SNOW

This weekend I was off call and I had an appointment in the city with the physician who is going to do my knee replacement. After that appointment we drove to spend the weekend with our daughter. We had a delightful dinner with them and visited for a while (it was raining), then went to bed (it was raining). We woke (it was raining) and cooked the cinnamon rolls we made last night had tea and generally enjoyed not rushing (it was raining). In the late morning we gathered ourselves and went on an adventure to the IKEA store (it was raining). When we arrived back at our daughter's house it was still raining and the prediction was for freezing rain and snow. We talked it over and decided that the best course of action was to cut our visit short and get home. It rained the entire trip home, but as we headed south, the temperature got warmer it was 34 degrees when we left our daughter's home and an hour or so south it was 41 degrees, we breathed a deep sigh of relief and kept driving to get home safely about 10:30 (it was raining) where we spent some time unwinding and then off to bed (it was raining). Wow! We woke to snow and snow and snow. I just talked to my midwife partner (who is at the hospital) and she said that the OR crew has been called in to just hang out and that ambulances are not doing transports because of the weather. She has been really busy this weekend. I told her that I'm not sure that I will be in tomorrow, because I don't know if I'll be able to make it down the hill. I live in the mountains above the town where I work, and there may not be a safe way into town. Oh darn - a real snow day!

Still catching up with EMR

All the ultrasound data for December is now entered. I added up the number of births that I did this year and it was 190 down from my high of 334 (2004) and up from my low of 138 (2001). Now all I have to do is get all the OB visits entered into the EMR prior to 1/2/08 when the office re-opens. My partner is on call these days, but I delivered almost everyone, so her days will probably be easy. I hope so. We are facing a big new year. I will be off for quite a while (12 weeks) due to knee replacement and she will be doing it all. I hope there is a practice for me to come back to when I'm healed from my knee. I keep seeing many requests for (partner's name) for care and delivery in the charts. If I'm not there working perhaps no one will want me to do their delivery.

EMR "electronic medical records"

Ah yes, the practice I am associated with has made the big transition to EMR's. Most of the time having the chart absolutely available all the time is wonderful. I am never searching for a paper chart. I am never looking for stuff that hasn't been filed properly. I am never looking for paper that hasn't been filed yet. HOWEVER, the 1 tenth of a percent when there is a server failure, I am left with nothing. That is not even a hint of what has gone on in the past. I don't know what labs have been drawn (of course they come electronically). I don't know the estimated date of delivery. I don't know any of the psycho-social history. I don't know anything that I can't remember on my own. Now you may be getting a hint of the fact that there has been a server failure in my practice and you would be so right. When this happens you scribble notes to yourself on little pieces of paper and put those pieces of paper into folders to be addressed later (when the server has been repaired). This doesn't sound bad, except that this went on for most of December, off and on so now that I have a few days where I am not at the birthing barn, I'm tied to the computer trying to get my nose above the surface so that I will be able to function in the new year. YUCK. I do love electronic records when they work well, but when they don't work it makes life absolutely awful.

The Operating Room Conundrum

The hospital where I deliver has had a recent upgrade and we now have a dedicated operating room in our labor and delivery suite, directly across from our newborn nursery. This should be wonderful on many levels. We now meet the state requirements (we had a waiver of this requirement for 10 years); we now should not be doing surgery in an area where sick and infected people are being operated on; we now should not have to travel from the first floor front to the second floor back with a patient in heaven knows what awkward position in order to deliver her infant by cesarean section; we now have nursery and infant care/resuscitation equipment readily available without a trek through the halls and the potential of being stuck in an elevator with a sick new born (yes, this really happened)! Except for a pissing contest between two departments this would be true. OB did get a beautiful operating room in the recent remodel. It is directly across the hall from the newborn nursery. The issue is that we are not allowed to use it! There was inadequate training of the OB nurses for their roll in the OR. There was reluctance from the OR staff in opening an operating room out of the main OR area. There were kinks to iron out pertaining to personnel and patients all of which take time, communication, and problem solving. We used the new OR for about 6 months and then it was arbitrarily closed down because of politics. I am frustrated and angry because no one is being well served in this little fit of temper. The OB patients are now being processed in day surgery and operated on the in main OR in a room that is too small, and that is inadequately set up without appropriate oxygen connections. The patients are moved through the main hospital halls from the operating room to the OB unit. The babies are transported through the main hospital halls from the operating room to the OB unit. This transportation is not only cumbersome, it is unnecessary. There is a functional operating room right in the Labor and Delivery Unit. What we need is responsibility, accountability, and communication in order to safely and successfully use the OR located in labor and delivery for operative delivery of obstetric patients.

Trouble

Went for an all time record the other day. Nurtured this gal along all night and half the morning. Got her to complete with only a few grey hairs. First real push dropped the FHR to 60 where it sat until I pushed the kid back up and then FHR recovered. Tried Mom pushing again, needless to say the deceleration repeated - imagine that. I called my consulting and we delivered by cesarean section. Baby had an OP presentation with a double nuchal cord, and a true knot. Hummmm. Not planning on a vaginal delivery with that mess was he. Cute little boy. More grey hairs for the midwife.

Breastfeeding frustrations

Alas, one of the services I offer in my practice is help with lactation. If a Mom plans to breastfeed I do a nipple assessment prior to delivery (actually early in the pregnancy) and we talk about what it takes to get nipples that stand up so the newborn can latch. After the delivery, I don't leave the room until the baby is well latched and suckling like a champ. This sometimes takes a while, especially if Mom has had medication and the baby is sleepy. My frustration arises when I see these Moms back in the office from 3-5 days after delivery and I am told: "I got a pump from WIC and I'm just pumping and giving my baby breast milk in a bottle, the baby really likes it." or "It is really hard to breastfeed at night so I have my boyfriend give the baby a bottle of formula so I can sleep." or "I don't have the time to breastfeed my baby, all the baby wants is to be held and suck on my boobies." I explain that pumping will not keep the supply of milk up and that every bottle of formula given works to decrease the supply of breast milk because breastfeeding is supply and demand - the more demand (nursing/suckling) there is, the more supply (milk) there will be. My clients all reply "Oh, I have plenty of milk, that is not a problem for me. The when I see them back at 4-6 weeks and sometimes sooner, they are whining and crying that they don't have enough milk and they don't know what to do, or they don't have enough milk and the baby really likes bottles better then breastfeeding and so they are going to stop pumping/nursing and just use formula. I am so very frustrated by this. My population is poor, young, ignorant and for the most part selfish. They find having to spend time with their babies a pain in the ass and are happy to pass the baby and the bottle off to someone else so they can go about their lives unencumbered by baby feeding. They all espouse the breastfeeding is best ideal, but when it comes to making it happen, they are not motivated, or unselfish enough to offer their baby their time or their breast milk from the source. Bah!

Lifes little trials

So, my body is wearing out faster than my spirit. This is causing my spirit to wear out faster. A long time ago, in a world far far away, I hurt my knee. Now, some thirty years later, it needs replaced. This is all well and good, and we have the technology except. . . . .I work in the medical profession and knowing what goes on "in the business" contributes a tremendous amount of terror to my decision making. Do I have the work done locally where I can pick my anesthesiologist; do I go to a bigger hospital where they do more procedures but I don't know anyone but the surgeon. Do I choose the type of joint I want put in and then find a physician that does that type of joint; or do I choose the physician and go with whatever type of joint he/she uses? Do I go to a local hospital where I know the infection rate, and lots of the nurses and staff; do I go to an out of area hospital where I don't know anyone and they don't know me. Is the number of times a surgeon has performed an operation more important or does that matter once competence in the procedure is obtained? For that matter, how does the consumer determine competence in a surgeon? How does one find out the MRSA infection rate for a hospital? They sure don't broadcast that information at the hospital where I work. Who do you ask for the answers to these questions. How does one decide where to go for something as important as a knee replacement. I want to be able to walk again, hike again, run again, bike again. I want to actually reclaim my life and get back to doing more physical things again. How do I choose? All inputs welcome