Tuesday, September 28, 2010

Nice Is Not Enough: Questions for Interviewing a Maternity Care Provider

Many women want to choose their pregnancy care provider carefully, but aren't sure what questions to ask when interviewing doctors or midwives. 

Here are some general questions from http://www.birthsense.org/ to ask any provider you are considering during your pregnancy and birth.

I don't want to reproduce the entire post, so be sure to go to her site and read the whole thing because the author wrote about the "wrong" answer and the "right" answer to each question, and that's really much more informative than just looking at the questions themselves.
  1. What is your philosophy of pregnancy and birth?
  2. How do you define “normal birth”?
  3. Can you give me an example how you typically manage a normal birth?
  4. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?
  5. How long will you “allow me” to wait if I go overdue?
  6. What position(s) will you allow me to use when giving birth?
  7. How do you feel about IVs and continuous fetal monitoring?
  8. How do you feel about a woman eating and drinking in labor?
  9. What do you recommend a woman do during labor?
  10. What are your thoughts on pain relief in labor?
  11. How do you feel about cesarean birth?
Some childbirth educators would substitute different questions here and there from this list (for example, I probably wouldn't use the first question) but it's a reasonable basic list to start with.   Adapt as necessary for your own personal situation and concerns.

Again, be sure to read the original article ("In Search of Dr. Right: 11 Questions to Ask") so you can see what are good caregiver responses to these questions and which ones should raise a red flag to you.

There are other additional questions I would ask if you are a woman of size, but more on that below and in future posts.  If anything, women of size need to be even more vigilant in asking questions of potential care providers because size bias is so prevalent in maternity care. But for now, the above questions are a reasonable start to the process.

Nice Is Not Enough

The author also cautioned against letting a doctor's bedside charm and personality supercede your own commonsense about interventions.  A doctor can be really charming, caring, and nice and still have a 50+% c-section rate and a 40+% episiotomy rate, which will do far more harm than good in the long run.

Just because they are "nice" doesn't mean you are going to get safe care from them that doesn't put you at risk for more complications. 

This same midwife told the story of the following doctor on her blog (note that the "Dr. Wonderful" in this scenario is not the same as the truly birth-friendly "Dr. Wonderful" discussed on some birth blogs):
What is the definition of a “good doctor”? I once knew a physician whom everyone believed was a “good doctor”. Let’s call him Dr. Wonderful. He had a very high cesarean rate, a high episiotomy rate, a high forceps/vacuum rate, and yet his patients adored him. Why?
He made each woman who came to him feel special. He was handsome and charming, and would treat each woman as if she were the only patient in the world that mattered to him. This is not necessarily a bad thing–I believe each patient should feel special and important to her provider. However, when this perception of being special clouds a woman’s judgment, it is time to have a reality check.
Dr. Wonderful would visit his patient after whatever unnecessary procedure he did, sit by the bedside, take her hand, and very regretfully tell her how sorry he was that she needed ___________ (insert the procedure of your choice), but if he had not done it, ___________ would have happened (insert catastrophe of your choice). So he very reluctantly had heroically intervened to save her life, or the life of her baby. The woman would be trembling with gratitude toward this marvelous physician by the time he left the room. None of his patients could ever believe that any of these procedures were unnecessary.
This bait-and-switch tactic is very common among some doctors (and even some midwives).  They know how to manipulate patients into going along with what they think is best and/or what is most convenient, even when the actual research doesn't support these interventions as best practice. 

Most women think that if their doctor recommends a procedure to them, it must be necessary, and who are they to question the doctor's judgment? But most don't realize how much interventions vary from caregiver to caregiver. Nor are most given adequate information about the pros and cons of most procedures.
The point is not that all interventions are "bad" or must be avoided, but that the benefits and risks of proposed interventions should be discussed thoroughly and true patient autonomy respected, not manipulated. 

If you are sure you want a hospital birth but you'd like to try and find a provider who is more friendly to natural childbirth and patient autonomy than most, this midwife summarizes one strategy for scoping out the possibilities:
I suggest that women who are planning hospital birth call their local [Labor and Delivery] unit, and ask to speak to a nurse who enjoys helping women who want unmedicated birth. Then ask that nurse for names of doctors [or midwives] that she thinks are most likely to support you in your goals.
Last, and perhaps most important, don’t be fooled by a charming bedside manner. Make sure there is substance behind it.
Amen to that.  "Nice" is great, but some doctors use it as a way to convince women into all kinds of risky interventions as a way to lower the risk for being sued. 

In particular, many women of size are just so grateful just to find a doctor who doesn't yell at them about their weight that they fail to ask further questions about the provider's rates of interventions that increase the risk for cesarean (a high induction rate, inducing for suspected big baby, etc.). 

I've been there, done that myself and gotten burned, so learn from my mistakes.

Don't fall for "nice" over substance.  Nice is a good start, but you still have to ask further questions.

Ask for Specific Intervention Rates

It's really important to ask a provider's intervention rates, especially his/her intervention rates for first-time moms.  What's the induction rate, cesarean rate, episiotomy rate? 

"I only do them when necessary" is not an acceptable answer; for some docs, interventions like these are "necessary" 50% of the time, and that rate presents far more risk than benefit. 

For example, episiotomy rates should be extremely low; if it's not, the provider is not practicing evidence-based medicine, which has clearly shown routine episiotomy to be more harmful than helpful. 

Many doctors say they "only do episiotomies when necessary" --- but if they find it "necessary" 40% of the time, there is something wrong with their definition of "necessary."  Actual numbers are important for evaluating a provider.

Primary cesarean rates (cesareans in first-time moms or mothers who have never had a cesarean before) is another benchmark by which you can judge providers.  Women who have not had cesareans before should not have a very high rate of cesareans during labor; if they do, it suggests that the doctor has a low threshold for surgery or encourages a lot of interventions that lead to more cesareans.

(Of course, if a provider regularly provides care to many high-risk women, the cesarean rate is going to be higher than a provider who mostly sees only low-risk women.....but generally speaking a high cesarean rate is a red flag.) 

It's also helpful to ask the question above about how the care provider feels about cesareans. 

If they have a high cesarean rate but are defensive about that, they'll likely say something that minimizes the impact of cesareans and ridicules the mother for caring. 

Watch for comments like, "The real priority is a healthy baby" or "A healthy baby is more important than the delivery method".....as if that justifies any intervention the doctor uses, as if the mother's outcome is of no importance, and as if the mother questioning things means she doesn't really care about her baby over herself.

Of course the priority is a healthy baby, but a healthy mother is also a priority, and one recovering from unnecessary surgery is not a healthy mother. Nor should a woman be ridiculed for caring about avoiding a cesarean or an episiotomy whenever possible. 

A provider that avoids the question of intervention rates by blaming the mother, brushing off her concern, or making her feel selfish for caring is a giant red flag.

Beware care providers that "don't know" their cesarean rate, "only do one when necessary," or who subtly deride anyone who asks questions about cesarean or episiotomy rates. 

Also ask when/why the provider would want to induce labor. 

If they routinely induce labor if the baby is thought to be  "big," that's another tremendous red flag.  Research shows that inducing early for a "big baby" actually increases the cesarean rate, not decreases it, but despite the evidence, many providers still induce early for a big baby anyway.  [This is one major factor driving the high rate of cesareans in women of size.]

If you interview a provider and they would induce early for a big baby, this is a huge red flag.

Many providers also routinely induce labor at 40 or 41 weeks (sometimes earlier!), and research is mixed on the pros and cons of this practice

Particularly for women of size (whose pregnancies tend to last longer), inducing labor early or right around term "just in case" probably leads to more cesarean risk and a whole host of other potential complications.  Find a provider who is more willing to wait and not rush things as long as mother and baby are doing well.

Conclusion

You can have the "nicest" doctor or midwife in the world, and he or she can coax you straight down the path to a cesarean or episiotomy you don't need by engaging in unnecessarily high rates of interventions with dubious benefits.

Being nice is just not enough.  You have to ask careful questions when interviewing a care provider, you have to ask for specific intervention rates, and it's very important to watch for the classic red "alarm" flags.

*What questions were most helpful to you when you were interviewing providers?  What questions do you wish you had asked?  What advice do you have for other pregnant women looking for maternity care providers?

Thursday, September 23, 2010

Prenatal Weight Gain: When the Conclusion is Made Ahead of the Results

Several people wrote me last year to send me the link to the New York Times article, "New Goal for the Obese: Zero Gain in Pregnancy."

Believe me, I'd already seen this article and others similar to it. There are SO many things to object to object to or comment on, it was hard to know where to start and I've been spinning my wheels for a long time, trying to find a way to communicate my concerns effectively without a giant rambling reply. 

But darn it, this sort of thing needs to be challenged, and currently very few people in the media, the fatosphere, or the birth world are even questioning strict limits on pregnancy weight gain in "obese" women. 

So I'm going to ramble away, because this sort of thing must be challenged.  Here are a few of my concerns with this specific study and so many of the others like it.

Publicizing the Outcome Before The Study Even Begins

I think the thing that bothers me most in this Kaiser study is that the results are a foregone conclusion.

It floors me that these researchers published an article ---in the New York Times, no less---essentially promoting a conclusion they hadn't even studied yet.

It's not like these researchers had already done the study and concluded from data that gaining no weight in pregnancy was best for obese women.

No no no!! They were just starting the study....so why were they already publicizing their conclusions?

The problem is that these doctors have already made up their minds that little or no weight gain leads to the healthiest outcomes in obese mothers, and that this was the message that needed to be pushed to consumers and other doctors.

It's marketing this message that is their main concern. Why else would they be publicizing their uncompleted research like this?

There is an army of OBs out there who have reverted to the old teachings about the "dangers" of too much weight gain in pregnancy and have a TREMENDOUS agenda to promote extreme restriction of weight gain (or even weight loss) in "obese" women in pregnancy.

These OBs have been aggressively marketing the idea to the press that fat women gain "too much weight" in pregnancy and that restricting such weight gain can improve outcomes. Over and over, we have seen them pushing this agenda with the press.  This is just the latest salvo in their campaign.

The phrasing of the NYT article (just look at the title...."New Goal for the Obese: Zero Weight Gain in Pregnancy") also bothers me because many people will scan the article and conclude that the study has already been done and that gaining no weight in pregnancy is best.

In fact, all the article is doing is telling people that they were starting a study to see whether gaining no weight improves outcomes......but many people (including many doctors) probably read the story and believed that gaining no weight is now the standard of care.

These researchers are trying to create an expectation in the public and among birth attendants that this no-gain policy is the new standard of care for obese women, that any gain must be prevented for women of size....and perhaps even that weight loss during pregnancy is the most optimal course of all.

This is what I'm hearing from women of size now....that they are being told to gain little to no weight in pregnancy, and many more are now even being told to lose weight during pregnancy.

In fact, THIS IS NOT THE STANDARD OF CARE AT ALL, nor should it be.  There are significant reasons for concern with a policy like this.

Prenatal Weight Gain Politics


The IOM (Institute of Medicine) came out with revised guidelines earlier this year, recommending a new pregnancy gain of 11-20 pounds in obese women.

This is down from a previous recommendation for obese women to gain "at least 15 pounds" (often misreported as "no more than 15 pounds"), but the news wasn't all bad.

The good news was that the IOM resisted pressure to lower the guidelines to NO gain (or even weight loss) for "morbidly obese" women, saying there was not enough evidence in that group to make a decision.

The bad news is that now we are going to see a plethora of studies, intervening and trying to keep "morbidly obese" women from gaining any weight in pregnancy....and no doubt coming to their conclusions ahead of time, just like this study.

My concern is that the studies we will see on this topic will not be fair, rigorous, or powerful enough to really make any decisions about the best course of action.....but that it won't matter, because The Powers That Be have already made up their minds about what's best, and will use bad science to try and push their agenda as part of their "war on obesity." 

And I'm afraid of what the price will be for women of size and their babies.

Details on the Study

Here are more details about the study from the Kaiser press release on October 21, 2009.
Kaiser Permanente is launching the first clinical trial to help obese women control their weight during pregnancy. The “Healthy Moms” study, funded by a $2.2 million grant from the National Institute of Child Health and Human Development, will begin recruiting this month.

“The goal of the study is to keep obese pregnant women from gaining weight. We believe they can safely maintain their pre-pregnancy weight and deliver healthier babies,” says Kim Vesco, MD, MPH, a practicing OB/GYN and researcher at the Kaiser Permanente Center for Health Research, who will direct the study.

This is the first study to test a weight maintenance program for obese pregnant women, and the first to use weekly support groups as part of the intervention. A small study in Denmark did limit excess weight gain in obese pregnant women, but they still gained an average of 14.5 pounds. Two other larger studies failed to prevent excessive weight gain in obese and overweight pregnant women.

“It may seem counterintuitive to suggest that women control their weight during pregnancy, but these women are already carrying between 50 and 100 extra pounds — and for them any more weight gain could be very dangerous,” said Vic Stevens, PhD, principal investigator who has studied weight loss and weight maintenance for more than 30 years...

The “Healthy Moms” trial will enroll 180 obese pregnant women from Washington and Oregon who are members of the Kaiser Permanente health plan: half will receive one-time dietary and exercise advice; the other half will attend two individual counseling sessions and then weekly group counseling for the remainder of their pregnancy. Women who attend the sessions will be weighed and encouraged to keep and turn in daily food and exercise diaries. Professional weight counselors will facilitate the groups and help motivate the women with behavior change techniques.

The study will follow women throughout their pregnancies to find out how much weight they gain, how large their babies are, and how much weight they retain one year after they give birth. It will also look at birthing complications, the baby’s growth and feeding practices, and whether the mother continues with dietary changes after the baby is born. The study will recruit women for 18 months, and preliminary results are expected in three years.
Thoughts on the Kaiser Study

First off, I should note that I don't object to everything in the study, contrary to what many of the Obesity Mafia would expect.

I think it's very important for women to exercise in pregnancy, and I agree it's good to discourage consumption of things like sweetened drinks and junk food. I don't have a problem with recommending those, and I have no doubt that these interventions probably will be associated with lower risks of some complications in pregnancy.

Nor do I think that obese women gaining little weight is automatically dangerous. I personally had a net gain of about 5 pounds in my pregnancies (lost 10 lbs., then gained back 15)...not because I was trying to limit my gain, was eating "better" than usual, or because I had a lot of nausea, but simply because pregnancy revs up my metabolism in a major way.

I know from personal experience that you can have a perfectly healthy pregnancy with a very small gain. Some fat women do gain very little in pregnancy, not because they have "healthier" nutrition than those who do gain, but simply because pregnancy changes their metabolism more.

My concern is promoting no weight gain as a goal for ALL obese women, and using potentially draconian means to get it.  Many women can't achieve null weight gain without drastically limiting calories and thereby nutrients. In what way is that healthy? 

The research (in other weight-limitation studies) shows that many "obese" women have difficulty meeting weight gain limits of 15 lbs. already.  Not because they are pigs and can't lay off the french fries and bon-bons, but simply because most pregnant women, including fat women, gain at least the weight of the baby, placenta, and extra fluids in pregnancy

In addition, many women of size who are chronic dieters or who have lost weight before pregnancy gain more during pregnancy because their bodies compensate physiologically to have enough energy for birth and breastfeeding.  The body thinks it's starving, so it becomes more efficient and stores up more fat for reserves, even with normal eating.

So is it really realistic and fair to make fat women gain NO weight in pregnancy and to make them feel guilty if they do gain weight, despite eating well?  I don't think it is. I think it sets them up for failure, for feeling guilty, and for disordered eating.

I think it puts the goal on the surrogate target of weight gain, when it really ought to be putting the target on the real goal...healthy nutrition, healthy baby, and healthy mommy.

If Only....

Wouldn't it be nice if this study had a Health At Every Size (HAES) component to it? If they had a group where increased exercise and reasonable eating guidelines were promoted, yet the emphasis was simply on really excellent nutrition and exercise, regardless of actual gain

Wouldn't it be nice if there were a group where women weren't made to feel like failures if they gained pregnancy weight despite doing everything "right"? 

And wouldn't it be great if they compared long-term maternal and fetal outcomes, long-term healthy eating practices, and long-term weight outcomes from each program to see which had the best results? 

I have a hunch the results would be similar to the U.C. Davis HAES study, which found that emphasizing healthy habits along with body acceptance resulted in better long-term health outcomes than emphasizing weight loss. 

I know, I know....it's a pipe dream.  When doctors are convinced that strictly limiting weight gain is the "magic bullet" to preventing complications in the pregnancies of women of size and preventing obesity in their offspring, it's too much to hope for that they could mentally uncouple healthful habits from restricted gain.  They simply cannot separate one goal from the other; in their minds, the two are always connected. 

But very low weight gains are already difficult for many women to achieve; lowering the bar to even more restrictive gain is not going to be any more effective or achievable.  Furthermore, weight gain is a poor surrogate for fetal outcome in most cases, so making that the focus does little to promote fetal health.

Perhaps what they should be doing instead is emphasizing healthy habits and long-term outcomes...healthy nutrition, healthy baby, and healthy mommy...over actual numbers on a scale.

Next up:  Study Design Issues and Long-Term Safety Concerns in these "restrictive weight gain" studies.

Thursday, September 16, 2010

"Catch-Up Fat" and Metabolic Issues

This sounds like a really interesting paper. Here's the abstract and a link to the full text.  Obviously, emphasis is mine.

Pathways from weight fluctuations to metabolic diseases: focus on maladaptive thermogenesis during catch-up fat.  Dulloo AG, Jacquet J, Montani JP. Int J Obes Relat Metab Disord. 2002 Sep;26 Suppl 2:S46-57.

Department of Medicine/Physiology, University of Fribourg, Switzerland.

Abstract

It has long been known that obesity is a high risk factor for cardiovascular diseases. In more recent years, the analysis of several large epidemiological databases has also revealed that, independently of excess weight, large fluctuations in body weight at some point earlier in life represent an independent risk factor for type 2 diabetes and hypertension-two major contributors to cardiovascular diseases.

High cardiovascular morbidity and mortality have indeed been reported in men and women who in young adulthood experienced weight fluctuations (involving the recovery of body weight after weight loss due to disease, famine or voluntary slimming), or when weight fluctuations occurred much earlier in life and involved catch-up growth after fetal or neonatal growth retardation.

This paper addresses the pathways from weight fluctuations to chronic metabolic diseases by focusing on the phenomenon of accelerated fat recovery (ie catch-up fat) after weight loss or growth retardation. Arguments are put forward that, during catch-up growth or weight recovery on our modern refined foods, the mechanisms of adaptive thermogenesis that regulate catch-up fat are pushed beyond the limits for which they were meant to operate and turn maladaptive.

The consequences are enhanced susceptibilities towards skeletal muscle insulin resistance and overactive sympathetic activity, both of which are major contributors to the pathogenesis of chronic metabolic diseases.

Since weight fluctuation earlier in life (independently of excess weight later in life) is an independent risk factor for metabolic diseases, the mechanisms by which body fat is acquired would seem to be at least as important as the consequences of excess fat per se in the pathogenesis of diabetes, hypertension and cardiovascular diseases.

PMID: 12174328

Free full text available at:  http://www.nature.com/ijo/journal/v26/n2s/pdf/0802127a.pdf

Interesting quote:

"Several lines of evidence suggest that the process of recovering body weight is itself an independent risk factor for the development of cardiovascular diseases."

Tuesday, September 14, 2010

Being Fat in an Emergency

We recently discussed Community Emergency Response Training (CERT), how I took CERT training this year, and what an excellent program it is. 

However, I also wanted to share one negative realization I had, not about the program, but from the program.  And that was how fat people might get discriminated against during an emergency.

In an emergency, some rescuers might be less likely to help us, based on our size alone.  Or we might be seen as less likely to recover and so moved down the priority list for treatment. Or, like during Hurricane Katrina, "caregivers" might be unwilling to evacuate us and maybe even willing to do worse. 

I saw this lesser willingness to help fat people among some people in our CERT class.  Not all, but some, and it really shocked me.  Call me naive, I guess, but it was a surprising lesson for me.

It's also a lesson I've debated blogging about, but in the end decided it was better to open a dialogue about it than to let the incident pass without remark.

Too Fat To Deserve Help?

During our second-to-last class, we did a paper simulation of a disaster as practice for the real-time simulation the following week. We divided the class into two groups, set up our organizational structures, and then pretended to be the Command Center for organizing emergency response to a flood. They gave us index cards with emergency scenarios on them and we had to decide how to prioritize assigning help, how to manage volunteers, and how to get/distribute emergency equipment needed.

In one of those index-card scenarios, a downed tree blocked road access to a 300 lb. man having a heart attack. An ambulance was on its way to him but couldn't get through.

Can you guess how the Incident Commander responded?

Yup. She completely wrote him off and sent the ambulance somewhere else rather than have a volunteer go over with a chainsaw and cut away the tree. She didn't say it literally but basically implied that it was survival of the fittest at that point.

I was so angry I could hardly see straight. As soon as she heard his weight, she wrote him off and didn't even try to brainstorm ways to help him. Augh.

This was not an obnoxious fitness fanatic, mind.  She was just an ordinary person, a little plump herself, with her own physical challenges from past injuries.  I would have thought she would have been more empathetic, not less --- but she completely wrote off this man without even trying to find ways to work the problem.

If it had been a matter of saving greater numbers of people, I would understand not making this man a priority. In an emergency, you have to help the most people possible, and a scene involving many victims in mortal danger is going to get priority over a scene involving only one victim in mortal danger.

But most of the multiple-victim events we were given were not life-threatening, this was clearly one of the most life-threatening events presented, and there was plenty of volunteer help to go around.

It was clear that she didn't choose to abandon him because he was only one person or because we had limited resources; she chose to abandon him because he was fat.

If it was simply a matter of not being able to lift him, I would even understand that up to a point too. Larger people are harder to lift and can injure their rescuers. In a really pressing, life-and-death, every-second-counts evacuation situation, hard choices might have to be made about who could be most easily transported and saved. While I wouldn't like it, there are some physical limitations that can cause hard choices to have to be made under the most pressing circumstances.

But this wasn't one of those. All that had to be done was to send someone over to cut away the tree. It would only take up the time of one or two volunteers, and chainsaws were available for use in our scenario

Ordinary volunteers would not have to lift this man because an ambulance was almost to his location.  Most ambulance crews have equipment and experience in dealing with larger patients. They do it frequently enough that they have learned how to do it as safely as possible.  It's not their ideal but they generally have experience with it. And unless he had passed out, the patient probably would have been able to help; many heart attack victims can move around to some extent. Furthermore, the crew was already almost there -- they just needed help to get the last couple of blocks there.  It's not like extraordinary measures would have to be taken to get to him or to get him into the ambulance.

I pointed all these things out during our paper simulation and fought for this theoretical guy's life....to no avail. I argued several times.....she wouldn't listen. Her mind was made up when she heard "300 lbs." As soon as his weight was said, she had an audible negative reaction and immediately decided not to send help. 

The ironic thing was, the patient wasn't all that large.  Yes, 300 lbs. is no lightweight but the public has a distorted view of what "300 lbs." looks like.  They think of the headless fatties photos in the media, or they think of the "super-super-obese" person who is bedridden and can't get out their door. In reality, they probably know several 300 lb. people but have no idea that these acquaintances weigh about that much.  Their view about what 300 lbs. "must" look like distorts their judgments about helping.

My husband is about the size of the man in the scenario, but he is tall, built like a linebacker, and carries it well enough that most people would never guess he weighed that much.  I wonder if our Incident Commander realized that someone else sitting in that very classroom was that size, and she was basically denying help to one of her classmates?  I thought about telling her that in essence, she had just decided to let my husband die, but in the end I decided that was too potentially embarrassing for my husband and son to bring that up, so I didn't.

In the end, I had to remember my CERT training, which is that sometimes you have to go along with a decision you don't agree with when you are not the one in command. If I'd created a big argument, needed help would have gone unassigned while people bickered, and theoretical victims might have died in the interim. I had to look at the big picture and move on, but I made sure she knew I disagreed first.

(In a real scenario, I hope I would've found a way to get this guy help even if I had to take the damn chainsaw and go myself.)

Post-Incident Reflections

When we discussed our decision-making process afterwards, no one else protested denying help to the person of size.  I mentioned my disagreement but didn't make a huge deal of it because it would lead to unpleasant places I knew my husband and son weren't ready for.  (No one is as easily embarrassed as a teenaged boy whose mother is putting up a fuss, and my husband wasn't really ready to have his weight discussed in a public forum like that.)

In retrospect, I wish I had been more vocal in pointing out the discriminatory nature of her decision.  I feel I dropped the ball by not making it an opportunity for dialogue, and I'm still kicking myself over that.

The supervisor did note another alternative no one had thought of -- instead of trying to get the ambulance to the heart attack victim, we could have tried getting the heart attack victim to the ambulance. The big guy's loved ones could have put him in a rolling chair and rolled him down the street to the ambulance. That wouldn't have needed any volunteers assigned to the case and wouldn't have required special equipment other than a rolling chair (which many people have in their home offices).  Its success would have depended on the condition of the roads but it was worth giving a shot. He said rolling chairs are excellent alternatives that are often overlooked in emergency scenarios.

However, I still felt like this was a clear case of discrimination. If the patient had been average-sized (or no specified weight), the Incident Commander would have found a way to get a volunteer with a chainsaw to the tree and gotten that ambulance to the victim. She was working the problem till the moment she heard his weight.

The one bright spot in this was that the bias wasn't universal.  The other team made the big guy a priority and he was one of the first people they helped. Weight didn't seem to influence their decision process.

It was good to know that not everyone would discriminate against larger patients during an emergency....but it was quite upsetting to realize that some would, even when there was a relatively easy fix.

Closing Thoughts

At this point, I should remind folks again that the CERT class was excellent.  In no way did it promote discriminating against fat people, and the skills it taught would be very valuable to people of any size.  It is certainly a class well worth taking, for people of all sizes.

But the "community" nature of the program means that the community responders may reflect many of the biases of society. Some of those people might see fat people as less worthy of saving than others, or as too much trouble to waste resources on.  It was frustrating to see that in action, even if it was "just" a theoretical scenario. 

The lesson I took from this disturbing incident was not to specify someone's weight in an emergency call unless it's really relevant (i.e. special equipment is needed), and to know that I, as a person of size, might have to be more assertive about getting myself or other fat loved ones equal care.

*Comments?  Thoughts?  Experiences?

Thursday, September 9, 2010

CERT - Community Emergency Preparedness

One of my projects for the past summer was to sign up for a "CERT" class.  It really was an excellent experience and I highly recommend it to others.

CERT stands for Community Emergency Response Training.  The idea is that if there is a serious emergency, police, firefighters, and EMTs will be overwhelmed and won't be able to get to all the people who need help in a very timely manner.  They will have to prioritize and go to the most critical locales first, places where the maximum amount of lives can be saved, or places critical to the community (like schools, hospitals, etc.).  Therefore, the chances of them responding to you in your neighborhood --- or at your workplace -- are small in the immediate hours after an emergency.  That means you could be a long time on your own before help arrives.

To help fill the gap, the government created a program to help train community responders to supplement the efforts of professional first responders.  Community responders would help their own families first, then respond to others in an expanding circle around their location, helping out until first-responders could get there to take over. 

CERT team members would help organize interim medical care, do light search and rescue, and do basic safety procedures (turning off the gas if it's leaking, operating fire extinguishers for small fires, find a safe location for victims, etc.)  CERT members would also do basic triage --- separating the wounded into different groups based on seriousness of the injuries --- so that when first responders arrive (or when transport is available), the most serious cases can get help more quickly.  Until first responders arrive or patients are transported, CERT members also provide as much medical care to victims as circumstances and their skills allow. 

I'd heard about the CERT classes in our area for several years, but never felt I could take time for the class.  I had small babies at home that I could not easily leave, or was responsible for the care of ill family members whose needs were too unpredictable for committing to a class series.  But finally, I decided the time was right and made it my goal to get this training going this summer.

I had to drag my husband and my oldest son to the class, kicking and screaming the whole way.  We've all had First Aid/CPR classes, my husband was an Eagle Scout, and my son has had e-prep (emergency prep) as part of his path towards becoming an Eagle too.  Both of them thought that this class series would be just more of the same stuff they already knew.

They were wrong, and at the end of the class, they admitted so to me.  (Yes!)  The classes went way beyond what they'd already learned, complemented the skills they already had, and took their preparations much further.  Now they are CERT converts, and we want to spread the word to others in the community as well. 

About CERT Classes

A CERT class is FREE; it doesn't cost you a penny to take the class. You can find out more about CERT here, and you can search for classes in your local area here. Or you can just google "CERT classes" and the name of your city or area to see if there is a CERT website specifically for your area. 

A CERT class is usually 6-8 weeks long, depending on your location, and 2-3 hours each session. However, many large employers arrange to have longer classes done in 2 work days for their employees, so getting it through your work is also an option if you don't want to commit to a 6-8 week session. CERT often also does 2-day training with local school districts; you might be able to get the class that way.

Bonus: You often get free "goodies" at the end of the class. The class is sponsored by grants from FEMA and other government agencies, so money is available for emergency coordinators to buy limited amounts of basic safety equipment for participants. What you get will vary from location to location, but our class gave us hard hats, high-visibility safety vests, tools for turning off gas and water, work gloves, eye protection, a waterproof book with all the CERT information summarized in it, and several other small little "door prizes." I packed these (plus a few other items, like nitrile gloves, flashlights, duct tape, etc.) into a backpack and now carry it with me at all times in my car for quick access in case of an emergency.

Here is some information about CERT classes from the official CERT website:
CERT is about readiness, people helping people, rescuer safety, and doing the greatest good for the greatest number. CERT is a positive and realistic approach to emergency and disaster situations where citizens will be initially on their own and their actions can make a difference. Through training, citizens can manage utilities and put out small fires; treat the three killers by opening airways, controlling bleeding, and treating for shock; provide basic medical aid; search for and rescue victims safely; and organize themselves and spontaneous volunteers to be effective...

The Federal Emergency Management Agency (FEMA) recognizes the importance of preparing citizens. The Emergency Management Institute (EMI) and the National Fire Academy adopted and expanded the CERT materials believing them applicable to all hazards.
What Does The Class Cover?

The CERT class series usually covers seven sessions/topics.  Some class series compress these into six sessions or expand them into eight, but basically there are seven sessions, summarized here from the website:
  • Session I, DISASTER PREPAREDNESS: Addresses hazards to which people are vulnerable in their community. Materials cover actions that participants and their families take before, during, and after a disaster. As the session progresses, the instructor begins to explore an expanded response role for civilians in that they should begin to consider themselves disaster workers. Since they will want to help their family members and neighbors, this training can help them operate in a safe and appropriate manner. The CERT concept and organization are discussed as well as applicable laws governing volunteers in that jurisdiction.
  • Session II, DISASTER FIRE SUPPRESSION: Briefly covers fire chemistry, hazardous materials, fire hazards, and fire suppression strategies. However, the thrust of this session is the safe use of fire extinguishers, sizing up the situation, controlling utilities, and extinguishing a small fire.
  • Session III, DISASTER MEDICAL OPERATIONS PART I: Participants practice diagnosing and treating airway obstruction, bleeding, and shock by using simple triage and rapid treatment techniques.
  • Session IV, DISASTER MEDICAL OPERATIONS, PART II: Covers evaluating patients by doing a head to toe assessment, establishing a medical treatment area, performing basic first aid, and practicing in a safe and sanitary manner.
  • Session V, LIGHT SEARCH AND RESCUE OPERATIONS: Participants learn about search and rescue planning, size-up, search techniques, rescue techniques, and most important, rescuer safety.
  • Session VI, DISASTER PSYCHOLOGY AND TEAM ORGANIZATION: Covers signs and symptoms that might be experienced by the disaster victim and worker. It addresses CERT organization and management principles and the need for documentation.
  • Session VII, COURSE REVIEW AND DISASTER SIMULATION: Participants review their answers from a take home examination. Finally, they practice the skills that they have learned during the previous six sessions in disaster activity.
As you can see, some of the class was review of First Aid skills we already knew, but it was still useful because it was more advanced.  For example, a lot of current First Aid classes don't teach you things like splinting broken bones anymore, because first responders can get there so fast and do a more reliable job. But in an extended emergency, you better believe that knowing how to splint bones (or how to deal with penetrating wounds) will come in handy.  Plus it's good to learn how to quickly evaluate and prioritize ("triage") wounds so you can deal more effectively with a large volume of patients.

The class also covered stuff I've never had before -- like Search And Rescue (SAR).  It showed us how to "crib" --- use wood and other materials you can scavenge from your area to lift heavy things off of people safely --- so you can get victims out of damaged buildings and into medical care. It was truly fascinating to see how putting physics to use in a practical way could help you rescue people you might otherwise not be able to help. (We lifted a giant van off of a crash dummy for our practice, something most of us would not have been able to do without knowing cribbing.) We discussed various ways of moving people and how to protect yourself when doing so, all very practical and useful skills.

The class gave us hands-on practice in putting out minor fires with fire extinguishers (which is how I convinced my teenage son to go to the class!).  That was fun.  Even though fire extinguishers are easy to use, there's more to consider than you might realize, so the hands-on practice was really useful.  Frankly, a small home fire is one of the emergencies you are more likely to encounter in your life, so although fire extinguisher practice is a really basic skill, it may well have been one of the most useful things we worked on. 

One of the best things the class taught us was the best way to organize others in an emergency, how to lessen the risk for rescuer injury, and how to document details of the situation to ease transition with first responders.  There are organizational structures that lead to more efficient rescues, and this leads to better outcomes than a lot of people doing free-lance vigilante rescues and possibly getting injured too.  Knowing how to set up an efficient organizational structure, knowing what safety hazards to look for, and knowing what information and on-ground organization would be most useful to first-responders when they DO arrive was incredibly valuable. 

And of course, the class also promoted getting yourself prepared for an emergency.  I'm more prepared than many folks because I at least have an emergency kit, but even I had a fair amount of work to do (and am still working on re-organizing things more efficiently). 

As I've mentioned before, some years ago I lived near an area that had a major earthquake, and I will never forget the news coverage of the aftermath.  Many areas really did have to fend for themselves for a while, people had to rely on each other for rescue and initial medical help, and people had to do without power, water and food for some time.  Are you prepared to do something like that?  Could you keep your family warm, hydrated, and fed if the power grid went down for days, weeks, or more?  Could you provide help if a loved one was injured in a disaster? This class helps you figure out what's most important to have in an emergency kit, where to get supplies, how to afford building a kit a little at a time, and how to organize it. 

At the end of the class, everyone had to participate in a simulated emergency so they could practice using the skills we learned.  That was really an eye-opening experience.  You think you've learned everything really well, but to actually put those skills to use in a safe test environment leads to insights and improvements you wouldn't have gotten otherwise. 

Our class simulated responding to a school (during extra-curricular activities) after an earthquake.  It was interesting to see which skills held up and which ones didn't, whether we remembered our training, and where the gaps in our learning were.  We ran the scenario twice, and of course the second time we improved our response....but it was really important to be part of that first, not-so-efficient response because that's the one we really learned from.

I was more than a little intimidated by the thought of participating in the simulated emergency....I hate doing a poor job at anything and I was also concerned about whether I could physically handle it......but it was fine. I was able to physically handle it, we all failed to one degree or another in our organizational tasks, and the firefighters who supervised us were pretty good at helping us learn from our mistakes.  That was incredibly useful and is an important part of the program. 

Once you complete the initial training, they also have follow-up training available in specific skills, and periodic emergency drills in the community where you can practice keeping up your basic skills.  Follow-up training and drills are all completely voluntary; you don't have to do anything more than the basic CERT training, but many people like to go further.  I think I will, in time.

What Emergencies Are Likely In Your Area?

It was useful to discuss the most likely emergencies in our area.  The organizers were not survivalists, preparing for the end of the world via nuclear attack by terrorists.  Although possible, that is not as likely an emergency scenario as natural disasters etc. Emergencies happen in all parts of the country, and we spent time discussing which were the most likely emergencies to prepare for in our area and what preparation would be most valuable for those scenarios. 

For example, in some parts of the country, the biggest thing to worry about is tornadoes, in which case search and rescue skills might be especially important. In others, it's hurricanes, in which search and rescue skills and ability to be without power for extended times might be important.  In others, it's wildfires or mudslides or floods, in which having a "grab and go" kit would be important. In others, it's winter storms, in which having a way to stay warm without power for a while and an emergency kit for your car would be important.  In others, it's earthquakes, in which many of the above skills would be needed. 

The key is to familiarize yourself with the most likely scenarios for your area, prepare for those, and then if you want to worry about the less likely things like terrorist attacks or nuclear fallout, you can prepare for those as well.

Can I Handle CERT Training?

One reason I had hesitated to become involved in CERT was because I wasn't sure I was fit enough to handle it.  I injured my knees in a bad car accident a couple of years ago and haven't been able to exercise as much as before, so I wasn't sure if I'd physically be up for what was needed.  Before I signed up, I wrote the emergency coordinator for our city and asked him whether I should take the class.

He replied yes, absolutely.  He noted that they have many people of all different physical abilities and challenges in the program.  Some skills, like search and rescue, need a higher fitness level, it's true.  Unless it was my own kids stuck in the rubble, I probably would not be aggressively going in and doing SAR.  But many jobs are supervisory, organizational, or medical, and I was more than capable of doing those. 

So that's what I did in our disaster simulation; the first time through I helped with the command structure and organizational stuff, and the second time through I helped with the medical treatment areas.  And I was perfectly fine at doing those, even with my physical challenges. 

So don't let being fat or having physical challenges keep you from getting trained.  Yes, there are some jobs you might not be able to do, but we really did have a wide variety of ages and abilities in the class.  Many were seniors; one had broken her leg really badly the previous year and could not help with Search and Rescue either.  So she become Incident Commander on our second run-through, and did a great job. 

The point is that everyone is needed in an emergency, and everyone has a potential role to play in helping others, and there are many jobs available.  Don't let fitness or physical challenges keep you from taking the training.

Wednesday, September 1, 2010

Delaying Routine GYN Care

Aldrich T, Hackley B.  "The impact of obesity on gynecologic cancer screening: an integrative literature review." J Midwifery Womens Health. 2010 Jul;55(4):344-56.

Abstract

INTRODUCTION: Evidence indicates lower rates of breast and cervical cancer screening among obese compared to nonobese women. This integrative review examines the association between gynecologic cancer screening and body weight, as well as potential barriers to screening.

METHODS: A literature search of standard computerized databases was conducted for peer-reviewed articles published between 1950 and January 2009.

RESULTS: Twenty-three studies met the criteria for review. Of the 17 studies that evaluated rates of cervical cancer screening, 13 found obese women significantly less likely than their nonobese counterparts to have had a recent Papanicolaou test, a trend that was stronger in white women when compared to African American women. Eight of the 15 studies examining routine mammography found an inverse association between increasing body weight and recent screening, although findings generally pertained only to women who were white and/or severely obese. Possible barriers to care included embarrassment and perceived weight stigma in the clinical setting, lack of appropriately sized examination equipment, and poor patient-provider communication.

DISCUSSION: Further research is needed to clarify the challenges that obese women face in accessing care and to evaluate strategies such as ensuring the availability of appropriate equipment and supplies, the use of alternative screening methodologies, and more culturally sensitive counseling approaches that may improve screening rates in obese women.

PMID: 20630361

*Have you delayed or avoided gynecologic care because of past size-negative encounters with healthcare providers?  Or because of lack of appropriately-sized equipment?  Or other reasons related to size or weight bias?