November 7, 2011
A recent article about the shameful infant mortality rate in the U.S. caught my attention. Certainly the statistics quoted are nothing new but still remains alarming. However, the Op Ed by CNN contributor Deborah Klein Walker gave the subject matter a new spin. Walker wrote “This is one of the greatest injustices in our country: that a baby’s chance of having a healthy life is largely dependent on where he or she is born. States and local communities vary widely in what care their leaders choose to provide to women and children.” If Dr. Walker were present, I’d give her a great big hug for her courage to say what no one else dared. A baby can die based on a hospital zip code.
Every pregnant mother needs to take a mini course in hospital politics because they are directly affected. A hospital is no longer a place of healing. It is a business and at times, ruthless. I have witnessed a colleague forced out of business because she said no when a hospital wanted to buy her practice so they withdrew her admitting privileges instead. I recall bitter battles with my former employer because I would not encourage my patients to deliver at a hospital that was notorious for being under staffed, overworked and a haven for medical errors, simply because of a business relationship that my employer had with thatehospital.
I commend our federal government for initiating programs such as Healthy Start and the new home visiting program, but dependence on government assistance alone cannot guarantee a healthy baby. A pregnant mom must do her due diligence. She must investigate the credentials of the provider and hospital where she intends to give birth. What should a pregnant mom do if she lives in a community or state that has a high infant mortality rate? Give birth at a teaching hospital that’s affiliated with a university or medical school. Most of these institutions receive federal and state financial support and are obligated to provide care to patients.
Can a baby die based on the zip code where it’s born? Unfortunately, yes unless the mother is willing to do her homework and take the necessary precautions to avoid that from happening. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
April 6, 2011
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.
March 30, 2011
I read an article in my local newspaper the other day that gave me reason to pause. The State of Florida intends to hand over 3 million Medicaid patients to managed care companies who will reduce payments to physicians and hospitals. In exchange for accepting these low payments for professional services, doctors are guaranteed through pending legislation that no matter what egregious errors they make, the patient will only receive a maximum of $250,000 in a medical malpractice lawsuit. This is definitely a “lose-lose” situation for patients.
Managed care is bad news for pregnant women. Extremely bad news. Every ultrasound, lab test and hospital admission that your physician or midwife orders on your behalf will have to be pre-approved by a gatekeeper who is on a mission to increase the profits of their company by reducing the amount of money that is spent on you. So you must therefore be on a mission to keep both you and your unborn baby out of harm’s way. How do you do that? Here are a few suggestions that are taken from The Smart Mothers Guide to a Better Pregnancy:
- Research your prospective healthcare provider through your State Board of Medicine’s licensing department to make certain they do not have any 7-figure malpractice suits settled or pending
- If you’ve had a previous high-risk pregnancy, request a referral to a Maternal Fetal Medicine high-risk specialist for your prenatal care
- If you delivered a preterm baby in the past, chances are likely you will do it again. Ask to have your cervix measured when you have an ultrasound and if it’s short , request a referral to a high-risk specialist
- If you have vaginal bleeding and are pregnant, do not leave a doctor’s office or an emergency room without someone doing an ultrasound to confirm that (a) the fetus is alive and (b) the pregnancy is not in the fallopian tubes (aka) ectopic pregnancy. An undiagnosed ectopic pregnancy could rupture and cause havoc.
- If you complain of a vaginal discharge, do not leave your healthcare provider until someone gives you a diagnosis and treatment. Untreated vaginal infections can lead to preterm labor. Bacteria is not your friend when you’re pregnant
- Back and lower abdominal pain should not be ignored, especially if you are less than 36 weeks. It could represent signs of premature labor
- Become familiar with fetal tracings. Flat lines and “u-shaped” curves during labor could mean your baby is in trouble and needs to be delivered quickly
- Try to deliver in a hospital that has a level 3 nursery and/or a NICU (neonatal intensive care unit)
- If a hospital mistreats you, contact its administrator. If you’re still not satisfied, file a complaint with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) http://www.jointcommission.org/
- Trust your instincts. I can’t emphasize this enough.
Prevention is the key to reducing medical injury, not taking away someone’s right to sue.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do. Check out the video below for my information and pick up a copy of The Smart Mother’s Guide
March 9, 2011
Did you ever love something or someone so much that you had to walk away because it hurt too much to stay? That’s how I feel about medicine. From the moment I saw my first delivery, I was hooked and there was no turning back. Perhaps I’m highly offended at our present state of affairs because I had to work so hard to gain acceptance into med school. I spent countless nights in the library at Columbia School of Physicians and Surgeons studying for the MCATs. Endured physiology, histology, biochemistry, gross anatomy (included the dreaded head and neck) and microbiology so that I could eventually diagnose clinical problems. I walked through the fire of residency training and came out whole on the other side. Yet, despite all of these humble achievements, I couldn’t see the destruction of healthcare coming. And neither did many of my colleagues. However, instead of banning together to save our profession, some of us allowed ourselves to be fiscally co-opted giving rise to the birth of “volume oriented medicine.”
Healthcare is now a business and quality of patient care has flown out the window. Billable procedures with diagnostic codes are the order of the day. “Productivity” is a buzz word, a euphemism for volume. The insurance companies are paying less, yet the healthcare providers are expected to do more. The number of patients on schedules increases and it has become “normal” for some of my colleagues to see 48 pregnant women in a day. A former medical director decided that he wanted to increase “productivity” even more so he paid physicians on a per-patient-basis and of course, his theory worked. When one of his cronies had 80 pregnant women scheduled in 5 minute intervals for one day, I had seen enough. I wrote a letter of complaint to the Florida Board of Medicine and was informed that there was no law that prohibited the number of patients a healthcare provider could see in a day. I then contacted the American College of Obstetrician-Gynecologists (ACOG) and they too, had no protocol or rule about volume. So, it was the wild, wild, west regarding patient care. No rules. No boundaries. And certainly no patient protection. Regime changes occurred, but the “numbers” game continued. I had had enough. So after 15 years of attempting to administer quality care in the midst of chaos and strife, I have tendered my resignation. There is nothing more that I can do except put it in the hands of God.
February 2, 2011
When our country starts closing obstetrical units in hospitals because they “cost too much” money to operate, pregnant women need to start running for cover and their babies are in serious trouble. Such was the case of the most recent casualty, South Seminole Hospital, a 200-bed hospital, that’s located within 30 minutes of my neighborhood.
More than 20,000 babies were born in South Seminole Hospital during the past 18 years and many of the babies were delivered by a local obstetrician who died approximately three years ago. I recall sitting in the emergency room of the hospital with a fractured ankle and listening to a chime that used to ring every time a baby was born. It was a soothing and humbling sound knowing that a new life was making its grand entrance each time that chime rang. Now, it will be replaced with silence.
Unfortunately, this phenomenon is not unique to Florida. In 1997 the closing of a North Philadelphia hospital (Northeastern) affected six additional hospitals in the community and their 23,570 annual births. In my hometown of Brooklyn, New York, Long Island Hospital had an annual delivery rate of 2,800 babies but still closed its doors to the community and sold the hospital as prime real estate to the highest bidder citing low reimbursement rates and high premiums for malpractice insurance as the culprit behind the decision. The Bedford Stuyvesant community of Brooklyn, New York lost St. Mary’s Hospital, a delivery center of thousands of babies in 2005.
Not only are hospital maternity units affected by money but by politics as well. How many times have I witnessed the closure of a hospital maternity unit because a “premier” ob-gyn group acted like spoiled brats when they didn’t get their proverbial way and took their patients en masse to a competitor hospital? A hospital might have hired a hospitalist group to deliver uninsured patients and the local ob-gyn physicians were annoyed because they weren’t “included in the decision-making process?” Or a popular ob-gyn physician is chastised by a head nurse for missing a delivery or having a preventable error and vows never to return to the hospital.
As pregnancy continues to be deemed a pre-existing condition with low reimbursement rates and high malpractice premiums, the disappearance of maternity wards will continue. If you live in a community where this phenomenon has occurred, I strongly encourage you to seek prenatal care at a teaching hospital where there are attending and resident physicians trained to manage low-risk and high-risk prenatal problems.
Remember a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
January 24, 2011
No longer living in New York, I received no less than three emails and phone calls from good friends and colleagues regarding the story of Carlina White, the 23 year old woman who was kidnapped from a New York City Hospital and then miraculously reunited with her birth parents. White was kidnapped from Harlem Hospital, my institution of residency training, one year before I arrived. What happened to White is every parent’s worst nightmare. You bring your sick baby to a hospital to be healed and discover that she’s been kidnapped. Sixteen year old Joy White brought her 19 day old baby to the pediatric department at Harlem Hospital because she had a 104°F temperature. The next day the baby was gone and her parents’ anguish continued for the next 23 years. Allegedly a woman impersonating as a nurse kidnapped the baby after experiencing a recent pregnancy loss.
By the time I arrived at Harlem Hospital (aka Harlem) the following year, security was heightened. I now understand the reason why some 23 years later. According to the National Center for Missing and Exploited Children between 1983 and 2008, there have been approximately 250 infant abductions in the U.S. hospitals prompting an increase in technology as a means of enhancing nursery security. As recent as 2008, a baby was kidnapped from the nursery of a community hospital less than 20 minutes from my home. Under similar circumstances, Jennifer Latham, a woman impersonating a nurse took a baby from its mother under the pretense of taking it for clinical tests. However, as soon as Latham left the hospital an alarm went off and the hospital was immediately in lockdown. Unfortunately, it was too late because Latham had already left the premises. Nevertheless, several hospital employees observed Latham getting into her car and the Sanford police quickly arrested her.
Do you know how secure your hospital nursery is? Most hospital nurseries have ID bracelets for both mom and baby that trigger an alarm if tampered with. There are other features such as a baby channel, locked nursery entrances and surveillance equipment. And never, ever give your baby to anyone who does not have proper hospital identification.
The kidnapping of Carline White had a happy ending albeit 23 years later. Unfortunately, that is an exception rather than the rule. In my next blog post I will discuss the importance of a labor and delivery tour and questions every expectant mother should ask. Until next time, remember, a healthy pregnancy and delivery doesn’t just happen. It takes a smart mother who knows what to do.
October 18, 2010
This past Sunday morning I awoke on a mission. I loaded my children in the car, went to church and stood in front of the altar asking my pastor and congregation to pray for our country’s healthcare system. Of late, I’ve been disheartened and weary. My mammoth burden needed to be turned over to a Higher Power.
One of the main reasons I wrote The Smart Mother’s Guide was to protect pregnant women from becoming victims of medical malpractice based upon practices of neglect and distraction. In recent years, I have witnessed things that I wished I hadn’t. How does one respond when made aware of an ob-gyn physician who typically schedules 80 patients a day at 5 minute-intervals because he’s being paid on a per-patient-basis? The State Board of Medicine deemed it to be “legal” because a statute or law was not written to address the issue. Welcome to Conveyor-Belt Medicine.
The battle of patient scheduling has become a national problem for conscientious physicians and nurses. Overbooking patients jeopardizes patient safety but complaints fall on deaf ears. Because of decreased revenue paid by insurance companies maintaining a medical practice above water has become a numbers game.
How many patients should a physician or healthcare extender see in one day? It depends on the specialty but anything over 30 is clearly pushing the envelope. In my research regarding the average number of patients seen per day by a physician, I came across a 2008 blog written by KevinMd that is shocking. In the thread, Dr. Anonymous admits to seeing 50 to 100 patients per physician per day because “30 to 35 patients per day would hardly pay the rent.” The conversation goes from bad to worse as Dr. Anonymous attempts to justify his actions.
The notion that patients are now “subscribers” that can be used as leverage to obtain insurance contracts and business deals is sickening. Where is the quality care in this? Where is the healing? Greed and immorality have high jacked our healthcare profession and thus far, there is no super hero has been able to lasso it back. Pregnant moms, be your own advocate and protector. Before selecting a healthcare provider, ask a simple question: how many patients does he or she see in a day? Avoid the conveyor belt at all cost. You and your unborn baby are more than just a number.
Do you know how to anticipate and manage the unexpected events that could occur during your pregnancy? You will if you purchase The Smart Mother’s Guide to a Better Pregnancy available on Amazon.com or wherever books are sold.
September 6, 2010
Although the cervix is supposed to hold a pregnancy until term things sometime go wrong. Women can lose an otherwise healthy baby because of a weak or short cervix. When cervical tissue becomes weak, this condition is known as Cervical Insufficiency (CI) and affects approximately 0.1 to 2% of all pregnancies. Women who have a history of painless bleeding in the second trimester or complain of pelvic pressure followed by the delivery of a fetus most likely have CI. Also, women who have had three or more pregnancy losses in the second trimester have CI as well. Patients with these types of histories have traditionally been treated with a procedure called a cerclage. Think of a cerclage as a stitch in the cervix that keeps it closed so that the baby can continue to grow.
There are many reasons why women develop CI and include women who have a short cervix, collagen disorders, uterine abnormalities and cervical lacerations. Some women are born with a short cervix while others acquire it because of surgical procedures such as a cone biopsy, LEEP (loop electrosurgical excision procedure) or laser ablation. Voluntary pregnancy terminations can also shorten the cervix and increase the risk for a preterm birth. The collagen disorder such as Ehlers-Danlos syndrome can so as well.
Can cervical insufficiency be diagnosed before pregnancy? Unfortunately not, however, the use of a patient’s history, physical exam and ultrasound can help tremendously. Visualization of membranes seen during a speculum exam is extremely suspicious for CI and requires a cerclage if the patient is less than 24 weeks. Any cervical length of less than 15 mm is diagnostic of CI and requires a cerclage.
The average length of the cervix at 20 and 22 weeks is 40 mm; at 32 weeks it’s 35 mm. A woman who has a cervical length of less than 25 mm will most likely get a cerclage if she has a history of a three previous second trimester miscarriages. A woman less than 23 weeks with a cervical length of less than 25 mm might be offered a cerclage or progesterone treatment.
Part 2 of this article will discuss what happens if a woman without symptoms of preterm labor is found to have a cervical length less than 25 mm and when and where should the cerclage be removed? What lifestyle changes should be made with a cerclage?
Do you know how to anticipate and manage the unexpected events that could occur during your pregnancy? You will if you purchase The Smart Mother’s Guide to a Better Pregnancy available on Amazon.com or wherever books are sold.
August 23, 2010
Pretty is as pretty does. It’s an old adage my mom used to say but still holds true. An article in the Orlando Sentinel discussed how hospitals have deep pockets regarding providing amenities for maternity patients as a means of soliciting “business.” One hospital spent $112 million dollars on its new all women’s facilities. Its competitor than felt compelled to spend $16 million to refurbish its maternity floors. While flat TV screens, wood floors, granite paneled bathrooms and a masseuse are nice, do these perks add to the quality of obstetrical care?
Make no mistake, ladies, the cost of these amenities will somehow show up on your hospital bill. Elizabeth Cohen, of CNN’s show, The Empowered Patient discussed toothbrushes that cost over $100. And ironically, I ended up on her show discussing my dissatisfaction of having to pay over $800 for a $167 disposable pair of forceps during my own surgical procedure.
While it is nice to give birth in a comfortable atmosphere, the quality of care is equally important. One of my patients was pregnant with her first baby and wanted to deliver at an upscale hospital. I supported her decision because the hospital provides excellent obstetrical care and it also happens to be aesthetically beautiful. My patient worked as a manager, had a picture-perfect prenatal course and had third-party insurance. What could possibly go wrong? The lack of compassion from the admitting physician.
Although she was in the early stages of labor at 3 centimeters and extremely uncomfortable, the physician refused to admit her. His attitude was both condescending and demeaning. My patient was close to tears and her nurse was livid. When she presented to my office, it was obvious that she was uncomfortable. I offered to call the hospital and advocate on her behalf but she wanted no part of them. She requested to be delivered at a less upscale hospital where she was subsequently admitted and treated like a queen. So much for the “resort” environment.
Hospital perks might be great for marketing but they need to be accompanied with quality care and good old-fashioned courtesy.
A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
July 26, 2010
When you’re constantly fighting for people to do the right thing, something is terribly wrong. One of my best friends called the other day in a state of despondency. Her patients needed to have a C. Section and the anesthesiologist was acting like a jerk. The patient had two previous successful VBACs but this time had a placenta previa which meant the placenta was covering the opening to the womb . A vaginal delivery was impossible. The patient was 38 weeks and my friend instinctively felt that she needed to be delivered. Gratefully, she wasn’t bleeding.
The anesthesiologist refused to give the patient an epidural, citing her “high-risk” status and was also rude in the process. He felt the main hospital operating room was a more appropriate arena for the delivery as opposed to the labor and delivery suite. My friend had had problems with this physician before. He would play the “dumping” game using any excuse to postpone performing a case until the next shift took over. My friend was not about to play Russian-Roulette with the patient’s baby and refused to send her home. “What should I do?” she asked in frustration. “I’m trying not to lose my composure and I’m not in the mood to fight.”
My friend needed encouragement. I reminded her that she was a brilliant physician whose calling was to heal women and save babies. I suggested that she get the hospital’s administrator and ob-gyn chairman involved to deal with the anesthesiologist directly and document on the patient’s chart why she was unable to deliver the baby. Above all, she must trust her instincts.
The high-risk specialist agreed with my friend’s assessment and wrote a note on the chart as well. My friend shared her dilemma with the nurse-in-charge who then took control of the situation and forced the hand of the anesthesiologist.
The baby was ultimately delivered and had a low APGAR score at one minute although there was nothing on the fetal tracing to suggest why. Had my friend not intervened, the baby could have possibly died.
My friend scored a moral victory with this delivery. But what will happen the next time?