THE STORY OF ONE PREGNANT PATIENT & THE APGAR SCORE

 

THE STORY OF ONE PREGNANT PATIENT & THE APGAR SCORE

Virginia Apgar

Writer and physician Atul Gawande, reminds us in his book, BETTER, that much of modern medicine did not just happen—it came to be through trial and error, through the deaths of others, the mistakes and triumphs that IS the history of medicine. In BETTER, a surgeon’s notes on performance, we meet Elizabeth Rourke in the chapter, THE SCORE.

OUR PREGNANT PATIENT

Rourke is forty-one weeks pregnant, having contractions. She’s an internist, on staff at Mass General. Her contractions are 7 minutes part. She reports this to her obstetrician at 8:30 am. She is told not to go to the hospital until her contractions are 5 minutes apart. Standard protocol. (this book was published in 2007). In medical school, Rourke has seen fifty births, delivered 4, and watched one in a hospital parking lot. It was winter, the baby was blue, crying. They covered the infant, raced back into the hospital. With that memory, Rourke finished packing her bag and her husband drives her to the hospital.

SOME HISTORY

Gawande then relates some history of pregnancy and birth that has been recorded. He writes of 21-year-old Princess Charlotte of Wales, in 1817, four days in labor, struggling to deliver a nine-pound boy in a sideways position, his head too large for her pelvis. When he finally emerges, he is stillborn. Charlotte dies six hours later from hemorrhagic shock. Gawande relates that her physician was reviled for not using forceps. In remorse for her death, he shot himself.

Gawande relates other statistical history of births—that in 1933, the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth in New York City. At least two-thirds of those deaths investigators found to be preventable, that many physicians simply did not know what they were doing. They missed signs, symptoms, incorrectly used forceps and spread infection. Midwives did better.

UPDATE ON OUR PATIENT, ROURKE

Her pain has increased, thinks she must be 7-8 centimeters. She is at 2. Her labor has stalled. Then at 2:43 AM she is at four centimeters. It’s been twenty-two hours. They give Rourke an epidural. This is not a simple procedure. Gawande goes through the steps, explaining the risks, one being the mother’s heart rate dropping and the necessity for a bolus of fluid injections and ephedrine to increase and stabilize hers and the baby’s blood pressure. The baby’s heart rate is being monitored constantly, showing decelerations during contractions and then recovering. When necessary, Rourke (and thus the baby) are given extra oxygen by a nasal prong.

At 6 AM Rourke is a 4 centimeters. At 7:30 Dr. Alessandra Peccei comes on duty. Rourke is 6 centimeters dilated and 100% effaced. Baby is seven centimeters from crowning, head becoming visible at the opening to the vagina. As the hours progress, Dr. Peccei punctures the membrane of Rourke’s amniotic sac. Waters flow, contractions pick up, the baby does not move and the heart rate begins to drop. 120, 100, 80. When the doctor stimulates the baby’s scalp, the heart rate responds.  

SEGWAY to: VIRGINA APGAR, the APGAR SCORE

Virginia Apgar was a doctor working in New York, a doctor who had an idea, one that Gawande states is “ridiculously simple.” It transformed childbirth and the care of newborns. And as Gawande states, she was an unlikely revolutionary for obstetrics, had never delivered a baby, not as a doctor, not even as a mother. But she would often sit down with someone having trouble and say, “Tell Momma all about it.” She was a surgeon, but joined Columbia’s faculty as an anesthesiologist. She became the second woman in the country to be board certified in anesthesiology, helping the practice to have its own division, on equal footing with surgery. Gawande writes that Apgar was appalled by the care many newborns received.

“Babies who were born malformed or too small or just blue and not breathing well were listed as stillborn, placed out of sight, and left to die. They were believed to be too sick to live. Apgar believed otherwise. She had not authority….She was not an obstetrician.  She was a female in a male world. Gawande: “So she took a less direct but ultimately more powerful approach: she devised a score.”

The Apgar score—as it is now universally known, allowed nurses to rate the constitution of babies at birth on a scale from zero to ten. An infant got two points if it was pink all over, two for crying, two for taking good vigorous breaths, two for moving all four limbs, and two if the heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.  

RESULTS 

Throughout the world, virtually every child born in a hospital came to have an Apgar score at one minute after birth and then again at five minutes after birth. It became clear that a baby with a bad Apgar score at one minute could often be resuscitated, with doctors, nurses providing warmth, physical touch and oxygen, to help the baby gain an excellent score at five minutes.

The results: neo-natal units! The score also affected the management of childbirth. Spinal and epidural anesthesia were found to birth babies with better scores than general anesthesia.

Prenatal ultrasound became a regular process used to detect problems for delivery in advance.

Fetal heart monitors became standard. All these changes, these procedures have produced amazing results. Gawande writes: “In the US today, a full-term baby dies in just one childbirth out of 500, and a mother dies in less than one in 10,000.”

FINAL THOUGHTS    How did Dr. Apgar’s work make doctors BETTER?

The Apgar Score changed everything, being a practical way to calculate and give doctors an immediate feedback as to how effective their care had been.

The Score also changed the choices that doctors made concerning how to do better! They poured over the Apgar results, wanting to encourage results that would make every doctor, nurse, from the most experienced to the novice, a better practitioner.

And our patient, Elizabeth Rourke? She had almost 40 hours of labor and finally a Cesarean section. Katherine Anne was born at seven pounds, fifteen ounces, brown hair, blue-gray eyes, and soft purple welts where her head had been wedged sideway deep inside her mother’s pelvis. Her Apgars: 8 at one minutes, 9 at five minutes—nearly perfect.

MORE TO READ: Find more wonderful information about Health Care in Gawande’s books: BETTER: A Surgeon’s Notes on Performance, COMPLICATIONS: A Surgeon’s Notes on an Imperfect Science, BEING MORTAL: Medicine and What Matters in the End, THE CHECKLIST MANIFESTO: How to Get Things Right 

I’ve read them all.

 

Being Mortal: A Doctor’s Hard Look at Mortality

Being Mortal: A Doctor's Hard Look at Mortality

We are all mortal. We are all going to die. And yet each day when we rise with that virtual list pounding in our heads as to what we have to accomplish, death is never on the list. And it shouldn’t be. But one day it will be—though it may be totally unexpected. Because—yes, we are all mortal.

In his comprehensive and helpful book Being Mortal, Dr. Atul Gawande (Complications, Better, The Checklist Manifesto) once again forges new territory as he educates physicians, other medical personnel and us about the importance of choice when one is severely ill or close to death. Because doctors are trained to heal and to save, more and more patients and their caregivers are realizing that how we will be living, the quality of our individual lives should be a major consideration when making difficult decisions about surgery, chemotherapy, clinical trials, and end-of-life therapies.

If you are in charge of someone’s health, do you know what that person truly wants?  

Gawande recounts the story of a daughter whose father was hospitalized with cancer—a tumor growing and filling his spinal column. While driving across the Golden Gate Bridge to her home, she was thinking about her father’s surgery that was scheduled for the following morning. She was going over all that the doctor had said. It was almost midnight, but she suddenly realized that she didn’t truly know what her father wanted. Yes, the doctor had talked about possible outcomes—but nothing had been settled.

Make sure you know. 

She turned around and drove back to the hospital, waking her father and asking him: If the surgery results in you gradually becoming a quadriplegic is that really acceptable? He thought for a while and finally answered yes. As long as he could eat chocolate ice cream and read he would accept the gradual loss of movement that might occur. The doctor was removing some of the spinal tumor but had stressed that he couldn’t get it all and the chances of it growing back were strong. So they talked! The daughter and her father had the conversation so that depending on the results of the surgery—if he woke up or if for some unknown reason he didn’t wake up—she knew—no intubation, no Intensive Care Unit for months and months because that would mean no chocolate ice cream, no reading.

The beginnings of assisted living. 

Gawande writes about Keren Brown Wilson who is credited with creating the model and the term assisted living. She fought for funding and was finally able in 1981 to open Park Place in Oregon, utilizing the following definition of the type of care the facility was offering: Assisted living… is a program that promotes resident self-direction and participation in decisions that emphasize choice, dignity, privacy, individuality, independence and homelike surroundings.

One of the things Wilson assured her clients, something they had asked for: each home or unit would have a lock on its door. Because nursing homes were more like large wards where people had little that they could identify as theirs and staff had access to their “space” whenever they considered it necessary. Wilson’s experiment was a huge success and assisted living facilities sprung up all over the United States. Some statistics: since 1981 there are 40,000 more assisted living facilities. Read more at: http://www.assistedlivinghistory.com

What current senior homes provide.

The assisted living model includes 24 hour staffing so there is always someone “in house” to provide needed care. Residents have their own home or apartment and they can prepare meals if they choose to, but there is often a community area for eating meals and participating in activities. Today, many senior living residences have a variety of living options. In addition to independent and assisted living areas special care units now exist.  These specialty units complete continuation of care: if a client ages or health deteriorates, 24 hour nursing care or a locked unit for Alzheimer’s and dementia is available.

Gawande and his father. 

The most affecting portion of the book is Gawande’s open discussion of helping his father who also developed a tumor in his spine and slowly found his independent life as a doctor, husband and father slipping away. The irony of researching and writing this book and then being faced with the very same difficult and personal issues of his interviewees underlines the strength of this physician-writer. He writes:

Certainly, suffering at the end of life is sometimes unavoidable and unbearable, and helping people end their misery may be necessary. Given the opportunity, I would support laws to provide these kinds of prescriptions to people. About half don’t even use their prescription. They are reassured just to know they have this control if they need it. But we damage entire societies if we let providing this capability divert us from improving the lives of the ill. Assisted living is far harder than assisted death, but its possibilities are far greater, as well. 

My personal experience. 

The last sentence rang true for me as I watched my mother experience living alone in her condo, then losing her ability to drive, then finally agreeing to move to a senior center. She did so with the hope that she could reside in independent living. But the beginning of her dementia signaled that assisted living would be her destination. As the months piled on, I often had to remind her to go to dinner or to take her medication. Soon the nurse was in control of that and as the disease progressed, Mom finally lived in the memory unit, something that was very hard for me and my family. There was no other solution. Her dementia prevented her from living with us as she could never be left alone near a stove or other appliance that might do her harm or worse. I remember arguing with the staff that my mother would never be a “flight risk.” I was wrong, even about that! Reading Being Mortal helped underline for me that we made the right choices.

End of life decisions should always include choice.

And that is what Gawande emphasizes in this book: choice. The cases he relates are all about allowing the patient to decide: should I have another surgery when death could be less than weeks away? Decision: no. Hospice: yes. Gawande takes us on his own personal journey of watching Hospice nurses do their work. He is amazed at how they approach a dying client and how they are able to help this person choose what they need as their end of life journey begins.

Gawande writes: When it is hard to know what will happen, it is hard to know what to do. But the challenge, I’ve come to see, is more fundamental than that. One has to decide whether one’s fears or one’s hopes are what should matter most.

P.S. In 1990, the state of Oregon began to research a better way to insure that patients being treated in the hospital or by EMT’s would have their healthcare wishes properly followed. Called the Physician Orders for Life Sustaining Treatment or POLST, the final stage for completion of the form occurred in 2009.

Definition of the POLST

POLST is a medical order. For those with serious illness or frailty, a POLST Form is completed with your health care professional to direct the kinds of treatment you want in a medical crisis. As a seriously ill or frail patient, POLST orders help give you more control over the treatments you do or do not want to receive in a medical crisis. The form works even if you later lose the ability to speak for yourself. The POLST order is signed by your physician, nurse practitioner or physician assistant after a discussion with you and/or your Health Care Representative. Since it is a medical order that will be followed in an emergency, it is important that it reflect your wishes now, in your current state of health.

To see if you live in a state where the POLST form is used, go here

Also, to view a video of how the POLST works go here.

P.P.S. The state of California has just made assisted-suicide legal.  

Being Mortal: A Doctor's Hard Look at Mortality

Thanks to: www.gone-ta-pott.com

Boomer Highway’s Very Late Summer Non-fiction Picks

Boomer Highway's Very Late Summer Non-fiction Picks

I love fiction, but non-fiction is good for you–and just like balancing your diet, now and again non-fiction should be your reading choice. Here are a few that will whet the appetite. And because we now often have hot weather in September, I’m still calling these Summer Non-Fiction Picks!

Boomer Highway's Very Late Summer Non-fiction Picks

1. During a time when I attended the University of Iowa Summer Writing Workshop, I had the privilege of working with writer David Payne, author of many novels including Gravesend Light and Back to Wando Passo. Payne was a sensitive and helpful teacher, a sharer of ideas and emotions. His newly published memoir, Barefoot to Avalon reflects such a persona. It recounts the time he was moving to North Carolina and on the road, through his rearview mirror, he watched his brother George A. who was driving another vehicle to help him, lose control, flip the truck over and die. Payne relates that the death of George A., a manic depressive, had such a powerful impact on him that his career as a writer stopped, his marriage disintegrated and his drinking increased. George’s death brought to the forefront a family history of suicide, mental illness and alcoholism and he realized the only way to dispel these ghosts was to write. Jay McInerney relates that this book is “one of the most powerful and penetrating memoirs I’ve ever read; it is fiercely honest, deeply engaging, and utterly heartbreaking.” Through this work, Payne is able to reveal the legacy of sibling rivalries and to break open family silences–the only way to free himself from haunting and debilitating memories.

Boomer Highway's Very Late Summer Non-fiction Picks

2. Next up: On Immunity: An Inoculation, by Eula Bliss. One critic writes: “On Immunity casts a spell. . . . There’s a drama in watching this smart writer feel her way through this material. She’s a poet, an essayist, and a class spy. She digs honestly into her own psyche and into those of ‘people like me,’ and she reveals herself as believer and apostate, moth and flame.”—Dwight Garner, The New York Times    Why did Bliss dig and spy–because as a new mother she realized she had fears–fears about her child’s future and health, about immunizations, the government, the medical establishment and what’s in her baby’s mattress, food and air. But she came to the conclusion that you cannot immunize your child from the world and as she investigated the very concept of immunity and then the uproar over vaccination, she finds that she: “…sanely takes on the anti-vaccine mob.”—Vanity Fair    An award-winning book, Bliss relates how she read and became convinced that we are all interconnected–our bodies and our fates.

Boomer Highway's Very Late Summer Non-fiction Picks

3. In his comprehensive and helpful book, Being Mortal, Dr. Atul Gawande, author of Complications, Better, The Checklist Manifesto, once again forges new territory as he educates physicians, other medical personnel and us about the importance of choice when one is severely ill or close to death. Thus this is a book every Boomer or person who is a caregiver must read, because though doctors are trained to heal and to save, more and more patients and their caregivers realize that how we will be living, the quality of life we will have should be a major consideration when making difficult decisions about surgery, chemotherapy, and clinical trials.

Gawande recounts the story of a daughter whose father was hospitalized with cancer–a tumor growing and filling his spinal column. While driving across the Golden Gate Bridge to her home, she was thinking about her father’s surgery that was scheduled for the following morning and all that the doctor had said. Close to midnight, she suddenly realized that she didn’t really know what her father wanted, though the doctor had talked about possible outcomes–but nothing had been settled. She drove back to the hospital, waking her father and asking him: If the surgery results in you gradually becoming a quadriplegic is that really acceptable? When he finally answered, he said yes, as long as he could eat chocolate ice cream and read he would accept the gradual loss of movement that might occur. The daughter and her father had the necessary conversation, so that depending on the results of the surgery — if he woke up or if for some unknown reason he didn’t wake up — she knew — no intubation, no Intensive Care Unit for months and months because that would mean no chocolate ice cream, no reading.

That’s what Gawande emphasizes in this book: choice. And he takes us on his own personal journey of watching Hospice nurses do their work when his father is dying. Amazed at how they approach a dying client and how they are able to help this person choose what they need as the last journey begins–Gawande becomes an advocate for hospice. He writes: When it is hard to know what will happen, it is hard to know what to do. But the challenge, I’ve come to see, is more fundamental than that. One has to decide whether one’s fears or one’s hopes are what should matter most. (taken from my article in the Huffington Post.)

Boomer Highway's Very Late Summer Non-fiction Picks

4. Meanwhile There Are Letters The Correspondence of Eudora Welty and Ross Macdonald. Edited by Suzanne Marrs and Tom NolanIf you like reading mainstream novels and short stories (Eudora Welty) or if you prefer detective novels with murder and mayhem (Ross Macdonald) or if you are fascinated by two people having a relationship through letters that covers not only writing but current history and then slips into profoundly romantic missives, then you will enjoy this book. One reviewer calls it: a prose portrait of two remarkable artists and one unforgettable relationship. Though they only met six times or so at writing conferences, their feelings for each other were deep and passionate. In the Washington Post Review, Michael Dirda recounts that in 1973 Macdonald interrupted Reynolds Price who was speaking about Welty saying: “No, you don’t understand. You love Eudora as a friend. I love her as a woman.” And when Macdonald was beginning to show signs of Alzheimer’s disease, Welty was still writing to him about her feelings: “Dear Ken, I have all your letter to keep me company. Every day of my life I think of you with love. Yours always, Eudora.”

Boomer Highway's Very Late Summer Non-fiction Picks

5. The Boys in the Boat: Nine Americans and Their Epic Quest for Gold in the 1936 Berlin Olympics  by Daniel James Brown. You will learn a great deal about rowing, about the making of the shell that is a rowers boat and the sport itself–the position of each rower, the talent and endurance each needs so they can obtain the perfect unison that moves the shell forward to victory. Featuring the lives of the nine men who were not born to wealth and position like some of the rowers they competed with–but who were the sons of loggers, shipyard workers and farmers from the state of Washington–this book recounts how they bonded as a team and rowed to gold as Adolf Hitler stood fuming. Even given the worst position on the competition lake, these tough Americans were still able to row to victory.

Wishing you HAPPY SUMMER READING and if you’ve recently read a work of nonfiction that will remain on your bookshelf as a favorite, please share.

P.S. A Mother’s Time Capsule, my collection of stories about motherhood, available on Amazon at elizabethahavey.com But it’s fiction!

Boomer Highway's Very Late Summer Non-fiction Picks