I Did It

I found myself standing in a house, sometime in the small hours. In front of me was a women who was just starting to go into the early stages of labour. Also in the sparse sitting room were four small children, a husband and a grandmother.”Do you mind if I have a fag?”, the woman asked, peering over her baby carrying belly.
“Been smoking a lot?”, I asked while eyeing an asthma inhaler.
“Yeah”, she replied, “they won't let me smoke in the hospital, will they?”
“No, they tend to frown on people smoking around newborns – not good for their health you know”.
I looked at the children again.
“Hi kids”, I said, “who here has asthma?”
Two of the children put their hands up.
“You know of course”, I said turning to the mother lighting up her cigarette, “that your smoking has probably given them asthma”.
“Yeah”, she replied, “Kids – go stand outside while your mum has her fag”.
The two children, one four years old, one perhaps seven, both dressed in their night clothes went out through the front door into the freezing air of the night.
I don't think the mother quite understood what I was trying to tell her.
Luckily the ambulance crew turned up before I could tell her that the best thing she could do was die quickly of lung cancer so her kids might get adopted into a family that may have the slightest concern for their health.
Yes – I am an anti-smoking nazi, especially when you are fucking up the lives of children who have no say in the matter.

76 thoughts on “I Did It”

  1. yes, I know it doesn't make it likely to happen, and I agree that it is wrong and selfish of her to act in a way that she knows is harmful to her children just for the sake of a cigarette.However I'd sooner the children were taken into care, than had to watch their mother die horribly.

    I'm not attacking you. Usually you come across as much less frustrated (right word?) in this blog and it seemed very unusual for you to say something as rash and extreme as the “lung cancer” bit. I guess it touched an extra nerve for me at the moment, is all.

  2. I agree with your points, especially about children bouncing around in the back seat of cars (I wish I had the power to stop cars for exactly that reason).This woman was smoking while she was pregnant – which is a contributing factor to asthma in the newborn. Sending her kids out into the cold so she could smoke gave me an idea of the sort of mother she is.

    It's not just this that leads me to despair either – but I think the combination of night shifts, SAD, and working on my own for too long has all conspired to turn me into a health nazi on this occasion.

  3. Actually she was just starting the first stage of labour. I think she had about four contractions before calling the ambulance, and I took less than eight minutes to get there.I'm not daft enough to think that she'd listen to anything I'd say when her cervix is 10cm dilated…

    But the odd twinge of a contraction (and I saw no contractions while I was there) means that she might listen to me a little.

  4. Re the GP's comments on smoking not causing asthma, surly its a trigger.I wasbrought up for the first five years of my life in a single-end. (Room and kitchen with a hole-in-the-wall bed) Both parents smoked – they came from the years when it was thought to be healthy to smoke and even medical people advertised fags, seen some crackers of adverts from the fifties – wonder what my saturation levels were with two parents smoking 40/day each (at least) plus any visitors in the room with a coal fire going, adding to the general fug. No wonder I'm bloody asthmatic and an anti-smoking Nazi.

    By the way, I've seen premature babies go into wee coughing fits when they've been picked up by parents whose clothes are stinking of nicotine. When you point it out to them they get really agressive, must be feeling guilty eh?

  5. Forgot to add – smoking when using nicotine patches – Turbo charging.If they get the doses right, you see white lines going down the arm where the patch is attached when the arteries go into spasm. If that dosn't illustrate how fags can affect the blood supply to limbs I dont know what will, and smokers will still keep losing toes etc.

  6. Agreed – you beat me to it. Cite us the evidence for or against your arguments, rather than anecdotal stuff.I'd be interested to see the peer reviewed papers that show one way or another the validity of your positions.

    (I mena, I have my own views, but it's just that – views, not evidence based practice).

    And no shouting “I ignore that paper because it is written by midwives/doctors*”

    *- delete as applicable.

    Ding! Ding! – Round Two!

  7. Hi guy from OzI agree.

    It did all get a bit overheated and silly.

    Time to calm down and be a bit more temperate.

    Beers on me, so to speak

  8. Hi TimOur comments must have crossed in the ether. I agree with the guy from OZ

    The odd heated harangue is always fun… but time to cool down and move on. As I said, beers on me, so to speak

    And on to the next topic.

    Let me ask YOU a question. The Blessed Patricia, for it is she, has announced to the media that the punter does not have to go to the local hospital, but can now choose from any four local ones. Trouble is, she hasn't yet let the family docs know what the referral mechanism is.

    Are you guys now going to have to have a have hour chat with the punters about which hospital is best for which, and which one would they like to go to?

    John

  9. Argh!My girlfriend was severely asthmatic as a child and her parents smoked at her all the time. As a primary school child she was accused of smoking herself because she stank so much of their smoke.

    Her dad is a doctor and her mum is a nurse. They still smoke at her when she visits despite her asthma obviously deteriorating in front of them. Her mum has emphysema and was given an inhaler by the doctor, so she thinks that 'it isn't that bad really'. Oh and she takes her inhaler immediately before her fags so she can inhale more fagsmoke..

    *shudder*

    Am totally with you on the antismoking front.

  10. I used to work in the midwifery section next to NICU in the hospital … the flat for parents was next to my office … somewhere for them to stay when their baby was in special care … 9 times out of 10 the mother smoked … they would smoke in the court yard …I had asthma until I was 16 …. both my parents smoked until my dad got throat cancer, that was enough to scare them and they gave up … oddly enough my asthma disappeared and has never come back …

    I am all for people not smoking around children or anyone that is a non-smoker for that matter …

  11. i agree, normally i'm a trendy wendy liberal……… but so long as your decisions/actions only affect YOU – if not, then you have given up your right to not be preached too. As aside, she will highly likely produce a small for dates baby too or IUGR in modern neonatal parlance…. (google it)

  12. When I was doing my bit in antenatal, if you told the mothers that smoking caused babies to be smaller their atttitude was – Good, it'll be easier to shove out!Ned-logic I suppose.

    Ned – Scottish for chav, otherwise Non Educated Delinquent

  13. The woman was actually smoking while waiting to give birth?And I'm sure that smoke was the first she'd had since getting pregnant. That poor little mite hasn't got a chance.

  14. (bbx don't most of our actions have consequences that affect others?) … added to the smoking, sending out your kids in the freezing cold in pj's has to be a social services issue?

  15. Both my parents smoked when I was a child and it irritated me so much that at one point I thought I would join them just to stop me hating them.I too am an anti-smoking nazi and take every opportunity to tell my kids about the the perils of smoking. I often point out to them people driving crap cars who smoke and I tell them that if that person did not smoke they could probably afford a better car – my kids get the logic.

    As for that mother, I think smoking round your kids is an abuse issue and I would like to see people like her prosecuted.

  16. Yes you are a bit of a health Nazi arn't you. There is a time and a place to fight battles, and that wasn't it. Really good psychology to make a woman feel guilty about giving her children asthma when she is about to leave them to go into hospital. And you are wrong; smoking sure as hell does not help asthama but it is unlikely that it causes it de novo in someone who is not already prone to it.And then you say, “Luckily the ambulance crew turned up before I could tell her that the best thing she could do was die quickly of lung cancer so her kids might get adopted into a family that may have the slightest concern for their health.”

    Is that supposed to be funny? I think not. You are beginning to come over as a bit of a sententious prick, if I may be so bold

  17. You've beaten me to one of my saved blog entries for a quiet/rainy day!I went to pick up the mrs from aqua-natal fat-lady swimming class thing a few weeks back, and it had been cancelled cos the pool was too cold so all the pregnant-types were sat upstairs in the leisure-centre restaurant bit having coffee. I found the mrs, and wandered over to where she was sat with her 'aqua-natal friend' who's 20 (i think) and pregnant with her 3rd baby. I smoke a bit, so when I got there the mrs immediately pulled me up for smelling of fags and did her paddinton bear patented hard stare while I looked a bit guilty. “Do you smoke then?” asked her swimming friend? “only a bit” I replied, which is true, cos I only smoke out of the house, and NEVER when the mrs and unborn are within breathing distance, obviously. “How about you?” she asked the mrs. “Oh not any more”, she said, “I've not had one since I found out I was pregnant” which is true. “Oh, I couldn't give up!” says swim friend, looking genuinely surprised that the mrs had given up just cos she was having a baby. “They're the only thing that keep me sane!” she joked.

    I didn't know where to start, so I didn't bother, but she's currently 28 weeks (ish) and keep having to go to hospital cos baby isn't growing properly.

    Urgh.

  18. You are entitled to your opinion and I will grant you two points. Point one, I wouldn't really have told here that her children would be better off if she were dead – it was just an idle daydream of mine.Point two – yes, the early stages of labour isn't the best time for some health promotion. But she wasn't distressed and sometimes you just have to say something.

    Now to the meat…

    I read a couple of your blogs posts a day or two ago, and thought that I'd stop by in a bit for a closer look. Having read one or two posts that mention Paramedics, I'd say you have a rather low opinion of us ambulance people, something that you, maybe unconsciously, show when you refer to me in your post as an 'ambulance driver'. Tut, tut, unless you do know that this is the quickest way to get our backs up. I'll put some comments in the relevant posts when I finish here.

    However, from what you write, I'm guessing that you are a GP, and I've been a shade dismissive of some of them myself over treatment of such common occurrences as MIs and asthma attacks.

    The thing is… My personal view of smoking has been coloured by seeing children die from asthma and cot death, where both parents smoke, and the relationship between smoking and childhood illness is a strong one. (for example the reference to research here) More research here and here

    Us ambulance people have a role in health education, just as everyone in the NHS has a role. Sure my timing could be better, but seeing a pregnant woman smoking, and then joking about it (the very common 'low birthweight is a good thing' that another commentor has noted) is enough to make me a shade angry.

    So, yes, bad timing perhaps, but I'm human too, and I get the occasional emotional response to something that is so stupid it makes my eyes bleed.

    Just remember that I'm around three times more likely to find myself at that house dealing with a cot death, than in a non-smoking house.

    At the end of the day, she didn't care what I said, she just sent her kids to stand out in the cold so she could smoke in the warm… How much should I respect a person like that?

  19. You're not an anti-smoking nazi. If so, I am the Fuhrer.My mother began to smoke at the age of 14. For years she smoked cigs without a filter and only halfway through did she start smoking cigs with filters.

    Once she tried nicotine patches but carried on smoking her regular amount each day 'just until the patches start working.' Needless to say she become very ill as she was now getting double the amount of nicotine. So she stopped the patches because 'they didn't agree with her.' But then her body had become used to the higher nicotine levels and she smoked even more.

    Today she is 77 (looks over 100) and for the last four years has been bedridden with an oxygen machine on 24/7 – even though she has been told to have it on for 18 hours a day max. She also has a nebuliser.

    She dosen't smoke anymore because she has an oxygen bottle beside her in case the machine breaks down. The only reason she stopped smoking was she was told if she smoked near the oxygen she would take out a jumbo on the way up and another on the way down.

    She can't even lift up an arm without being out of breath and lives in a constant state of panic, being so dependent on others.

    She admits to regretting ever smoking.

    Too late. Far too late.

  20. Amen. I WISH you had succeeded in making her feel guilty. She certainly IS guilty. What a crappy mom. Poor kids. I wish you had said the rest to her, but she most certainly would not have heard you. Immune to criticism, or information.Keep trying to teach, you never know when you might get through even the thickest skull. Even the Doc who ragged on you, but that is even more unlikely. He probably smokes, too.

  21. Hi:Re comments on smoking and asthma.

    I'm well into middle age. Both my parents smoked a pack a day or more of the good old-fashioned tarry cigarettes – Export Plain, Macdonald's. (These are, or were, Canadian brands.)

    There were four kids. We grew up and became anti-smoking N-zis.

    But — none of us ever had asthma.

    When I was growing up, this was a very common situation: parents that smoked heavily and kids with no respiratory symptoms. As a matter of fact, asthma was rare. None of my friends or schoolmates had it, as far as I know.

    I've read many things about why so many children have asthma nowadays. But, do we really think it's because their parents smoke? I do agree that if a child has asthma, their parents should not smoke, since smoking can bring on an attack that might be fatal and is at least debilitating and causes the child to take more medication that they would otherwise. This is a no-brainer.

    But to say smoking *causes* asthma in kids doesn't jibe with my experience. If that were true, my siblings and childhood friends would have never stopped wheezing.

    Your comments as a medical person would be interesting.

  22. Steady on.I'm a non-smoker, I hate people smoking around kids, I hate people smoking when pregnant. The sending the kids outside – I know a mum who drags the kids outside in order to not smoke in the flat and not leave them unsupervised and it makes me mad. Quitting's not *that* hard.

    Well done for telling her, well done for saying it in front of the husband and grandmother, and I hope for her kids sake she gets educated fast.

    However we're currently watching a family friend die a slow and painful death from smoking-related lung cancer. She has literally got a few days to go, and when she does go it will be a merciful release for all concerned.

    I would not wish the degree of prolonged physical and emotional pain that I have seen her, and her husband, and her son going through over the last year on *anyone*.

  23. Perhaps you had better go back to driving ambulances where someone with a bit more sensitivity can keep you under control…

  24. Vic, I believe you are seeing into my mother's future 🙁 She's 63, and if it wasn't for the fact that she hasn't really gone grey, you'd think she was 83. She smokes about 20-30 a day, and has done since she was 15. She gets out of breath so easily, always has a really horrible cough, and has varicose veins which are painful and cause her difficulty with walking. She won't see her GP about them because she knows full well he'll tell her to quit smoking.I'm an anti-smoking nazi, have prodded her countless times about giving up – and I'm sure you can guess the imaginative reasons for not quitting, even when she said she wanted to.

    She 'tried' one year, used the patches and smoked on top of them, wondered why she felt sick. (I read your post to my husband, and he said, “crikey, that sounds familiar”). I think she managed to give up for about two hours (which I think says more for the psychology of smoking than anything). She can do what she wants now. I can only tell her to give up, make her smoke outside when she visits. It's sad, but I rarely go to her house because I just can't stand the stench of cigarettes.

    I think the worst of it is, she watched her father die of smoking related diseases (emphysema and pneumonia), and even that didn't kick some sense into her…

  25. To be honest, it's one of the reasons why I'm heading back to an ambulance, I'm starting to get back into my 'nursing' frame of mind.

  26. The simple answer is that there are exceptions to every rule. Smoking more than 15 ciggies a day during pregnancy triples the chances of the child developing asthma, it doesn't make it a certainty.In a more extreme case it's similar to how some people shoot themselves in the head, but still survive – just 'lucky'.

  27. dominocat, it seems all smokers have the same excuses for their habit. As your father died of smoking related illneeses, so did my mother's father at 77. He went into a corner shop and while in there was taken ill. The shopkepper put him on a stool to relax. He fell forward. The pathologist said he was probably dead before he hit the floor. It was the second time someone had expired in this shop and the owner was so traumatised he closed his shop and retired.We both know the excuses. 'It's not a smokers cough, I've got a cold.', 'I need the cigs for my nerves.', 'I'm stressed and need some support.' The 'I can't' excuses.

    Going into a smokers home and seeing those wisps of smoke hovering in the lounge and all the windows closed. The stained wallpaper. Brown ceilings. It all adds to the feeling of hopelessness we feel. Sir Walter Raleigh has a lot to answer for.

  28. I knew that someone would mention a relative or friend dying of smoking related cancer.My nan died because of smoking, and when she finally died after a long illness my mother became so depressed my brother and I were seriously expecting to come home to find that my mum had killed herself. It made our teenage years 'interesting' to say the least.

    My next post will explain why I hate smoking so much, but consider this, the mother may well be slowly killing her children. If she were slipping a slow poison into their food you would expect the children to be placed into care. Smoking while pregnant and in front of children is a similar thing, except that the smoker gets a physical high while doing so. At no point could she turn around and say “I didn't know it was hurting them”, this in my eyes makes her selfish in the extreme.

    Please remember, my wishing something doesn't make it in the slightest bit likely to happen. Otherwise Blair and Bush would both be in their graves…

  29. That is a really complicated question.1. The risks of passive smoking are real, are genuine and cannot be ignored. It is appalling that smoking is still allowed in public places, restaurants etc in this county. As so often we need to take a lead from the USA particularly California.

    2. Having said that the media exaggerates the dangers because it is good paternalistic “granny knows best” copy. Compared with the dangers of sitting on the back seat of a car without a seat belt (and you see that all the time with small children) it is trivial.

    3. Both my parents were 40 a day smokers. And they both died of lung cancer. But neither me nor my sister are asthmatic. Long term damage? Will I get lung cancer? I will tell you in 40 years (I hope)

    4. Does passive smoking CAUSE asthma. There's a difficult one. The health police would like to tell you it does but it is not proven. What is proven, and is beyong argument is that it aggravates asthma and predsiposes particularly small children to both upper and lower respiratory infections.

    And like Tom, although I thing he went OTT in the blog, I must say it reduces one to despair to see a kiddyrespiratory problems living in a heavy smoking household. I still think, on balance, that the child has to have a pre-existing proclivity for the problem. I see lots of smoking families in which the children DO NOT get respiratory problems, but please don't tell anyone that. The health police will be angy

  30. Yes, nicotine patches.I get really pissed off with these. The Tony Blair spin doctors have decided that these should be available on prescription, and people regard it as their “right” to have them. So take the punter who smokes 40 a day. Sure, lets help him stop. But he is spending in excess of 70 as week on cigarettes. Why in Gods name should the NHS provide him with free nicotine replacements at a cost to the tax payer of say 20 a week. You are not allowed to smoke when you use patches (though many do) and so you are saving 50 a week.

    It drives me bonkers.

    Is this why we cannot afford Herceptin to treat breast cancer properly?

  31. The effects of passive smoking are not as clear cut as the media would have you beleive. Of course one should not smoke around small children (actually, one should not smoke around anyone). The biggest risk may be the long term risk of increased incidence of lung cancer, and that is diffiuclt to prove.

  32. Hi Joan.I don't smoke, actually. I gave up 25 years ago so I am the worst beast of all, the sanctimious ex-smoker. And if Tom's pregnant smoker were my patient, I would be doing my best to get her into our nurse specialist led stop smoking clinic, and I would do my best to help her. BUT the fact that she smokes does NOT ipso facto mean she is otherwise a bad patient, and she does deserve to have “the curse of Tom” inflicted upon her.

    As I say, there is a time and a place for everything. I don't know if you have had a baby, probably not I guess, but I tell you, when you are entering the second stage of labour, you will not be partiuclarly disposed to having a lecture on health education!

  33. Hi bookwormomDisagreeing with someone is not impolite. And one tries to reply in the character of the original blog.

    Tom said: “Luckily the ambulance crew turned up before I could tell her that the best thing she could do was die quickly of lung cancer so her kids might get adopted into a family that may have the slightest concern for their health.

    Yes – I am an anti-smoking nazi, especially when you are fucking up the lives of children who have no say in the matter.”

    You must be a Tom groupie if you don't find that impolite. But I would lighten up a bit. The general language may be a bit OTT but there is a really important point to debate here (which I might say, Tom is doing)

    And I would say to you, as I have said to others; I don't know if you are male or female. Eitherway, you obviously know bugger all about having a baby. Starting the second stage of labour is very painful, it is a time when women are understandably feeling vulnerable and fragile, and it is ABOSLUTELY not the time to start criticising them or giving them inappropriate and gratuitous health education.

    You have a lot to learn about life.

  34. “It's not just this that leads me to despair either – but I think the combination of night shifts, SAD, and working on my own for too long has all conspired to turn me into a health nazi on this occasion.”Oh boy, I'm with you there. Sometimes working in the NHS is very lonely even though one is surrouned by people. Yes, I have severe SAD syndrome…so this is the best time of year. The days are now getting longer, thank god

  35. I THINK and I'm not sure that he's the guy who swears there's no such thing as ADHD, too.And inhaling water doesn't cause drowning, right?

  36. To be fair, on this I think that he is right, in that ADHD is overdiagnosed in children from 'deprived' households. the reasoning behind my thinking – Well I was a teacher, and my brother currently is a teacher (a bloody good one as well), and the local education authorities have made it well known that every child diagnosed with ADHD is more funds for the school, and more child support for the parent.Awful I agree, and yes, some kids are ADHD, but at the moment a stupidly high number of children are being medicated into the ground for the sake of bigger budgets for schools, and bigger handouts for parents.

    Not that ADHD doesn't exist, but the distribution of this disease is hideously skewed towards the lower incomes, which tends to raise a few eyebrows about the diagnostic proceedure for spotting it…

    As far as I can remember NHSBLOGDOC has a similar view to this.

  37. No, KarinKarinKarin, that is not me, you must have got me confused with someone else.ADHD most certainly does exist; it is a serious problem; it presents huge difficulties to families; it needs skilled managagement and frequently (but not always needs treatment with amphetamine derivatives such as Ritalin.) But is a RARE condition. At present it is being “diagnosed” by the world and his wife, and as a result our children are being often inapropriately filled up with psychoactive medication which can be damaging.

    If you had read the article http://nhsblogdoc.blogspot.com/2005/12/suffer-little-children.html

    you would understand what I was saying.

    Please disagree with me. Please slag me off if that is what you want to do…. but PLEASE do not misrepresent my view.

    ADHD exists. There are plently of conditions that DON'T exist such as “repetetive stain injury” (RSI) of “myalgic encephelomyelitis” (ME) but ADHD…oh yes, it exits

  38. Thanks Tom for an entirely rational response to KarinKarinKarin. Gosh, you have a wonderful fan club of supporters! I feel as battered as I would be if my four teenage children heard me I criticise “Coldplay”.I am really concerned about drugs/the drug industry, and the conspiracy to get doctors and others to insert drugs into patients. This may be a bit “off piste” for a paramedics blog (I don't know, I bet you have pretty strong views on it!). There is nowhere that is is worse than in the ADHD industry (have a look at Strattera.com) but it is all over the place. I was appalled to read in the BMJ that the drug companies have been targeting hairdressers (yes, hairdressers) to flog VAGIFEM (a hormonal lubricant that makes intercourse easier for menopausal women who have dryness)….. and so it goes on. They are everywhere. It is scary. Look at (acutally, I think you already have) http://nhsblogdoc.blogspot.com/2005/12/mrs-crippens-vagina.html

    They are everywhere. It is scary scary scary

  39. I'm not trying to get into your argument discussion on either side, but I couldn't resist…“Compared with the dangers of sitting on the back seat of a car without a seat belt (and you see that all the time with small children) it is trivial”

    You're basically saying “A is a problem. B is a problem, and B is a worse problem than A, therefore A isn't actually a problem”. Which is clearly a logical contradiction (and is one of my pet hates!)

    It doesn't add any weight to your argument. Yes, children being in cars without seatbelts is dangerous, but that doesn't make children inhaling secondhand smoke any less dangerous.

  40. “As so often we need to take a lead from the USA particularly California.”Oh God, please don't. One of my most favorite catch phrases is “like all bad ideas, this one started in California.”

    The only thing worse than people blowing smoke in my face is the government telling private business owners that they can't choose to have a smoking or non-smoking facility.

    However, since our percentage of smokers is fairly low, there are a whole bunch of places missing out on the non-smoking boat. My girlfriend and I repatronize one restaurant in particular because it's non-smoking (by owner choice), and I'm sure that any restaurant owner who banned smoking would see many more customers.

  41. It strikes me that FRU personnel should do 'shifts' – so many weeks in an FRU, so many weeks in an ambulance. That might help to solve some problems. Even so, I still think it totally unsafe to expect you to work on your own.

  42. Hi,Couple of things to say. First, at no point did Tom intimate, write or otherwise, that this woman was in the second stage of labour. If she was, he would hardly have been having conversations with her about anything apart from the impending birth of her baby!

    Secondly, there IS a lot of research out there that documents quite clearly the impact of smoking when pregnant on the fetus and the imapct of smoking around newborns and it all basically shows that smoking equals increased morbidity and mortality.

    As a midwife, it annoys me when people who are not the experts in pregnancy talk about things as if they know all about it when in actual fact it is easy to become out of date with research in obstetrics and neonatology. I also generally don't expect GPs to know all the up to date research in this area because one can't know everything about everything and I would expect a GP to refer to a midwife for pregnancy related queries. Otherwise you get things like GPs doing internal examinations to confirm pregnancy, telling women they can't have a homebirth as they have size 4 feet, and weighing people routinely for no clinical reason.

  43. Common reaction. So why are their babies smaller?There is less oxygen going through the placenta, which is less healthy as a result of the smoking, which means the baby can't get the oxygen it needs in order to grow properly. So it is compromised, which can lead to it becoming distressed. Add to that the fact that the head circumference is no smaller, they just have skinny bodies, so all in all the baby will be no easier to push out, there's no real benefit to smoking in pregnancy.

  44. Oohhh… you snuck in that 'RSI and ME don't exist'… I'm kind of hoping that it is the names that you disagree with, and not the actual disease.I'd love to see your views on those diseases on your own blog citing research and the like.

  45. Well Clarabelle, Hi.You seem to be rather typical of one of Tom's groupies – any criticism of Tom results in a rabid irrational rant. Well, good for you.

    Tom acutally seems perfectly capable of rational discussion and I think he accepts that his orgininal blog was a bit OTT.

    He does not really want parents who smoke to die prematurely so that the children can be adopted.

    You clearly don't see that. But then you are a rather bossy sounding midwife.

    My main problem with “nurse-specialists” (and you may not even be a nurse of couse these days) is that becuase of their lack of breadth of training they don't know what they don't know and tend to assume that they know everything.

    I don't care what stage of labour the dear lady was in, Tom's remarks were inappropriate and offensive. If you don't understand that, you are either a fool, or have no understanding of female emotions during labour.

    Of course, seeing the patronising way that so many arrogant midwives treat pregant women, I would not expect that most of them would realise how inappropriate his behviour was.

    I am so glad you think you are an expert. Keep up the good work. I don't know where we would all be without you.

    I advise all women not to have a home birth (however big their feet), becuase this country is not geared to home births and they are not safe. You wont understand that because of your obession with “touchey-feely” nonesense.

    One of the main reasons they are not safe is because midwives do not have the expertese to resuscite flat babies, and even if they did, they do not have the equipment.

    To make matters worse, non medically trained workers such as you encourage women to embark on this dangerous practice.

    Well, it's looney tunes.

    We can all jump into the birthing pool with the madwive, the vicar, the social worker and the husband and sing ten green bottles together prior to eating the placenta…..but this is the way that babies die.

    They don't have midwives in the USA by and large becuase no one will take the medico-legal responsbility for their actions.

    I think British midwives do pretty well considering their superficial knowledge and lack of medical training, and given that there is a lack of doctors we have make do – but in reality it is just another example of the health service dumbing down.

  46. Hi Tom, I'm afraid I'm getting a bit of a touch of the giggles about this. I think your blog is brilliant and I have been reading it a while now. Your remark over that poor women was OTT (I think you agree with that) but heavens I don't think the world is going to stop turning.I just think it is wonderful the way you clearly have thousands of fans for whom you can do no wrong. I have obviously become their big bad bogey man (which I am not really – I'm acutually a wishy-washy confused liberal, [with a small L}) which is all rather fun really.

    So, a bit more ground bait; I just slipped in the bit about ME and RSI to see if it would generate another 40 comments from “outraged of Stoke Poges”.

    I will do ME and RSI seriously at some stage.

    But first, just let me say that I hate mother-hood and apple pie, that Mother Teresa was a fraudster, the Queen Mother a crook and Vera Lynn a slag.

    So there.

    Now I am off to my bunker with my tin hat.

    Happy New Year!

  47. This post has been an interesting read on many fronts. I was going to start this reply with a simple 'thanks Tom' for sticking up for those that can't yet. Smoking is a pet peev of mine and so I must be lucky to live in a city where indoor smoking is banned almost unalaterally.The posting re California reminded me, of the old adidge that 'polution doesn't stop at the boarder, so why should I', when one EU country got told to 'clean up' when it's neighbour didn't.

    I feel for the Asthma kids, being told to go stand out in the cold whilst Mum has her cig in the warmth. Does what? they get the extreme temperature changes, and possibly colds because of it? They only have to walk back in to the house where the smoke still is after she's finished. Lightbulbs aren't expensive, maybe hers need changing. (ie get an idea lady).

  48. Erm, you need to get up to date with the research honey, home birth IS safe in the UK – read what Enkin et all say in A Guide to Effective Care in Pregnancy & Childbirth, and also Royal College Of Midwives (2002) who state that homebirth should be integrated into mainstream maternity services as a normal option.Planned home birth is AS SAFE as hospital – research proves it, also planned home birth (even if mother transfers to hospital) results in lower rates of intervention and better outcomes for mother and baby.

    And there are big advantages to being at home – not least less MRSA !

    And I'm not a health professional, just someone whose GP refused to care for her during her pregnancy (although he took the money to do so) because I wanted a home birth, so I did my own research.

  49. Hi Val, Look, I think it is important to be serious about this, rather than just responding angrily to a rabid madwife as before.The first thing to say is that I wish home births were safe, and could be recommened in the UK. I really hate the way that so many “normal” parts of life have sort of been institutionalised and removed from the home environment to hospitals. The classic current example is the hospice movement (which is wonderful, and above criticism) which is being portrayed by the media in a way that people are starting to beleive that they are not allowed to die at home.

    Home births are a practical proposition in some countries. Holland has always lead the way here.

    They are vastly superior for mother/baby, for bonding, for avoiding post-natal depression, for allowing other children in the family to participate. They are vastly superior psychologically to the overcrowded understaffed maternity units that exist in this country at the moment.

    I am aware of the data you quote but, with respect, your data does not give the whole picture.

    And again, with respect, as a lay person, it is difficult to get an overview of ALL the data.

    The problems of home deliveries are two fold; avoiding maternal death and avoiding foetal death.

    Some (but not all) of the midwives who do home deliveries are pretty good. Unfortunately, a lot are not, and a lot of them work outside the NHS as “independent” midwives.

    There is excellent data which show that you cannot predict with accuracy which pregnany will result in problems. You can exclude prospectively the obviously high risk ones, but there are no guarantees. And an experienced midwife can often spot in the early stages of labour that something is going wrong in time to get the customer to hospital. But sometimes no one, however experienced, spots the problems until they arise.

    And in the UK we do not have obstetric flying squads. If you are going to have a general system of home deliveries you must have a flying squad which has a doctor on the team who is capable of resuscitating both mother and child. And to do this he needs equipment, and quite a lot of equipment. He needs a range of drugs, he needs blood for tranfusion, he needs plasma expanders and so on and so forth.

    This does not exist in the UK. It should. If it did, we could have home deliveries safely, but it does not exist.

    Maternal death.

    This is, to be fair, extremely rare. The commonest acute cause of it is massive post partum haemorrhage. You have probably never seen one. I have. Thank god in a hospital. A 27 year old woman, second pregancy, not high risk, no problems, normal birth of baby then in the third stage, without warning, she bled. And I am talking LITRES of blood pouring out of her vagina. Fortunately, within a short time she had 3 peripheral lines, a CVP line, an anaethist, an obstetrician etc etc and her life was saved. Had she been having a home delivery in the UK she would have been dead.

    That is I admit a rare occurrence. But it happens. Is the pleasure of a home delivery worth the risk? You may say so. But ask your husband or your other children.

    Foetal death/brain damage

    This is much commoner. Unexpectedly, the baby comes out flat. Apgar 0. It does not breath. The midwife cannot intubate; she tries, but she does not have the experience to do it, becuase she only tries to do it once in a blue moon. The baby needs fluid, urgently. Midwifes cannot put up drips on babies and even if they could, they do not have the kit. And so it goes on. A neonatal paediatrian however in a hospital (and I have been that person) is doing it every day, has the experinece and has the kit. It took me three months under supervision from a very experienced senior registrar before I was happy and confident about intubating neonates. MIdwives do not have that expertese and what is more they do not have the training in anatomy, physiology etc that they would need to understand the training. (I can feel midwife hackles rising already – but it takes 2 years to train a midwife; it takes 6 years to train a doctor – what do you think they are learning about during that six years?) I have not intubated a baby now for ten years; I could probably still do it, but I sure as hell would not like to trial that hypothesis. I know my limitations. I know where my experience starts and ends. Midwives rarely do. They mean well, but they don't know what they don't know. If they did, they would not do home births in the UK

    So, in the UK you do not have the expertese at home, and there is no flying squad to get it to you in time.

    Yes, the small number of highly selected home births that take place have not had excessive morbidity…. but let homebriths become widespread and common and there will be disasters.

    Ask Tom. He is an experienced paramedic. Ask him how he would feel if was presented with an unconscious mother haemorrhagingm and a baby not breathing. And bare in mind that unexpected problems in so called low risk pregnancies with difficult deliveries tend to cause maternal and foetal difficulties at the same time. Diffcult birth predisposes to haemorrhage and foetal problems.

    Hospitals are horrible places to have babies compared with home, and yes these days you start to think about the increased risk of infection in the hospital. Nonetheless, you are safer there.

    The main problem about this issue is that there are a number of “right-on” rabid midwives who are so obessessed with the touchy-feely idealised home delivery that they forget about the risks, and they overestimate their abilities to deal with unexpected problems. We are talking about the LIVES of mother and babies, and you don't gamble with things like that.

    If you want home deliveries in the UK, then what you need to do is press for aunified system geared to home deliveries with properly equiped obstetric flying squads available in all areas.

    A tree-hugging, yaks-milk drinking, ten-green bottle singing, Guardian-reading, right-on midwife with an obsession about home deliveries and a knee-jerk hatred of the medical profession is no subsitute for 6 units of “O” negative blood and plasma expanders when a mother is unexpectedly bleeding to death.

    Until we have such a system (and I wish we DID have one) then sensible people will compromise – and I would heatily recommend some variant on the domiciliary midwife system where, when you go into labour, your own midwife who you have known throughout your pregnancy comes to your house, takes you into hospital to a midwife run unit, delivers the baby and takes you home a few hours later.

    It may not be totally “right on” for the looney-tune brigade, but it is a reasonable compromise and IT IS SAFE

    Phew! Sorry that was so long, but this is really important

  50. I am not at all offended. Remarks like that do not reflect on me at all. Have you anything constructive you would like to say?

  51. OK, first, I actually can't be bothered to pick apart that tirade against me, because there is so much glaring factual inaccuracy it would take me all night. I don't think I was 'ranting' in my first post, I was just pointing out that some of the things NHS… said were inaccurate, and I never said that Tom was right about the things he said re dying of lung cancer etc.What I will say, is this (bearing in mind there will be members of the public reading this, who may be terrified by some of the things that have been said in the above post): for term healthy pregnancy, research shows that home birth is as safe as hospital birth for mothers and babies.

    With regards to midwives' training, we are actually not nurse specialists. We are a separate profession in our own right and have been since 1902, in fact. We train for three years. We are trained in adult and neonatal resus, and carry oxygen and resus equipment to homebirths. We are trained to recognise the signs and potential precursors to obstetric emergency and act accordingly (for example, if at any point there was something not quite right with a labour at home I would recommend to the mother that we transfer to hospital).

    I would wonder what the good doctor thought was 'experienced' enough to carry out home birth? Some midwifery practices have homebirth rates of over 30%…. and that is in the NHS. On a personal level, I would question whether a woman and her baby are indeed safer in hospital (I have known several occasions where a midwife has had to resuscitate a baby in theatre when the Paediatric SHO has been unable to deal with it, in one instance the midwife was trying to calm the SHO down at the same time as she was having a noisy panic attack and scaring the parents!).

    And on a final note, more because I can think of it than anything else: how dare you question my practice? You have made sweeping generalisations about midwives, you have been derogatory about my own ways of practising; how do you know what I am like with my clients? I would like to stress that homebirth is a choice that I would promote, as with any other choice. However, that is all it is- a choice- and I give the women and their families the information so they can make their own choices about things, and that includes reasons why I would maybe advise them against home birth in some cases. Not everyone makes the choices I'd like them to- but they are not my choices, I do not have to live with them and I would not be doing my job if I were to force, coerce or bully women into doing something because I thought it was in their best interests.

    Oh, and it's expertise, not expertese. Six years of medical school…

  52. I'm sorry about the spelling mistakes Clarabelle; that's a really important point and indicative of the level at which you operate. And I am not in any way criticising YOUR practice because I have no idea how YOU operate.You have however got a lot of the characteristics of the obsessional blinkered ancilliary health worker that I utterly detest.

    You are much more concerned with your obessions about what “you” see as the best way of doing things. And you have the chacteristic knee jerk “I hate doctors” approach to medical care.

    What you don't understand, becuase your eyes are closed, is that it is possible for doctors and midwives to work together to improve health care.

    You want to have some sort of amatuer night in the birthing pool; you clearly don't understand the issues surrounding safety.

    The post I did was not in any case addressed to you, though you are welcome to read it.

    It is of course entirely typical of your sort of approach that you entirely ignored the reasonable suggestion of the midwife managed pregancy with the delivery taking place in hospital.

    Your lack of understanding of the real interaction of smoking and asthma does not stop you from presenting your rabid views as thought they were gospel.

    What you need to learn is that so much of medicine is about compromise, about finding a reasonable course of action in difficult and conflicting circumstances, of exercising judgement, of working with colleagues both senior and junior, and of working with colleagues in different disciplines.

    You are not interested in health care for women and babies; you are interested in the political issue of “home births” and you will adapt the data to buttress your position. You do not have the skills to resuscitate babies and mothers, and you do not carry the equipement so to do. It may not be politically correct to say this in your little world, but the fact is, you need a doctor, and a pretty skilled one at that, to do it. You also need a lot of equipment.

    I think that airhostesses are lovely people, they have lots of time to spend with the passengers, and they are jolly good at showing people how to put the life jackets on. But I don't want them flying the plane, and I don't want you delivering babies without a doctor with all the appropriate equipmant being available. You don't understand that, and that is the problem.

    And pointing out my spelling mistakes does not help your case.

    It is dumbing down the health service.

    Just who is flying the plane?

    http://nhsblogdoc.blogspot.com/2005/12/who-is-flying-up-your-backside.html

  53. I am slightly at a loss to how you see midwives as 'ancillary workers' etc? At no point have I ever said that I don't value doctors' input into OBSTETRIC care; I do, and I refer my clients to them regularly. I don't as you say 'push homebirth' as a political issue but it is a woman's right to have her baby at home if she so chooses and it is in my code of conduct that I have to advise her appropriately and then support her choice whatever that is, regardless of my own views. I have no problems with births taking place in hospitals; the thing I have the problem with is crass generalisation (your posts have painted those wanting homebirth as irresponsible and naive, which is actually the total opposite of many homebirthers, and you continue to generalise about midwives. I think you will find I have never at any point said 'I hate doctors' or 'all doctors…').And I am guessing that you have had some bad experience with a flat baby at some point. Yes, you do need a doctor, an experienced doctor (which sadly you do not always get; I've seen many anaesthetists have to take over intubation of the neonate because the paed couldn't do it, or was too frightened of the situation); however, we do carry resus equipment for neonates, we carry oxygen and bag and mask and are able to do ABC including chest compressions and ventilation with oxygen. We also carry IV fluids and oxytocics to homebirths, and we can cannulate and suture and can perform bimanual uterine compression in case of severe haemorrhage and we are also trained in adult resuscitation. This isn't something I have made up; this is what midwives have to do otherwise we are in breach of the NMC standards for midwives and we can be struck off, if we are not appropriately updated in these skills, so I don't quite understand where you are getting your information from that we can't do these things.

    I am interested in health care for women and babies, but I am bound to give women a choice in their care, and all I can do is advise, and that advice must be based on the best available evidence and my own Trust's policies and guidelines. Do you honestly think that Trusts would encourage unsafe practices as routine, as you seem to be suggesting? Midwives aren't just 'allowed' to do as they like, you realise. I am fast coming to the conclusion that either you have little contact with midwives, that those you do need updating, or that you are actually not a doctor, or at least have not practised in a while, because I can't understand where you are getting your evidence from.

  54. Just to put a non-professional slant on this doctors v midwives discussion …. I'm neither!I am a mother of 2 though, with my first being born in hospital, a perfectly normal and straightforward birth but I felt the hospital were understaffed and couldn't cope, the only doctor I saw (after the birth!) referred to me continually as “this woman”, my newborn had to be placed under a heater after a midwife bathed him until I commented “aren't his lips a bit blue”, all of this and much more made me ask loads of question when my second one was expected.

    My second was born at home, perfectly normal and straightforward birth. The midwives were not rushing in and out of the room, there was no sense of being in the way, we'd already discussed at length the equipment they would bring, what would be done should an emergency arise. It was a much happier and less stressful experience. My own GP arrived later in the day to check on me and my daughter. He had the time to stop and chat, making sure everything was ok.

    From a mother's point of view, I would like to see the NHS work together to make home births more widely available. I was made fully aware of the things that can go wrong with home births as well as hospital births, my choice wasn't made out of any “touchy-feely political” bias but on my previous hospital experience (the one and only hospital experience in my life!) and after much discussion, what my husband and I felt was right for our family.

  55. Hi ClaireI feel ashamed when I read your comment. You are absolutely right; there are some appalling tales of women having bad experiences on labour wards and postnatal wards; no doctors; inexperienced doctors; stressed over worked midwives, it goes on and on and it is getting worse. I dread seeing women postnatally because where I work, and I don't think we are exceptional, the experiences in hopsital are worrying.

    I am really glad your home birth went well, when they work they work, and I think it would be great if we had a system in this country where they were genuinely safe.

    The fact is, they are not. No midwife by herself can resuscitate a seriously flat baby, or an unconscious haemorrhaging mother. They don't have the skills. They don't have the equipment. This is not a criticism of midwives. It is just a fact of life. There IS a criticism in that many of them do not understand or beleive that they do not have the skills, and they start feeling professionally threatened when someone suggests that a doctor should bet involved.

    I think it would be great if we moved towards home deliveries in this country. To do that, we don't need to go out tub thumping and saying midwives are omnicompetant gods; we need to recognise there many skills, and supplement them with proper medical back up when it is needed. i.e. a good obstetric flying squad, with a doctor and yes of course a midwive and a nurse. For a real obstetric disaster you need someone for the mother, someone for the baby and some one inbetween to run everything and pick up the pieces.

    If we had that, then home deliveries would be viable.

    Until we do, I think the best option is to go in with the midwife and then get the hell out ASAP.

  56. Tom as a recent Dad, I totally agree with you?Why someone can be so selfish, I have no idea? What would it take for them to want to give up!

    Everyone has a right to what they do to themself, but give the child a chance to live.

    Shola Ogunlokun

  57. Hey guysInteresting discussion. Everyone seems to be getting a tad personal though. Not necessary, and it degrades your argument, displaying invective, overt or implicit. As docs, we're trained in the art of medicine superimposed on a backbone of hard science. All these anecdotal tales are meaningless, they obviously cannot be generalised to the wider population. There's a lot of hinting at 'evidence' and 'proven in studies' and so forth. Well, you're all talking out your a*** unless you give us an actual hard reference we can look up. That way, those of us with epidemiological training can decide for ourselves about the strength of any evidence, or lack thereof, as the case may be. Put up or shut up, eh ??

    Like the blog, wouldn't want your job mate!

    Dr Epicurus, in Oz

  58. Hi NHS Blog Doctor,Sadly I don't think an “obstetric flying squad” will be appearing in the near future. As always with the NHS it comes down to money (the lack of it) and management systems …. somehow I can't imagine safe home births will be at the top of the list!!

    I agree that some midwives think they are the be all and end all, but so do some doctors! Luckily for me the Somerset community midwives (including a trainee) worked very well with me, my GP and the hospital staff and I was never under any illusions of what they could or could not deal with.

  59. Hi ClaireI agree. Obstetric flying squads would been a “front end spend” and the government always trys to avoid that even in long term there were a saving. And a good system of home care, so that midwives could do deliveries at home safe in the knowledge that appropriate help was at hand, would in the long term save money. It is very expensive having women in hospital, particularly when the are not “ill”. Taking pregnant women into hospital does make them adopt an “ill” role, and makes people treat them as “ill” which they are not. And home deliveries would, I feel sure (though I cannot quote data, becuase there is not enough) reduce the rate of both foetal and maternal infection.

    So in the meantime, I still beleive that the happiest compromise is to extend and buttress the community midwife service; the main problem with it at the moment is that it is understaffed and under-resourced (tell me what isn't in this wretched NHS at the moment). If that were done, you could have 98% of your maternity care done outside the hospital, go in with your midwife for the delivery and all being well be back at home with the baby in a matter of hours.

    Maybe you should ask Tom to start a “write to Patricia Hewitt” to ask for more obstetric flying squads campaign. If she got 2000 letters asking for it, the spin-docotors would notice, deem it to be a vote winner, and THEN something would happen.

  60. Is it just me, or has it gone quiet since the word evidence was mentioned ?? Perhaps the discussion has just gone stale…I personally am half a world away, as my moniker suggests.I'm with you Tom, opinions are fine for dictating your own individual healthcare decisions, but when discussing health policy in the population context, evidence is what counts. Our opinions are worth one vote at election time, quintessentially, in this context. In my opinion.

    I'm a new visitor here, so wandered through your archives (well, searched on 'home birth' at least). I get the impression the issue is not one you've specifically addressed. I also get the impression that commenters here have debated this issue before, maybe, in your comments 'forum' ?

  61. I'd have replied, only some of us have to work for a living ;)Couple of points: 1) never in my posts have I slagged off doctors, I have no problem with doctors, only have I tried to defend my own position as a midwife and a professional, without being called 'rabid' or 'amateur' and have posted accurate descriptions of what we have to do. I can only direct you to the NMC publications that lay out our roles and responsibilities in full but I doubt anyone will actually go and read them!

    2) also I haven't really commented on the asthma thing, as don't have much expertise in that (I have asthma and my mum smoking never really set it off); my main entry into this was in defence of Tom, re the woman being in second stage. Having reread my post I am sorry if I came across as irritated with ALL GPs, for I am not; but I still don't think I deserved that totally unprovoked attack about 'all midwives' that followed.

    As a matter of information, if you want I will do a literature search on smoking and the effects on the fetus and also the safety of home birth but again I think it would be a big waste of my time as how many would actually read it?

    What you were talking about, midwives knowing their women and going to the births etc, that is actually what I do as a job… I do all their antenatal and postnatal and go on call for the birth. I do this in the NHS.

  62. Hi ClarabelleI have to work for a living as well beleive it or not!

    Look, I really did not want it all to get as heated as this. The doc from Oz is right; if one is going to conduct this sort of thing truly seriously, then one needs references etc etc.

    The is not the BMJ. It's a blog. It's a place where we let off steam, where, yes, we make some serious points, but also a place where we have afterwork fun.

    You and I are not going to agree on home deliveries, though oddly I think we are closer than might appear because we would both like them to be much more common.

    There IS a problem about resources in the Health Service, and part of the way this wretched goverment is dealing with it is by deskilling the service – for example by having GPSI (so called GPs with a “special interest”) act as quasi-consultants. It's a nonesense. GPs are highly specialised generalists – and I mean that seriously – but once they start behaving as though they are consultants, they just make tits of themselves. So I take the piss from them, just as much as I do from “nurse-specialists”. Look at my examination of the GPs who do BASICS (and see what Tom thinks of them) in : “Death in the Field” – http://nhsblogdoc.blogspot.com/2005/12/death-in-field.html.

    You see? You will have to get in the queue to bite me?

    Blogs are not learned journals. They are blogs. I have been on dozens of committees over the years and I used to shout a lot. It is a complete waste of time. So now I try to make my point by lampooning people, not be lambasting them.

    As I say, I will buy you a virtual beer!

    It is all meant to be good fun. If you take the NHS TOO seriously, you will crack up.

    So in response to Julie (comment on “Two empty bottles with different labels” : http://nhsblogdoc.blogspot.com/2006/01/two-empty-bottles-with-different.html)

    I have now written a serious and temperate article on nurse-specialists – which I know will make you bleed out of your ears! But don't take it too seriously, and don't you love the photo?

    John

    “The role of the nurse specialist in the NHS”

    http://nhsblogdoc.blogspot.com/2006/01/role-of-nurse-specialist-in-modern.html

  63. lol, see what you mean. Truce though!(oh, and you won't ever get me on the 'nurse specialist' thing… cos I've never been a nurse and don't want to be!)

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