Calvin Trillin’s rule of thumb

The writer-humorist Calvin Trillin has said that his idea of alternative medicine is a doctor who was not trained at Johns Hopkins School of Medicine in Baltimore, Md. To the extent that Johns Hopkins is considered the gold standard of medical care, the institution's excellence owes much to its beginnings.

Johns Hopkins

Johns Hopkins

Johns Hopkins, the son of prosperous Maryland Quakers (his first name was his great-grandmother's maiden name), made a fortune investing in America's first important railroad, the Baltimore and Ohio.

In 1867, he established funds for a university and hospital to bear his name, and when he died in 1873, he left $7 million for the two institutions, the largest gift ever bequeathed in America up to that point.

John Shaw Billings, a major in the U.S. army who had distinguished himself as a surgeon in the Civil War, and for his writings on, and criticism of, the care of sick and injured soldiers, created a plan for the hospital that reflected his keen interest in infrastructure, and his assiduous research into the best hospital designs in Europe.

John Shaw Billings

John Shaw Billings

For example, he had the hospital wired for electricity years before it was on the grid. Johns Hopkins was also the first hospital in the country with central heating.

The measures Billings took to prevent the spread of disease throughout the hospital ranged from the horizonal layout of the wards, to the decision not to include elevators, to the elaborate ventilation system that prevented patients from breathing each other's air.

Billings also came up with the idea of a four-year medical school and favored a tough curriculum to weed out all but the best candidates. According the John Hopkins Medicine website, history has not given this remarkable man his due.

Getting the hospital up and running took 12 years. Even though many of the revolutionary ideas the institution embodied were his, Billings decided it was time to move on. He ended his career as director of the New York Public Library.

Johns Hopkins Hospital

An early view of the hospital

Opened in 1889, Johns Hopkins Hospital had 17 buildings (three of which remain today, part of a 22-acre campus) and cost $2 million.

Johns Hopkins Hospital had no religious affiliation, which made some people nervous. In 1896, William Wallace Spence, a wealthy Baltimore businessmen, donated a large statue of Jesus Christ that still stands in the rotunda of the Billings Administration Building.

All aboard!

Remember, dear reader, I said there would be tangents. Now we are embarking on a trip to Baltimore, Md., and childbirth will barely be mentioned for a while.

Locomotion

In his groundbreaking 1982 book, The Social Transformation of American Medicine, Paul Starr plumbs the source of mainstream medicine's authority. Simply put, it comes from the public's dependence on the doctor's superior competence, real or perceived.

As the title of Starr's book suggests, doctors were not always able to lay claim to that authority. Indeed, before the germ theory was proved and methods of administering anesthesia devised, making possible the development of effective surgery, physicians had very little to offer. (That didn't keep them from practicing, though.)

But in Baltimore, late in the 19th century, with new technologies and understandings developing rapidly on all sides, events were unfolding that would help solidify the medical profession's authority.

Image by permission  http://creativecommons.org

Fears about VBAC

Taffy Brodesser-Akner's first-person piece in the Los Angeles Times today about her impending birth is a candid, affecting counterpoint to a symposium the National Institutes of Health held last month in Washington, D.C.

With her first baby, born 2 1/2 years ago, Brodesser-Akner endured an emergency Caesarean section after 29 hours of labor, she writes. The experience left her traumatized. Now in the early weeks of her third trimester, waiting to deliver her second child, she is hoping for a vaginal birth after Caesarean, or VBAC.

The VBAC has been the subject of a lot of discussion lately. The NIH held a three-day conference on the topic that encouraged supporters of the VBAC -- and there are many -- by recommending that the VBAC be a more readily available option than it has been in the past.

In her essay, Brodesser-Akner writes, "I agree that women should have the right to try for a VBAC; I'm just not sure if they should try for one. Rather, I'm not sure if I should."

Of women who want a VBAC in a particular pregnancy, she writes, "the more honest and maybe the more uncomfortable way to say it, is that they want to give it a shot. They want a TOLAC, a trial of labor after a C-section."Pregnant Graffiti

Only 60 to 80 percent of women who attempt a VBAC actually get to have that vaginal delivery, Brodesser-Akner writes; the remaining women wind up getting another C-section. And perhaps 1 percent will have a uterine rupture (with a previous low transverse uterine incision, the most favorable for a VBAC; other types of incisions carry more risk), which can threaten the lives of both mother and child.

"When a uterus ruptures...things go wrong fast — and they go wrong big," she writes, adding that a high-risk obstetrician told her that one-quarter of those ruptures end in hysterectomies, brain damage and/or the baby's death.

"As that doctor said to me, 'The risk may be low, but it's 100% when it's happening to you,' she writes.

Brodesser-Akner is right. Every pregnancy is different, and I can assure you from experience that when you find yourself living out that small, shocking statistic, it is 100 percent real. And I am one of the lucky ones.

But why couldn't she be in that 60 to 80 percent of women who have the "normal" birth experience she says she desires? And if she births in a hospital with capable OB/GYNs who perform a good number of Caesareans -- and 24-hour anesthesiology coverage -- she should have the backup she requires in case of an emergency. That shouldn't be hard to find in Los Angeles.

Any birth can take a turn toward the worst-case scenario, and it's impossible to fully predict which ones actually will do so. It is probably all too easy for a woman who had a wretched experience during her last birth to imagine all the things that could go wrong.

But the numbers are with mothers in general; that is, the odds are in their favor. The fact that the pendulum might be swinging back toward a trial of labor in some challenging situations is, I think, a good thing. And I am by no means alone.

I would tell Brodesser-Akner what I tell my own daughters, not only about childbirth but about life in general: Don't let your fears rule your life. Don't be foolhardy, but don't think the cosmos is out to get you, either. I know it's a cliche, but it's true: The most dangerous thing many of us will ever do is ride around in  cars (or worse yet, on bikes), and nobody seems to spend much time worrying about that.

Whatever she decides, I hope Brodesser-Akner has a beautiful birth story to tell this time. It should be one of the best days of her life.

Image by Petteri Sulonen

To the Lighthouse

My favorite book about a mother is To the Lighthouse, by Virginia Woolf. I read it for the first time only recently. I couldn’t believe how powerful it was.

I have had friends who loved To the Lighthouse. They usually admired the character of Lily Briscoe, an artist and independent woman who seems to stand in for Woolf herself in some ways. In the book, Briscoe visits a British family, the Ramsays, at their vacation home on a Scottish island before World War I.

To the Lighthouse

Incredibly, to me now, anyway, my friends never talked about Mrs. Ramsay. I guess I can understand why they didn’t. Lily Briscoe was what we wanted to be at the time, serious women devoted to our art. Or at least that’s what we thought.

Mrs. Ramsay. Woolf doesn’t even give her a first name. Mrs. Ramsay is married to a celebrated intellectual who has come to Scotland with his favorite students. While he marches up and down the beach spouting great thoughts and obsessing about whether his work will live on after him, she is thinking about all the people in her home, her children and guests, and how she might make them happy.

Using the stuff of ordinary life, Mrs. Ramsay pulls off one magical evening in particular, even in spite of a number of glitches, that will stay with all of them for the rest of their lives, tying them with emotion and memories to that time and place.

I don’t want to trivialize a literary masterpiece, but that is what mothers do. Woolf is making that point, of course, that this woman who is almost part of the furniture to the people around her creates the moments that make their lives worth living.

I’m starting to think about Mother’s Day, and I hope you are, too, especially if your mother is still alive. Make that dinner reservation. Plan to give your mother something that will make her happy — flowers, a card, a phone call, a big kiss, or maybe a copy of To the Lighthouse.

Whatever your relationship with your mother, she is the only one you have.

Swine flu more deadly to pregnant women

Pregnant women were more likely to die in last year’s outbreak of the so-called swine flu than other people were, the Journal of the American Medical Association reports in the issue published today.

Pregnant women represent only about 1 percent of the population of the United States, yet they accounted for 5 percent of deaths from the H1N1 flu between April and August of 2009, according to an analysis of data from the Centers of Disease Control in Atlanta, Georgia, by Alicia M. Siston, Ph.D., of the CDC, and colleagues.

Taking antiviral drugs soon after they became ill greatly helped pregnant women who were hospitalized.

Of 788 pregnant women who were reported to the CDC to have become ill with H1N1 virus between April and August, 30 died. That was 5 percent of all swine flu deaths for the period. Of 509 women who were hospitalized, 115 were so sick they were admitted to intensive care units.

If they had waited four days after the onset of symptoms to go to a doctor, pregnant women were six times more likely to wind up in an ICU than if they sought treatment after only two days.

Pregnant women should be vaccinated against H1N1, and should be treated quickly with antiviral drugs if they do become sick, the authors recommended.

Two-thirds of the women who died in the final tally for the year were in their final trimester of pregnancy. “Changes in the immune, cardiac, and respiratory systems are likely reasons that pregnant women are at increased risk for severe illness with influenza,” the authors wrote.