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.