Author: OnCallToday

A physician trying to make sense of US healthcare

My journey of breastfeeding (1)

Young parents usually underestimate the work needed for feeding their newborn.

First night

Our son was born around evening time, and on that specific night, I was so tired from the 12-hour long laboring and really wanted to sleep through the night, but when the nurse asked if I would like to have some room-in time with my son to try breastfeeding, I said yes. As you know, we’d better take advantage of newborn’s suction instincts, the earlier we try to let them latch on, the better. If you put them on your breasts for the first hour of their life, they actually start seeking out your nipple just by instinct. But trust me, when you are so tired, you forget all things learned from breastfeeding class took weeks ago (early room-in, early hand expression of colostrum, etc).

So, when I tried and failed my attempt for breastfeeding for that night (there was no lactation consultant  to help you at night) and overwhelmed by the desire to sleep, I tried to send him back to nursery (during the tour of the labor & delivery ward, they told us we can leave the newborn in the nursery overnight). It turned out I am too naive about this.

After I sent him back and started to fall asleep, my door was knocked and a nurse assistant wheeled him in. Instantly I knew what was wrong, the nursery staff didn’t want to deal with a crying baby! With the very last strength in me, I picked him up and held him on my breast and he calmed down a bit.

He slept on my breasts for a few hours and started to cry again. I noticed he has a poopy diaper so I tried to send him back to nursery again to change his diaper. This time I even walked him to the nursery myself with the hope that he won’t be sent back to my room again. I was totally wrong – in 15 minutes, the nanny wheeled him back to my room again saying he was hungry and he needed to eat. I was so tired thinking – “I tried, there was no milk yet…” and almost argued with her about this practice of bringing him to my room every one hour just because he was smacking his lips…

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Looking backward, there were a few things we could have done better to kick-start our breastfeeding journey.

  1. Put the baby to your breast right away after delivery – I felt very weak after the labor and initially didn’t even want to have a screaming baby on my chest but once he was there I felt a flush of love and joy for this little guy.
  2. It is not a crime to give some formula to a baby if you felt too tired to feed him the first night, but you need to discuss this with your nurse.
  3. You can hand express some milk and feed to him if the baby still hasn’t got the hang of latching yet. Check out “hand expression Stanford hospital” for the video.

Continue reading “My journey of breastfeeding (1)” →

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Delivery

Our son was born.

Similar to my memories of OB rotations while in medical school, my labour and delivery experience was full of painful screamings and jokes about “poop and baby coming out at the same time”, as my nurse said in a funny way “you know that this can’t be changed as physiology doesn’t allow that, right?”. Haha, yeah, I know, when you push down and your abdominal pressure increases, both orifices open up for passage. Sometimes a third orifice also opens – I heard someone was able to push Foley out as well.

Several lessons learned – first, would you rather have a practitioner with 25 years experience to do the procedure on you or a resident who just came out of medical school? I thought I bypassed that choice by choosing a private practice as my primary OB, but I was wrong as the very last minute a resident showed up at bedside and vacuumed my baby out – at the end of the day, this was a teaching hospital and residents need to learn from doing.

Secondly, epidurals are god-send. I got my “last-minute” epidural just fine but I might not be this lucky next time. I was offered epidural when the cervix was 3cm dilated but I declined it thinking pain is still durable. Later when the pain became not that tolerable, I asked for morphine – and then things went downhill. Because once I got the morphine, I felt an overwhelming flush of warmth and I had to lie down for some sleep which cost me the mobility. The only way to keep the pain under control during labour is to sit up or stand or walk around. It turned out lying down on a bed is the worst position for labor pain. So once the morphine wore off and I was still lying down with limited ability to move due to the drowsiness from morphine, I was really left with the only choice of epidurals as the pain became really unbearable after another pelvic exam. Considering I was induced with contractions coming at every 2 minutes for the last 6 hours and with oxytocin running at its highest possible dosage, I asked for an epidural. Once it was done, my cervix changed to fully dilated upon exam. Luckily, I was able to feel the contractions and push without feeling the pain. The funny thing was that initially, I was still able to feel severe pain from contractions on the right side due to the catheter inserted was likely on the left side in the spine canal; after I turned onto my right side for a few minutes, the magic juice of anaesthesia dripped down due to gravity to the right side and then my right side pain was gone. However, I pushed for 2 hours under epidural and baby still not out so they had to use vacuuming. I don’t feel too much regret for enduring the labor pain for many hours without epidural as it might slow down labour and I wanted to wait until I absolutely needed it but next time I might just have it once cervix turned out to be three centimetres as I might not have that much time for active labour for second babies.

What can go wrong in a hospital?

What can go wrong in a hospital? The answer is anything. From Emergency Room provider doesn’t give treatment to a patient with potassium value of 6.5 thinking it is from a hemolyzed blood sample then patient coded on the floor (see here), to misinterpreted radiology reports, missing lab reports not reviewed by primary care physician, to a million things that could happen.

If you are a physician/medical student, you will benefit from reading horror stories happened in a hospital as 99% of our daily practice usually has some safety margin built-in, but that 1% of not-so-textbook clinical presentations/rare situations may sink you and you need to develop some sensitivity to that rarity.

There is a tendency among healthcare environment of underestimating the risks because those horror stories do have a low incidence rate. Nurses called you multiple times for false alarms on that telemetry patient and asked you to turn it off/discontinue the telemetry order, at that time can you imagine that specific patient was found a few hours later deadly cold and pulseless? You may brush it off as in your mind this event is so rare that it is almost impossible (see here).

Some good advice – stick to clinical routines, develop a wide differential diagnosis, build redundancy and double-check mechanism in your practice and be careful about those high-risk life-threatening potential diagnosis.

Reading stories on WebM&M provided by AHRQ.

Attend M&M conferences in your hospital.

Read books about medical mistakes such as

“Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes“,

“Your Patient Safety Survival Guide: How to Protect Yourself and Others From Medical Errors“,

and “Bitter Medicine: What I’ve Learned and Teach about Malpractice Lawsuits (And How to Avoid Them)” (recommended for surgical specialities as the author is a surgeon and mostly talked about mistakes in the surgical world in the book).

 

Healthcare for immigrant parents

When your parents come to the United States, what should you think about regarding their healthcare?

If they come here for a short-term visit, like a six-month stay, a short-term healthcare insurance for visitors could be your choice, but those usually don’t cover for existing conditions. If your parents have chronic conditions like diabetes, hypertension, heart diseases, etc, they may need medications and maybe some visit to the clinic or emergency room.

US healthcare insurance is largely based on employment and due to parents’ immigrant status (B1/2 visitor visa), there are very limited choices for healthcare insurance. A few options are as belows, but I suspect better knowledge is with local healthcare brokers.

-some employment-based healthcare insurances allow you to add parents as dependents, such as VA or Tricare

-some supplemental healthcare insurance offers some cost deduction by providing low out-of-pocket costs

-some visitor healthcare insurances offer choices for acute onset of pre-existing conditions

So what if an emergency happens and parents are not insured or under-insured?

-emergency rooms, according to law, all the ERs in the US have to accept patients no matter what, so they will be seen in the ER but you are going to expect to receive some bills with large numbers. Well, you can negotiate with their billing department later but it is always not pleasant to receive a bill that may make you broke. But if there is really any life emergencies, don’t hesitate to bring your parents to ER.

-free clinics or fee-scaled community health centers, usually different states and cities have some free clinics run by government or charity groups but they usually open on 9-to-5 regular hours. If they need hospitalization, the social workers at a hospital will help you apply for emergent Medicaid (depends on states), which will cover the costs of in-patient stay.

-private cash-only clinics, you can find some private clinics in lower Manhattan/Chinatown or Flushing, NY that accept cash for visits.

-call your own primary care physician and see if he/she can fit your parents into a schedule and charge a reasonable fee based on cash or fee-scale.

-some cash-based telemedicine services

How about medications?

They can bring enough medications to the United States for the duration of stay.

Or

-some pharmacies provide low-cost common medications like CVS, Target, Walmart’s low-cost Rx program

-use GoodRx for wholesale prices for medications

-ship medications from home from mail but sometimes the Customs may be scrutinous about that since there are regulations to prevent smuggling cheaper medications to the US

If you have any experience exploring the US healthcare system with immigrant parents, share it in the comments section!