Monday, September 13, 2010

Obstetric Trauma on Healthbeat

An interesting thread developed last week at Maggie Mahar's Healthbeat blog regarding a guest post by one Jordan Grumet, an internist in Chicago, writing about an experience he had while a medical student rotating through OB/gyn.

He writes about a patient in the third trimester of pregnancy who arrived in the trauma bay bleeding profusely from a stab wound to the neck. As the trauma team fought to control the bleeding, Grumet's chief resident donned a gown and grabbed a scalpel. The woman's blood pressure dropped. The fetal monitor showed deccelarations in the baby's heart. I'll let Dr. Grumet describe the rest.
My chief cleared her throat: "Okay, guys, we're gonna lose the baby if we don't do something fast!"

Without taking his eyes from the patient, the trauma surgeon said authoritatively, "We can't. If you cut her, she'll die. Give us a minute."

"It will take a minute-and-a-half to have this baby out," said my chief. She got no answer.

She stood poised over the patient's abdomen, arm raised, scalpel in hand and ready to pounce.

The patient's blood pressure dropped even faster, and the baby's heart rate plummeted.

"It's now or never," said my chief. Then the cardiac monitor began beeping.

"Ventricular fibrillation!" The ER physician grabbed the cardiac paddles and shouted, "Clear!"

With a sweep of his arm, the trauma surgeon moved everyone away from the table, then stepped back--and crashed into my chief. She fell to the floor, extending her arm to avoid slashing anyone with the scalpel.


Dramatic, no? I especially like the image of the resident bravely controlling the scalpel so as not to "slash" anyone as she toppled to the ground. The writers on ER couldn't have scripted a better scene.

My initial comment on the post was this:
I work as a trauma attending. In obstetric trauma, the mother always takes precedence----the single biggest determinant of fetal survival is mother survival. This is Trauma Surgery 101. Once the mother progresses to unsalvageability, there is some evidence to suggest that post mortem delivery of the baby can lead to meaningful survival, albeit at meager rates of success.


Maggie Mahar responded by averring that such guidelines "must be a mistake". I then posted a second comment, politely reminding her that simply disagreeing with the evidence based, algorithmic approach to major trauma purely on emotional grounds is not a credible argument. I even posted a power point presentation I give for CME at one of my hospitals on obstetrical trauma. Pay particular attention to slide #15.

Maggie then posted a final comment where she basically just reiterated her contempt for established trauma practice. She gave no indication that she reviewed any relevant literature or even the power point link that I provided.

If the mother is hypotensive, the baby also is not getting enough blood flow. Hence oxygen exchange is compromised at the placental level. In layman's terms, if the mother is unstable, the baby is in just as much trouble. The fastest way to improve a baby's condition is to make the mother better. Maggie is seemingly unaware of the fact that a c-section requires an actual incision in a mother's belly. Furthermore, anticipated bleeding from a c-section, even in ideal circumstances, is generally expected to be around a liter. So not only would trying to perform a c-section in a hemodynamically unstable, actively bleeding pregnant woman be negligently unwise, it would arguably venture perilously close to the realm of criminal assault.

Maggie Mahar does great work analyzing the intricacies of health care policy and reform but in this particular post she has written irresponsibly. If you're going to use a wide platform like Healthbeat to write about actual medical practice, then you have a journalistic obligation to do so in a much less capricious fashion.

18 comments:

Carrie said...

Interesting post - I'm a NICU nurse, and I want to review your power point as well as look at some articles. My hospital is one that provides cooling therapies for hypoxic ischemic encephalopathy in the neonate. If the mother can be recovered, I agree that this would be beneficial to both - but what if the lack of recovery in the mother continues to compromise the baby and it is unknown if the mother will be able to recover at all? I'm not questioning what you wrote - just curious as to where the line gets drawn. I'll admit to providing this comment before reading your powerpoint, etc. My experience has been with the neonates after delivery. As a high risk OB and trauma center, we deal frequently with mothers who also have life threatening conditions. All of our care begins after delivery, and it is the OBs and other physicians caring for the mother who determine when this delivery will occur.

Carrie said...

Read your slides - very informative. On slide 7, we have actually taken care of babies as the result of uterine rupture that survived. Mortality and morbidity are obviously NOT good - but have not seen 100% mortality if the infant is recovered immediately. I would speculate it approaches 100% but not a guarantee.

Sergiu said...

Where did she go to med school? Somalia? No pun intended for the Somali people. She must've been the last in her class.

"In obstetric trauma, the mother always takes precedence". Always. Another baby can always be conceived or adopted if hysterectomy is undertaken, but the mother comes first no matter what. And there is no contra-argument.

She would do the world a good and change her profession.

Carrie said...

Sergiu, I won't disagree that the health of the mother is paramount, but what you've worded in the middle is a terrible argument in fact: ""In obstetric trauma, the mother always takes precedence". Always. Another baby can always be conceived or adopted if hysterectomy is undertaken, but the mother comes first no matter what. And there is no contra-argument."

Would you say to a woman who lost a baby (when her life was not at risk) - "it's okay...you'll have another"? Or perhaps to a mother in which a twin has just died, "Well at least you still have this one..." As if the loss of life didn't matter. Your statement completely devalues the baby as a unique human being. The mother in the case presented died, and would not have survived no matter what they did. So the baby should just have been abandoned? And in case you want to attack my argument in this way, this has absolutely zero to do with abortion and fetal rights, as I am pro-choice.

Anonymous said...

For me, the importance of the story was how fragile the strong are.

Accomplished she is. But she is a lay person. Her inability to think objectively in response to horror is normal.

-SCRN

Jordan Grumet said...

Buckeye,

This story is a true story posted originally on "Pulse...voices from the heart of medicine" which is a medical humanities site dedicated to medical writing. Maggie reposted it.

The point was to describe how we are exposed to heart breaking experiances during our training and how this can affect our development as human beings.

In no way was the point of this essay meant to critique the trauma surgeon or the trauma surgeon's actions in the story.

In fact the general consensus at the time is that appropriate medical care was taken (by all involved including the chief resident).

Maggie Mahar posted my story aftert seeing it on "Pulse". While I believe she is a brilliant health care analyst the opinions in the comment section are not mine.

Please don't assume what I do or do not beleive.

Jordan Grumet

Emmanuelle said...

I practice MFM and completely agree with you. Especially in an emergency situation like this:
- if the baby is not doing well because mom is unstable (hypotensive, bleeding, septic, diabetic ketoacidosis, name it), you HAVE to stabilize the mother first - in 99.9% of the scenarios. Most of the time, you will resuscitate both patients when resuscitating mom; if not, not sure you would have "saved" the baby.
- if the baby is not doing well when mom is stable, then you go for the baby
- as in the slides: you go for the baby 4 minutes into a code (which arguably could have been attempted then in the case presented)

Buckeye:
Nice slides. It's always nice to see non-OB who are not deathly afraid of treating pregnant women :)

As for the fetal mortality of 100% with uterine rupture, these stats have to be when uterine rupture occur in the setting of a trauma.

Buckeye Surgeon said...

Jordan-
I made one alteration in my post to reflect your point---it was wrong of me conflate your thoughts with Maggie's. Thanks for stopping by.

Carrie said...

Emmanuelle,

I don't disagree with you at all - just merely was curious. The slides were very informative - especially about the 4 minutes. As I don't take care of the mother, I don't know the protocols for how these things are dealt with. It would be the rare occasion that we've recovered babies from mothers who have died, but I do know of one that we had that actually did do okay, with some deficits.

I misread the slide for #7 regarding the uterine rupture. I got thrown by the part stating that it usually occurs in women with prior c/s, and forgot it was on a slide regarding blunt trauma. And you're right - couldn't comment on that as the cases we have seen have not been due to trauma.

Overall, it's an interesting post - I do agree that the point of the original story was the emotion, not the medical facts. It appears the comments on the other blog are what spurred the medical discussion of how to manage trauma in a pregnant woman, and I think it is nice to have a spin off post here highlighting the practices.

Jordan Grumet said...

Changes noted....Thank You!

maggiemahar said...

Buckeye--

It's interesting that you didn't mention the fact that I was responding to comments from two physicians who wrote in to say they thought the obstetrical resident who wanted to save the baby may have been right.

I began my second reply to you by saying:

"As I stated earlier on this thread I realize that I am not an M.D. I was responding to doctors who said that, given the circumstances, the mother had no chance.
I reallly don't know.
And given the fact that none of us were there, it's probably also hard for doctors reading this story to know."

I wonder why you didn't quote this? Instead you portrayed me as a layperson arrogantly making a medical call . . .

Here's how the post ended: "In the end, perhaps this is a story about the ambiguities of medicine. Often, there is no “right answer;” doctors and nurses can only learn to accept the inevitable uncertainty, self-questioning, guilt, and feelings of helplessness that cases such as these” inflict” upon the care-giver—the “wounds” of practicing medicine."

Also, the doctor who commented on the post saying:

"Wow. Reading that story . . .hurt.
Hindsight is 20/20. We'll never know if the outcome would have been different had the resident done the emergency C section."

A second physician wrote:
" Definitely a story about the ambiguities of medicine. We can only judge because of hindsight.

Then, a "medical investigator" commented writing,"

"Oh, COME ON.

"She was "actively exsanguinating," her BP was dropping despite nurses 'pumping blood' into large-bore IVs in both of her arms," and she went into V-fib. Does anyone honestly think defibrillation was going to save her? Trying to get the baby at least made some sense. The ER trauma doc must have been thinking with his equipment."

His language is pretty strong--and I was startled--but then the first physician, wrote:

"Dennis does have a point. I agree that defibrillation was probably a waste of time. You can't have cardiac output if you have nothing for stroke volume.

"We get so caught up in our own specialties that sometimes it is easy to lose sight of the big picture. I don't think the issue is of "if the technology is there you must use it", not from this particular case anyway.

"I think the issue is, the ER doc was focused on the mom, and the OB was focused on the baby, and neither was thinking of both."

This comment from a long-time thoughtful physician/reader .

As for your rule that "the mother always takes precedence . ." I just suggested that "always" is strong, making this a "rule" rather than a "guideline."

If the mother appears to have no chance, it would seem that it's time to try to save the baby . . .
Of course "appears" is the key word here. We're back to the ambiguity of medicine--something that Dr. Atul Gawande writes about so very well in his book "Complications" . One of the things I most like about Gawande is his humility in the face of the uncertainty of medicine.

This was a snarky post, Jeffrey. You didn't even have the courtesy to give me a head's up so that I could reply while others were commenting on the thread.








"
"

Buckeye Surgeon said...

Maggie-
I very politely commented on YOUR blog post what my thoughts were on this matter in such a way to clarify the manaement of complex trauma in obstetrics. Twice, even. I provided a CME lecture power point for you to read. You chose to both not acknowledge my points and to continue to talk over me as if I were some baby killing fanatic. At no point did you feel the need to concede the fact that the trauma literature places great importance on the life of the mother. Did you consult the trauma literature? Did you contact a maternal fetal medicine expert or a trauma surgeon from an ivory tower institution to rebut my claims? No. You just ended the thread by re-asserting your "feeling" that the policy of placing the mother's condition in a paramount position just had to be ambiguous and perhaps even wrong.

You had plenty of chances to engage me cogently on your blogpost. I don't see how my post here was either rude for not giving you a "heads up" or especially how it is "snarky". You have a wide audience. You were promoting a viewpoint that portrays the management of trauma in an incorrect manner. If simply pointing this fact out is "snarky" then I don't know how we are supposed to have a meaningful dialogue in the future. You're a journalist. You've been doing it for a long time. Thick skin is part of the deal, right? My intent was not to score snarky points but to simply clarify the way things ought to be done. I dont doubt that the death of the baby had a wrenching effect on all the doctors involved. But the management of the case was by the book. Bad things happen in our world and I hate it.

I like Gawande too, but I don't see this case falling under the category of "ambiguous" medicine. The improvement in survival and outcomes in traumatic injuries over the past 25 years is directly related to the implementation of trauma systems and algorithmic practices. Hell, run this case by Atul himself. He rotated through trauma as a resident. He'll tell you the same thing.

You imply that "humility" is something I lack in your final thoughts. I invite you to spend some time reading through some of my posts, especially under the heading "my favorites" to get a sense of how "arrogant" I am. Your insistence, even now, that the baby perhaps ought to have been delivered, seems to suggest that the lack of humility lies not with me.

maggiemahar said...

Buckeye--

I am very sorry that you felt that I didn't respond to you on my blog.

I did respond to both comments, and tried to explain that I was questioning whether the mother Always should take precedence.

In an e-mail, I asked you: "If, in your judgement, the mother is clearly beyond help--i.e. is dying--wouldn't you feel that it's time to go in and try to save the baby?

"Or, would best practice rules for trauma surgeons say 'you have to wait until the mother is definitely dead?'" I explained that I was asking this as a serious question. It strikes me as possible that if a doctor did a C-secton on a dying mother and she bled to death, he might be charged with killing her--even though, in his judgment (and in the judgment of other doctors and nurses present--she had no chance.

As I explained, I don't know the answer to that question.
Amd I still don't--you didn't reply to that part of my e-mail.

Finally, in terms of the post being "snarky", I was particuarly struck by your comment on Jeffrey's piece.(This is actually what made the S word come to mind.)

First, you quote Jerffrey's non-fiction,
1st person story:

" With a sweep of his arm, the trauma surgeon moved everyone away from the table, then stepped back--and crashed into my chief. She fell to the floor, extending her arm to avoid slashing anyone with the scalpel."

Then you write: "Dramatic, no? I especially like the image of the resident bravely controlling the scalpel so as not to "slash" anyone as she toppled to the ground. The writers on ER couldn't have scripted a better scene."

You seem to be suggesting that Jeffrey made this up--or is exaggeraing the scene in a sentimental way.

"Finally, if a reader goes to my original post at www.healthbeatblog.org, --and the comments that follow--I think he/she will find that I wasn't expressing "contempt" for the best practices of trauma surgeons.

I'm sorry you took it that way.

maggie mahar said...

Buckeye-

I did not "talk over you as if you were some baby-killing fanatic."

I'm not sure where you got that idea. Here's what I actually said:


"The two other doctors [commenting] on the thread seem to suggest that, given the amount of bleeding, and the fact that the transfusion wasn't working, the mother couldn't be helped.

"Even if I were a doctor, I wouldn't know; I wasn't there.

"But it does strike me that a guideline which says that "the mother Always takes precedence"--a rule which tells trauma surgeons to ALWAYS follow this guideline is a mistake. [I think it's pretty clear that I'm referring to "ALWAYS" as the mistake.]

I added: "In medicine, things are often just not that cut and dried.

"Clearly, there are times when the mother is beyond hope and the baby might be saved . . . Those are the cases where someone needs to make the decision that the baby should be treated first."

I don't understand what in that comment suggested that you are a baby-killer. Perhaps you over-reacted?

. . The only other doctors who had commented on the thread seemed to suggest that the mother couldn't be saved--or that it was very unclear.

The medical investigator who commented indicated that there was No Way the mother could be saved.

I made it clear that I didn't know--
You also wrote: "At no point did you feel the need to concede the fact that the trauma literature places great importance on the life of the mother."

Buckeye-- I never questioned but what the trauma literature places great importance on the life of the mother and that normally she comes first. Anyone who has ever had a child know this.

. But I also made it clear that assuming, for a moment that the other doctors were right, and the mother couldn't be saved, wouldn't this be a very ambiguous case? Is there no situation in which you would feel it was futile to try to save the mother, and thus turn your attention to trying to save the baby?
As for "snarky," your commentary on the story itself was, at the very least, unnecessarily sarcastic:

"Dramatic, no? I especially like the image of the resident bravely controlling the scalpel so as not to "slash" anyone as she toppled to the ground. The writers on ER couldn't have scripted a better scene."

Then there was this bit of sarcasm:
"Maggie is seemingly unaware of the fact that a c-section requires an actual incision in a mother's belly."

What if I told you I've had a C-section?

Finally, you seemed very upset that I hadn't looked at your Power Point presentation. As a matter of fact, my computer at home won't open Power Point.
When you mentioned your power point a second time, I probably should have explained that I couldn't open it. I'm sorry, I didn't meant to leave you with the impression that I was simply blowing it off.

Buckeye Surgeon said...

Ok Maggie. Thanks for your input.

Anonymous said...

Maggie,
Here is the problem, you are delving into the big heavy.

The more attempts you make at clarifying the more you muddle.

You gotta make a choice. Get some clinical experiences, or not. It'll change you forever if you can find someone willing to let you shadow even the tough dark stuff. It'll scare the shit out of you, and you will never be the same. BUT, you might write and converse with a glimpse into our lives and these decisions.

Please know I say this with the best of intentions.

-SCRN

Anonymous said...

Buckeye:
I think you nailed the nail on the head with respect to Maggie Maher here. I used to read her health beat blog. With one thread a PA discussed how he "knew" a lesion was melanoma and immediately did a "shave biopsy" just in time. As I am sure you know, if you really think a lesion is melanoma you do an excisional biopsy for diagnostic and therapeutic reasons (determining the need for sentinal node, length of wide exision, or adjuvant therapy). Usually the pathologist's can figure out the depth based on a shave then excisional biopsy. But not always. Anyways, this turned into several replies stating how the PA has PhD (we all know docs who do this do, mid-level is not the issue here) and then links from the american cancer society. During one of my replies I had an epiphany...Why am I arguing with an english PhD about the appropriate way to treat a patient. I have not been back to her blog since. You see, though I often agree with Maggie on her blog, I also often find that she steps over the line of being a health care wonk, to actually making comments about medical care. An area that she really has no formal education. Google does not replace a medical education. I also have found that while using google she quotes conclusions of studies without really reading or understanding the methodology and results of those studies. Sadly, it is people like here the politicians will listen to, not you or me.

Supastaru said...

"Finally, you seemed very upset that I hadn't looked at your Power Point presentation. As a matter of fact, my computer at home won't open Power Point. "

LOL! what, her home computer doesn't have google docs?!?