September 12, 2012
There are few times that I become gravely concerned about the way medicine is practiced and this is one of them. A recent medical study in the Journal of Hypertension reported some startling facts: pregnant women are receiving blood pressure medication that might be harmful to their babies.
When physicians decide to specialize in obstetrics, we know exactly what we’re getting into. We have two patients, both mother and unborn baby and we don’t want either to die. Each year 4 million babies are born in the U.S. and between 6 to 8% of their mothers will have high blood pressure. Why are physicians and healthcare providers concerned about high blood pressure? Because if untreated, it can cause a stroke leading to death.
During pregnancy, a patient can have there are 3 types of high blood pressure: (1) chronic hypertension that occurs before 20 weeks, (2) gestational hypertension that occurs after 20 weeks but is not associated with protein in the urine and (3) pre-eclampsia that occurs after 20 weeks and is associated with protein in the urine. Pre-eclampsia, if untreated can lead to seizures (also known as eclampsia) and strokes. It is one of the most common reasons for death as a result of pregnancy. The treatment for pre-eclampsia is the delivery of a baby because the placenta is causing a problem. If the patient’s blood pressure is extremely high and life-threatening, medicine is also given to prevent the woman from having a stroke until she is delivered.
On the other hand, chronic hypertension is treated with medication during pregnancy to prevent strokes from occurring. But what type of medicine? The FDA classifies medicines in 5 categories from “A” to “X” to describe how they will affect the unborn baby. Category A poses no harm to the baby and Category X should never be given because it has been proven to cause birth defects. The blood pressure medication Lisinopril is a category X medication. It should never, never be taken during pregnancy.
Pregnant moms please read those labels and ask questions before taking medication. A healthy pregnancy doesn’t just happen. It takes a smart mom who knows what to do.
August 6, 2012
New York Times writer, Anemona Horticollis has written yet another telling story. The Short Life and Lonely Death of Sabrina Seelig describes why entering a hospital could be hazardous to your health.
Sabrina Seelig was a writer, a student and came from a family of artists. Both of her parents previously taught at the University of Art in Philadelphia and then moved to an artists’ colony in Maine. Sabrina eventually moved to my hometown of Brooklyn, New York in a neighborhood that was changing. Like many New York neighborhoods, Bushwick has experienced significant transformation and revitalization, thus attracting young professionals, students and artists. Unfortunately, the neighboring hospital remained unchanged and had been cited for mismanagement, was under investigation by the Brooklyn District Attorney and didn’t carry medical malpractice insurance. Had Sabrina had known those facts; they might have saved her life.
According to The New York Times, Sabrina took Ephedra (a stimulant) to stay awake all night so that she could write her Latin paper for school. She also took an herb called Valerian. Feeling sick, she contacted the public health Poison Control Center after calling an ambulance that never came. The Poison Control Center wasn’t that helpful and basically told her to wait for the ambulance. It’s not clear how Sabrina arrived at Wyckoff Hospital but a cascade of unfortunate events sent her to the grave:
- She was given a sedative that made her sleepy although she had taken Valerian
- Her wrists were bound in restraints
- She was never given oxygen
- She lie on a small hospital cot unresponsive for over 12 hours
- She never received a breathing mask or tube
- She was never transferred to the ICU
- There were few notes written in her medical chart
- She did not have vital signs recorded for over 3 hours despite the fact that she was unconscious
- Her parents had her transferred to another hospital but by that time she was brain dead
- The nurse involved stated “writing vital signs were unnecessary because she was watching the cardiac monitor. “
- Her family had a challenging time finding an attorney who would take the case
- A jury found the hospital not guilty and made snide comments about Sabrina’s alleged drug use
As a physician and parent, I am outraged about the death of Sabrina. Wyckoff Hospital should be shut down immediately.
There are two lessons to be learned from this case. (1) Know your hospital. There is a chapter in The Smart Mother’s Guide that addresses this issue. If a hospital does not carry medical malpractice insurance, RUN in the opposite direction; and (2) to quote Sabrina’s dad, “Never enter a hospital alone.”
August 1, 2012
JoNel Allecia’s NBC News article, Burned Out Nurses Linked to More Infections , addresses an important issue that is often overlooked and ignored. Let’s be brutally honest, without an appropriate nursing workforce, our entire healthcare system would collapse. As our healthcare system continues to shift to a business and profit model, both nurse and physician burnout will only increase.
Decisions to “cut corners” by not providing adequate nursing staff are made on a daily basis to our detriment. There was a time when additional nurses would be brought in based on the patient census for the day or evening shift but those days are gone forever.
According to a recent medical study, for every extra patient added to a nurse’s workload, there is one hospital acquired infection for every 1,000 patients. While this may not sound significant to the uninitiated, a hospital acquired infection can wreck havoc because it is usually caused by antibiotic-resistant bacteria that are difficult to treat and Methicillin-Resistant Staph Aureus (aka flesh-eating bacteria) or MRSA is a perfect example.
The study goes on to report that when an additional patient is added to 5.7 patients per nurse, 1,351 additional hospital infections occur that are preventable. The statistics are alarming.
A few months ago I reviewed a medical ob-gyn case where the labor room nurses were short-staffed and the patient unfortunately died of complications. The physician had patients in labor but chose to finish his office hours rather than attend to a sick patient so the short-staffed labor room nurses were essentially managing his high-risk patients.
What can a patient do? Plenty.
- Ask what the patient to nurse ratio on the day of your hospital admission and if the nursing staff pattern is inappropriate, ask your insurance company if you are eligible for a private duty nurse based on the increased hazards associated with inadequate nursing staffs.
- Ask your physician to come to the hospital to closely oversee your care or make sure there’s a hospitalist on duty
- File a formal complaint with the hospital administrators, State Board of Nursing and the Joint Hospital Commission for jeopardizing your patient safety based on inadequate staffing patterns
When nurses are overloaded with work, an entire community suffers.
January 18, 2012
Although most women will spontaneously develop labor by their due date, there are exceptions to the rule. Some women may have to be delivered earlier because of complications such as high blood pressure, pre-eclampsia, diabetes, poor fetal growth or low amniotic fluid. Other women may have to be induced because they have exceeded their due date by one to two weeks. Why are inductions of labor necessary? When the conditions within the uterus or a medical condition pose a threat to either the baby or the mother, the baby must be delivered. While most labor inductions are successful, there are some questions that pregnant moms need to ask in order to increase their chances of having favorable outcomes.
- Is my cervix favorable? The softer the cervix, the greater the chances are of having a successful vaginal delivery. If the cervix is not “favorable” or soft, medicine will be necessary to make the cervix softer, usually in the form of suppositories.
- How long will the induction take? This is a legitimate question because the longer the induction takes to occur, the greater the risk of developing complications such as infections. Most inductions of labor and delivery occur within 48 hours of admission. First-time moms dilate 1.2 centimeters per hour while moms who have had previous children dilate at 1.5 centimeters per hour. It can take up to 20 for a 1st time mom and 14 hours for a mom with previous children to develop active labor (meaning she is dilated 4 centimeters) but thereafter she should deliver within the next 12 hours. A 3-day induction of labor is a red flag that there might be potential problems that could compromise the health of the unborn baby or mom.
- If you are being induced, break your water but are not having contractions, ask your provider whether he or she will give you antibiotics to prevent infections. The longer your membranes are ruptured, the greater the risk of developing an infection.
- A multiple-day induction of labor involves many providers and nurses who will be changing shifts. Sometimes things or information gets lost in the transition. Ask who the lead person or team leader is regarding your care and make sure everyone is on the same page regarding your information. Try to obtain this information, BEFORE you are admitted to the hospital.
- Trust your instincts. If things appear complicated during your labor, ask for a maternal fetal medicine consult. These are high risk OB doctors who specialize in managing complications.
Most of the medical malpractice cases that I have reviewed as an expert have involved the issues discussed above. To be forewarned is to be forearmed.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what do to.
May 11, 2011
At one time, a hospital would be called a 24-hour institution but now it’s a business. Within this business are shift workers that include nurses, technicians, clerical staff and even hospital employed doctors who are now called hospitalists. In a teaching hospital resident physicians also work in shifts so the responsibility of patient care is always being transferred from one group of healthcare providers to another. Do they always communicate effectively? Regrettably, “no.”
Sign-outs, handoffs, shift changes, nurses’ report. These are the multiple names for the process where a departing provider is responsible for letting the arriving provider know what’s going on with the patient. According to statistics, 80% of medical mistakes occur during shift changes and 50 to 60% of them are preventable. Listed below is an excerpt from The Smart Mother’s Guide to a Better Pregnancy that teaches pregnant moms what things should be known during a shift change.
“While in labor, there will most likely be a change of shift and a transfer of information should occur. However, it is not always successful. Information is sometimes lost, incomplete, misunderstood or inaccurate. Your doula or a family member should make a list of all tests that have been ordered since your admission. He or she should also know your most recent vital signs, including your blood pressure and whether your baby’s fetal tracing was reassuring. Other important include:
- The length of time since your membranes ruptured: the longer your membranes have been ruptured, the greater your chances of developing an infection in the amniotic sac around the baby called Chorioamnionitis
- A positive group B strep that must be treated with antibiotics to prevent your baby from contracting the infection
- The length of time you have been receiving Pitocin. The status of your fetal tracing should be noted to make certain that the baby can tolerate the contractions caused by Pitocin.
- Any other significant clinical issue that might have been discussed that could adversely affect your labor
Before the end of a shift, your family member or doula might ask the departing nurse or provider to review his or her notes regarding your care and ask “Is this correct?” When the new shift takes over, your doula or family member would show them the notes and ask whether they received the same information that was verified by the previous shift.
The path to a successful delivery becomes much straighter when everyone marches in the same direction. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
March 23, 2011
Periodically, the FDA publishes drug warnings that should be shared with the public, especially if it affects pregnant women. Each year, over 4 million babies are born in the US and 43% will continue to be breast fed at 6 months. All of these moms will invariably use meds at some point after birth, so which meds are helpful and which are potentially harmful? These questions may now be answered by the Infant Risk Center, at the Texas Tech University Health Center, in Amarillo, Texas. This center provides up-to-date information regarding the safety of medications that are taken both during pregnancy and after birth.
Most drugs enter breast milk immediately after birth and during the first 4 to 10 days of life at a fairly fast rate based on the physiology of breast cells. New moms must therefore be careful of pain medications that are prescribed during the post partum period. Hydrocodone aka Vicodin is a potentially addictive opiate that is given for pain management. When it is processed by the body, it breaks down into a component called hydromorphone that is even more potent. The University of California at San Diego Medical Center performed a small study to determine how much of the drug is secreted into breast milk and what percentage is absorbed by newborns. 3 to 4% of hydromorphone was found in breast milk which is considered safe. As a rule of thumb, nonopioid medication should be prescribed first during the post partum period for pain relief. If the pain persists, no more than 6 Vicodin (hydrocodone) tablets or 30 mg should be prescribed in one day. Dosages greater than 40 mg should be avoided and the newborn should be monitored carefully for depressed behavior or inadequate breastfeeding.
Recently the FDA sent a drug warning to healthcare providers regarding the risks associated with the entire class of antipsychotic medications such as Haldol, Risperdal®, Risperdal® Consta®, Invega® and Invega®Sustenna, Clozaril, Zyprexa, Seroquel, Abilify, and Geodon. These medications are used to treat schizophrenia and bipolar disorders but are associated with abnormal muscle movements and withdrawal symptoms of newborns whose mothers took these medications during the third trimester. However it is recommended that patients should not abruptly stop taking these medications without speaking with their healthcare professional first. For further information, readers may go to the FDA website http://www.fda.gov/Drugs/Drug Safety/ucm243903.htm.
Remember, a healthy pregnancy 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.
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.
August 26, 2009
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.