Damania says borderlines are nicknamed “splitters” because of their ability to split a medical team in two, pitting one side against the other. The categories cluster B and axis deuce reference the DSM’s organizational structure: using five axes or classes, the diagnostic manual attempts to group all of the various disorders and disabilities. Axis two encompasses personality disorders, including borderline personality disorder. “If someone has an axis two diagnosis, that usually means they have some kind of personality disorder that’s going to overlay their care,” Damania explains. “Borderline is a classic.”
When Damania was an attending at Stanford Hospital in California, he cared for an axis deuce splitter. The patient was in her early fifties and suffered from severe high blood pressure and chronic pain. Her daughter had recently died of breast cancer, leaving the patient quite depressed. Believing her blood pressure to be dangerously out of control, the patient’s internist arranged for her to be admitted into Damania’s care.
The patient decided Damania was a bad doctor. He says she made his life a living hell, but when her internist came to visit, she was sugary sweet. Much to Damania’s disgust, the internist validated the patient’s complaints about Damania.
Eventually, Damania had enough. “I understand you’re not very fond of me,” he said to the patient, “and that you’re very fond of your internist.” He felt compelled to offer to hand her primary care entirely over to the other doctor.
“Part of my ego structure in doing my job is that I tend to connect to patients very well,” Damania says. “I have a pretty good bedside manner. I can make people comfortable and feel at home and have a therapeutic presence that way.” His inability to do this with the borderline patient frustrated him. When the borderline patient was nasty toward him, it was difficult for Damania not to be nasty in return. Psychiatrists call that counter-transference.
Damania’s story reminds me of one of the things I appreciate most about being an ER physician. My involvement with patients is transitory. When I have a patient who is pushing my buttons, I almost always have an out: I can refer the patient to someone else. As a hospitalist, Zubin Damania doesn’t always have that luxury.
* * *
There is abundant evidence in medical journals that a psychiatric label isn’t just pejorative: sometimes it can be fatal. Patients who present to a hospital with psychiatric complaints are less likely to be diagnosed, less likely to receive treatment and more likely to die much sooner than patients who do not have psychiatric conditions.
If anything, the gap in life expectancy between psychiatric and non-psychiatric patients is growing, according to a 2013 study published in the British Medical Journal. The study of more than 250,000 mental health patients in western Australia concluded rather shockingly that they lived an average of nearly sixteen years less than non-mental health patients suffering from the same medical conditions. Most of the deaths in the patients with mental health problems were due to undiagnosed and poorly treated cardiovascular conditions such as heart attack and stroke and cancer.
Another study published in JAMA Psychiatry in 2013 concluded that the death rate among psychiatric patients diagnosed with cancer is 30 percent higher than among non-psychiatric patients with the same types of cancer. The authors also found that psychiatric patients are less likely to receive specialized treatments for their cancer—such as surgery and chemotherapy—leaving tumours to metastasize.
I’m sorry to say that I have not only heard of this disparity in treatment, I have seen it with my own two eyes. During my training many years ago, when I was doing a rotation in internal medicine, my team was asked to see a patient complaining of severe pain on the right side of her mid back. The woman was about 70, and had been admitted to the psychiatric ward with a diagnosis of psychosis.
When we saw the woman, she was writhing with flank pain, a classic symptom of a kidney stone. The stone lodges in the ureter, a thin tube that carries urine from the kidney down into the bladder. The stone blocks the flow of urine, causing the kidney to become swollen with urine, which causes incredible pain. A sample of the patients’ urine tested positive for blood, another telltale clue that the woman had a kidney stone that was scraping the inside of her urinary tract, causing microscopic blood to mix with her urine.
At the time, the standard way to diagnose a kidney stone blocking the ureter was to do an X-ray test called an intravenous pyelogram, or IVP. An X-ray technician injected some dye into the patient’s blood vessel and then X-rayed her kidneys to see if the right kidney was swollen.
Both kidneys appeared normal, but the appearance of the right ureter suggested that the stone might have passed. The woman was still in pain, but instead of looking further, the team assumed that the woman was exaggerating her symptoms because she was depressed. We recommended that she take some painkillers. Mission accomplished, we crossed her off our list of patients to follow during their illness in hospital.
Three weeks later, an attending urologist (a surgeon who treats diseases of the kidneys, ureters and bladder) summoned us to the X-ray department to take a look at a second IVP that he had requested. During the ensuing three weeks, the woman had continued to suffer from flank pain, and the psychiatrist had asked the urologist for a second opinion.
When the urologist put the second X-ray up over a lighted view box, we looked at it in stunned, uncomprehending silence. The right kidney, which had appeared normal on the previous X-ray, was gone. It was gone, the urologist explained, because the woman did not have a kidney stone. She had a tear in the artery that nourished the right kidney. That had not only caused pain, it had blocked the flow of blood to the kidney, causing it to die. That’s why the kidney was no longer visible on the X-ray.
The patient—whose rare condition might have been treatable when we first missed the diagnosis—died soon after.
Diagnosing problems like that is what people like me do for a living. The story of the woman and the lesson it taught me is something I try to keep in mind: even swallowers eventually get physically sick and die.
7. Caesarean Section Consent Form
The nursing station on the labour and delivery floor is throbbing with activity at 6 a.m. In the state-of-the-art birthing centre, banks of monitors—half of which have alarms going off—track fetal heart rates. The electronic bleeps are punctuated periodically by the sound of a woman in labour crying out.
Serena Fuzukawa, a second-year resident in obstetrics and gynecology (OBGYN), is handing over to fellow OBGYN resident Carl Young.
“You look like you’ve been to war!” says Young.
“G3P3 42-weeker three days postpartum with a PPH,” says Fuzukawa. “She had a very successful home birth—until she started hemorrhaging, like three days ago. She arrived at 4 a.m. with a hemoglobin of 40 and a blood pressure of 60 over palp. I think we got all the RPOC out. She’s getting blood and she’s on IV antibiotics. Oh, and we saved her uterus.”
“Sounds like a candidate for a Darwin Award,” says Young.
“Nomination papers have been filed,” says Fuzukawa. “Next, in birthing room 4, we have Rhonda Chan,” 34-year-old 35-weeker, whiney primey, fourth visit. Not in active labour.”
“Is she a diva?” Young asks.
“Just anxious,” says Fuzukawa. “She’s at two centimetres—exactly where she was the last three visits.”
“Check her stress test and street her,” says Young.
“Exactly,” says Fuzukawa. “Amina Khan is just being brought in. She’s G2P1, 36 weeks, BP 150 on 95.”
“That was the puffy I saw on my way in!” says Young. “Am I sectioning her?”
“Nope,” Fuzukawa replies. “She’s NMD. Hutchison’s on her way in to do it.”
“Excuse me for having a Y chromosome,” says Young resignedly.
“Don’t mope,” says his female counterpart reassuringly. “Tabitha Baker is G1P0 41-weeker with
failure to progress. Let’s see—presented with a carrot.”
“Has she been pitted?” asks Young.
“Pitted, ARMed, frozen, which made her an ice cube. Now she’s failure to progress.”
“I assume I’m sectioning her,” says Young.
“Talk to her doula first,” says Fuzukawa. “They’re still working on the lotus.”
“I assume that’s on the C-section consent form,” says Young.
“Nothing like natural childbirth!” says Fuzukawa. She and Carl Young roll their eyes in unison.
* * *
The scene I just told you about is made up but the situations and the slang are not. Jargon and slang allowed Fuzukawa and Young to pile a lot of clinical information and some attitude into a short exchange. Let me unpack some of the highlights:
The first patient Fuzukawa talked about—the G3P3 42-weeker three days postpartum is a woman who has been pregnant three times and has had three children, the most recent being born at 42 weeks’ gestation (two weeks late) at home three days earlier. A PPH stands for a postpartum hemorrhage. A hemoglobin of 40 translates into 40 grams per litre, roughly one-third of a normal blood level. A blood pressure of 60 over palp is slang for 60 systolic, well below a normal blood pressure of 120 over 80—indicating severe shock.
As Fuzukawa explained, the woman arrived in shock. Thanks to the doctors’ quick action removing the RPOC (retained products of conception—bits of placenta still inside the womb), plus blood transfusions and intravenous antibiotics, they were able not only to save the woman’s life but her uterus so that she’d be able to have more children.
Darwin Award is obstetrical slang for a woman who chooses to have a high-risk birth at home—far away from a hospital with its life- and womb-saving doctors and equipment. It’s a reference to the annual Darwin Awards given to individuals who carry out colossally stupid or foolish acts that usually end in death.
Fuzukawa referred to Rhonda Chan as a whiney primey—slang for a woman who keeps coming to the Labour and Delivery ward because she thinks she’s in labour when she isn’t. Whiney is slang for anxious, while primey refers to the fact that the woman is a primp, or primipara (first pregnancy). The cervix dilates during labour to make way for the baby. At ten centimetres, it is fully dilated; at two centimetres, the cervix is nowhere near ready.
Young asked if Fuzukawa is a diva. That’s OBGYN slang for a woman who keeps complaining about being in labour in the hopes that her doctor will perform a Caesarean section and get the whole thing over with.
Next up was Amina Khan. With a blood pressure of 150 over 95, Khan has pregnancy-induced hypertension. The normal blood pressure during pregnancy ranges from 110/70 to 120/80. Puffy is a slang term used by OBGYNs to say the woman’s face is swollen and her complexion is grey—both subtle indications that she has pre-eclampsia, a condition during pregnancy associated with high blood pressure. Left untreated, it can cause seizures and threaten the lives of mother and child.
One of the main treatments of pre-eclampsia is an urgent Caesarean section; that’s why Young asked if he would be sectioning Ms. Khan. Fuzukawa’s reply that the patient was NMD was a deal-breaker for Young: it stands for “no male doctor,” an increasingly common request.
Tabitha Baker’s story is filled with jargon and slang. Carrot is slang for the fact that the configuration of Baker’s cervix meant that a vaginal delivery was unlikely. Pitted, ARMed and frozen meant that Baker had been given the IV drug Pitocin to make her womb contract forcefully, her membranes had been ruptured (ARM stands for “artificial rupture of the membranes”) to induce labour, and she had been given an epidural (frozen) to reduce her pain. Unfortunately, the epidural had frozen Baker so well she stopped being in active labour—hence the reference to ice cube.
Baker has a doula, a non-medical person who provides support to the mother before, during and following delivery. The reference to lotus is not slang per se. A lotus birth is the practice of leaving the umbilical cord uncut after birth so that the baby is left attached to the placenta until the cord separates naturally after a few days. Lotus birth—once rare in Western culture—has become increasingly popular among proponents of natural childbirth. In this case, working on the lotus was code for saying that Baker—supported by her doula—was reluctant to agree to a Caesarean section.
The reference to Caesarean section consent form was pure slang. It’s a subtle dig at birth plans, which are favoured by proponents of natural childbirth as well as by mothers who want to control almost every aspect of the birth. It was coined by OBGYNs on the assumption that of all the procedures that can take place during a birth, a Caesarean section is just about the last one a mother-to-be with a birth plan would ever consent to.
The slang enabled Fuzukawa and Young to share a great deal of information with lightning efficiency. Moreover, it reflected the ever-present tension found on the labour and delivery ward. I’m not an OBGYN, but what struck me was just how much latent and manifest tension was packed into such a spare conversation: tension between mother and OBGYN; tension between OBGYNs and midwives and doulas; tension between male OBGYNs and female patients; tension between family doctors and OBGYNs; tension between different worldviews of pregnancy and birth; tension between the close proximity of happy endings and unspeakable disasters.
Looked at in that way, OBGYN slang is a critical safety valve that defuses the tension and permits people under conditions of extreme stress, fatigue and sleep deprivation to work and function together.
Still, the tension is always there. It’s been that way for a long time.
* * *
Today, the Tabitha Bakers and Amina Khans of the world come to hospital to have their babies. A hundred years ago, they would have had their babies at home. Whether they and their babies would have survived back then is a pertinent question. Changes in where and how babies are born have led to changes in language. Understanding the tension produced by those changes is key to understanding OBGYN slang.
The transfer of childbirth from homes to hospitals gave rise to many medical procedures that have since been judged unnecessary. A family physician who has practised low-risk obstetrics for twenty years and who is deputy chief of family medicine at a hospital in Toronto says that in the 1950s, for instance, “every woman, that’s all women, needed an episiotomy to create extra room whether they needed extra room or not. And forceps on the baby’s head to protect the fetal head.”
An episiotomy is a surgical cut in the perineum, the skin and underlying tissue roughly between the vagina and the anus. Today episiotomies are known to heal poorly and to cause loss of bowel movement and bladder control and are used only if the baby is in distress or the woman is at risk of tearing. Forceps were used in conjunction with episiotomy to pull the baby by the head from the woman’s body.
All this snipping and pulling came from a popular notion that babies could be harmed as they travelled through the birth canal. Today we know better. “There’s no part of the female pelvis—vagina side wall, even ischial tuberosities (the bones along the birth canal)—that harm that baby’s head,” says the family doctor.
Rosanne Gephart, a certified nurse-midwife in Santa Rosa, California, believes the motive for some of the extra work involved in birth is financial. “A lot of money is made off the complications of birth,” Gephart says. “The physicians and the anesthesiologists—everybody—make more money when things are complicated.”
In 2010, 98.5 percent of births in Canada took place in a hospital, according to Statistics Canada. During the same year in the United States, the number of hospital births was slightly higher, at 98.8 percent.
The shift from home to hospital also means a shift in who is attending the birth. Formerly the domain of midwives and family doctors, births are increasingly being attended by OBGYNs.
In 1986, 43 percent of American family physicians performed deliveries, compared with 28 p
ercent in 2006, according to the American Academy of Family Physicians.
One of the reasons family physicians have moved out of obstetrics “could be the obstetricians’ faults,” says Dr. Shiraz Moola, an OBGYN in Nelson, British Columbia. “If we assume that we’re the best at doing this, that nobody else can do as good a job, then we may push family physicians out. And I don’t think that’s ideal.”
Moola believes “a family physician is an optimal specialist to provide good care. You know they’re looking after you through your pregnancy. They very well may have looked after you through your infancy and your childhood. They may look after you as you get older in life.”
A few family doctors still do deliveries, and they love their work. “I’m what’s called a birth junkie,” says one family physician. “It never goes away, the high that you get from having that baby.”
Dr. Gerry Prince, director of the Family Medicine Maternity Clinic in Medicine Hat, Alberta, offers a couple of different explanations for the exodus of family doctors from maternity care. “One is the time commitment. The inconvenience of the on-call requirement,” he says. “The other would be training and competence and confidence. Today’s residents aren’t permitted to be on call as often as we used to be. Which means they can’t get as much experience doing obstetrics. Obstetrics and other procedural things are mostly experience based: you have to do enough to feel good.”
When Prince was doing his family-practice residency, he did 100 deliveries on his own. Now, he says, residents are lucky to do as many as twenty.
While family doctors may continue to be absent from maternity wards, there’s evidence to suggest that midwives are on the rise. In the United States, the number of births attended by certified nurse- midwives more than doubled from 1989 to 2002, rising to 7.7 percent from 3.3 percent of all births, according to a study published in the Journal of Midwifery and Women’s Health. Since then, the numbers have held relatively steady and are expected to increase.
The Secret Language of Doctors Page 13