friends can fill that in. But…I will say that the youngest pregnant patient I’ve cared for was 12 years old, though hers was not consensual sex. Anyone through puberty has the capability to become pregnant/cause pregnancy.

Pregnancy is logged in weeks from the last menstrual period, with 40 weeks being “fully cooked.” In fact, most women become pregnant mid-cycle, so they are only pregnant for 38 weeks. During those first few weeks of pregnancy, lots happens to the mother-to-be. She may feel out of breath as her brain resets the target amount of carbon dioxide in her body. Her breasts begin to grow, slowly. She feels exhausted, maybe emotional, nauseous (man, what we put up with for our kids!).

At this point, the only way to really assess the baby is with a trans-vaginal ultrasound – a probe advanced to the cervix, with which an image of the lima bean is visible. A single pixel blinks on and off…that’s the heartbeat, and it’s visible at about 5 weeks, but it can’t be heard quite yet.

The first trimester (approximately 13 weeks) is the worst for nausea, and the most

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10 week ultrasound

important for fetal development and avoidance of exposure to drugs and chemicals. With an ultrasound probe pressed hard against the lower abdomen, the heart beat can first be heard around 12 weeks. So if you want the mom and dad to smile lovingly at each other at the sound of their baby’s heart…make sure she’s at least that far along.

The second trimester is when things become apparent to others. First-time moms feel the baby move for the first time (“quickening”) around 18-20 weeks. Repeat moms recognize the fluttering a little earlier. The baby bump starts to appear (different from just over-eating and becoming overweight). The height of the fundus (top of the uterus, measured from the pubis) in centimeters, should be about the same as the number of weeks pregnant (assuming a single baby). Healthy moms visit their ob about every 4-6 weeks at this point, with and ultrasound around 16 weeks to look for major structural problems in the fetus.

Viability (where the baby has a chance to survive outside the womb) occurs between 23 and 24 weeks, so just over half-baked, but these babies require major resuscitation and advanced care. If your character is delivering a 24-week baby in the woods, it won’t survive. Most babies achieve lung maturity around 34 weeks, so that’s about the age a baby born in the woods could very reasonably survive.

Since 2000, we almost never deliver breech babies vaginally, unless it’s the 2nd twin. We might try to flip a breech baby before labor, but the success rate isn’t great, and there can be complications.

Unless there are problems, like high blood pressure, diabetes, a huge baby, etc, we don’t induce labor or perform an elective Cesarean until 39 weeks gestation. This is also relatively new. Turns out baby lungs do better if we wait those extra few days. In fact, if we do an elective Cesarean at 36 weeks and 6 days our obstetricians have to defend the move…as if we know with certainty the exact day the baby was conceived. Rarely do we allow a woman to go past 41 weeks either.

Lots more info about pregnancy and delivery. Bring on the questions!

 

Bruising

I have a character who is beaten up.  How long does it take for the bruising to show?
bandaged-smiley-face-100x100
I envision her having a black eye, a busted lip, a broken arm and perhaps a broken rib or two.  I think her arm will have broken as a result of being slammed against the edge of a brick wall, and I assume there will be a major bruise at the point of impact.  I want to describe the state of her arm when the police examine it about 1 1/2 – 2 hours after the fact.

Bruising is blood under the skin. That won’t necessarily happen from a broken limb, depending on the mechanism of the break. She would have a road rash type picture from the roughness of the brick wall (though long sleeves might minimize that), and may develop a bruise from that crush, though 2h is a little quick. The appearance of the arm itself would depend again on how exactly you imagine her breaking it. It can look normal, or have a lump, or best might be for it to have an obvious deformity, a bend where there shouldn’t be one.  That’s called a “displaced fracture.”  If you want to get gory you could have a piece of bone sticking out of the skin, that’s an OPEN fracture and would bleed. Though by 1.5-2h the bleeding should be stopped.

A bone will only break if there are forces opposite to its length, like slamming it against the corner of a brick wall so part of it wraps around the corner, if you know what I mean. Or twisting it. Just slamming someone against a wall wouldn’t break it, unless they had their arms out to break the fall maybe.

Broken ribs CAN bruise, since they’re so close to the skin, assuming your victim isn’t obese, but again it’s not that quick.  As an aside, depending on the mechanism of breaking a rib, a portion of it could poke into the lung and cause a “pneumothorax” (air in the chest, but not in the lung). That causes chest pain, breathing difficulty, and can be a major emergency, or not, depending on what you want to happen with your poor soul.

 

Why do so many women feel guilty for getting epidurals?

This post is unrelated to writing, but I couldn’t resist when this headline came through…”Why do so many women feel guilty for getting epidurals?” It gave no real answer regarding epidural-induced guilt, only mentioned there was a push in the UK to have women use midwives, which they credit with reducing the epidural rate from 69% to 59% over a 10-year period. Which revives the interesting argument of “natural” childbirth and the impression forced on many women that they are somehow less if they request an epidural for their delivery.

Labor is natural, so the argument goes, and the pain of labor is ordained by God (Genesis 3:16 “in sorrow thou shalt bring forth children” – so we can blame Eve). However, kidney stones, so MY argument goes, are just as natural, if not specifically mentioned in the Bible. And who would argue that someone who suffers a kidney stone should go without pain relief? What about an abscessed tooth? Or an amputated digit? Just because thousands have lost digits over the millenia, no one would argue you should grin and bear it like Adam.

I have a theory, grounded in absolutely no facts, about the modern perception of pain. In the thousands of years women had babies without analgesia, they suffered pain frequently…headaches, broken limbs, saber-tooth tiger bites…so their innate mechanisms were honed to internalize (or externalize) their pain in such a way they remained functional. Now we take Tylenol/Motrin/Advil for the slightest ache. Perhaps, my theory goes, our brains have lost the ability to ignore pain, our natural endorphin mechanism no longer kicks in.

Despite being an obstetric anesthesiologist, I marveled at the intensity of my own labor pain with baby #1. (“Marveled” may not be the right word, but let’s go with it.) Believe it or not my labor nurse, apparently unaware of my career, told me an epidural would cause a cesarean delivery. I was shocked, appalled, outraged. Well aware of the risks, and cesarean delivery is not one of them by the way, I went around Nurse Ratched and called my friendly neighborhood anesthesiologist directly.  When I received said epidural (at 8 frickin’ centimeters dilation), I realized what an incredibly wonderful thing I do for a living. Baby #2 came too fast, so I did get the full-tilt blessing of natural childbirth. And for #3? Epidural when she decided not to come out after less than an hour of labor like her impatient big brother.

And the moral from my experience both as a laboring mother, and as an obstetric anesthesiologist with twenty years’ experience? It’s YOUR delivery. Do whatever you want. Epidural, no epidural, breathing, no breathing…okay, not that last one – BREATHE!  It is my considered opinion that some women must have fewer nerve endings in their cervix/uterus. Occasionally someone will come in saying they’ve had minor back pain for hours, and are 9cm dilated. Others come in screaming “F— the birth plan, I want my epidural!” at 2cm. It is not all toughness, willpower and intestinal fortitude. And it is no one’s business what any woman chooses for her labor. Grin and bear it, say every swear word under the sun while shrieking the virtues of vasectomy to your spouse, or relax and enjoy (assuming you have an awesome, attentive anesthesia provider). Either way, you’ll have an amazing gift afterward.

 

 

Allied Health Personnel: Who are they?

EMTs vs paramedicsstethoscope-294378_1280

Optometrists vs ophthalmologists

Anesthetists vs anesthesiologists

In your novel, which term should you use when?

Emergency Medical Services (EMS)

The most common providers riding ambulances, fire trucks, etc are EMTs (Emergency Medical Technicians). They complete about 150 hours of training and can provide CPR, oxygen, glucose for diabetics, but they can’t start IV’s or give many medications. Paramedics, on the other hand, complete 10x the hours of education and can administer medications, start IVs, manage airways, and more. So if your victim needs a breathing tube, an IV, or major resuscitation, be sure you call the main provider a paramedic and not an EMT.

Extenders

NPs (nurse practitioners) are nurses with additional graduate school training. Many subspecialize in critical care, pediatrics, etc. CRNA (certified registered nurse anesthetists) practice anesthesia, generally under the supervision of a physician anesthesiologist. Nurse midwives practice usually with an obstetrician medical director.

PAs (physician assistant) are not necessarily nurses first, but must have some direct patient care experience to gain acceptance. They generally work under the authority of a physician, and many subspecialize.

There are many other physician extenders:

Optometrists check general eye health and prescribe glasses, ophthalmologists are physicians who also prescribe medications and perform surgery.

Midwives can do prenatal checks and deliver babies, but an obstetrician is required for cesarean delivery.  Interestingly, there are two different kinds of midwives with very different skill sets.

Any questions about physicians, extenders or allied health personnel skill sets?

 

Head Injury and Medically Induced Coma

Question:

My victim was deliberately run over by a mountain biker. Skull fracture, internal injuries broken bones. Would the victim be put into a medically induced coma and what drugs are used. How do doctors determine when to bring someone out of a coma?

Answer:

The short answer is…maybe (if necessary to control intracranial pressure (ICP)), propofol or pentobarbital, and it depends (probably ICP coming under control).  (helpful, right?) Scroll to the bottom for the short summary, or read on to understand what’s going on.

Traumatic brain injury (TBI) might occur with a skull fracture, with outcome ranging from complete recovery to death, and everything in between. Best if they are managed at a Trauma Center or at least a hospital with neurosurgical services.

Patients with TBI frequently have other injuries that complicate care, but here I’ll focus on TBI itself.

Prehospital

Glasgow Coma Scale (GCS): This would be performed early on and is a measure of brain function. It includes three areas:

  • Eye opening (spontaneous (4) down to none (1))
  • Best verbal response (not looking for a great pun, but oriented (5) down to no response (1))
  • Best motor response (obeys commands (6) down to no movement (1))
    • Yes, teenagers can still get a 6. They just have to squeeze your hand…but preferably not pull your finger.

GCS 15 is max; 13 is mild brain injury, <9 is severe. This is something the paramedics would report over the radio to the receiving hospital.

If the score is <9, the victim would be intubated (breathing tube in the windpipe) and the paramedic would be squeezing a breathing bag. They would also place an IV (intravenous) catheter and give fluids to maintain blood pressure. The GCS would be determined every few minutes to look for deterioration.

Emergency Room

They would follow the Advanced Trauma Life Support (ATLS) protocol (ask if you want more info), and scan the head (CT scan) to assess the brain. The big fear is “elevated ICP.”icp

Intracranial pressure (ICP) is the pressure inside the cranium (skull). In adults, the skull is solid, with just a few holes (e.g., eyes, and where the spinal cord departs for points south). Inside that solid skull is the brain, blood vessels, and another fluid (CSF: cerebrospinal fluid).

When something else takes up space (e.g. blood that has escaped), the skull can’t swell. Instead, the pressure inside the skull rises which can (1) reduce blood flow and (2) cause the brain to get squeezed toward the hole for the spinal cord. Unfortunately, the part of the brain most likely to get squished (herniate) through the hole is in charge of the most basic life functions (like breathing). So herniation is quite lethal. Incidentally, we look at pupils because the nerves that control them are in that same area.

So…if the CT showed a “hematoma” or blood collection, beneath the skull, it would likely be surgically drained immediately. For a skull fracture, as in your case, surgical treatment would depend on whether it was open (scalp open as well) and how deeply depressed the skull was.

So you could get away without surgery if you want. But they would at least have “minor” surgery with the placement of a pressure catheter into the brain to monitor ICP. The patient would be on a ventilator with a breathing tube, and would be receiving medications to maintain his blood pressure and try to minimize his ICP. He would be sedated, potentially to the point of a medically induced coma.

Medically Induced Coma

(you thought I’d never get there)

When nothing else works, the brain might be put to sleep. The goal is to minimize the oxygen needs of the brain, and thus the need for blood flow. Either pentobarbital or propofol would be used. The latter had become more popular, then a “new” disorder cropped up called “propofol infusion syndrome” which can be lethal and has reduced enthusiasm for long term use of the drug.

These patients have continuous EEG monitoring (electrodes on the head) to make sure we are sufficiently depressing their brain activity.

When to wake them up depends on why they were placed in the coma in the first place, but usually it’s based on the ICP, so when the ICP stays down, it’s time to stop the sedation and see how the patient wakes up.

Summary

Of course much more could be said. From a fiction standpoint, realism would come from the initial evaluation, the GCS, intubation and ventilation. A CT scan with results, the choice to induce a coma, with plenty of discussion from the physician to the family about the low likelihood of a return to prior functioning, but that it wasn’t time yet to talk about withdrawing care. Then a GRADUAL awakening when the sedation is discontinued – much faster with propofol than with pentobarbital. By the way, more realism, the propofol is a white milky liquid going into their IV.

Also plenty of opportunity for additional tension with complications like infections, other injuries, discussion of a “DNR” (Do Not Resuscitate) since the outcome if the victim’s heart stops is truly dismal. Oh the possibilities….

Let me know if you’d like more information about any of this!

Residency Training

Residency is largely a paid apprenticeship. The new MD works under the direction of licensed physicians termed “attendings,” whose job it is to supervise, teach, and evaluate the residents, while also ensuring the safety of the patient.

Residents rotate through various areas of their chosen specialty in a relatively strict curriculum set out by the Accreditation Council for Graduate Medical Education (ACGME). As they progress through training they earn more autonomy and responsibility, but are always under the direction of an attending who is ultimately responsible for the patient.

Duration of residency varies by specialty. Most primary care fields (Family Medicine, Internal Medicine, Pediatrics) are 3 years, Neurosurgery is 7, everything else falls somewhere in between. Some fields (anesthesiology, dermatology, radiology, etc) require a year of internship prior to starting in on specialty rotations. Residents are labeled by their Post-Graduate Year in training (PGY1, PGY2,…)

A physician can obtain a medical license after completing an internship and passing USMLE Step 3.

Residency, so called because in the old days one actually lived in the hospital to be amply available, has continually decreased in required hours.  When I was a resident (residents love it when you start a conversation like that), there were no hours’ limits (and the hospital was uphill in the snow). A pediatric surgery colleague was on call for 14 days straight (never left the hospital), though that was certainly the extreme.  In our Critical Care rotations we took in-house call at least every 3rd night, and occasionally every other if someone went on vacation or fell ill (can’t imagine why that would happen).  That means we worked 36 hours, went home for maybe 12, and returned to do it again, including weekends. Calling in sick is frowned upon for obvious (if illogical) reasons.

In July 2003 the ACGME implemented a new set of rules. Dubbed the “80-houImage result for 80 hour rule ACGMEr rule,” it put specific limits on resident work hours for the first time :

  • 80 hours per week, averaged over 4 weeks
  • at least 10 hours off between duty periods
  • no more than 30 straight hours of work
  • 1 day off in 7, averaged over 4 weeks

So, if in your story you want the resident to work ungodly hours, it would be more appropriate to put them in residency pre-2003. That said, violations continue to occur and some specialties pay lip-service to work rules, with residents still working 100+ hours per week.

Fellowship

After residency, many graduates choose to pursue sub-specialty training, termed fellowship. Some of these are regulated by the ACGME, but many others are not, and have more flexibility in their design and accreditation (and salary).  After Internal Medicine residency, one might spend another 3 years to become a Cardiologist; after 5 years of General Surgery, one might spend 2 more years in Pediatric Surgery; after my own 4 years of Anesthesiology, I did a 1-year Obstetric Anesthesia fellowship.

These can be stacked…after becoming a cardiologist, one might complete another 1-2 years to become an Interventional Cardiologist (putting in coronary artery stents, etc). One could become a career trainee if one were so inclined (and crazy).

Graduation

Then, on June 30, residents and fellows around the country graduate and start a new job, probably in private practice, and 24-hours later they have no supervision, no duty hours, no back-up. Hmmmm, what could possibly go wrong?

Board Certification

Graduates must complete a national specialty-specific exam, written +/- oral to become Board-certified. Board-eligible means they are eligible for board certification (d’uh) …which might mean they have not yet been out long to enough to complete the examinations (it takes at least a year in some specialties), or they chose not to take them (suspicious), or they already failed once or twice but not the fatal third time that would require additional training.

Moral of the story?

Look for Board-CERTIFIED physicians; don’t get sick in July, don’t choose physicians right out of training, and if in doubt, academic medical centers can actually be a great place for superb, if not efficient, care. There are always more brains involved…you’ll have to decide if that’s good or bad…

Medical Education

The latest question I received was about what a second year medical student would know if they happened upon an accident victim, which brings up the question of the medical education process in the US. Quick overview: 4 years of college, 4 years of medical school, 3-9 years of residency (the first year of which is called internship), +/- 1-3 years of fellowship.

Pre-Med

Except for a few specialized programs, medical school requires an undergraduate degree in anything really. The Medical College Admission Test (MCAT) is quite rigorous (understatement) and covers biology, chemistry, organic chemistry, biochemistry, physics, statistics, and so on, so a major that requires those courses makes some sense. But we look for students with a wide range of backgrounds, and most important, at least at UF, is evidence of “other-centeredness.”

Many students now take a gap year. Graduate, then spend a year doing something before matriculating to medical school. For some it’s financial, for others it’s a break, but for many it’s to enhance their application and odds of getting in. Regardless, the age at matriculation then is at least 22-24.

Medical School

medical-education

Usually begins in July/August. The first two years are generally still in the classroom, though they’ll have some patient contact while shadowing other physicians.  At the end of the second year, students must pass Step 1 of the US Medical Licensing Exam (USMLE). It largely covers the basic sciences they learned the previous two years.

Third year consists of 4-8 week rotations in various fields:

  • Internal Medicine (adults, outpatient clinics and inpatient wards; often includes some time on sub-specialties – e.g., cardiology, pulmonology, gastroenterology)
  • Pediatrics (kids, but same as above, including time in the newborn nursery)
  • Family Medicine (outpatient clinics, might include children)
  • Surgery (mostly inpatient, seeing patients before and after surgery, and observing during operations, rarely suturing the wound at the end of an operation); often involves some sub-specialty experience
  • Obstetrics & Gynecology (inpatient and outpatient clinics, deliver a few babies, otherwise similar to surgery, except with MUCH nicer docs)
  • Psychiatry (inpatient and outpatient)
  • Neurology (inpatient and outpatient)

By the end of third year or early fourth year, students should know what field of medicine they wish to pursue.

Fourth year is mostly elective. Students spend more time in fields they think they might wish to pursue, and do “audition rotations” at institutions where they might wish to complete their residency. Rotations are four-weeks long, usually with a few required courses: Emergency Medicine, Anesthesiology, Critical Care Medicine (Intensive care unit). During fourth year students must pass USMLE Step 2, both a written and a practical exam. The scores on this exam weigh heavily on residency applications because it is the only available national comparator.

From October to February of fourth year, students interview for residency positions.

The Match

CaRMS-updated-graphic

Despite legal challenges, the match process remains. Using ERAS (Electronic Residency Application Service), senior medical students are “matched” with residency programs. Students fill out an application, then direct it to the programs in which they are interested (all general surgical residencies in the southeast US, for example). Students are advised to apply to 20 programs or more, depending on their class standing/MCAT scores and the competitiveness of their chosen specialty (dermatology vs family medicine).

Admission committees at residency programs review the applications and invite for an interview those they consider competitive. After, the students rank the programs in order of their preference, programs do the same for the applicants, and a computer matches them up. The process is binding on both sides.

Should a student fail to match, there is a “scramble” afterward to find them a spot somewhere, perhaps in a different field, or just a one-year internship somewhere, with a plan to reapply the following year. Meanwhile the programs that didn’t “fill” are scrambling to find unmatched graduates to fill their openings. Though it’s becoming much less true, the cogs of an academic medical center still run to great extent on the work of residents, and a hole in a residency class means more work for everyone.

Graduation

ms-graduation

My graduation in 1991, with my awesome parents

Students graduate with an MD in May/June of their senior year, but cannot obtain a medical license to practice until they complete an internship (one year of training) and pass Step 3 of the USMLE.

Matriculation to residency is July 1 – a really bad time to be in the hospital!!

In the next blog, I’ll cover residency.