Medical Knowledge, Uncertainty and The Standard of Care

Pre-term, premature rupture of membranes remote from term is a serious complication seen often in any active Obstetric Practice. A women is cruising along in her pregnancy and without warning experiences a gush of fluid from her vagina. She seeks medical care and examination shows a immature or premature fetus who could experience serious or grave complications if delivered so early. Examination of the uterus with ultrasound shows the paucity of amniotic fluid in most cases. The baby is squooshed into the smaller intrauterine space. Potential complications to the mother include infection because the membrane barrier to bacteria is broken, trauma to the uterus resulting from premature attempts to deliver a baby from a uterus not prepared to go into labor, and psychological trauma from the sudden and unexpected jolt that changes the happy uncomplicated pregnancy into a medical nightmare. Potential Complications to the baby include, immature lungs, decreased immunity, poorly developed digestive system, thin skin, a brain and nerve tissue that is precariously balanced over risks of hemorrhage, trauma, too little or too much oxygen.

Often especially close to the due date the mother goes into labor. In cases close to term it seems that mother nature has things worked out and it is best for the physician to follow nature's lead and allow her to deliver. But what if she does not go into labor? What if the baby is very premature, say less than 33 weeks, or immature, less than 28 weeks, or non-viable, less than 24 weeks? Do you induce labor hear? Do you try to stop labor? Do you give the mother antibiotics to prevent infection? Do you give her medication to accelerate the baby's lung maturation? Do you deliver by Cesearean or Vaginally? How can you tell if the baby is thriving in the uterus? Can the umbilical cord be crushed or kinked without its cushion of amniotic fluid? Where should the premature baby be delivered, in the community hospital or at a "center" many miles from home and family?

The reason I am writing about this is to illustrate the variability in expert management of this problem. About 20 years ago a leading medical journal in Obstetrics and Gynecology published a study on the management of PPROM (Pre-term Premature Rupture of Membranes Remote from Term.) The study consisted of a survey of Perinatologists (High Risk Pregnancy Specialists) in how they manage this problem. There was no consensus. This means that if a baby is born to a women with this problem and if that baby dies, or has neurologic problems as a result of being born prematurely it could always be possible to find a specialist who could state that he or she would manage the problem differently. Parents of these unfortunate children are under enormous social and economic stress. Attorneys advertise on TV that they can help parents make claims against medical caregivers and seek economic compensation for damages resulting from medical "mismanagement." A lay jury of so called peers can't help feeling sorry for the families of these unfortunate children. There is enormous downside risk defending these claims. A physician expert witness has little downside risk. All he has to do is testify in court. He can sell his testimony. He does not have to get up at all hours of the night to attend to women in labor with complicated cases. Many physician expert witnesses are former faculty members of medical schools that have been forced to downsize recently. They have impressive resumes that look great in the court room.

I worked very hard in medicine. I saved my money for my family's future. As I accumulated assets I began to feel more and more like I was a target of the plaintiff's bar. There was no way that I could get enough insurance to protect my assets. I saw each medical problem as a potential economic liability. Each patient, no matter how much she enjoyed my care for no matter how long was only one decision away from taking away everything that I had saved form over thirty years.

There was this beautiful young mother of three. She was a member of a large family which I considered to be my friends. I delivered her three children I made sure that I was available to take care of her when she went into labor and I was not on call. Six months after she gave birth to her third child I found out that she had suddenly died while I was out of the country with my wife on vacation. My nurse attended her funeral and found out that this patient's mother was blaming me for her death. It turned out that she had a rare tumor of the heart that the coroner thought could have caused an irregular heart beat. There was no way that I could have known about this. The lesson learned is no matter how good you are and how well you treat your patients they can turn against you in a heart beat. Today's physician has to be tuff enough to cary that burden.