September 13, 2010
I shook my head in sad recognition as I read the story about a newborn baby found in a trash can at a Filipino airport. The baby was found by the cleaning crew inside the toilet trash bin of a passenger jet that had landed from Bahrain. Gratefully, an airport physician examined the baby, rushed him to the hospital where he is reportedly doing well. Baby George Francis (a name given to him by the airline staff) was lucky. Many babies are not.
The article invoked an indelible memory of a notorious night on-call during my first year of residency training. I was called to the ER to evaluate a woman who had significant vaginal bleeding. Upon my arrival, I encountered a plain-looking woman in her late thirties accompanied by a man who appeared to be the same age. She was a minister’s daughter who still lived with her parents and appeared extremely nervous. When the nurse placed her feet in stirrups, I immediately knew why she was bleeding. “Where’s the baby?” I asked. Both the patient and her male friend looked at me as though I had burst into flames. “Baby? What baby?” they asked in unison. My patience was running thin. “Look,” I snapped and held up the placenta with a pair of forceps. “This is an umbilical cord attached to a placenta. WHERE IS THE BABY?” They continued to feign ignorance reminding me of the characters from the old movie, Arsenic and Old Lace. I stabilized the patient and then told the nurse to call Security.
The police went to the patient’s home and discovered a baby in the trashcan. Her father almost had a cardiac arrest and her pious mother was in profound denial. Her middle-aged daughter had cohabitated with a man. The baby was a stillborn that had probably never received prenatal care. The Safe Haven Law for Abandoned Newborns didn’t exist in 1987, but it certainly does now. A baby up to 3-days old can be dropped off at a fire station or a hospital instead of a trash can. No questions asked.
Baby George Francis was preordained to live. A trashcan can never change that.
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.
April 7, 2010
Last week the Internet was replete with stories regarding two North Carolina obstetricians who performed a c. section on a non-pregnant woman (see ABC News). Sadly, mistakes of this magnitude occur more often than the public is made aware to the detriment of both unsuspecting patients and unsupervised resident physicians.
Residency training is a pecking order and the neophyte intern is the first responder. He or she must evaluate the patient, and then report their findings to their senior resident or attending physician. More than likely this particular patient was obese and had “no previous prenatal care.” According to the ABC News report, the intern performed an ultrasound and was not able to “see a fetal heart tone.” It’s possible that the intern thought the patient’s baby had died and ordered an induction of labor for its delivery. The “induction” allegedly lasted two days and the patient and her husband requested a c. section. The case was allegedly discussed with a senior resident and attending physician who agreed with the intern’s management. Upon entry of the uterine cavity, a non-pregnant uterus was diagnosed to the chagrin of the physicians and the patient’s abdomen was quickly closed.
Here comes the stampede of lawyers.
Let’s rewind the tape, then hit the play button and describe what SHOULD have happened:
- The intern takes the patient’s history and then examines the patient to determine whether the patient’s cervix is dilated (open) and if the baby’s head is down. If she can’t feel the head, she needs to order an ultrasound in the radiology department. If it’s after hours and a radiologist is unavailable, she can do an “unofficial” scan and see if the scan can be read by either an offsite radiologist via telemedicine or her attending physician.
- She attempts to obtain a fetal heart tone. If none is obtained, she needs an OFFICIAL ultrasound to make certain the baby is alive.
Doing steps 1 and 2 would have documented an empty, non pregnant uterus and eliminated unnecessary surgery. Also, the intern’s senior physician and attending should have BOTH examined the patient to confirm or dispute the intern’s exam.
Our ob-gyn protocols are clearly established. Why on earth can’t we follow them?
February 24, 2010
“Let them eat cake” was the response uttered by a French aristocrat upon learning that her impoverished citizens did not have bread to eat. The US State Medicaid offices have essentially said the same thing. (See US States Slash Medicaid by Tom Eley) If the proposed Medicaid cuts are enacted, being poor will become equivalent to having a death sentence in one of the most prosperous countries in the world. Don’t believe it? A 76-year old woman in Michigan died from dental abscesses in Michigan when her dental coverage was revoked.
If you’re poor and need eye services? Forget about it. Live in Arizona and have children in the CHIP program? It might very well disappear. Have mental health problems and live in poverty? You might not be treated. Pregnant and live in California? You’ll have to be poorer than dirt in order to receive insurance. Your doctors’ Medicaid and Medicare payments have been slashed severely so very few will be able to treat you. No one wants to work for free. Are you incontinent with urine? Sorry, no more adult diapers. If you live in Tennessee, please don’t have a car accident or heart attack. Your state is only going to pay a lifetime Medicaid benefit of $10,000 for inpatient care.
If state legislators need money to fund our healthcare system why don’t they start by commandeering the obscene salaries and fiscal perks of insurance CEOs? Make the lobbyists empty their deep pockets. Raid the trust funds of spoiled brats who never did an honest day’s work in their lives. Empty the bank vaults in the Cayman Island and bring home all of that tax-free money. Tell the oil barons in Dubai to stop milking us dry. How about manufacturing something “Made in the US” for a change?
Billy Graham once said “Hot heads and cold hearts never solved anything.” Performing slash-and-burn maneuvers will NOT eliminate our healthcare’s fiscal problems. The poor are sick and the sick are poor. Please do not increase their numbers.
December 14, 2009
An IVF patient posted a blog complaining about the possibility of only receiving two ultrasounds during her pregnancy and I could feel her pain. Quite recently I had a protracted discussion with an imaging center that kept denying my patients an ultrasound based on Medicaid’s rule of only one ultrasound per pregnancy.
Medicine has become a BUSINESS and many clinical decisions are now based on whether or not someone will be paid. Those who know me or read The Smart Mother’s Guide to a Better Pregnancy know that I abhor “keepsake” ultrasounds that are done for gender determination and entertainment. However, I value legitimate fetal ultrasounds that are reviewed by radiologists because they have saved lives. The earlier the fetal ultrasound is done, the more accurate the fetal dates. This could become an issue if you unexpectedly need an induction of labor.
An ultrasound done at 20 weeks provides information regarding the anatomy of the baby. Is there a 4-chambered heart? Are the baby’s intestines normal? Has the brain developed properly? Everything’s okay? Great, but what happens at the end of the pregnancy? The real-time information that ultrasounds provide to determine fetal well being is priceless. This year alone at least seven of my patients’ were spared stillbirths because we detected poor fetal growth, abnormal placentas, low amniotic fluid and umbilical cords wrapped around their babies necks, thanks to a third-trimester ultrasound.
So how do you get around the only-one-ultrasound-per-pregnancy rule? Your physician must write an order as a “follow-up” of a condition previously detected or diagnosed. Did you have previous abdominal pain or bleeding? Was there a suspicion that your baby wasn’t growing properly? Was the placenta in the correct position? These conditions justify obtaining a follow-up ultrasound. If you have a high-risk condition, don’t hesitate to request a referral to a high-risk specialist who can monitor your baby using 3-D ultrasounds.
Visual access of your baby is extremely important. The one-ultrasound-per pregnancy rule is total nonsense.
December 2, 2009
However, what Woods and I DO have in common is our public visibility. As a public health employee, my life is an open book.
A few years ago I had to report a former boss for inappropriate behavior based on several patients’ complaints. The case “blew up” because of his notoriety as both an elected official and a physician and I ended up with the media on my doorstep. The reporter, camera crew and satellite truck remained parked in front of my home for almost three hours, reported the 11:00 o’clock news and then finally left. Although I didn’t speak with them that night, I knew that I would have to do so the next day. “Never say ‘no comment’” was the advice that I had been given from a law enforcement agent who was investigating the case.
When I reported to work, a public information officer suggested that I participate in an elaborate scheme to avoid the media. And when I flatly refused, she told me that “I was on my own.”
The maintenance man and a secretary accompanied me as I walked out the door and faced the paparazzi. It was one of the most difficult days of my life. However, I was polite, non-judgmental and advised them that I was leaving the matter in the hands of the courts. My former boss lost his medical license and was removed from political office by the Governor. He faced criminal charges and the case dragged on for years.
In the court of public opinion Tiger, a lie unchallenged becomes the truth. The media is NOT going to go away.
November 16, 2009
Shame on the companies who sell fetal diagnostic equipment to the lay public in the name of profit! They should be hung upside down and left to dry. The New York Times article, The Risk of Home Fetal Heart Monitors (by Tara Parker-Pope) tells a precautionary tell of a woman who purchased a fetal home monitor and then ended up with a dead baby.
The patient was a 34-year-old first-time pregnant mom living in Britain who had an uneventful pregnancy until 38 weeks. She had a home fetal monitor and unfortunately used it after she did not feel her baby moving. To her untrained ear, she thought the sounds from the fetal monitor were normal and was falsely reassured. She did not consult her physician immediately and when she did, an ultrasound confirmed a fetal demise.
The article generated 28 comments, most challenging the “validity” of the fetal monitoring process. Here’s the issue: anyone (both lay or professional) who thinks a fetal monitor is not helpful does not know how to interpret the fetal tracing. Period. Flat tracings, variable and late decelerations speak volumes regarding the oxygenation status of the fetus. Babies can’t tell us when they need to be delivered but they give us profound clues. Unfortunately, these clues are often ignored or misinterpreted with egregious consequences. This is the very reason that I included the topic of fetal tracings in my book, The Smart Mother’s Guide to a Better Pregnancy AND provided pictures of normal and abnormal fetal tracings. As a patient, you need to be empowered to recognize abnormal fetal patterns in the event that someone else doesn’t.
There are women who believe that they have a “right” to purchase a fetal monitor because it’s “their body.” Well, let me say this: if the machines’ manufacturers did not provide instructions on how to diagnose fetal bradycardia, fetal tachycardia, variable decelerations, fetal arrhythmias or ectopic beats, then PLEASE do not be reassured by the sounds that you hear. What appears to be “simple” quite often isn’t.
A fetal monitor is not a toy and in the untrained hands, deadly. If you do not feel your baby move after one or two hours, please call your obstetrical practitioner immediately!
“A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.”
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.
July 23, 2009
I’ve loved writing for as long as I can remember thanks to my late Aunt Dot, who instilled this passion at an early age. She would proudly tell her friends that I had been reading the New York Times since the age of 8. While I don’t know how true that is, I do have an intimate relationship with the written word and know that it is mightier and stronger than man-made weapons.
For the past five years, I’ve tried to put words on paper that would empower pregnant women to take control of their pregnancies and thus my book, The Smart Mother’s Guide to a Better Pregnancy Was Born. The landscape of healthcare as changed dramatically since I stepped out of residency training. Physicians no longer control the healthcare profession.
Right now, we’re in the midst of a pitched battle to reclaim our profession but in the meantime, four million babies will be born each year in the U.S. Those babies and their moms must be protected. Please read my interview with Carol Borthwick of the Qean Group below to find out how.