Pre-eclampsia or Toxemia

Toxemia is a big problem.

Toxemia strikes about one in twenty pregnant women. It is usually mild, but sometimes is severe. Occasionally it will become life threatening. When it gets really bad, it develops into eclampsia (instead of pre-eclampsia). When it is super bad, it leads to a failure of the blood systems, then we call it HELLP syndrome. HELLP is an acronym for "Hemolysis, Elevated Liver Functions, and Low Platelets". About one out of 75,000 pregnant women will get toxemia so bad that they die of it. 

The professors of Ob all call this pre-eclampsia. The old folks will likely call it toxemia. Personally, I like to call it toxemia. I think the name toxemia better reflects an understanding of what the disease process is. The old latin name of pre-eclampsia just doesn't create any useful meaning to me. In any case, all physicians know both meanings. 

To put the mortality rate into perspective, there are about 5000 hospitals in the USA. This means that about 1 in 15 hospitals can be expected to lose a patient to toxemia in one year. And about one in 20 Obstetricians will lose one patient in his or her's entire career. This is assuming an Ob career involves about 5000 babies. Personally, I have already delivered more than 5000 babies, but I believe I have more experience than most. 

Some hospitals have more high risk cases. Those high risk hospitals will obviously have a much higher count of the risky cases. 

My hospital, The Valley Hospital in Ridgewood NJ, attracts these extremely high risk cases. We have one of the best Neonatal Intensive Care Units in existence. Our chief neonatologist is Dr Frank Manginello. He is a noted author of one of the best NICU reference books in existence. His best selling book is called Your Premature Baby. The book is available on Amazon. Here is the Amazon link: http://amzn.com/0471239968 . 

We also have a superb IVF program, and a wonderful Maternal Fetal Medicine team, not to mention a medical staff in the thousands, most of which were trained in New York City. Many of them maintain privileges at University hospitals. 

For instance, my favorite fetal cardiologist is Dr Zvi Maran. He has privileges at both Valley and at Columbia University. Columbia is about 20 minutes away just over the George Washington Bridge. Dr. Maran took care of my daughter when she had a very frightening cardiac arrhythmia. He and his excellent partners got her through this and eventually her heart healed itself. 

So, hospitals with a higher risk population is going to see a lot more of the riskier cases, and their experience is going to be higher than just the numbers will show. 

What is Toxemia? 

Nobody really knows for sure. But, even though we aren't sure what it is, we do know an awful lot about what it does. The body of the pregnant women is behaving as if there were a really bad toxin in the blood stream. No toxin has ever been found. But all of the organs start to fail. First, the blood pressure starts going up. This is due to the arteries feeding these organs squeezing down on the blood flow, leading to less flow to these organs. Early on, the kidneys start to malfunction. The kidneys start making less urine. This leads to fluid retention and severe swelling, and usually 10 pounds or more of fluid is retained all throughout the body.  The kidneys start to "spill" protein into the urine. There is usually no protein in urine because the kidneys are good at making clear urine and keeping the valuable protein in the body. In toxemia the protein spills out. 

So a lot of prenatal care is designed to check for these things. In a prenatal visit, the blood pressure will be checked, the patient will be weighed to see if there is this sudden severe fluid retention, and the urine will be checked for protein. All of these checks are to test for the signs of toxemia. 

Officially, the diagnosis of toxemia requires an elevated blood pressure, and some protein in the urine. 

The brain will eventually be affected. Some of the signs of toxemia affecting the brain are: a bad headache, visual changes including dark spots, sparkles, blurry vision, loss of vision, or more rarely, personality changes. 

The liver will be affected some times. This will lead to an elevation of the "liver enzymes" on a comprehensive panel of blood tests. If the liver gets too swollen, it can cause pain in the liver area of the abdomen. This is considered the right upper quadrant of the abdomen, just under the lower edge of lowest rib. A very swollen liver can actually rupture. If this happens, the patient may die from the blood loss into her abdominal cavity. I have never seen a liver rupture, but I have seen many many painful tender livers, with elevations of the liver blood tests. This is all quite common if toxemia gets to the HELLP stage. 

In the blood, the red cells can rupture. This can lead to severe anemia, and elevations of bilirubin in the blood on tests, and bilirubin in the urine as well. Also, in the blood, the platelets can get used up by the toxemia, leaving the platelet count perilously low. These women may need platelet transfusions.  Platelet transfusions are easy to order from the blood bank, and can be lifesaving If the platelet count gets too low, a life threatening hemorhage becomes likely, especially at the time of delivery. At delivery a woman needs all the platelets she has to shut off the blood flow to the placenta. Without that, there will be a hemorrhage. 

The blood flow to the heart muscle can be compromised, leading to heart failure, or a heart attack. 

All of the organs can be compromised. 

None of the toxemia directly affects the baby. Only to the extent that toxemia affects the mom or the placenta. 

If the blood flow to the placenta is compromised, then the baby may become short on oxygen, or may be short on nutrition. The baby may stop growing. The babies blood pressure may become very low. 

The placenta might even disconnect from the mother. If this disconnection is more than a mild case, then the baby will be distressed or even die. We call these placental disconnections Abruptions. Placental abruptions are much more common with hypertension, than will normal blood pressure. Abruptions can also happen from some kind of trauma to the pregnant uterus. Car accidents, falling over on ice or on the stairs, or physical assault on the fetus, can all cause the placenta to abrupt. A complete abruption when a woman is far away from the hospital will almost certainly end the babies life, and will very much risk the mothers as well. Sometime the blood just pours out of the vagina like a hose. If this happens there are only a few minutes, perhaps 10 but maybe up to 30 minutes, to try to save the baby and the mom. I have seen many abruptions. If it happens in the hospital it is almost certain that we can save the mom and the bay. If the private obstetrician is not there with the patient, then we have the on call ob. The "doc in box". In my years doing the on call, I have saved maybe 4 or 5 or more from a placental abruption. Mostly by doing a really fast C-Section. 

After the baby is delivered the nurses will sometimes come up to me and say, "thank you for coming right away when I called you. You saved this baby". My answer to that is, "no, you saved the baby by being there, recognizing the problem, and calling me without delay. You saved the baby, I was just doing my job". In the end, doing our jobs requires a lot of teamwork. Everyone becomes a link in this chain of human events. And when it all works out, we can all be really proud of what we do. 

But not all abruptions are complete. Many are partial. It is easier to save those babies. 

How to diagnose it? 

If the blood pressure is elevated, then we know there is a problem. It might be "gestational hypertension", which used to be called PIH, or pregnancy induced hypertension. Or, it might be toxemia. We will look for protein in the urine, either on a urine dip strip or on a 24 hour urine collection. We will order blood tests to look for hemolysis, low platelets, and liver function tests. We will likely need to do these tests in the hospital. The patient may be formally admitted, or she may be kept as an outpatient for up to 24 hours. 

We will ask her if she has a headache, or visual changes, or sudden fluid retention and swelling, We will ask her about nausea, and pain in the liver area. 

We will weigh her, examine her lungs, heart, liver, and uterus. We will check the reflexes. If they are elevated, that is a sign of toxemia. 

If the blood pressure is below 160/100, and there is no hemolysis and the platelets are normal, and there is no liver involvement, and no brain involvement, then we call it mild toxemia. Mild toxemia remote from full term can be observed, usually in the hospital, but sometimes at home. Mild toxemia at term should be delivered without delay. 

Delivery cures toxemia 100 percent of the time. If the women has permanent damage to her kidneys, or heart, or anything else, as result of a terrible toxemia, then those problems can last forever. But the toxemia itself will be gone. usually it fades away from hours or days after delivery, and is completely gone in 6 weeks time after delivery of the baby. 

A patient with severe toxemia will need to be delivered regardless of the gestational age. Even if it means losing the baby. We have to deliver the woman, even at 22 weeks, and sometimes deliver a non-viable baby. If we do not deliver the baby, then the mother may die or be permanently damaged from the multiple pathways of pathology I described above. We do not want to have a maternal mortality. 

Even having said all of that, ACOG (American College of Ob/Gyn) has written a recommendation that some milder cases of severe preeclampsia, if they are remote from term, may be allowed to stay pregnant a little bit longer if it means the difference between life and death for the fetus. ACOG will only allow this protocol under certain circumstances. Among them are an experienced facility with very experienced Obstetricians, perhaps with Maternal Fetal Medicine specialists available. Our facility fulfills all of those criteria. Therefore I am comfortable managing a "moderately" preeclamptic patient without immediate delivery. But in most cases, immediate delivery is necessary. 

Who is at risk? 

Some women are much more likely than others to get toxemia. Hypertensive patients, diabetics, older pregnant women, over stressed women, women who have had it before, women who use drugs like cocaine, women without prenatal care, women who suffer from poverty or who don't have a family or husband to help, women with anxiety disorder. 

But even so, it can happen to anybody at any time. 

Prevention? 

Many things have been tried to prevent toxemia. Nothing has worked. We can certainly prevent some of the risk factors, though. We can provide proper prenatal care, proper nutrition, prevention of diabetes, lower lifestyle stress issues, prevent drug abuse, and engage the family into a social support group. 

Aspirin has been tried and it doesn't work. 

Calcium, magnesium, vitamins, none of them work. 

We usually advise some moderate bedrest to lower the blood pressure, but most Obs don't believe that bedrest will actually prevent it. And bedrest itself has a number of severe risks, especially including lethal embolisms from DVTs, but also including severe decondioning, which may require physical therapy to overcome. 

Someday, someone may actually find the toxin of toxemia. If they do, there will surely be a Nobel prize to that individual. 

Thanks for reading. 

John Marcus MD Ob/Gyn 

89 North Maple Ave 

Ridgewood NJ  07450 

201-447-0077 

blog at doctorjohnmarcus.blogspot.com 

Influenza after Hurricane Sandy

It is now Saturday November 10th, and it's my first weekend off since Hurricane Sandy came through. When I woke up today I was struck by the thought that I haven't had any phone calls for influenza yet this season. We are well into flu season. Usually, by now, there are a ton of calls. I wondered "what was up with that?" Why no calls for influenza? So I did what I usually do with these kinds of influenza questions. I opened my iPhone and surfed over to Google's flu tracking tool at http://www.google.org/flutrends/  Immediately I discovered that the United States is having a bad flu year. Here is a screen shot of my iPhone page: (Hint: If you click on this picture, it gets much bigger and more readable):

The line for the present year is a darker blue than prior years. This years line ends at about November first, because that is the most current data.  You can see that the present incidence of influenza is well into the moderate range, and it it well above prior years. This years line is above all prior years, with the exception of the really high H1N1 year. That tall peak was the year that H1N1 happened. Google's web service tracks influenza by analyzing search terms that people type into Google. Google's flu tracking technique is statistically validated, and their results are published in the scientific journals. It turns out that Google's technique gives us flu data about two weeks sooner than the old way. The old way was just collecting case results from emergency rooms, and things like that.

So, if the US is having a bad flu year, why am I getting no calls? I decided to look at New Jersey's results. When I clicked on New Jersey on the map, I got this:

You can see that New Jersey's incidence is not only low, but has dropped off quite a bit over the last week. So Google's flu tracker seems to confirm my suspicion that we are having an anomalously mild flu season. Either that, or people with influenza are neither calling me about it, nor are they searching Google for answers. It seems to me that we are actually having a mild year.

Could it be hurricane related? Maybe so. There was no bus or train service for a very long time. Maybe no one is spreading flu on the bus, so the incidence is very low and dropping. It could be that no one was going to work, and therefore not spreading the flu at work. Or, a big factor might be that the kids are out of school for more than a week. If the kids cannot spread influenza at school, that might be enough to lower the incidence of influenza. Are there any other factors? Maybe all of the houses without heat were inhospitable to the influenza virus.

So, you heard it here first. This is headline news. Catastrophic Hurricanes during flu season causes a reduction in influenza incidence. The evidence is the strong dip in the dark blue line on the second screen shot above. This is a tiny silver lining in the cloud over our heads. If no one has noticed this effect before, maybe I can get the hurricane effect named after me, :). The Marcus effect, maybe? If it hasn't been named before?

If this reduction is real, then I would like all of you to consider the lethal nature of influenza. Every year, 25 to 50 thousand Americans die of influenza. Please compare that number to the 200 or so people who died in Hurricane Sandy. Maybe the silver lining isn't so small after all. If these statistics hold true, it may be that Hurricane Sandy saved more people from influenza than died from the storm. If you look at the yellow picture of the United States in the above two web pages, you can clearly see that the northeast states have a much lighter shade of yellow, compared to, say, the south from Florida to Texas. The northeast may have been affected by the hurricane, whereas the south is having a normal flu season. Maybe someone can compare this with prior years to see if the effect is real.

In my office I try to immunize all of my pregnant patients against influenza. All of the professional groups, such as the American Congress of Obstetrics and Gynecology, recommend  that pregnant women get a flu shot ASAP. In fact, pregnant women should be first on the list if there is a shortage of vaccine. When H1N1 happened a few years ago, there was a severe shortage of that vaccine. Who was offered the vaccine first? Those most at risk were offered first. And that meant pregnant women were offered the vaccine first.

When the power went out in my office I took my boxes of vaccines home. I did that so I could keep them in a fridge at home, and keep them safe in the power outage. But I missed a box in the dark office. It warmed up and I had to throw out the whole box. That was a shame  because I had the single dose vials. These have no preservatives and are better for pregnant women.

Back in 2009 I was a speaker at an influenza symposium given by our hospital, The Valley Hospital. At that time, influenza type H1N1 was running it's course. H1N1 is unbelievably evil. There were two giant epidemics last century that each killed millions of people. H1N1 came back again in the year 2009, and there were worries that we would once again have millions of people die. Well, that didn't happen. Our public health measures were very successful at averting the mortality rate of prior pandemics.

What is influenza? It is a virus that infects humans via microscopic airborne droplets. It doesn't just infect the lungs though, it gets loose into the blood stream as well. The major signs that one has influenza is high fevers and muscle aches. There is usually profound fatigue, some respirator illness such as a sore throat and cough, and maybe some intestinal discomforts.

Whenever a person has high fevers and muscle aches, we call that illness an Influenza Like Illness, or ILI. An ILI does not require a visit to the doctor or the emergency room, but a phone call to the doctor would be a great idea. The doctor can phone in a prescription for an antiviral medicine. One such medicine is called Tamiflu. Pregnant women with an ILI really should take the Tamiflu. In my experience the Tamiflu sometimes stops the virus in it's tracks. A persons energy then pops right back. The Tamiflu really avoids the prolonged fatigue that one gets while recovering from this nasty virus. Also, when one is recovering from an ILI, one should be resting and drinking plenty of fluids. This is especially true of pregnant women. Pregnant women simply don't have the reserve energy that non-pregnant adults do. Some of them cannot possibly recover from the profound fatigue unless they take the time to rest.

So the lesson for influenza is this:

Get vaccinated to prevent it.
If you get an ILI, then push fluids, rest, and maybe take Tamiflu.
If you are pregnant, then you must stop working, rest, push fluids, and take Tamiflu.
Call your doctor.
You won't need to go to the doctor unless there are other complications.

Once again, thanks very much for reading my blog. Please post links to my blog. It is really great to see all the people who are reading this from all over the world.

Sincerely,

Doctor John Marcus MD
89 North Maple Ave
Ridgewood NJ, 07450

phone 201-447-0077
fax 201-447-3560
blog at doctorjohnmarcus.blogspot.com

I am soon to start twitter as well, as it was one of the only services that actually worked during the height of the storm. I do have an account, I just never really used it. I am still not sure if I tweet to other people, or if they tweet to me. In any case I just tweeted that I have a new blog post up. Where that tweet goes, I have no idea.

Hurricane Sandy Recovery, and more yeast infections. Some photos of tree damage in my town. 

Today is Monday November 5th. Hurricane Sandy came through here exactly one week ago. Power came back at my house about 36 hours ago, and electrical power came to my office about 24 hours ago. This morning we went in to the office and restarted our business equipment. The phone system has completely lost it's mind. The programming is gone. This means that every phone in the office rings for every call. My staff was extremely busy all day taking phone calls and arranging  new schedules. And they did it with our malfunctioning phone system. It sounds funny, but the fax machine started to answer every call. I am sure that was frustrating to callers who were answered by a fax tone. We unplugged the fax and forwarded those calls to a Lifeline fax server. And when we tried to send faxes, the receiving fax machine was putting our fax machine on hold, complete with music. Our fax machine does not need, or even like, music, so that obviously blew up our communications systems. Once, when I got tired of the phones ringing nonstop in the exam room, I pulled the phone off the wall and unplugged it. I think I moved much too fast. Besides alarming my patient, I banged my head into the corner of the cabinet by the phone. Ouch. That hurt. But I had a good laugh about it. Probably everyone's phone and fax system is deprogrammed by now.  If it wasn't so serious it would be funny. Today, I had a women who needed to know a vaginal biopsy report to decide if she was going to have a C Section or not. But the lab couldn't get the test done, so now we have to decide without that information. That's kind of stressful. We will take good care of her anyway, and I think she will be satisfied with what we have done.

I think Halloween is cancelled now. It was rescheduled by Governor Christie, if you can believe that. First to Saturday, then to today, Monday. This, despite Halloween not being any kind of official holiday. But, since the streets are full of fallen trees, fallen power lines, piles of leaves, and piles of branches, there is just nowhere safe for the kids to go around trick or treating.

Most of my town is still without power, and the gas lines are still very long. Most of the gas stations are closed due to either running out of gas, or no electric. I called the Governor myself and was utterly surprised when a women answered the phone. I asked her to relay a message to the Governor that I thought the gas stations should get generators. Now, everyone must realize that Generators are dangerous machines. Our military has a spate of soldiers who died in war zones because of improperly wired generators. The press uses the term "faulty wiring". Faulty wiring means that electricity flows were it doesn't belong. Generators are only safe if they are operated within codes. That means that "electrical ground" is grounded, and "electrical neutral" is "bonded". If that is so, and connections are secure, than there is no danger. So, I asked the Governor to make sure that every local code official inspects the gas station generators, but not deny it due to permits. The other generator safety factor is that the generator must not "backfeed" into the power mains. If it does that, then there will be dangerous electricity where the power company thinks there isn't, and power line workers can get hurt, or worse. Worse, when the electrical mains come back, the generator cannot fight the strength of the power company, and the generator burns up in a ball of fire, especially including the gas tank on top of the generator. In an emergency, the best way to safely prevent backfeeding, is to pull the electrical meter. This completely prevents backfeeding. But, pulling the meter is illegal. I urged Governor Christie to explicity alllow pulling the meter at gas stations, by qualified electricians, so generators can be hooked up safely.  Pulling the meter reduces the electricians job to just a few minutes. We know that generators are scary dangerous. We in Jersey know that. But, here in New Jersey, we are facing a killing freeze tonight, and many folks have no power. And many folks cannot get gas due to the lines (lines are called queues in other countries). Something has to be done. It is my belief that the legal electrical codes need to be modified to suit the emergency. Pulling the meter is a no brainer, and allows safe electrical supply to Gas Stations.  The Gas Stations need to get electricity, and to start pumping gas. If generators are properly operated, then they do their function very safely. The electrical code officials are the best troops on the front lines of getting everyone the gas they need.

I don't see any gas stations on generators around here, with the one exception being the gas station that is owned by the mayor. That one has a nice generator hooked up, and at least our town can get gas there. But, there is still a giant line of waiting people queued up. I am sure that the mayor had no problem with proper hookup, or with the towns electrical inspector.

So, it is my opinion that getting the gas stations on generators is a priority. Moreover  it is an easy job for an electrician. It will save lives and prevent misery over the next few days.

Unbelievably, we have a Nor'Easter coming in two days. These storms are "winter hurricanes" centered out over the Atlantic Ocean, which blow strong winds and rain inland. Usually there is a lot of wind damage and power lines down. We only get one every few years. It will only add to the misery, especially to those without power. I hope no more lives are lost.

I have lent my generator out to a local family without power. I hope it helps them, and it keeps their pipes from freezing.

What was the most common Gyne problem I saw in the office today? Yeast Infections. True to form, on Halloween and Easter, there were a ton of yeast infections. I carried my bottle of diflucan around in the office. And handed them out. I think the yeasts were worse than usual today. It is possible that the stress of the hurricane is worsening the situation, but it seems to me there is something more. My theory is that all of the veggies were gone from the grocery store and the peoples fridges, so people were compensating with lower quality food, with more carbos. Obviously that would include Halloween candy. But it would also include donuts, chips, and other junk food. Personally, I bought a box of donuts and brought it home, and no  one at home complained there were too many donuts. How could I resist? The store had them out at the front. And everyone was stressed. The donuts were great.

I have a stack of photos of the tree damage done a week ago. There were trees snapped off at the trunk, and uprooted, some onto cars and houses. I have heard of no one in my town getting directly hurt by the hurricane.

Here are some of my photos. They are all within a two minute drive of my house:

The above tree snapped off at the main trunk.

This tree was uprooted and fell over next to a stop sign. The stop sign was turned upside down by the winds.  That root ball is 7 feet tall.

This big healthy tree was snapped off. 

This tree was uprooted and landed on the car in the background. The car has a tarp on it. 

These folks got a car smashed, and their house. 

1, A power line in the foreground 2. A Gen running in the garage! They are lucky to outlive this severe generator error. I informed a fireman around the corner, but he said he could do nothing. This is a lethal error. Never run a combustion engine inside, ever.  

This is a nice Honda Accord smashed by a tree. Obviously the driver would have died if it hit with him in it. 

This uprooted tree barely missed the house. 

This area was spared, but look at the power lines. Buried power lines look better and are safer. 

A different view of an undamaged lot. 

Another undamaged Wyckoff lot? look in the back yard. A tree is down there. 

This nice Mercedes Benz sacrificed itself to save the driveway. Obviously passengers in that car would have been killed. Look at the size of that tree trunk. It is as wide as the Mercedes. Only a part of the tree fell. it was a twin oak, or maybe a triplet oak. 

This is a short 30 minute line just for gas cans, for generators. Notice the police keeping the peace? They all did a really great job. They came around, asking questions, and making sure everyone was ok. The guy behind me in this line had a tree branch come through his roof. The branch penetrated his bed where his legs would have been, had he been sleeping there. Thankfully, he wasn't in bed. But if he was in bed, he was ignoring the towns advice to stay on lower floors. To my knowledge, no one in my town got hurt in an upstairs room of their house. And there were no floods. 

That's it for today, 

Thanks, 

Doctor John Marcus 

Ob/Gyn 

Ridgewood NJ 07450 

Office number 201-447-0077 

Blog is at doctorjohnmarcus.blogspot.com 

I corrected a few typos on November 10th. My editor must have been taking a break. 

Hurricane Sandy

   The hurricane passed us last Monday. Today is Thursday. It was a historical storm, doing things that have never been done before. The radar and satellite images of Sandy at the time it hit southern New Jersey stretched from the arctic circle to South Carolina. The eye hit New Jersey, and that means that the storm surge on the right side of the storm, hit northern New Jersey and New York. This is where I live. Right at about 11 PM the remains of the eye of the hurricane passed just to the south and west of where I live and work, near Ridgewood New Jersey. Actually this hurricane briefly had a double wall, and it was the outer wall that hit us. Since then the power has been out, the phones were out, the cells were out, and the phone texts were delayed by hours. I am right now running on a generator at home. That is keeping some of the lights and the heat on. The TV's are working and the internet is back now. The answering service that I use is based at the hospital, and they are swamped. If you need to call me via the service just wait on the line and call back if necessary.
   I like to tell my patients that if they cannot get me on the phone, and they may be in labor, or the baby is not moving well, or they have some emergency, then they should just go to the hospital. We always have an Obstetrician physically present in the hospital, 24/7. We call that the Valley On Call Ob Service, or informally, we call it the Doc in Box. We do 12 or 24 hour shifts. It is voluntary for us Ob's to be part of that service. Personally, I am part of that service. I have been since the start. We only allow experienced Obs to do the On Call Ob service. The hospital pays us for this service, but it is not enough to cover the business expenses, especially the malpractice insurance costs, of providing the service. I do it because it is great to stay part of the system, it is really great to save lives, and the money is welcome. Right now there is about 14 of us that share in that service.
   I was on duty for Hurricane Irene last year. It was a busy shift. Many of the Obs could not make it in to the hospital, so I covered their needs while they were away. I was on duty when the power went out in the great power outage a few years ago. We made do with various generators, and backups to generators. We kept everyone safe, and the power came back eventually. We definitely deferred some elective procedures, such as labor inductions and C-Sections. Our hospital now has really giant generators, the kind that are built on  Semi Truck trailers. They are permanently installed.  When the power goes out now, there is just a brief flash of the lights, and everything seems perfectly normal. We still try to defer elective cases while on the generators, though.
   Around my town, and in all of northern New Jersey, there are trees down. Some came down on houses. There are about 30 houses smashed by trees in my town. Many cars are smashed. Many of the trees came down on power lines. Many of the trees were uprooted and toppled. A lot of the trees just broke off on the main trunk. During the hurricane we could hear trees cracking all over town. It makes an unbelievable sound. Usually there are about 3 or 4 cracks over a few seconds, and then the tree falls. When the power lines fall, the transformers near the fall are overloaded and explode, creating a huge flash. If the transformer doesn't explode, then the power lines that make it to the ground start sparking an electrical fire. The brightness and the colors of those fires are amazing. At 11 pm there were giant sparks of these fires all over town. It went on for hours like that. It was a like a lightening storm with continuous flashes all over town. The fire department and police just didn't stop working keeping everyone safe. They cordoned off the wires, used heavy equipment and chain saws to keep some of the roads open, and rushed all over the place. They told the entire town with a reverse 911 call to stay out of the upstairs of the houses. Personally, I saw a tree lifted up into the air about twice it's height, spinning around, leaves and dirt flying everywhere, the air so dense with debris I couldn't see through it, and then the tree was ripped apart and the branches dropped about a hundred feet (30 meters) in front of my car. That was a sight I will never forget. It was like slow motion watching it in my mind.
   During the storm I sometimes would stand at my front door. The wind was not steady, but gusty. I could hear the wind, but then would come a really loud gust just howling out of the north. It would really roar. Then the trees would start cracking and falling. My town has millions of trees. I think if it wasn't for the trees, the houses would have lost many of their roofs.
   Oddly, my town never got a lot of rain. I was watching the rain bands on radar, and the rain just skipped us most of the time. We never got it heavy. This storm was really wide. There were rain bands up to Toronto, and down to South Carolina, and it mostly skipped us. Then, the mountains west of us got several feet of snow, and the ski resorts had their earliest opening ever.
   It is now Thursday. There is no power in my office yet. The power is restored within a few blocks of my building, but not up to my building yet. So, I cannot see my patients. Originally, when we cancelled Mondays hours, we scheduled a lot of them for Wednesday. But Wednesday came and went without power, and still barely with phones. So we have been trying to communicate with them via my phone calling service. But that is really problematic. For instance, the phone calling service called all of my Mondays patients to remind them of their appointment, but they also got a message that the hours were cancelled. The reminder was automatic, and we didn't stop the automatic reminders. I can't blame people for being confused. I just hope they aren't too upset. My phone calling service is called SecureReach, and they are based in Ohio. During the emergency, it was difficult to get everything perfectly right.
   Most of the people around here are taking these problems in a good mood. I have seen these situations before, when everyone comes together to help each other out, and everyone tries to do all the right things. That especially happened after 9/11. But sometimes trying too hard to be nice backfires.
   There are lines for gasoline throughout New Jersey. The lines are hours long. The stations that have power to pump gas run out of that gas in a matter of hours, and the stations that have no electricity have their gas locked up underground. Last night I waited for Gas at a Hess station. One guy was done pumping, but couldn't get out and make room for the next guy, because he was blocked by another car. So we tried to help guide him out so other people could get their gas, but he wouldn't move. People started yelling at him, people who already had their gas. They wanted to help the people behind. Nobody from behind came up to yell; they were being patient. Eventually, the guy blocking him moved and everything got back to normal. So, the only stress there was that everyone was trying to help each other, but one guy didn't want to help enough by moving out of the way. So he got yelled at.
   My power company has about 1700 workers on the power line repairs, and some more tree workers to move the fallen trees. Even so, there are millions of trees down and it will take weeks to get it all fixed. Usually, with a natural disaster, neighboring states will send their power line workers to help. After last years freak October blizzard brought down a bunch of trees (because the leaves were still on), the crew that fixed my neighborhood was from North Carolina. They were prowling around in a pack of about 10 large trucks just looking for the problems and fixing them as they went. This time, the damage covers such a wide area, that if the North Carolina workers are not working in North Carolina, they will be in Maryland or Delaware, where they need just as much help. This time, the news reports that crews are coming in from as far as Texas and California. That would mean that the entire country has mobilized to help repair from the storm. I don't think this has happened before, except maybe with Katrina. But the width of destruction this time goes from Canada to Cuba. So the mobilization will have to be very very wide.
  Meanwhile, my patients will need to just go to the hospital if they cannot get me on the phone. And there is a good chance they cannot, as the cell service is very weak. And the phone lines are dependent on fickle generators. The phone company has a generator running right now, but who knows how long their gas will last. When they run out, if they do, there will be no internet for me to post a blog.
  The food stores are mostly open, but they are completely out of perishables. Most of the perishables were thrown away, because there was no power to keep them cold. And many people, especially the ones without a generator, have lost all of their perishable food.
  Me and my family are doing fine. I wish you all well. Send your prayers for the more than two hundred people that have died, from Canada to Cuba. People have died from drowning in floods, from being washed away in rushing water, from live electrical wires, and by being trapped by falling trees.
  On a lighter note, there will be a baby boom in 9 months. There certainly was one 9 months after last years freak blizzard. All the local hospitals Ob units were quite busy. So, look for lots of new babies next summer.
  Once again, thanks for reading my blog.

Dr John Marcus
Ridgewood NJ 07450.
Phone 201-447-0077
blog at http://doctorjohnmarcus.blogspot.com