May 16, 2011
“But for the grace of God go I.” My late aunt drilled that value into my six-year old head and it has never left. An article regarding a New York politician recently caught my attention. When New York State enacted a bill to ban the shackling of pregnant prisoners, a New York State Assemblywoman objected. The article goes on to discuss the case of Jeanna M. Graves, who, in 2002 was arrested on a drug charge and began a three year sentence. Graves was pregnant with twins and while in labor, was handcuffed during her entire C. Section. How utterly ridiculous.
Before a C. Section begins, a patient is usually given either an epidural or spinal anesthesia. On rare occasions, she is put to sleep with general anesthesia if the baby must be delivered emergently. On all accounts, the patient’s legs will either be numb from anesthesia or she will be sleeping. Why then does she need shackles? She’s certainly not in a position to run. Although I addressed this issue last August, it needs to be revisited again.
Women’s health and pregnancy should not be political agendas. I recently tweeted about another controversial article that blamed the reduced workforce in Memphis on teen pregnancy. Yes, it’s true that 49% of teen pregnancies are unplanned and unwanted but somehow the teens eventually mature and become productive human beings for the sake of their children. Our workforce problems stems from the outsourcing of U.S. jobs overseas, not teenage pregnancy.
Jeanna Graves was not perfect but neither did she commit a heinous crime. She used drugs and had a self-inflicted disease. In the course of my professional career, I have witnessed the most egregious acts corruption, fraud, deception and medical negligence, all under the rouse of helping the poor yet not one administrator ever left the building in shackles or seen the inside of a county jail.
Here’s a question for New Yorkers: Would you really elect someone who approves of shackles on pregnant to be your congressional representative?
April 13, 2011
Twin pregnancies have always kept me in wonder and awe, especially at the time of a delivery. At present, they represent 33% of all live births and their numbers are rising thanks to the increase in older women who are successfully conceiving through In Vitro Fertilization (IVF). Fertility drugs account for a 70% increase in multiple births. Are you at risk for having a twin pregnancy? You are if you have:
- Advanced maternal age
- Are African or African American
- 3 or more children
- A tall height or are obese
Unfortunately twin pregnancies can be complicated and everyone must be appropriately prepared.
Twins can be divided into 3 categories: monozygotic (identical); dizygotic (fraternal) and conjoined. In a monozygotic (MZ) pregnancy, only one egg was fertilized but “split” and then divided. MZ pregnancies represent the greatest risk for complications because the babies share the same placenta and circulatory system. One baby can have too much fluid and the other baby not enough. This is called a twin-twin transfusion or TTS. Dizygotic twins involve the fertilization of two eggs and have two separate placentas. It is more common, representing 69% of all pregnancies. Conjoined twins result when a single, fertilized egg only partially splits and the babies share a delay or a partial split from when there is a delay in the division of the fertilized egg and the babies share are physically connected. This is sometimes referred to as Siamese twins and represents a very poor prognosis in terms of survival. ALL twin pregnancies are at risk for preterm contractions and delivery and therefore are high risk. I am therefore perplexed when patients with twin pregnancies are not referred to a high risk specialist for a consultation.
At minimum, patients with twin pregnancies should have
- Monthly ultrasounds to document appropriate fetal growth. The number of ultrasounds might increase as you get closer to the due date
- Nonstress tests beginning at 32 weeks to document fetal well being
- A well thought out delivery plan in a level 3 hospital with a pediatrician waiting in the delivery room
Twins are a joy but remember their pregnancies are high risk. If you are pregnant with twins and no one has recommended you to see a high-risk specialist, make some noise . . . loudly. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
Check out my informational pregnancy video!
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 16, 2011
To everything there is a season and mine comes to an end today. For 760 weeks I attempted to give quality care to my patients. The task was not always easy especially when most of my patients held the unenviable position of having a high risk pregnancy and receiving Medicaid or being uninsured. Babies have a right to be born healthy regardless of their mothers’ income or insurance status.
The memories of my tenure at the county health department are indelible. I remember the woman who paid to be taken across the border only to be abandoned and walked from San Salvador to Texas. And the obese patient who rode a bicycle to the clinic with a blood pressure of 221/110. Of course she refused to go to the hospital because she alleged that they treated her “like dirt.” I begged, pleaded, and personally drove up the street to fill her blood pressure medication prescription to avoid her having a stroke or seizure in my exam room. My nurse found an ambulance company that was willing to take her to the high risk specialty hospital where she delivered prematurely in order to save her life and that of her baby’s.
And then there was dear Priscilla* (name changed) who had a bipolar breakdown and was about to be inappropriately discharged from the labor room triage until I advocated from my home around midnight and found her a hospital bed in my county where she was appropriately admitted, treated and subsequently delivered. There was also Katy* (name changed) who was sent home inappropriately with low fluid and subsequently went “on vacation.” I tracked her down in another state, told her to go to the nearest hospital where she was emergently admitted and delivered via c/s. My advocacy, diagnostic saves and battles with hospital clerks (who practice medicine without a license) continued for almost 15 years. It was difficult, stressful and at times frustrating, especially when the administration’s emphasis was on patient volume and money as opposed to quality patient care.
As this chapter of my life closes, I’d like to think that I’ve made a small but unique difference in the lives of others. I will indeed miss my patients, but I will not miss the stress. Service is the price we pay for being here. I hope I have served humanity well.
March 14, 2011
So, here we go again. Yet another slap in the face by big Pharma. Something is fundamentally wrong when a company charges $1,500.00 for a $10.00 drug that will not only save the lives of human beings but also reduce the annual $26 billion dollar cost of premature births.
Hydroxy progesterone caproate, marketed as Makena, has been around since 1956 and has been used for the past 15 to 20 years to help reduce premature births. It was originally manufactured by Squibb Pharmaceuticals but was removed from the market for reasons unknown. However, physicians were able to continue prescribing the drug by having it made in compound pharmacies for $10 to $15 per injection. The FDA subsequently gave KY Pharmaceuticals the exclusive right to produce the drug. Well, that was a glaring mistake. Why would the FDA want to give a company EXCLUSIVE rights to produce the drug? In a free market, competition is critical in keeping prices down. Twelve percent of births in the U.S. occur prematurely and a disproportionate number are African American women and teens. The drug has to be given between the 16 to 20th week of pregnancy and continued up until 36 weeks. Let’s do the math. The medicine has to be injected weekly. A patient taking the drug beginning at 16 weeks will have to continue taking it for approximately 20 weeks and 20 x $1500 =’s $30,000. So what originally costs $200 to $300 to prevent preterm pregnancy has now spiked to $30,000. How many different ways can we spell the word, GREED?
The prevention of premature births is paramount to the well-being of a newborn. Makena is not an optional drug. It will benefit many unborn babies and especially those whose mothers have a short cervix. Because Makena is now an FDA approved drug, the off-label brand previously made by compound pharmacists is not an option because of liability issues. Do you really think the insurance companies are going to pay $1500 for this drug?
I leave you with a profound quote from one of my readers, Dorice Arden:
“. . . a shocking reminder of just how low the value for humanity has sunk. The notion that patients are considered a commodity has far-reaching consequences. The very thread that ties us to our humanity is the value we place on life and life-sustaining measures. The attention and care we share with each other sets the tempo for the future.
Well said, Dorice. Well said.
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.
March 7, 2011
My profession has been “outed” by the New York Times’ articleTalk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy, by Gardiner Harris and I am breathing a sigh of relief. It’s about time the public knew the repugnant truth.
Harris describes how psychiatrists no longer perform talk therapy because of changes in how much insurance companies will pay. So they now prescribe and adjust medications leaving the personal crisis of patients “unexplored and unresolved” and relegate talk therapy to a lower priced therapist such as a social worker or a psychologist. The article centers around Dr. Donald Levin, a psychiatrist who has relinquished his professional protocols in order to accommodate the insurance industry. Levin can no longer remember his patients’ names and by his own admission, “trains himself not to get too interested in their problems. He does not want to get sidetracked trying to be a semi-therapist.”
According to the article, recent studies suggest that talk therapy is as good as or even better than drugs in the treatment of depression but less than half of the patients receive talk therapy. Levin earns $150 for three 15-minute medication visits as compared with $90 for a 45-minute talk therapy session. Levin, like many physicians had his wife, a former therapist, take over the role of his business manager and her comments were all too familiar and sad. Harris writes “Ms. Levin firmly asks for a co-payment which can be as much as $50. She schedules follow-up appointments without asking for preferred times or dates because she does not want to spend precious minutes as patients search their calendars.” Ms. Levin states “This is about volume and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do that.”
Levin states his office is like a bus station; that the “quality of care he offers was poorer than when he was younger; and how he makes a diagnosis within a 45-minute visit because he “plays the game” in order to get paid. Although Dr. Levin’s specialty is psychiatry, the phenomenon that he described applies to ALL specialties, including obstetrics. The doctor-patient relationship is dead and nothing short of a miracle will resurrect it back to life. In my next post, I’m going to share some personal experiences and make an announcement. Until then, remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
June 7, 2010
I nodded my head in recognition as I read the Sunday New York Times article “Growing Obesity Increases Perils of Childbearing.” According to the article, one in five pregnant women are obese and 38-year-old Patricia Garcia was one of them. During her pregnancy, Garcia almost died from a stroke and was forced to deliver her baby eleven weeks early by C. Section. Her baby had stopped growing in her womb and he needed to come out.
Obesity in pregnancy can be a trial by fire, for both the patient and her healthcare provider. I am presently taking care of three obese pregnant women and am keenly aware that they, like Garcia, can have a stroke at any given moment. One of my patients has sleep apnea and I was grateful to find a sleep specialist who accepted Medicaid. Her sleep study showed that her oxygen becomes extremely low when she’s asleep which places her at tremendous risk for anesthesia complications. We will now have to negotiate with Medicaid in an attempt to get her special equipment to minimize complications during her pregnancy. Two months ago an imaging center refused to perform an ultrasound on one of my patients who weighed over 400 pounds because they were afraid that she would break their table. We finally found a hospital that was willing to see her because they had equipment that could accommodate her size and girth. I see a fair amount of obese women in my practice because I am sensitive to their plight. Like the physician mentioned in the article, I too, had obese people in my family.
The statistics in the article were alarming: babies born to obese women are nearly three times more likely to die within the first month of life. They also have twice the risk of having a stillbirth. Five New York hospitals have formed a coalition to determine how best to address the problems associated with obese pregnant women. Wider beds and exam tables, longer instruments and high-definition ultrasound equipment must be purchased. These efforts are commendable and other hospitals should follow suit. Obese pregnant women are at high-risk for death, if mismanaged. Until we, as a nation, do a better job of promoting prevention, the incidence of obesity is not going away. I hope my colleagues are prepared to handle the crisis.
May 31, 2010
My institute of residency training is in hot water again, and I groan in despair (see Heart Tests at Harlem Hospital Went Unread). The New York Times reported that Harlem Hospital had performed nearly 4,000 cardiac echo exams in a two year period and none of them had been read by a physician. The Times alleges that the responsibility of reviewing these labs reports had been given to the cardiac techs and now the consequences of that decision was coming back to haunt the entire hospital.
This scandal reminds me of another that occurred over 25 years ago. Hundreds of New York City women entrusted their PAP smears to city hospitals that were never read by a gynecologists. By the time the debacle was discovered years later, some of these women developed cancer. With a failing economy and budget constraints, I’m sure someone had the misguided perception that they could save money and resources if the technicians read the lab reports and reported the “abnormals” back to the physicians. The same principals apply to nursing. Medical assistants are now expected to perform duties traditionally done by nurses as a means of “saving” money. These “cost-saving” strategies have a chilling effect.
Harlem Hospital is an historical haven for the poor. Despite limited resources, its dedicated staff saves lives on a daily basis. However, please don’t push the envelope. The quality of medical care greatly diminishes as the volume of patients increases. Delegating a physician’s duties to a technician will NOT remedy this problem.
A team of 15 to 20 physicians from other city hospitals were assembled to review the cardiac records and miraculously no abnormalities were found. There were also disciplinary actions that resulted in the termination of a clinical director and the demotion of a physician. The take-home message for ALL patients regarding this debacle is to obtain the results of all of your medical tests. Do not assume “no news is good news.” And if someone wants to give you an injection, please verify that they’re truly a nurse.
Our present healthcare system is on automatic pilot. It’s up to you to grab hold of the wheel.
April 26, 2010
Anything that save’s a baby’s life warrants the public’s attention. A few months back, I had a conversation with a New York colleague who raved about a new method that helped prevent brain injury of newborns. When I inquired further, she stated that a baby with an APGAR score of 1 after five minutes had escaped permanent brain injury through the use of a “cooling blanket.”
Anyone who is remotely familiar with obstetrics knows that the APGAR score is a useful tool for determining the newborn’s status shortly after it is born. APGAR scores were developed by Dr. Virginia Apgar, a Columbia University trained anesthesiologist and evaluates the baby’s heart rate, muscle tone, respiratory rate, reflex response and color at one and five minutes of life. Each criterion is given either 0, 1 or 2 points. An APGAR score of 0 to 3 after five minutes is suspicious for a birth brain injury.
When the baby does not receive enough oxygen in the womb, its brain cells becomes damaged causing permanent injury. However, that dismal prognosis has begun to change, thanks to hypothermia (cooling) therapy. According to a large medical study called Cochrane, “. . . parents should expect that cooling will decrease their baby’s chance of dying, and that if their baby survives, cooling will decrease his/her chance of major disability.” What a MAJOR breakthrough in medical science and a reason to celebrate for expectant parents.
One of the first institutions to use this method was the University of California at San Francisco. I contacted the nurse in charge of the program and she was kind enough to share their protocol. In order for the cooling method to work, it must be used within the first six hours of life. Here’s how it works:
- Your baby must be 36 weeks or greater
- Must have an APGAR score of less than 5 at 10 minutes
- Must have received chest compressions and/or intubated or received a mask helping it to breathe at 10 minutes of life
- Have a low blood gas within the first 60 minutes of life
- Have signs suggesting HIE which include having a seizure, poor muscle tone, poor feeding or be in a coma.
Although the cooling method is expected to become the standard of care in the future, there are hospitals that are already using it. Does your hospital use hypothermia? The answer could save your baby’s life.