Wednesday, March 21, 2012

A VBAC Story - Part 2

Continuing the discussion of the Vaginal Birth After Cesarean section. Now Part 2 . . . 
This is not my c-section; I actually searched vacuum delivery.

My VBAC story:

My induction took about 2.5 days, and it was very painful as the medications make labor when your body hasn't naturally arrived there. I had an epidural most of the time, which is generally necessary in case they need to quickly move into a c-section. They put extra monitors on my uterus and the baby's head. The same resident was always on the dayshift as I had 3 different attendings. She admitted me and broke my water 24 hours later which really started moving labor along.

By the morning of the third day, I was ready to deliver except Child2 had not fully descended. Also, Child2 was having 'variable decelerations' which is when the baby does not recover normally from each contraction. Early decels are normal, late decels are a danger sign the baby isn't getting enough blood, and variable decels are in the middle. They are often caused by the common issue of nuchal cord (cord around the baby's neck), but they can be harbingers of much worse problems. The OB team was getting concerned about how long my induction had lasted, the lack of descent, and the variable decelerations. They were seriously contemplating performing a c-section. In their eyes, it was a little like watching someone run into a brick wall over and over when they could just open the door. (If that metaphor was confusing, if my induction was not moving forward, I was going to need a c-section anyway. Rather than wait for things to get unstable, c-sectioning me while stable was much preferred.)

Fortunately for me, my second resident had my back and thought we could continue trying to push. She and my nurses told me I was a great pusher - I did ask her if she was telling the truth since I've been at many deliveries of women who are horrible pushers and get told the same thing. She assured me I was, but she really wanted me to get further along so she could convince her attending to hold off on the c-section. (Her attending knew we were pushing and was coming to see us last after the rest of the team finished rounding on the rest of the patients.)

At this point, my husband was a little freaked out, particularly when the resident said that we might have to vacuum deliver the baby since Child2's head looked like it might need a little aid. The attending came in and watched me push for a little bit and asked what I thought about a c-section or vacuum delivery. I said the equivalent of "I'm going to keep pushing until we get to late decels. I'm not scared of a nuchal cord or a vacuum." The attending was ready to discuss the risks and benefits of vacuum delivery until she remembered that I was the pediatrician who attended vacuum deliveries daily. I did ask that the pediatric delivery team come to my delivery just in case.

Now, if you've never been in labor, during contractions they have you push for a count of 10 three times per contraction. As they turned up the pitocin for stronger contractions, I was pushing for a count of 10 five or six times. Then suddenly they were breaking down the end of the bed and moving my legs into delivery position. I asked if they needed a vacuum still and they told me 'no.' Hubby JD wasn't sure he believed them and stood at the end of the bed. (OMG, I can see his head!!)

Three more pushes and Child2 was out. The resident unlooped the nuchal cord before cutting it - Hubby JD doesn't like blood much so he wasn't cutting it. Child2 was immediately handed off to the pediatric team who had to suction out his nose and mouth and give him a brief amount of oxygen. His apgars were 6 and 7 at 1 and 5 minutes and he was crying so I wasn't worried while the OB's sewed me up. At 10 minutes his apgar was up to 8 and he appeared stable enough to come to me, which was fine - and I reassure the team jokingly that I knew the signs of respiratory distress.

I was very happy with how things turned out; I recognized that my OB resident had a big part of that since she really fought for my VBAC. I even wrote her program director an email, highlighting how important the resident was to my delivery. (You should do that anytime you have particularly good service.) I jokingly told the attending that she could email all the doctors in her group with my result. One of the other OB residents, with whom I had trained, came by and told me she would have definitely c-sectioned me.

I wasn't upset that the OB team was close to doing a c-section. It's their job to assure the safety of the patient (me) and the passenger (Child2). Not everyone can or SHOULD do what I said or did. I am a medical professional who works significantly in labor and delivery. It is my particular area of expertise, and I would have been the first to ask for a c-section if anything more worrisome had occurred. I also had trained some of the OB residents in pediatrics or entered training with the senior OB residents. On the flip side, I would never have asked for a similar amount of leeway on getting my appendix taken out or my tonsils.

To speak briefly to the economics of VBAC versus c-section, a VBAC generally has a shorter recovery time because it has less limits on activity since it did not involve surgery. There are cases where it could be worse, like if the baby's head really tears up the vagina coming out - a 4th degree tear is pretty seriously painful. My hospital stay was not that different than a scheduled c-section. I was there 4 days, 2.5 for induction, 1.5 post delivery. A c-section generally is 48-72 hours post delivery. VBAC will probably cheaper from an insurance standpoint because it doesn't involve OR fees. My breast feeding wasn't significantly affected by either one, but I did have less time with lactation to confirm my milk coming in.

Hilariously, I spent my day prior to discharge peppering the OBs and nurses about vaginal delivery recovery. we'd spent so much time discussing the risk of c-section, we never discussed it would be like if my VBAC was successful.

Thanks for tuning in. After my next post, there may be a little delay since we are moving this week and I may have less time/possibly be without internet access.

Next post: Carseat Roulette - challenges of fitting 2 carseats into a tiny car!

Monday, March 19, 2012

What percentage am I in?

It's not the 1%! Turns out you need to make about $350K a year to be in the current top 1%. I guess that means no one will be picketing outside my apartment since we are in the top 5%. Unfortunately, that means that you can find a surgeon from my last post and go picket outside his/her house instead. The protesters really seem to also be angry about the trappings of wealth the Wall Street people are displaying so ostentatiously.

Thus, even if I did make 350K, you probably still wouldn't be able to find me since I didn't purchase my McMansion, head to toe Prada or buy that flashy sports car I've always wanted. Lots of people think 'doctor and lawyer, you must be rolling in dough.' Wrong again, as evidenced in this blog. Here are the signs we'll just keep wandering around incognito.

No flashy sports car here. In fact, during residency, my car was totalled while parked outside my apartment. We'd been putting off various repairs while I was on such a tough service, and I was walking to work anyway. My husband texted me during rounds that the assessor had come by and gave us $275 for the car. At least that is what I saw when I glanced at my messages between patients, which I felt was totally acceptable. Turns out that he had sent $2750, making things much more bearable as an unexpected 'windfall.' We didn't actually get another car for 6 months; I just didn't have a car.

Now, we drive two compact cars; one of which is 10 years old. One is leased, but we'll plan on returning it at the end as our family is growing faster than our compact cars. We're actively searching for a used mini-van, though we are going to delay that as long as possible.

Many of my family and friends think we are crazy to continue to rent apartments with our salaries. 'You could buy somewhere really nice.' 'How can you let your kids grow up without a yard.' My kids are 1 month and 13 months old. They don't care about a yard! We already have a home loan out-of-state and we still have a good 240K in student loans to pay off. And one of my other favorite links - Better to rent or buy? reminds me that I still have years to rent.

Besides, I don't want to be tied to yet another property if we decide to move cities or states. We are moving to a bigger apartment very soon, mostly because we outgrew our 2B, 1BA 850 sq ft apartment. After I've been there a month or two, you'll certainly get a review of how that has or hasn't worked out. It's still an apartment and not a brand new glorious building with stainless steel appliances and marble counter tops. We didn't even bother to look at buildings like that because we knew the space for price wouldn't be worth it.

I do not think I own anything that counts as designer. It's possible I bought a Kate Spade scarf for 95% off at an outlet mall once. I wear scrubs at work which are free and freely laundered by each facility. Hubby JD had a previous job as a corporate suit and has only needed to buy a new suit once in the past 3-4 years. He didn't wear his old ones much during law school. The suit he did buy was at a discount at an outlet mall for something like $150 at most. Same thing with his shirts and ties, all outlet mall purchases. Often, I will buy him shirts or ties and then let our family give him them as gifts.

As a woman I do admit to having multiple sets of clothing to fit my different shapes and you won't convince me to toss them. I have maternity clothes, post baby clothes, and fit weight clothes. It takes up alot of closet/box space, but you can't buy a new wardrobe every time you have a baby. Again, none of it is designer and anything expensive looking/appearing was an outlet mall purchase. Even my almost non-existent jewelry was bought with coupons, none of it costing more than $30. (BTW, 3/4 of my exercise clothing was purchased in college or medical school. It may be time to replace some of it - online deals, TJ Maxx, or outlet mall will be the main destinations.)

You've heard me say it before, I bought next to nothing for Child2.We bought very for Child1 except a carseat, pack-n-play, and a bassinet. I believe I have purchased a few pairs of 2 dollar pants from Walmart and I used a Carters gift card at the outlet mall to buy a hat for Child1.Nothing else though. Everyone else keeps buying us clothes or giving us their old stuff. I have a box of 'to give away' baby clothes for showers still with the tags on since we have received so much. (Before you regift something, remember to make sure that it is seasonally and gender appropriate for the upcoming child) As I write the post, Child2 is sitting in his carseat and I rock it every once in a while with my foot since we did not buy a bouncy chair or a swing. He still seems happy.

I get a kick out of reading different selling points of strollers and baby furniture. Why do you need a $600 stroller? I don't care if its a Donkey or a City-mini. Why are you worried about the impact rating of a stroller? Are you playing bumper cars with it? Get one at a garage sale or a thrift store and make sure there hasn't been any product recalls. A stroller is not a car or a carseat which need to be able to protect you from a high impact collision. That $15 umbrella stroller at Walmart has worked great for us.

So someday you may walk by me on the street. You'll see a reasonably dressed young couple pushing to children in non branded possibly used double stroller. Please don't chase us down the street to see if we are making out 200K.:)

In case you are wondering what brought this on. A few weeks ago, No More Harvard Debt and I both read the same article about some Wall Street guy whining about his pain and struggles after only making $350K.

Sunday, March 11, 2012

A VBAC story - Part 1

While waiting for deliveries in labor and delivery, I often flip through the channels and invariably come across 'A Baby Story,''Make Room for Multiples,' 'I Didn't Know I was Pregnant,' 'One Born Every Minute,' and so forth. Oh, the drama of birth, reality tv, and often fake re-enactments. It is hilarious to watch these parents with the illusion that they are in some way controlling their outcome or how their delivery will go. Even more hilarious are watching reactions to certain events. 'My doctor is moving my scheduled C-section to today instead of next week. OMG, I'm not ready! I'm only '38 1/2 weeks!' we're supposed to be at 39!!!"

Really? Thanks TV. However, with the recent Today show discussion of VBACs and stupid shows giving horrible medical advice like The Doctors, I am willing to have a little longer discussion of VBACs, vaginal birth after cesarean section. (I refuse to link to that since the Doctors employ pseudoscience and has an anti-vaccine physician on it). I'll give you a little history on VBACS and then discuss my own personal story.

(Today's photo is of Ethel Kennedy. She had 11 children, with the last 5 being born by c-section. Supposedly the world record for c-sections is 11 for 1 person, but I can't confirm that. Nor do I recommend performing a c-section on yourself like Ines Ramírez Pérez did - the only person known to have performed on on herself and survived.)

The VBAC's story.
Conventional wisdom had dictated that if you had a c-section, it was recommended you have another 'repeat' c-section without labor. It was safer for the mother, and she often had a medical complication or issue that led to her having a c-section to begin with. In the 1990's-early 2000's, VBACing was all the rage. Maybe many of those women could deliver vaginally. OB's admitted that they sometimes performed c-sections for some weaker reasons and were willing to try more VBACs. During that time, they would allow anyone who had a c-section at any time for any number to try a VBAC and had success rates in the 60-70% vaginal deliveries. C-section rates fell, and it was a great time to do vaginal deliveries. . .

As with all good, safe medicine, people then sat down looked for patterns in risk and success. A major pattern was discovered; 1% of all VBACs will have uterine rupture. In uterine rupture, the uterus tears itself open during the contractions and there is a good chance without IMMEDIATE medical intervention, the mom and the baby can bleed to death and die.

This knowledge led to a big change in OB practice. The only places to continue offering VBACs were high risk places that could always offer a c-section at a moment's notice. To do that, there needed to be an OB, anesthesiologist, and surgical team in house 24/7. Most hospitals schedule their c-sections or call their OB's in when delivery is close. A scheduled c-section is much more controlled and has a lower risk of infection to the mother than a c-section after labor. Many OB's say the safest delivery is a vaginal, followed by a c-section without labor, and then a c-section with labor.

There was also a few other patterns noticed in the likelihood of VBAC success. Multiple previous c-sections increased the risk of uterine rupture and decreased success. Obesity, diabetes, large babies all were less likely to deliver vaginally. Inductions made it less likely and earlier gestational ages too. White patients did better than African American and Latino patients. The reason for the previous c-section also played a big part - if you were failure to progress or dilate, your chances fell alot. Therefore, if you had two previous c-sections, were an African American gestational diabetic, you had very LOW odds of finding an OB willing to attempt a VBAC.

Why did I want a VBAC? C-sections are extremely safe operations, and many people have repeat c-sections without problems. However, most people in the US stop at 2-3 c-sections. I'm a pediatrician, I love kids, and I want more than 3. According to my OB coworkers, the main issue with multiple c-sections is how bad the uterus has scarred. With a second c-section, they will know how bad you scar when they get in and thus how difficult future c-sections will become. I don't want to be the crazy pregnant lady in the OB office who has been told to stop having kids because her uterus just isn't up to it anymore. I'm a medical professional who would have to look other medical professionals in the eye and explain why I would be pregnant against medical advice. (I also saw someone die on her 13th pregnancy after her OB had begged her to stop having kids.)

After asking around, I ended up going to the large high risk practice at the local teaching hospital where I trained and lucked out that my main OB ended up being on board with my goal of VBAC. Between ultrasounds, stress tests, and rule out labors, I saw seven different OBs and figured out which three were most supportive of VBACs. I had always planned on delivering at that hospital anyway since it had a large NICU, just in case.

Then we ran into the problem of waiting for Child2 to arrive. My work schedule is determined monthly, so was off the schedule on the first of February till April. I wanted at least 6 weeks of maternity leave, but when the baby didn't come in early February, I was burning through my maternity time. You can wait until 41 or 42 weeks gestation, except that would have left me with 3 weeks of maternity leave. I was working out 2 hours a day for two weeks; I could induce contractions but didn't go into labor. After discussion with my OB, we scheduled an induction.

Yes, I already know that inductions decrease the chances of VBAC success, I just didn't have the time to wait. My OB was quite canny about the whole thing and scheduled it so I tried to deliver in a three day stretch where my 3 most pro-VBAC OBs were covering their service. I also knew I would be allowing residents and medical students to examine me and that if I missed my VBAC window, I would almost certainly be c-sectioned. My computed odds of VBAC ran between 40 and 60 percent. (I told my Hubby JD that it was 60% to keep him on board)

If you really want to calculate your personal odds, VBAC success rate calculator. The most important factor though in calculating success is - you guessed it - having a previous successful VBAC!

Next we'll talk about the 1% and then move on to discuss My VBAC story.

Sunday, March 4, 2012

Filthy rich doctors . . . not so fast.

So how much do doctors really make? I watched Grey's Anatomy and they seem to have EVERYTHING . . .

As ever, TV does not reflect reality, even if I wish it did. For doctors, your specialty determines what your pay rate will be, what kind of lifestyle you will have, and how long your training will be.  The lowest paid specialty is psychiatry followed by pediatrics and family medicine.  The middle of the road is emergency medicine, internal medicine, anesthesia, and OB.  The highest paid specialty is neurosurgery with radiology, additional surgery disciplines of general surgery, orthopedics, ophthalmology, ear-nose-and throat and plastics.

Rather than break each one of them down, I'll do some examples of what the lifestyle is like, using JaneMD's modest loan amounts. Keep in mind that many start with much higher loans in the 200-300K range from undergrad and medical school. Banks like to loan doctors tons of money because we appear to be good risks. As you'll see shortly, they should be rethinking that plan.

Scenario #1: Jane MD owes 150K when she graduated from medical school. She got married and started a 3 year pediatric residency. Her loans were put in deferment for 2 years and forbearance for one year since the poverty rules changed.  She made 40K as a first year and got a 2K raise every year.  She couldn't pay off her loans at all during residency, had a baby, and worked on average 60-80 hrs/week.  She graduated and decided not to go into office practice which would have paid about 90-115K for a first year.  She works as a hospitalist 50 hours a week and gets a few extra days off per month, making the bottom end of the scale, but her malpractice is covered by her group. She owes 175K after interest at her first 'real' job at the age of 30. She is expected to pay 220K in interest over the life of her 30 year loan with a $1100 monthly payment for a total of 395K.

Scenario #2: Jane MD owes 150K when she graduated from medical school. She started a 4 year anesthesia residency. Her loans were put in deferment for 2 years and forbearance for 3 years since the poverty rules changed. She lived in Oklahoma for her first year of 'transitional/intern' year and then moved to another state for her next 3 years of training. She stayed single because of her moves and decided to move again to do a one year adult cardiothoracic anesthesia fellowship. Her salary slowly rose to 50K over her for her 5 years. She can only work in a hospital environment, gets yelled at by the surgeons daily, and works 4-5 12hr shifts a week for a salary of 230K of which her malpractice insurance is 75K. She owes 210K at her first real job at the age of 32. She is expected to pay 260K in interest over the life of her 30 year loan with a $1325 monthly payment for a total of 470K.

Scenario #3: Jane MD owes 150K when she graduated from medical school. She got married before she started a 5 year surgical residency. She decided to specialize in thoracic surgery which required a move and an additional two years of training and one year of research. Her loans were put in deferment for 2 years and forbearance for 6 years since the poverty rules changed. Her salary during her training was up to 70K, but she didn't make any student loan payments.  (She and her husband bought a house so he had somewhere to hang out since she worked 80-120 a week.) Her salary potential of 350K to 700K, if she is willing to work 80-100 hours a week and perform a huge number of surgeries.  She also is required to pay 150K in malpractice insurance no matter how many surgeries she performs. Her husband really wants to start having kids, a life, and is discussing divorce if he doesn't finally get some attention now that her training is done.  She owes 255K at her first real job at the age of 35. She is expected to pay 310K in interest over the life of her 30 year loan with a $1620 monthly payment for a total of 565K.

Jane seems to be having a rough time on her personal life in Scenario #3, doesn't she? It's not a joke though. Some surgical programs have been known to brag about their 100 percent divorce rate of their resident trainees. I kept the scenarios a bit simplified. Just imagine what Joe MD, the surgeon, would have owed if he had a wife and 3 kids over those 8 years, bought a car, and a house. Please don't say that is short sighted of him. Time is marching on for the doctors as many graduate medical school at 26-27 years old and then go one to low paid training despite college degrees and professional degrees.

If you want a very in-depth evaluation of exactly how doctors are paid, I recommend reading a much longer blog post by Benjamin Brown MD "The Deceptive Income of Physicians." He really breaks down the hourly pay rates and points out that physicians typically cannot deduct their loan repayments on their taxes. (This may be the only year we can because we only had 'good jobs' for less than half the year and had a family of 3)

You may ask if this makes me wish I had selected a different specialty or not gone to medical school at all. Some of my fellow physician friends note that many specialized physician assistants make similar or better money than pediatricians with 6 less years of loans and education. I do understand that type of thinking, but I am happy with my life and my job. I did not become a doctor because I believed I was going to make my first million before I was thirty, though I didn't think through that I could possibly owe 1/2 million dollars.

Next post: Risk and benefits of VBACs - economic and otherwise.

Thursday, March 1, 2012

Making your own Pedialyte

Pedialyte vs homemade oral rehydration solution

This week I had a glorious storm of family illnesses. First over the weekend, I got sick with a stomach bug. Two days later Chilld1 got sick with a stomach bug and a fever. Then Hubby JD reported a fever and a headache. I started Germ-X-ing like crazy and disenfecting the diaper changing station between Child1 (13 months) and Child2 (2 weeks).

Note that I said 'stomach bug.' There is no such thing as the stomach 'flu.' Technically they are gastrointestinal viral illnesses or sometimes food poisoning which tends to be bacterial. It is easier to say 'stomach bug' than all of that. The flu is actually influenza which is a respiratory viral illness without any gastrointestinal symptoms. Scary stuff like salmonella and dangerous e.coli strains have bloody stools.

When faced with a pukey, poopy toddler, a parent has to realize that eating takes a backseat and keeping fluids in the child is the most important part. One should know a few things.
a) You can generally keep even a vomitting your child hydrated by giving him/her 1-2 teaspoons every 5 minutes as the body usually doesn't throw up such small amounts. It is time consuming and tedious, but much better than a trip to the ER.
b) Milk products, other than breast milk, are generally VERY poorly tolerated. The illness usually strips the enzymes that break down lactose from the gut which results in worsening diarrhea and vomiting with dairy.
c) Juices, water, sports drinks, and flat ginger ale are probably not the best thing to give your child because they are also losing electrolytes. Sports drinks for example are too low in sugar and too high in salt. Juice is too high in sugar and has no salt.

This leads to the Oral Rehydration Solution (ORS). The World Health Organization (WHO) recommends a specific mixture of salt, sugar, and clean water to replace most of the fluid losses. This ORS is used in all sorts of epidemics like cholera in Haiti to replace fluids with great results and decrease in loss of life. Pedialyte and its imitations pretty much follow the ORS formula and add color, flavoring, and zinc to their product. The zinc is moderately important if the diarrhea is severe and prolonged in a child as she/he will lose zinc. The sodium and sugar are actually MUCH more important.

So I had this sick child and one liter of pedialyte in the house. I didn't know how long Child1 was going to be sick and when we'd buy any more. Besides, Pedialyte is $5 a liter, and I'm a doctor. I decided to make my own.

I went to for the recipe. I have a recipe somewhere from a pediatrics journal I saved - except that I put it somewhere that I wouldn't lose it and have now lost it. Per their recommendations, I added 6 teaspoons of sugar to 1/2 teaspoons of salt in 1 liter of water. As the site mentioned that it would probably taste gross, I added one 1/2 of a mashed banana, which also adds potassium, and 1/2 cup of cranberry juice. I didn't have the suggested orange juice, and the type of juice is not important. At this point, I was feeling quite accomplished that for around $0.30 I had made my own Pedialyte.

Not so fast Jane. Child1 refused to drink it. He clearly felt that the small addition of cranberry juice and banana did not improve the taste enough. I ended up mixing two parts pedialyte to one part homemade ORS to get him to drink it. Eventually, I even tried giving it to Hubby JD with extra cranberry juice, and he wouldn't drink it either. He felt the mashed banana was unappetizing.

A word about dehydration: It is important to note if your child is dehydrated. If they are still crying tears, peeing, sweating, and spitting at you, they are not dehydrated. If they stop making tears, have poor energy, and their skin seems dry or less tight, you should be concerned for dehydration. Unvaccinated children in daycare or school are a higher risk for rotavirus which carries a very high risk for dehydration and death. Kids used to die all the time of rotavirus, pre vaccine, because they got so far behind on their fluid balance.

At the hospital: if your child comes in and they do not appear dehydrated, very little is going to be done for them. As previously stated, most kids even with severe vomiting will take 1-2 teaspoons of fluids without difficulty. In fact, in most case, we'll try to avoid putting in an IV and giving them fluids. Lately, we give them a 'po trial' (Per os = by mouth). First we see if your child can drink a bottle of pedialyte. If they can, we send you home. Often, we'll give your child a dose of zofran - an antinausea/vomitting medication - and then see if they handle the pedialyte. If so, we'll even send you home with a prescription for a dose or two.

Keep in mind that your child may have to be in the ER for 3-7 hours between the waiting to get a room and the po trial. Hopefully you have tried all my previous recommendations to keep fluids in the child first and they are vaccinated, decreasing the risk for dehydration. If your child has some type of underlying medical issue - genetic disease, cancer, cardiac disease, new infant - you are in a higher risk category and should have called your specialist/PCP and be following their instructions. (Many metabolic and genetic diseases need very specific IV fluids because their electrolyte and fluid balance is EXTREMELY delicate and just a small change can lead to a fatal domino effect.)

Take home lesson: Oral rehydration solution is very easy to make. You can make it for free at Starbucks with a few packets of sugar and some salt. It just won't taste very good. If Child1 had been extremely thirsty, I'm sure he would have drunk it. As it was, you can use this strategy to make your Pedialyte type drink last longer. Dehydration can be dangerous so do everything you can to prevent it and get your child vaccinated.

Next post: Filthy rich doctors . . . or not?