April 6, 2011
Could the Tragedy of Patricia Garcia Have Been Avoided?
In the wee hours of the morning, Patricia Garcia took her last breath and made her transition. Her death was not a total surprise, she had almost died before. Garcia was 39 years old and the mother of an 11-month old son name Josiah who had made his entrance three months earlier than expected because he had stopped growing in his mother’s womb. During her pregnancy, Garcia was concerned that she might die before Josiah was born because of her complications of having a stroke, obesity and failing kidneys. At barely 5 feet, Garcia weighed 261 pounds and was decidedly obese with a basal metabolic index (BMI) of over 40.
Obese pregnant women are plagued with almost every type of complication imaginable from miscarriages, higher rates of cesarean deliveries, birth defects, pre-eclampsia and sometimes death. Garcia received general anesthesia during the cesarean birth of Josiah. It would have been technically challenging to attempt to give her an epidural or spinal anesthesia. Because she was put to sleep, the surgical team had to move quickly to remove the baby so that it would not receive excessive amounts of the anesthetic. Garcia’s procedure was unfortunately prolonged by several minutes, again due to technical difficulties.
Obesity is a national epidemic with 26.7% of our population affected. Garcia was considered the smallest person in her family because her brother weighed 700 pounds prior to receiving a gastric bypass. Obese patients often face discrimination and humiliation from within the medical community. Diagnostic procedures have been cancelled when it is determined that the patient is over a certain BMI for fear that their equipment would not sustain the additional weight. Patient safety experts propose that “obesity centers” for pregnant women be established to provide nutritional counseling, emergency cesareans as necessary and neonatal intensive care units.
Garcia promised her physician that she’d lose weight after she was discharged home. She didn’t. Although Josiah is now more than a diminutive 1-pound-11 ounce baby, he is still very small and was recently diagnosed as having dwarfism. He will be raised by his sixty-something year old grandmother who is also taking care of Garcia’s mentally disabled brother. Obesity is not a benign disorder. Until Americans make better lifestyle choices, tragedies like Patricia Garcia’s will continue.
January 4, 2010
Keep Your Hands Off Our Preemies!
I read the Politics Daily article by Joanne Weiner, Preemies, Health Care Reform and the Cost-Benefit Conundrum and shook my head in frustration. It irks me when people attempt to place a dollar sign on the value of human life.
It is a well known fact that most hospital costs are over-inflated yet no one calls them to task. Premature babies may cost $26 billion dollars per year but how much money has been spent on prevention? We’ve done a lousy job in reducing the occurrence of premature labor or making pregnant moms aware of its dire consequences. For example:
• Back pain should not be ignored (because it could be a sign of early labor)
• Patients should be discouraged from drinking soda because they contribute to urinary tract infections
• Urinary tract infections should be treated aggressively because it can be a precursor to premature labor
• The cervix of pregnant women should be automatically measured after 14 weeks by ultrasound imaging to determine if it’s short (2.5 cm or less increases the incidence of preterm labor).
• Complaints of vaginal discharges should not be ignored (especially from lower socioeconomic women) because it could represent an sexually transmitted infection (another risk factor for premature labor)
• Pregnant women in stressful occupations (professional women included) should be given a leave of absence so their bodies are allowed to rest
• Steroids should be administered to women with preterm labor so their babies will be able to breathe
And the list could go on infinitum. The May 18th 2009 edition of People Magazine had a fabulous article about six amazing college students who were all born premature at less than 27 weeks. Their story not only brought me to tears but also inspired a blog, (see Miraculous Babies). The most premature baby of the group was born at 23 weeks and weighed 1.8 pounds. She is also a college student today.
So, unless you’ve worked as a nurse or a physician, please keep your untrained hands off the destinies our preemies. The “cost-benefits” of their future is priceless.
December 9, 2009
An All Too Familiar Horror Story
The tragedy of Roshunda Abney, (Las Vegas Review, Woman Says She Was Ignored in ER, Paul Harasim ) occurs much too often. She went home after a six-hour hospital wait, and returned with a dead baby.
Abney was a part-time customer service rep in Las Vegas who lived with her high school sweetheart. They had relocated from Mississippi for a better life.
Abney had irregular menstrual periods, so she didn’t know that she was pregnant. For the past two days she had experienced menstrual-type cramping that wouldn’t go away despite taking over-the-counter painkillers. When the pain became unbearable, Abney went to a hospital-affiliated urgent care center. A nurse requested a urine sample but Abney was not able to supply one. Thirty minutes later a decision was made to transfer Abney to the hospital ER because she needed “higher care.” She was also uninsured.
Abney’s vital signs were taken upon her arrival to the hospital ER and then she proceeded to wait. And wait. And wait. Her pain became worse and she unsuccessfully attempted to receive medical attention. When she told a certified nursing assistant that her pain was getting worse, he told her that if she endured it for two days, “another 45-minutes wouldn’t make a difference.”
Sympathetic patients who were present in the waiting room offered to allow Abney to go ahead of them. They were subsequently informed to “mind their business or they would never see a doctor.” After a six-hour wait without being seen, she went to another hospital where she was also not seen and went home thinking she had gallstones. Twenty minutes after she reached home, her membranes ruptured and the feet of a baby was emerging. Paramedics were called and subsequently delivered a 24-week breech baby girl who was lifeless.
Abney’s case illustrates why hospitals and physicians get sued. She had to contend with layers of arrogance and calloused gatekeepers.
I strongly encourage all pregnant women to read The Smart Mother’s Guide to a Better Pregnancy. If you think the story of Roshunda Abney is an isolated incidence. Please, think again.
September 7, 2009
National Infant Mortality Awareness Month
Did you know that nearly seven babies will die before their first birthday for every thousand who are born in the U.S. and the rate for African American, Hispanic and Native American women, are even higher? Premature births occurring before thirty-seven weeks and low-weight babies, weighing less than five pounds account for the highest number of deaths in the U.S.
In recognition of September as the National Infant Mortality Awareness Month, I’d like to share some SMART tips to pregnant women:
S = Seek prenatal care early. Problems in pregnancy cannot be fixed at the last minute. Tests for genetic problems can only be detected in the early first and second trimesters. A first trimester ultrasound is also the MOST accurate in terms of a due date.
M = Mention all high-risk factors such as family history of diabetes, high blood pressure or bleeding. Do not omit information such as smoking or “recreational” drugs. It will come back to haunt you.
A= Ask to have your cervix measured during your ultrasound if there is a previous history of premature contractions or delivery. A cervical length of 2.5 centimeters or less is a risk factor for preterm labor.
R= Research your hospital and prospective physician or midwife carefully. Is the physician or midwife skilled in managing high-risk conditions? Will they continue to see you even if you lose your insurance? Has the hospital had any recent outbreaks of antibiotic-resistant – infections in the newborn nursery? Is there 24-hour anesthesia?
T= Test for potential problems such as Gestational Diabetes, Sickle Cell Trait or sexually transmitted infections.
The U.S. is one of the most industrialized countries in the world, yet we rank below Cuba and Taiwan, with respect to our national infant mortality rate. The health of a nation is judged by its national infant mortality rate. We can do better. We must do better. The health of our future generation is depending on it.
September 2, 2009
Invoking the Miraculous: A Case for the Public Health Option
If JT had private insurance and not Florida Medicaid, her baby would probably be dead.
JT’s pregnancy was miraculous, considering she had conceived with only one fallopian tube and ovary and she had no prior children. Things went well until her 27th week when she developed vaginal spotting. She went to a local hospital and was discharged home with a clean bill of health although they never ordered an ultrasound.
Bleeding during pregnancy is not a normal phenomenon. When I saw JT three days later during a routine prenatal visit, I ordered an ultrasound although the bleeding had stopped. A few hours later, the radiologist emergently reported that the placenta completely covered the opening to her womb and the baby’s umbilical cord was wrapped tightly around its neck three times. JT had a complete placenta previa and someone at the local hospital had regretfully missed the diagnosis.
I discussed JT’s case with a high-risk obstetrician and we both agreed that she should be admitted to the specialty hospital if only for observation. Thankfully, JT had state-sponsored Medicaid insurance because a commercial insurer would have made us jump through hoops. They would have required pre-authorization, endless forms and an inappropriate premature discharge home where she would have subsequently returned to the hospital with a dead baby.
What was supposed to be a 24-hour admission turned into a sixty-four day hospital stay because JT bled on a weekly basis. The cord remained around the baby’s neck and the prognosis was guarded regarding successfully carrying the baby until it was full term.
At 35 weeks, JT had an amniocentesis to make certain that her baby’s lungs were mature. She was subsequently delivered by cesarean section with the umbilical cord STILL wrapped around her baby’s neck. Because of skill, compassion and medical expertise, both mother and baby are just fine.
Marie Curie once said, “Nothing in life is to be feared. It is only to be understood.”
Please do not let fear cloud your judgment. Support the public health option, America. We need these miracles to continue.
August 26, 2009
The Death of Quality Healthcare
Quality healthcare is dead. And it was murdered by penny-pinching administrators.
An ultrasound report came across my desk the other day that made me scratch my head. On the first page, the fetus was listed as head down and on the second page it was listed as breech (feet first). Well, what was it? The patient was almost ready to have her baby and I needed accurate information in order to make a clinical decision. It wasn’t the first time I had received a conflicting report of that nature and I was becoming highly annoyed.
A few days later I received two PAP reports printed in large font that included an apology for the “discrepancy” of the original reports. A technician had originally read them as “normal”, but after they were re-read by a physician, they were in fact, abnormal. I had the unpleasant duty of reporting to my patients that they were now at risk for developing cancer.
In an effort to “cut costs”, professional standards are cast to the wind. The radiology department in question reverted to a voice-recognition system, eliminating transcriptionist jobs. Because the computer can’t recognize certain words the ultrasound reports are often riddled with mistakes. The problem is further compounded by a revolving door of radiologists who are hired as temps and read the reports remotely (outside of the hospital). As a result of an absence of physician leadership, the radiology technicians have inadvertently “taken over.”
Yes, you can nickel-and-dime health care services, but you will also get what you pay for. Voice-recognition software can never replace qualified human beings and neither can improperly trained technicians replace pathologists. Physicians love to scream about tort reform, however how about putting some of these hospitals in check? I wish my colleagues would get their complacent heads out of the sand and DO SOMETHING to promote patient safety.
I’m tired of fighting this battle alone.
June 4, 2009
A Deadly Risk
And there it was on the front page of the New York Times for the whole world to see. Where Life Starts Is a Deadly Risk, by Denise Grady, described a harsh reality that is often mentioned as a mere footnote. More than half a million pregnant women die from preventable deaths and over a quarter million occur in Africa. Of course there are not enough financial and human resources available and their stories are disheartening. For each woman who dies, 20 more encounter serious complications. Physicians state that more deaths occur outside the hospital because many try to give birth at home. This leads to my next point.
There are a growing number of women who want to give birth at home alone, without a midwife or birth attendant. I posted a blog about this “unassisted” phenomena a few weeks ago after one of their advocates’ baby ended up dead. I subsequently received a comment from a woman who discussed how “tribal” women would rather deliver without intervention and their biggest obstacle was poverty. Not so. There are millions of African women who would love to trade places with the “unassisted” crowd in a heartbeat. Yes, childbirth is a natural act but it is not exempt from danger.
Grady’s article reads like a litany of horror. A mother of six bled to death because the nurses did not know how to remove the placenta. A mother of quadruplets died leaving four beautiful babies in an orphanage. Two and three laboring women sharing one cot. America, we are so blessed. The cost to run a hospital in Tanzania costs $200,000 a year. I challenge the American College of Obstetricians-Gynecologists (ACOG), the American Board of Obstetrician-Gynecologists (ABOG) and all the rest of the deep-pocket women’s organizations to step up to the plate. We are our sisters’ keepers. When a mother and baby die, the whole world mourns.
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May 9, 2009
Swine Flu and High-Risk Pregnancy: A Precautionary Tale
It seems we’re not completely out of the wood yet. Unfortunately, the second US victim of the H1N1 swine flu virus was a pregnant woman.
Judy Dominguez Trunnell was a 33-yeard old special education teacher from Cameron County, Texas that lies on the US/Mexico border. CDC reports that she was admitted to the hospital at approximately thirty-three weeks because of respiratory problems. Her pregnancy was complicated by asthma, rheumatoid arthritis and psoriasis. She remained in the hospital for two weeks then succumbed to a coma. Although an emergency cesarean section delivered a baby girl, mom died on May 7th leaving behind two daughters and a husband.
Tunnell had a weak immune system making it difficult to fight off infections. Rheumatoid arthritis and psoriasis are autoimmune diseases that attack its own body. Living near the Mexico border and teaching special needs children probably increased her risk of exposure to the H1N1 virus as well. Some necessary precautions are in order:
• Most symptoms of seasonal flu involve fever (90 percent); cough (84 percent) and a sore throat (61 percent). However only one in four people complain of vomiting or diarrhea. Symptoms of vomiting or diarrhea along with fever, sore throat or a cough, requires a trip to a healthcare provider for further investigation that includes obtaining a special swab from your nose.
• CDC reports that the virus spreads not only through the air but also through feces-contaminated hands. Wash your hands; wash your hands; wash your hands; PLEASE – and preferably with an alcohol based gel.
To be forewarned is to be forearmed. I will continue to report updates as they emerge.
May 4, 2009
A Mother’s Decision
Just when I think I’ve heard and seen it all, something pops up that proves me wrong. Both Amy Gates” article, Home birth advocate’s baby dies during free birth: Do you blame or show compassion? And Cate Nelson’s Unassisted childbirth one woman’s story, gave me reason to pause. Both journalists discuss the March 27th death of Janet Fraser’s infant daughter and the controversy regarding unassisted childbirth.
Fraser is an Australian advocate of the unassisted childbirth movement that encourages pregnant women to deliver babies alone without the benefit of a midwife, a doctor, or a hospital. She used phrases such as “birth rape” to describe a delivery assisted by a healthcare provider. Please. As a descendent of a slave midwife and an obstetrician I am highly offended. Birthing is in my genes. There is nothing more satisfying than assisting in the delivery of a healthy and crying baby be it by midwife or physician. Heck, even a cow gets a c/section when necessary.
Cate’s article described a woman who had an “orgasmic” unassisted delivery during the birth of her daughter and then made frozen smoothies out of the placenta that she ate for the next thirty days. A placenta smoothie?
A reality check is in order. Forty percent of women died in childbirth during the 19th century but less than one percent, or 520 women today; and even those deaths are preventable. Do we really want to proceed in reverse? Perhaps members of the “unassisted” crowd would like to trade places with women in Sierra Leone and Afghanistan, who have the world’s highest number of childbirth deaths.
We need our babies born healthy and alive. All of them, without exception. The adverse outcome of the Fraser’s “unassisted” delivery speaks for itself. Here’s hoping she’ll never experience it again.
