Monday, June 18, 2007

Seeking Cover

Fully clad in black, she walked the hall toward my office carrying a cane but not using it, accompanied by a daughter and grand-daughter, the latter to be her translator, the former her guide. Clouded over and looking like ivory, her eyes were blind; her face worn and wrinkled, weary and severe; yet her posture was erect and her dignity so profound that I felt as if I were in a regal presence. Her family treated her with deferential honor, and it was clear that I was expected to do so as well. It wasn't hard. If I didn't, it seemed, I might be struck by lightning.

This part of the Pacific Northwest is a melting pot. Forty-seven languages are spoken in our school district. Every day, give or take, a new ethnic deli or exotic restaurant opens; I salivate thinking about them. My patient population included many with whom communication was difficult, if fascinating. (My middling Russian, po moyemu nye plokho, comes in handy.) This lady, it was made apparent, was to be referred to as "Persian," not Iranian. And she absolutely would not allow me to see or touch her skin.

With clear-cut lab and sonogram and a classic history, that her gallstones were the problem was not in doubt. I didn't feel bad about doing a no-frills physical exam (like a surgeon!), through her clothing. Explaining the situation, describing the needed surgery and its aftermath were the most important issues of the encounter. It would be necessary, I said, stating the obvious, that when it came to surgery there'd be a need for exposure and more intimate touching. As long as it all happened after she was asleep, she was OK with it. Reluctantly.

She arrived in the pre-op area garbed as the day we met, and remained so while wheeled into the OR, and as she went off to sleep. No one in the crew had a problem with it. In exposing her for the operation, I raised her clothing to above her ribs, while keeping her lower body covered with a blanket. My patented mini-gallbladder operation went quick and slick; on her post-op visit to my office her gratitude and satisfaction were indicated by her grand-daughter. I took her word for it: the lady's demeanor never changed, not a crack.

Recently I had a conversation via email and comments with a reader about body-exposure during surgery. It's an interesting topic. I think it's true that there's more recognition of the issue recently than there has been in the past, but as with much about surgery, there are no straight lines from thought A to thought B. There's more dissonance now when I see a completely naked body on the OR table than I felt in training. There are times when the visage has caused a lump in my throat and moist eyes. Frailty, total vulnerability, responsibility, honor, beauty, are words that come to mind when I consider it. Callousness? Crassness? I don't think so. Sexuality? Does that fall into the category of beauty? Perhaps. But what, more than the sight of a human being having laid him- or herself before you, naked and paralyzed, bespeaks the responsibility and trust a surgeon is given?

Finally, it's just "let's put on the paint and get to work." Been there, seen that. I know it's a concern for many people. Whereas I can't say that modesty and dignity are maintained at all times in all operating rooms, exposures are pretty universally met either with decorum or boredom. As long as it happens after going to sleep, is it OK?

I think I've always empathized with my patients, whatever the situation. Dress -- or lack thereof -- was a thing of unspoken concern, and I don't recall it ever being mentioned in training. It was matter-of-fact, job at hand, not an issue. Even then, though, I never uncovered any more than absolutely necessary, even after the patient was asleep. And I was always very careful in my office: I've never had people fully undress, usually waiting till the last minute to expose anything. Hernia: lower the pants, not remove them. Rectal exam: slide 'em down, keep 'em on, lay on your side. Given the number of women I saw with breast problems, and the time constraints of keeping the office running, I did have them put on vests before I formally met them (when I brought them into the room myself, I'd introduce myself, confirm a bit about why they were there, hand them the vest, then exit for a few moments.) The vests -- unfashionable as they may have been -- did allow the preservation of modesty.

I once recommended a surgeon to my dad, who went to see him for a pretty routine, minimalist sort of operation. The surgeon's nurse instructed my dad to strip completely and lie down on the exam table to wait for "doctor." When they first met, dad was totally naked and supine. Angry more than embarrassed, he never forgave that surgeon. Nor did I.

When I was in the military a fellow doc said he had a sure-fire way of dealing with a self-important officer who'd come in and try to pull rank. "Remove all your clothes, Colonel," he'd say. "I'll be back in a minute." Guess it cuts both ways.


Anonymous said...

I've really enjoyed your series on the chronology of an operation. Thanks for taking the time to write it. Many have credited reading your blog with academic motivation, and I'll add to that as well: reading your blog has made me more motivated to prevent as many surgeries as possible by decreasing smoking, obesity, and other risk factors, and appreciate everyone who improves the process, up through the health services researchers.

I'm interested in reading a description of a C-section: with 20-30% of all pregnancies delivered by surgery, and vaginal birth after C-section no longer recommended (as far as I know), I think that this is likely a highly relevant topic for many. Do you know of any such descriptions?


A public health PhD.

Anonymous said...

Anon, VBAC exists but there are limitations on which HOSPITALS will allow it. Your doctor can be all for it, but if you will deliver someplace that doesn't have a certain level of 24/7 surgical coverage and/or a specialized infant nursery, they won't permit it.

I do know that if you have had a previous c-section, they can't use Cytotec/misoprostil (sp) to ripen the cervix in an induction because it makes the uterus contract so strongly that it has a risk of uterine rupture at the scar. I believe Pitocin can still be used for induction if necessary.

rlbates said...

I have never gotten over my modesty (or prudishness)even after all these years as a surgeon (graaduated med school in 1982), so I try very hard to respect my patient's modesty. I appreciate that you do too.

Bongi said...

a surgeon's description of a caesar section. cut until you find a baby. remove the beby. suture whatever you cut.

tongue in cheek.

Midwife with a Knife said...

anon: Vaginal birth after c-section is certainly an option. We mostly just counsel patients on the risks and benefits. The problem is that you have to be able to start a c-section within 30 minutes of a problem... (decision to incision time), and some smaller hospitals don't have the ability to do that (you essentially have to have 24/7 anesthesia coverage to pull it off). Also, the malpractice climates in some areas are preventing it from happening.

Anonymous said...

Here in the Netherlands I think everybody in principle gets a vaginal delivery after c-section if there are no other contraindications, the only difference being that you have to deliver in the hospital (most routine deliveries here are done at home, not in the hospital).

Anonymous said...

Here in the USA, a few years ago, the American College of Ob/Gyn (ACOG) updated their practice standards on VBAC. In a nutshell, the standard of care now is to be able to do an immediate C-section and deliver the infant as soon as possible after making the decision to do a section. The word used in the standards is 'immediate' and there is much consternation over just how fast is immediate. Most clinicians feel that 15-30 minutes meets the 'immediate' definition.

The practical reality of this is that unless you practice at a hospital that has 24/7 OB and anesthesia coverage, you don't do VBACs anymore. Thus, they are primarily done now at academic and large city/community hospitals that either have 24/7 residency coverage or they can afford to pay the anesthesia providers to sit around and wait to get called into the delivery suite.

And yet, with the rise in fetal monitoring and the increase in C-sections over the past 30 years, there has not been a concomitant decrease in cerebral palsy cases and some other types of birth injuries.

The Enormous Clinic

Anonymous said...

After several surgeries, two car accident traumas, and also six babies, I've lost all modesty. But I would still like to have my dignity. The only doctor who really didn't give me that was the surgeon who took out my gall bladder. I had a new nurse who wasn't sure about what she was doing on the day after my surgery, and when he was making his rounds to check on his patients she had told me to take a sponge bath. He popped his head into my room, then out again as he spoke to someone, probably to give me time to dress but my nurse told me to continue my sponge bath because he had probably left. He then opened the door wide just as people were walking through the hall and everyone saw me standing there naked, then he came in. I still feel horrible about it.

SeaSpray said...

Dr S. I thought everyone is draped and only the surgical area is exposed?

So, is the patient momentarily covered and then uncovered to drape accordingly?

Come to think of it - I have always gone into the OR in a hospital gown and hospital socks. I am guessing for the procedures they just lifted the gown up or do they undress a Pt for that too?

Are trauma patients totally exposed? there an ooops! and the covering falls to floor and the Pt is totally nekkid?

And about those socks. PAT nurse always says women can't wear mascara, lipstick, etc. and I am guessing that is because of bacteria. Yet, while waiting in SDS - I can walk in those socks to the rest room (all over the floors) and then they wheel me into the OR with the socks on -which come in contact with the OR table when I skootch over and then BTW down to where my feet were with the contaminated socks so I can be in position for the urology procedure.

How is that o.k. but a little light mascara or a little something on my lips isn't alright? Last December - I did break the rule and just put a faint coloring on my lips nothing shiny or moist looking or they would have known.

A girl's gotta break the rules once in a while. :)

Seriously, I have often wondered about the socks. Even as an inpatient. There I was with a foley and no undergarments getting an IV to fight an e-coli infection in my ureter or where ever and yet I am wearing socks that scuffed across the hospital floors on my bed sheets and under the covers. Could that stuff travel upward? Not to mention - again no undergarments now skootching across the bed to get out. This happened every time I was there and finally ,I asked a nurse and she said I shouldn't be wearing them. Why didn't they catch that?

Just wondering. :)

Oh and when I was 23 I went to an old time town doctor(my husband's doctor) because after jogging in the fields I came back breathing with little bronchial squeaks.

I was sitting on the exam table and he told me to take my top and bra off. He listened to my chest and then sat back down across from me. He was talking to me but never told me to put my stuff back on. He never offered to leave the room. I was feeling really uncomfortable and embarrassed but I thought I was just supposed to wait until he said something. Fortunately, I was hardly ever sick and so didn't have much experience with doctors and didn't know the protocol, although I don't remember my doctor ever doing that. I never said anything to anyone either and he did this a couple more times. I decided to go to someone else and when that doc listened through my sweater I thought he was doing it wrong. I actually questioned him the first couple of times wondering if he could really hear what he needed to and I always left feeling like maybe he wasn't doing it right. DUH! That new doc must've thought I was odd to question him like that.

Happy J - I can't say why but I totally relate to you. I feel better knowing that you still feel horrible about it because I am bothered by a different but similar experience and quite frankly - it makes my skin crawl when I remember it. It was an accident and I am not hurt other the extreme sense of powerlessness, vulnerability, humiliation and yuk, creepy factor. I want to run away from the thought whenever it pops in. Medical staff really should me more careful when they open doors from either side.

I think it is terrific that you were careful to protect your patients privacy and dignity Dr Schwab.

Sid Schwab said...

Seaspray: in general people arrive covered and are exposed only as much as needed to access the relevant area. Some trauma patients -- especially those in extremis -- are stripped completely in the ER, covered with a sheet for transport to the OR, and the sheet is removed while prep solution is splashed and drapes are laid on in a hell of a hurry.

SeaSpray said...

And of course if the trauma or other emergency is THAT bad, I would much rather be totally naked under forty thousand bright lights, knowing you all are saving my life than be in the upper corner of the room looking down at my modestly draped body, watching the final draping go over my head.


I am just glad I don't know these things while they are happening. I do wish they didn't give versed though. I HATE that feeling of thinking I may have said embarrassing things. Like for instance - what if someone is easy on the eyes, particularly your doctors - who you WILL see again. Does a patient say things they might think - like how handsome they are - where normally you would never give any indication of that?

Then of course Pt doesn't remember but Doc does? Does that happen? Or is that an industry secret that you'll never tell.

For instance - one episode in Grey's anatomy had Meredith getting prepped for her appendectomy and the pre-op drugs had her feeling light and breezy - to say the least.
She was very free with her thoughts that she never would have revealed otherwise. The other Doc said the only reason I am discussing this with you is because you won't remember late.

Believe me when I tell you I could totally picture myself being light and breezy. I am a complimentary type person anyway. If I see or know of something good I can't help but to share my positive thoughts! YIKES!!

Another patient kept asking the same question over and over again and the doc every time kindly answered the same question each time. Is that the versed effect and does everyone do that?

Personally - I remember everything (so I think) from when the doc gave me the cocktail before even going in to the OR. I remember the warm fuzzy feeling and all the conversation. I remember getting on the table and talking briefly afterward and then waking up in post-op.

When the anesthesiologist gives me the final push of whatever - the stuff that has me out in seconds - am I really out or do I just not remember?

I do know that when the ED gave the conscious sedation drugs people were loose until they got worked on - then they screamed- then they left all happy.

Thanks Dr S.

SeaSpray said...

P.S. I always play this game with myself in the OR. I guess it is the competitive, frisky side of me.

I try to stay awake and fight the drug from the point the Doc tells me I will be out soon. I look around the room and try to focus on something to stay awake.

Ha!I lose every time! :)

I was recently telling one of the hospital radiologists this and he said I shouldn't do that because patients that do that can be agitated when coming out of anesthesia. Is that true?

Anonymous said...

Seaspray and Dr. Schwab,,
For my first accident trauma the paramedics cut my clothes off at the scene, which is understandable because my mom had gone through the windshield and there was glass everywhere so they would have had to know immediately what my injuries were. I was out or don't remember for my second trauma, but my clothes were cut off then too. They were both really bad accidents, though.

I think Seaspray had an interesting question about how docs deal with a patient's openness or confusion when under, and I wondered if you wouldn't mind writing a future post on that topic, Dr. Schwab?

Sid Schwab said...

OK, I will!

SeaSpray said...

Dr Schwab - of all the questions I have ever asked - the effects of anesthesia on a patient is probably "The" question I want answered.

I had a spinal for the birth of my 2nd son and was looking forward to talking with doc and staff when they were finishing up. The next thing I remember is waking up in recovery.

I asked my Doc why they put me out and he said,"We didn't - you talked the whole time."

I didn't say anything at first because everything that I would never want to say was flying through my mind and I am pretty sure that based on the amused expression on his face a look of horror must have been on mine OR he was remembering something OR multiple things I did say and was also amused at my expression. The thing is he seemed to be enjoying the moment!

When I asked the anesthesiologist he just said, "I gave you the whole pharmacy." and then finally I asked a friend who was an OB nurse to find out if she could. She said the nurse in the OR with me said that I kept saying,"It hurts - it hurts."

As much as I don't like admitting that I was a wimpette - I can live with that. However, my Doc said I talked the whole time and he looked too amused. Darn! I know if you take my inhibitions away -I am going to be loose and breezy.

And then...everyone has secrets - secrets about themselves and others - things never meant to be spoken.

An SDS nurse was telling me last fall that veterans will sometimes relive their experiences under conscious sedation. That must be awful for them and then I guess they wake up not remembering.

The breezy ones must be really funny sometimes though. :)

I am one of those patients who is conscious before I can open my eyes or move and so I have heard the post-op conversations. I vividly recall 3 post-op conversations/events as they pertained to me. Hospital staff should be really careful about what they say around the patients and never assume the pt can't hear you.

Happy J - I am sorry I said I felt better about you still feeling horrible about your exposure event. I was tired and I meant to say that it felt good to know that I am not the only one who still feels weird after something like that has happened to them.

And regarding my incident - I KNOW it was an accident. I want to clarify that I don't at all dwell on this and mostly forget about it - but that "if" I think about it I feel those things. This YUK feeling just shoots through me! I am not at all superstitious, but if I was then I would say Murphy's law - if it's going to happen to someone - the embarrassing thing is going to happen to me. I could probably turn it into a very funny post. I did have the 2 friends I confided in laughing but they also were horrified for me at the same time.

I will say this again. Medical people - BE CAREFUL WHEN YOU OPEN A DOOR FROM EITHER SIDE - MAKE SURE YOU KNOW WHO IS IN THE HALLWAY AROUND YOU AND THAT THEY CAN'T SEE THE PATIENT. It would be helpful to pull any appropriate curtains in the room too.

Another embarrassing nekkid thing that happened to me happened just after the birth of my 1st son.

I had just gotten out of the shower when the pediatrician opens the bathroom door without knocking! So there I am standing there with nothing but my long hair and the covering over my vertical c-section incision! He just started talking so I stood there dripping and listening. I didn't ask any questions. I didn't grab a towel. I was like a deer in headlights.
Then he left.

I can see where a doctor that has examined your nether regions or done a breast exam might not think it's any big deal (seen one seen em all - sort of) but we had just met. The only thing he got to see previously is my intestines - if he was the peds doc in the OR! He was actually my favorite pediatrician in the group.

One more- I had just finished getting a hysterosalpingiogram for part of my infertility work up. I was now in a little booth with a curtain when my OBGYN whips open the curtain and of course - I-was-not-dressed! He just stood there with the curtain wide open and talked with me. Again - I just listened and didn't ask any questions.

Back then I rarely asked questions and I just nodded in agreement or understanding even if I didn't. Ha! My doctors that I have today probably couldn't even imagine that! I worked with you all too long to feel intimidated or shy anymore. :)

So, Dr Schwab - 25 years ago - were doctors more loose about a patient's privacy or sense of modesty? Did they approach those issues differently back then.

Today it is so different and everyone covers you and usually seems sensitive to your privacy even the nurses go out of their way to cover you up.

Regarding vbacs - I wanted one for my 2nd child and when I was about 7 mos or so pregnant - I asked the new OBGYN that came into the practice if I could still have a vbac and he said," Not unless you want your baby to be born dead." He left the room and my older son who was there to hear the baby's heartbeat said "Mommy is the baby gonna die?" to which I responded, "No honey, Mommy is going to have a C-section and the baby will be fine." It would've been a c-section anyway because our younger son weighed in at 10lbs,6oz and the doctor was and is a good doctor but he was new and just needed to work on his bedside manner a bit. :)

Dr S - sorry so long - making up for my absence I guess. :)

Sid Schwab said...

seaspray: I think that for various reasons modesty is more attended to now, at least in terms of "official policy." But a guy who'd let you sit there naked in front of him in the office would do it now, then, anytime. Some people are clueless no matter what.

SeaSpray said...

Dr S - I think my husband's Doc had other motivations other then medical. I think that because of how he was leaning back in his chair all comfortable like he didn't have a care in the world. I was naive and very trusting back then and even though I was embarrassed it didn't occur to me that he was doing anything wrong because he was a Doctor and they always look out for you.

But my OBGYN for my first son and the pediatrician I am sure were just busy and in work mode on the move trying to get things done. The peds doc was on morning rounds and the OBGYN probably had to get going too as it was the middle of the day.

I really liked those 2 docs and the only reason I switched from that peds group is because I got to know a pediatrician at the hospital that I have always liked.

And I liked my OBGYN too but he got detained in Iran in 1986 and rumor has it that he was tortured. He and a urologist were both detained. (Didn't know the urologist) When my Doc came back his whole demeanor was markedly different(his face had a flat affect to it, eyes seemed hollow and his handshake was really limp) and he closed his practice and moved to CA. I asked him why they detained him and he said it was because he delivered the Sha of Iran's wife's babies. I guess the Ayatolla Khomeini government didn't like that.

But I digress. Those 2 docs and all docs I have had right up to the present have all been great and I have been blessed to have them.

Fortunately for us - up until my ureter stuff we have all been a healthy family needing very few trips to the doctor. :)

Anonymous said...

Wow - that's refreshing coming from a male surgeon. As a young lawyer, I worked at the Medical Board and was horrified - I heard it all - male doctors taking advantage of female patients, sexually assaulting them, humiliating them....
It gave me nightmares...
I don't see male doctors for anything - I lost trust many years ago. I'm angered also by the unnecessary, invasive and potentially harmful tests and exams that are pushed and forced onto women. We get no risk information so informed consent is impossible.
I actually believe the way women are treated by the medical profession is shameful.
I asked a cervical screening expert at a conference some years ago why women weren't told of the risks of screening (& the risks associated with mammograms)...she said, "If they knew, they wouldn't show up for screening"...
So women are kept in the dark, not given the opportunity to make informed decisions about their own health.
Screening IMO has helped a few and harmed thousands.
I'm pleased to hear one male surgeon at least respects his patient's privacy - one case that I'll never forget...a woman in stirrups and a door left wide open...I don't know how women get over that sort of sadistic treatment.
I fear ever going into hospital and having surgery - particularly the lack of control while I'm asleep - I was also aware of cases of orderlies assaulting sleeping women, orderlies allowed to stand around while a woman is naked and being prepared for surgery - women treated disrespectfully - providing a show for voyeurs.
Of course, there was all the controversy recently when it was discovered anesthetized women were having unauthorized pelvic, rectal & breast exams from multiple medical students before/after surgery. The students became concerned about the issue of consent - apparently many senior doctors still can't see a problem with this practice.
You can only imagine how they must have treated their female patients over their careers - makes me shudder.
Women need to get informed and say NO to exams and tests that do not pass the risk v benefit test.
Ignorance is not bliss in this case - it's downright dangerous!


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