¶ Previously on Dr. Outside the Box
previously on Dr Outside the Box .
Listen up everyone , particularly if you're a program director and you're listening . I'm going to tell you something right now . These students are special yo , how they work , how they hustle , they all have a mission . And when I say mission , it's not like I just want to become a doctor .
It's I want to become a doctor because I want to do this for family community . If you're looking for leaders , look of leaders . Look here , look at the SNMA .
Let's change direction a little bit and let's do a little bit of some clinical talk . Ew , all right , we don't talk about clinical stuff on Docs .
Outside the
¶ Clinical Talk: OB Doctor's Shocking Story
Box . We're about to talk about clinical stuff , so I'm going to share this . I saw this video that was put out by an OB doc about a week ago and another doc had reposted this and gave her example of what was going on , and I really needed you to explain this to me .
So I'm going to play this and then I want you to really go into depth about what is going on here .
Okay , I am going to share a story that I've thought about sharing a gazillion times since I've been on social media . I think today's today . So I was in medical school from 1996 to 2000 when I was in my third year OB rotation . Back then all the patients delivered in the OR . Vaginal delivery C-sections they all delivered in the OR .
Vaginal delivery C-sections they all delivered in the OR . And I remember going back for a delivery black patient this was her fifth , fourth or fifth delivery delivered seamlessly , not an issue . And I remember it was me , the faculty and a resident Don't remember what year the resident was , doesn't really matter .
But after the patient delivered , the faculty looked at the resident and said have you repaired a fourth degree laceration yet ? And the resident said no , so . So the faculty got a pair of scissors . Okay , the faculty got a pair of scissors and he put one blade in the vagina and one blade in the rectum and he cut .
He cut a fourth degree in a patient who had already bled . Now I was a medical student . I didn't know if that was what was done and that's how they trained residents . I don't think it even computed with me what was happening and how wrong it was , obviously , until I got more training and became a resident myself and realized what had actually happened .
There's a lot of things that happened back then that we were made a party to because of the practices and obstetric abuses that were commonplace and we couldn't say anything . We couldn't say anything and although I will never know what it's like to be a Black pregnant individual in this country , I can educate myself and understand and teach and learn some more
¶ Explaining Fourth-Degree Laceration Abuse
.
All right , we get the point . So I wanted you to explain this because I think there was another doctor . She did a really good job of explaining this . Well , she did a good job of saying what happened in her experience . But I even had to come to you because I didn't understand specifically what was going on and who you explained to me .
I was like wait , that's what happened . And I was like , hey yo , so please let the audience know , explain to them what happened in this situation .
So first I want to say that this is an indictment on your OB rotation as a medical student . You said what ? This is an indictment on your OB rotation as a medical student , that you did not understand this story .
Wow Listen , man your OB rotation . Those days have gone and passed . Those days have gone and passed . Those days have gone and passed . Did I get my ?
degree . Please explain Did you deliver a baby ?
That's the question . Explain please .
Okay .
I did deliver a baby . Okay , sure you did .
So this is a unfortunate and egregious obstetrical abuse that she is describing . So , for context , she says that she had a Black patient who was having her fourth or fifth baby and what is very important about that ? Right , because it's a fourth or fifth baby being delivered vaginally .
What's important to understand about that scenario is that oftentimes if you are delivering a fourth or fifth baby , it's a very seamless delivery , right . Oftentimes these patients will not even tear . I even told you I've had patients .
I had a patient once who had her fifth baby and I literally was just standing there telling her jokes so that she could laugh and she laughed the baby out . She didn't even have to put much effort into pushing and she did not tear . So I want people to kind of keep that in mind at how seamless and easy that delivery is .
So the fact that this patient had already delivered means that there was really nothing to do in terms of repair . It sounds like there were no lacerations .
repair it sounds like there were no lacerations and so so this is a perineal tear that could occur between the vagina , the bottom of the vagina and the anus .
If there is something to be repaired , right If there is a tear , but it doesn't sound like there was a tear right . Patient delivered , it was seamless it was fine , based on the story that she told . So that should have been pretty much after the placenta .
That should have been the end of the delivery , but it sounds like the faculty member , the doctor , the attending doctor who was supervising the resident , wanted the resident to have an experience of repairing a fourth degree tear , and so , very simply
¶ Personal Experience with Questionable Medical Decisions
, the tears or the lacerations that can occur when you are pushing a baby out can go pretty much from any point you know , anywhere in the vaginal area down all the way to and through the anus , okay , and involve the rectum right , involve the actual rectum itself , that's a big deal .
If it goes all the way through and into the rectum , that's a huge deal . And the problem with those tears that go all the way through is that they have a really bad complication rate or risk , at least they have major complication risks , especially for what we call fistulas , which is a hole that develops between the vagina and the rectum .
And so you know , communication , communication , right . So stool getting into the vagina and and all of this kind of stuff , so it can be a very bad social thing as well . Right , for these women , because if you have stool kind of leaking into your vagina , that has a lot of different social implications , implications .
Yeah , and it sounds like what this doctor did was he took a pair of scissors and essentially cut a fourth degree laceration or episiotomy .
In this case we call it episiotomy because he did the cutting after the patient delivered , so not to facilitate delivery , because this patient already delivered , just so that he could have the resident practice a fourth degree laceration or episiotomy repair , which is egregious , unethical , immoral , frankly , it's assault really is what it is .
It's assault and so for me , in uncertain terms , really should have been followed up with some sort of legal action , if not criminal legal action , legal action , but you know it sounds like this young lady .
Here's a picture of the repair , but these are not . That's not insurrection , but this is a second degree repair .
Yeah , so it sounds like you know . When she was a medical student , it didn't dawn on her what was going on , right ? Because you don't actually know exactly what's going on , because you're learning for the first time , and so when you're learning for the first time , you may not realize that what you're witnessing is something that is extremely abusive .
You may not even realize that , right , I don't know at what level the resident was and what I forgot the name of the other doctor , but she puts out good content .
But she said that this happened to her .
Or to a fellow resident she was a witness witness .
She was witnessing what was happening as a med student and the resident stepped in and said no , like you are not going , she said . The resident said this to the attending you are not going to create a fourth degree tear in this patient .
Absolutely , absolutely . I will tell you , as a resident , I likely would have done the same , because you can't . You can't stand there and watch somebody do something to someone and just not say anything .
Yeah , have you ever seen anything like this before ? Have you ever ? Okay , maybe not to this . Well , yeah , have you ever seen anything that crazy in residence ?
Not to that extent . Not to that extent I've had an attending jump the gun
¶ Ethics, Patient Advocacy, and Moral Courage
before . I've had an attending jump the gun and make the wrong call due to impatience . You know , there was a point at which I was signing , so I came in on the 19 . They were signing out to me about this patient and there was a question of whether or not she had an ectopic pregnancy .
But they were asking if it was a corneal ectopic pregnancy , basically a pregnancy that's kind of stuck in the corner , if you will , of the uterus , in one corner of the uterus , and those require resection . You have to actually cut those out .
But the story that they gave the patient kind of walked into clinic and she didn't have any pain , she didn't really have much in terms of bleeding , and then somebody did an ultrasound and they saw this cystic structure .
There wasn't a fetal pole , but there was a question because she had a positive HGG level X , y and Z and the story just wasn't quite making sense to me . The problem was that we were in sign out and this patient had already been sent down to same day surgery , right To pre-op , you know to to essentially be whisked off into surgery .
So the day team was now signing out and so me , as the night team , I was gonna be taking over and doing this surgery . And so , because the story didn't sound right to me , I was like hold on a second , let me look at the ultrasound myself . Go back in her records a little bit . The problem was the technology at that time .
I forget what system we would use at the hospital , but the technology at that time you try to sign in to their PAC system , you know , to see the images , images , and it was like it would take forever and ever and ever , and then it would log you out , then log you back in and then log you out .
So it kept doing that and anesthesia was like are we going yet ? Are we going yet ? And my attending goes oh well , don't , let me be the hold up , let's go . And I was like wait . And I literally said to her I was like wait , I mean I want to see the images . And she's like no , no , no , let's , let's take her back . So they start taking her back .
I try again , try again . The system is not working . And I'm like okay , whatever , so we go back to the operating room . As we're in the operating room , I'm like let me just do a quick vaginal exam on her , because for me I was like is she really having an ectopic or is she actually just miscarrying ?
And one ways that you might be able to tell is if her cervix is open . Right , if her cervix is open , then you know she might be miscarrying or she might be having , you know , an incomplete miscarriage or something , cause I don't remember exactly what the story was , but I remember thinking that and my attending said no , do not examine her , let's go .
They said it's a corneal leg topic , let's just go . I'm like I don't agree with this , fine . So she goes and she starts operating . She makes the cut , she keeps going down , she keeps going down to the point . I even say to her wow , you , you're really doing a good job at at um , at doing this surgery right .
Meaning you know I'm supposed to be operating but you're doing it . But okay . So she goes down , down , down . We go to the uterus Nothing there .
Like weapons of mass destruction . Yes , ain't nothing there .
Nothing , not a bulge , not a nothing . And then I say to her can I do a vaginal exam now ? And she's like uh , yeah , so I do the vaginal exam , cervix one centimeter open , and get my finger right through it , which she probably just needed . Dnc .
Right so anyway , we patch her up , we do the DNC um , take her out and at some point during the night I go back and I'm like let me see if I can get into the images . And finally I get onto a computer where it is working and I go back two years before . Guess what's on that ultrasound Little cystic structure right at the corner of her uterus .
It had been there the entire time .
So what would you guys , what'd you guys tell the patient ?
So I told the patient the truth . I told the patient the truth . You know I'm like the truth . You know I'm like you didn't . That's not the surgery that you needed . And I told her surgery that we did . You know , I wanted her to know like this is . You know cause patients will confuse things . This is not a C-section . You did not have a C-section .
You just had a cut where we went . We looked inside to see if we could find a pregnancy there . We did not find it . Instead , we I ended up doing a vaginal exam , found that you were miscarrying and we did a DNC . She must've been , she must've been bleeding .
She actually must've been bleeding , but um , so I I think I try , I try to figure out if does this happen in surgery ? I'm sure it happens in surgery .
I just can't think of it because this like I know we were talking about this last , you know a couple of days ago like man , what's would you see an attending like injured a common bile duct , so that their resident can fix it ? And I'm like I can't see that happening because it's such a vital structure , the complications are so high .
Why would you even F of that ? The thing that the closest thing that I can see , where it's kind of like the gray zone , who knows , but it's sometimes for the most part is a benefit to the , to the resident , is the appendix . You know you do like an incidental appendectomy . You know you have a gunshot wound to the belly .
You have injuries all over .
Sometimes they're like hey , man , take , take this appendix out so we don't have to ever come back into this belly . I've seen that happen and so forth . But I just , man , I really I can't see that happening .
I , yeah , I just I cause I , I I understand what you're saying , like the based off of the pictures , morbidity , right , like the issues that you could have of creating this type of tear that I'm assuming based off of this video . Just the ob dog did it because I'm for fourth degree tears , isn't ?
That should not be a combination of like surgery and ob , you don't have to I mean unless it's really that bad .
But no , you don't usually we will repair that and it's a . I mean , I'm sure you know it's a . It's a extremely delicate repair , a very time consuming repair , a very risky repair . And just you know , you deliver a baby and you pray you never get a fourth degree tear . You just don't want it , do you ?
do you think ever ? You know I always think about like , so , for example , like we're going to talk about sinners and , like you know , making a deal with the devil . Or you know you won't ever wonder how some people get to a point where they make a really bad decision . Or you know when people get into a bad situation .
When you go back and you look at that bad situation , it's usually there are multiple mistakes that are made before that really big bad decision right ? what I'm saying is like for a resident at that time to see that type of situation occur and for them not to say anything for a whole host of reasons .
Maybe they don't want to say anything because they don't have the courage to say something , or maybe just have they don't say anything because they just don't know . But do you think that's kind of part of like the process of like leading down a bad oh yeah , path , so that when you're in attending like you really don't , your moral compass is off ?
Oh , absolutely , you see what I'm saying .
Whereas , whereas even if you're a resident and you see that happening , like it takes a lot of balls and a lot of guts to be like yeah , that's not happening on my watch , right , but like , is it worth it to speak on something like that then , so that by the time you're attending , you've already flexed that muscle multiple times to be like I'm going to really
stand up for what's going on with the patient . What are your thoughts on that ? Because a lot of times I feel like people who really make bad decisions in attending a lot of times they were making bad decisions as residents .
Or they saw people making bad decisions and really didn't think about how bad a decision , those decisions were right and so they gave themselves a pass , or they gave that person a pass and justified in their minds that , well , it was for the greater good of name . Whatever good they have , you know , in their head , right ?
And so , in this case , the good quote , unquote being that .
Well , I get to teach my resident how to do this repair . Because if I don't teach the resident how to do this repair , then if they should ever encounter fourth degree repair , how will they ever know how to do it ?
and there are ways . The question , though , is would you , would you do that on a patient that is of a different hue ? Would you do that on a page ?
you know , like these are things that you know , that that's the question right would . Would would this physician have done it on a white patient ? You know , I've I've had , I've had attendings . Tell me that patients are VIP . Yeah , yeah , and I had one physician , one attending that said , oh , this is my VIP patient , she's a lawyer .
And I flat out said to him I was like your patient is not VIP to me . She might be VIP to you , I said , but she's not VIP to me . I'm like every single patient will get the care they're supposed to get on my service , that's so . Oh , but she's a lawyer .
I'm like I don't care what the hell she is , she's going to get the care that everybody else gets . On my watch , you know like sometimes you got to say things like that because otherwise you know you . You feel like here's my question what does it do to you ?
What , like what do you think that it does to you to watch these things happen and never say anything that don't eat you up inside like it doesn't ? You got to speak , you know , because you know a lot of these mugs be a lot .
A lot of times you talk about this stuff on your personal statement or you talk about certain things . It's like yo , this is your time to shine . You remember what you said in your personal statement . Whatever it may be , this is your time to shine . So you got to speak up on this . I got you 100% on this . I got you 100% . What's good everyone .
This is Dr Nii Yo . This is the end of
¶ Episode Conclusion and Next Steps
this segment . I appreciate you for listening , but this ain't the end . If you want more , go ahead and click the next button on your favorite podcast app Listen . That's next for more banter between me and Dr Renee . That's next for more topics . That's next for more segments .