Delivering physicians as patients.

Yesterday I delivered a fellow physician. A 37 year old cardiologist at 40 weeks.

She started her labor naturally, a few hours after breaking her water. The labor progressed well, naturally and on it's own. She arrived in the hospital at a very appropriate 3-4 centimeters dilation, and progressed at better than 1 centimeter per hour (this is the standard rate for the first baby).

She received her epidural at 5 cm, as she didn't want to continue with the natural discomforts. She still felt some pressures and a bit of pain with the contractions, but I assured her that feeling some of the contractions is a good thing. She certainly did not appear to be in any distress from the pain.

This physician was medically healthy and was planning a normal labor. And she and her husband were really nice to be around.

The thing about physicians, nurses, and pretty much any other licensed professional, is that their life may be bit more stressful than, for instance, a hairdresser, a truck driver, or a chef, for instance. And undue stress makes any pregnancy high risk.

Because of the requirements of being a licensed professional, I consider a licensed professional to be a high risk pregnancy. This is my opinion. I don't know if the textbooks or medical journals would confirm this or not. High risk pregnancies would of course include lawyers.

Malpractice attorneys are even higher risk. Most physicians hate taking care of malpractice attorneys. I don't. They are people too. They require very good care. I provide that for sure. Most physicians think that malpractice attorneys are lying evil bastards. The attorneys don't think of themselves like that, but as defenders of the weak, downtrodden, and injured. The attorneys believe that they are seeking the truth for justice sake. Most physicians believe contrarily that they are liars one and all. Physicians call them "Trial Liars", which is a play on the name the lawyers call themselves, "Trial Lawyers". In any case, they are also high risk pregnancies. It is clear that the trial lawyers have an unbelievably stressful life. And you can see it in their eyes when they are not working.

There is a big disagreement on the meaning of "truth" between doctors and lawyers. The lawyers engage in what they call "truth seeking" behaviors in courtrooms and pretrial activities. The physicians see those same courtroom activities as remotely disconnected from the truth. Physicians see trials as complete shams, as nothing but highway robbery by brigands and liars. With briefcases instead of guns.  Why such a discrepancy in the belief in truth? Physicians see truth scientifically. Especially if it has been experimentally established, as is done in medical science. Lawyers see truth as a culmination of belief, by whatever method makes it believable. The lawyers believe that truth is whatever the Judge and Jury believe it to be.

Personally, I believe that truths exists in the space of ideas. There are real, absolute truths, as Plato would have described them. They are not physical things. You cannot weigh a truth with a scale. This is similar to a human soul, and mathematical theorems. These truths are real, but you cannot hold them in your hand. Only in your head, and written down on paper. So, physicians and lawyers will never agree on what the truth really is. Physicians ignore this reality of truth at their own peril, when a skillful attorney rips them apart as part of a trial strategy.

Anyway physicians are not immune to the stresses of being a professional. Therefore physicians have a high risk pregnancy. I think this risk is manifested in several ways.

One, they work ungodly hours. Pregnant women are supposed to be off their feet once every three hours, resting for 15 minutes. This will let the natural adrenaline of a normal day fade down a bit. These are work rules that are enforced by the federal government for everyone. But most physicians will not stop working after three hours. Especially if there are sick patients that need their attention, and they are behind schedule. All physicians are behind schedule, because there are people with unpredictable needs. And no one wants to say to someone, I think you have a tumor, but we will talk about it next week. So, we do our best to comfort the patient in front of us, and then get behind schedule a bit.

Two, physicians know about pathology personally. They see it on a daily basis. And if they do not see it in themselves, they will be hard pressed to believe that it is there. So many physicians will ignore indications of serious trouble.

Three, physicians still get "medical students disease". This disease is an inappropriate belief that some pathology affects them. To mix a metaphor, they are in a forest but cannot see the forest because they can only see the trees. Physicians make poor doctors to themselves, and have a fool for a doctor, and a fool for a patient. These are old sayings in medicine. Every doctor should have a good therapeutic alliance with another good doctor, to keep these anxieties in check. And the doctor for the doctor should have a calm demeanor, and a lot experience. This will prevent medical students disease by proxy.

Anyway, this particular patient was doing beautifully in labor. She was physically strong, and a very good pusher when it was time to push. But, as a physician, we need to consider this is a high risk patient, and we need to be ready for complications.

So, after pushing for an hour, the babies heart beat starts going much faster than normal. I discussed with her and husband the reasons why this might be the case. A common reason might be infection. Another reason might be the babies head getting squished in the birth canal. Ultimately this was the cause for her. But no one wants to leave the baby in a stressed out condition, so I decide to help the baby come out a bit sooner. Before the baby really gets stressed from the rapid heart beat. She obviously agrees.

When the baby was on the "outlet" of the vagina, I decided to use the vacuum forceps. This will help the baby be born a bit sooner. And there are many studies which show that "outlet forceps" have as good a prognosis as natural labor, or better.

So I used the vacuum. True to form, the high risk factors start coming in to play.

First of all, there was a loose nuchal cord.

Then, there was a "shoulder dystocia". This means the baby is stuck with it's head out, and the shoulders are holding the baby in. Shoulder Dystocia is a bad thing to happen. Babies can get injured or worse by the difficulties associated with delivery past the stuck shoulders. I have an entire blog post already written about shoulder dystocia. I still need to edit it some before it becomes good enough for publication on this blog, but that blog post is coming.

So, we wind up doing two basic maneuvers to relieve the shoulder dystocia. We did a McRoberts, and suprapubic pressure by a very skilled nurse. The shoulder dystocia was then released and did not cause any harm to the baby, thank God.

Then we had the third stage of labor. The placenta came out. And then she had a postpartum hemorrhage.

In a normal pregnant woman, the baby gets about half of the mothers cardiac output of blood, directly to the underside of the placenta. The uterus gets it's blood supply from the mom via very very large blood vessels. They may be as thick as your thumb. What stops the blood flow normally is that the uterus contracts down tightly. These uterine muscles, which just finished pushing the baby and placenta out, need to continue to contract, and get very tight, to close the placental blood flow. Without the placenta blocking it, and if the uterus doesn't contract, the blood flows out of the mother like a river. It literally pours out like a thick waterfall. In the presence of postpartum hemorrhage, a woman can bleed to death in minutes. Postpartum hemorrhage is the number one cause of maternal death in advance countries. The last I looked, about a hundred women a year die from postpartum hemorrhage in our country alone.

So here we are with a high risk pregnancy, a fellow physician, and we have already dealt with a shoulder dystocia. Now we have blood pouring out like a faucet. What to do?

The first thing is to get the uterus to contract. We literally compress it with our hands. One had in the vagina, and one hand on the top of the uterus. At the same time we compress the uterine vessels with our vaginal hand, and give the new mom some medicines that will further tighten the uterus. We not only compress it, but we massage it. That seems to work better than just squeezing it. A hemorrhaging uterus can be more or less controlled by physical pressure. In fact, all bleeding, from anywhere, responds to pressure, if there is a way to press on either the bleeding place or the blood vessels feeding the bleeding. In this case we can do both. Just remember that pressure stops all bleeding, no matter where it comes from.  Anyone can save a life by remembering that bleeding stops with pressure. That is the point of a tourniquet that all boy scouts learn about.

So then I stopped the bleeding with pressure, massage, and medicines. Thankfully she had an epidural. Without the epidural these pressures are very uncomfortable, to say the lease. I even had our anesthesiologist come and boost her epidural quite a bit. This worked to keep her comfortable.

After the pediatric physician checked the baby, and declared the baby healthy, our new mom got her new baby while I finished up the vaginal repairs.

The next day on rounds, she and the baby looked wonderful. She was walking around with a big smile.

So, we have to be ready for pathologies like Shoulder Dystocia and post partum hemorrhage at any time.

A good obstetrician will review the protocols many times in their career, and stay up to date, and ready, willing, able, and confident, to manage these things on a moments notice. For that matter, midwives need to stay on top of these things as well.

Thanks for reading my blog. Comments are encourage.

Available at doctorjohnmarcus.blogspot.com

Doctor John W Marcus MD FACOG PC
89 North Maple Ave
Ridgewood, NJ, 07481

Phone 201-447-0077
Fax     201-447-3560

Thanks for reading.

People you would like to know:

It is now just after midnight on the beginning of Thanksgiving day. I am trying to catch up on my labs and reports for patients. 

I am looking at a report from a Neurologist consultation for a 26 year old nurse who has terrible migraines and some painful disk disease in her back.  So I am thinking of her personality and her character strengths. I know her well. 

She also has two small children that I have delivered for her. She is in the late stages of nursing her second baby now. 

Despite having these medical and life challenges, this is a person that I think that you would be glad to know her acquaintance. 

Think of her lifestyle: She is a nurse. This means she is dedicated to the proposition that other people need hands on care to improve their well being. She also has two small children, who obviously need her time. In addition to this, she has back and neck pain, and frequent migraines. 

Despite all of this, this person is never in a mood to be mean. She seems to always be in an uplifting mood. Her husband is the executive chef for a large corporation. He is a big guy, tall and substantial in size. He is similarly in a good mood. They are both busy in their life, but they get along very well, and their kids are doing well. 

It is people like this that make the world a better place. Both of them, the new mom and her husband, are the kind of people that anyone with any sense would like to surround themselves with. 

In my role as her personal physician, I am dedicated to helping her optimize her life. But for my sake, I am glad to be able to be there and do my best. I feel myself lucky to be able to be a big part of the life of people who give so much value to the world. 

I try to live my life in a way that is an example for other people. I try to do good deeds, because they come back 10 fold. I try to have good karma, because that reflects back on me as well. 

I think that many if not most people are really good for the world. The good people of the world, which is most of them, make the world a much better place for all the rest of us. I hope I am numbered among those of us who enrich the lives of others. I think I do. But ultimately others will need to judge me. And then I, like all the rest of us, will face my judgement day. 

Upon further reflection, I find that most of my patients are very good people in their hearts. Everyone has challenges, but most people enrich the world more than they take from it. 

So that is my Thanksgiving message on this Thanksgiving day. Among all of the turkey feasts, and pumpkin pie, I give thanks that there are so many good people in the world that enrich my life, and that allow me a position of honor to enrich their lives. 

Thanks for reading my blog 

Dr John W Marcus MD FACOG  

Obstetrics and Gynecology 

89 North Maple Ave 

Ridgewood, NJ, 07481 

Phone 201-447-3560 

Fax 201-447-3560 

Blog is at doctorjohnmarcus.blogspot.com 

Comments are welcome 

International Medicine, British-isms, and "Melting Pot" medicine


I just did a checkup for a 35 year old woman who had a very nice cockney accent. This means she is from a central neighborhood of London. I think that means she grew up within listening distance of a certain cathedral's bells. Or maybe Big Ben. I am not sure which cathedral, but it is a somewhat small area. The cockney accent is unique in the English language. Once you understand what it sounds like, you probably won't forget it. I delivered her baby about two years ago. Having a nice conversation with her was really fun. I like to provide my care in a culturally aware manner and I did no different for her. Knowing peoples backgrounds is not only fun for me, but it allows me to fine tune my conversation and words in a manner that enhances communication and maybe makes them a little less uncomfortable in the office.

Either that or I make myself into a culturally clumsy buffoon <sigh>.  But I try and it is fun.

Here in Ridgewood, in Northern New Jersey, 20 minutes from the George Washington Bridge, I get customers from all over the world. I have many patients from all over Europe, especially Germany (BMW is close by). I have patients that work in Embassies, and in the United Nations. Many of my patients hail from all of the big countries of Europe. Many from Eastern Europe. I have learned a little bit of Russian from my Russian patients. I would like to say Bolshoi Spasibo to my new Russian mommies. One of which is leaving The Valley Hospital with her new 7 pound 10 oz baby tomorrow.  There is a ton of South Americans here. Brazil is well represented because it is a giant country with a lot of corporate connections. I have decided that my favorite Cesarean Section music is called "Brazilian Soul". Think of the "Girl from Ipanema". It is beautiful and peaceful music, and I started that music with a super nice couple from Brazil.

Check this out http://www.youtube.com/watch?v=kDGUZeZWKZo

This is a song from the musical genre called Bossa Nova, from Brazil. It is mostly in Portugese. Not that song itself, but the Bossa Nova.

But I have patients from most of the South American countries and cities, Buenos Airies to Caracas, even Havana. These folks are so lucky because their winter vacations brings them to summertime when they go back home. Some of them stay there for a month, and avoid our winter snows.

Of course no city on the planet doesn't have a lot of Chinese, and we are no exception. Mandarin, Cantonese, Taiwan, Hong Kong, etc. They are all here.

There are so many ethnic Asian Indians that I think of them as locals now. No matter what city they come from, Mumbai to Calcutta to the small towns, they seem more local than foreign. Many of them speak their uniquely accented English.

There are many Japanese folks. Konichiwa my friends.

There are a good amount of families here that hail from Turkey. Many of them speak German, American English, some speak Aramaic,  (The language of Jesus Christ), Swedish, etc.

Lebanese? Of course. They have a most beautiful French sound to their accent. I try to say Bon Jour to them when I arrive in their room. Comment Alei Voux, mon ami?  I really don't know how to spell in French. And I certainly don't know how to write the special characters. Other Arabic countries as well. Then there are many Persians, from Iran.  No middle east list would be complete without all of the different kinds of people from Israel.

And there are a number of Australians of course, not to mention New Zealand. G'day, mate.

As I sit here now I realize that my customer base is from all over the world. And I find that I like it. It is really fun. My own ethnic heritage is very very mixed. I am northern European, but I don't think I can claim any one ethnicity as my own, other than maybe Chicagoan. (From Chicago, Illinois).  My mom is Canadian, and that makes me a Canadian Citizen as well. Canada is very easy on their foreign based citizens. They have never asked me to pay taxes, or even to report a single form to them. Nevertheless, I carry an American Passport. I am certainly an American, born here in the Chicago area.

When I was a child back in Chicago we were taught that the USA was a "melting pot" of ethnic heritages. This was the preferred terminology. This means that the American Culture has melted and formed out of all of the cultures of the peoples that came here before us. This even included the Native Americans obviously.

But tonight I was having my conversation with a fluent Cockney speaker so I decided to use my little bit of British knowledge. I was mostly having fun.

How does that go? Well, they know pharmacists as "Chemists". Emergency Rooms there are called "Casualty". The word Vitamins uses a soft i, like the word Bit, not like the word Bite. Vacations are "Holidays". There are a lot of other changes. When saying the letter Z, it does not rhyme with "Tea" or "Tee", but is Zed.

Now try to sing your ABC's with Zed instead of Zee.

I have found an ABC song on youtube. It is very interesting in that the child bear has a mild cockney accent, sings the zee as the zed, but the daddy bear speaks like he is from Philadelphia. Here it is.

http://www.youtube.com/watch?v=TGHidmEKU44

So, right there, is a little bit of the melting pot.

Thanks for reading my blog

I have a lot of other blog posts partially written.

Comments are welcome.

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

phone number 201-447-0077
fax 201-447-3560

blog is at http://doctorjohnmarcus.blogspot.com

Comments are welcome.

AntiMullerian Hormone (or Mullerian Inhibiting Factor) 

I would like a share a story about the perils of believing that all that is new and modern is better. 

I have a patient who is about 42 years old. She had one child about 4 years old and she desperately wanted another. I took her through the basic infertility workup that I have described on these pages and we found that she had nearly run out of her supply of eggs. So try as she might, and push fertility meds as far as she can (Follistim, Perganol, Menotropin, Menopur, Repronex, urofollitropin, Gonal-F, Fertinex, and many more), she could not make her own good eggs or embryos. 

So for a woman such as her, all hope is not lost. Nowadays, she can still have a baby or babies. The problem becomes how does one get good eggs? What she frequently does, is she borrows them! What she does is, she finds an Egg Donor. The egg donor is usually a younger woman, who is willing to share her eggs with the other woman, the one who no longer has enough good ones of her own. Lets call this one the patient. Once the donor is selected and screened for an appropriate family history, and infections like HIV are ruled out, the donor is put into an IVF cycle. But the donor will not use her own eggs, she will give them away to the patient. The donor is usually paid for her time and effort, and risk, but I think the ethics of the transaction have to be that the eggs are not the purchased item. The eggs are given freely. 

The IVF specialist doctor will then give fertility medications to the donor, to deliberately hyper-stimulate (to a moderate degree), and make 10-25 eggs or so. Then the IVF specialist will retrieve the eggs from the donor. This involves some anesthesia, a sterile operating room, a sonogram to find the follicles, and a longish needle to aspirate the eggs. One egg from each follicle. A follicle is about 2.5 cm, a little less than an inch. But the egg is much smaller than a period at the end of a sentence. Then the IVF specialist will hand the eggs over to a specialist called an Embryologist, who will mix the egg with sperm from the patients husband (or whoever is selected to be the genetic father. Sometimes sperm donors are used as well). If the eggs cannot be penetrated by the sperm, the embryologist can force a sperm into the egg with a tiny needle. This is called Intracytoplasmic Sperm Injection, or ICSI. ICSI is very common nowadays. It is used, for instance, if the husband/father has only a few sperm to work with. Or if the sperm are weak. 

ICSI is well established, it works, and the babies seem to be fine. I have delivered a lot of ICSI babies, no problem. For awhile, the MFMs were worried about chromosomal damage, heart problems, growth problems, etc. The MFMs were scanning these babies up down and sideways, doing invasive amnios or amniocentesis to see the chromosomes, and ordering all of these babies to have cardiac echocardiograms. I guess that is what MFMs do. MFMs will reach to the ends of the earth to find ways to make sure that everything is ok. And if they don't know, they will order every test under the sun. I don't say this because I begrudge their skill, and they are a very valuable service. But sometimes their need to analyze really piles up to uncomfortable levels. I think part of my job as a compassionate physician and counselor is to explain to my patients what the odds are in any given set of stressful circumstances. This way, people can take control of their own risks and plans and hopes. Sometimes we just have to say no and stop the testing. And sometimes we just have to say that not knowing the science is different from knowing the science shows risk. 

In my practice all of the ICSI babies have seemed normal to me. 

Anyway, this 42 year old I was telling you about was really really careful and picked her egg donor from clear across the country. This way many things matched up just right. (height, color, eyes, intelligence, ethnicity, etc). The egg donor was an otherwise healthy 27 year old. She was going to fly to New Jersey when her follicles were just about ready to be aspirated for the eggs. 

But, there was a sudden fly in the ointment. Just before she started the egg stimulation cycle, it was found that her AMH was a bit low. Her Anti Mullerian Hormone. This implies that the donor was short of her own eggs. If the donor couldn't make eggs then the whole plan would fall apart, including the patients own hormonal preparations to accept the embryos in a few weeks. Since I don't do IVF, but I do counsel my patients to the best of my ability, my patient called my up in a seriously stressed out condition. She still was thinking clearly. But to cancel her preparations up to this point would have delayed her family another 4 to 6 months. And she would have to do all of this hard work all over again. 

Mind you, this patient is an extremely intelligent executive for a large successful corporation. She knew as much as anyone would about her entire story. She did not suffer from any kind of character flaws. She was psychologically very strong. 

So I reviewed the entire history with her. We knew that the young donor had no gynecological problems. By all the evidence other than AMH she was able to make normal eggs, and normal menstrual cycles. 

And when I looked at the scientific literature of various sorts around the value of the AMH test, it was said that the AMH test should not be used in an isolated manner, because it was not 100 percent reliable. 

But, wait a minute, they say that about all tests. No tests are 100 percent about anything. In something as complicated as human biology, there are no certainties about anything. (except maybe death and taxes). But I thought about it for awhile. 

Her IVF docs told her to cancel the cycle, as they don't like IVF failures. Why? Anything that throws their stats off will make the IVF docs look like buffoons when potential patients look up the ever present success rates that are published all over the place. Everyone, every potential patient, wants to go to the best IVF doctors, so they look up success rates and wants to get an appointment at the best place. If someone else is zero point eight percent lower in the success rates, then they are going to take their business to the best place. Which is elsewhere. 

So IVF docs hate failures, and hate anything that might affect their success rates. If any IVF docs have a tiny bit higher success rate than anyone else, and they are getting a lot of patients because of it, those IVF doctors are not going to advise any marginal cases to go forward with IVF. In other words, they will give IVF mostly to the people who need it the least, and avoid given IVF to the patients who need it the most. 

This leaves some patients dejected.  And many marginal cases that have some hope for IVF are turned away. 

This is, I suppose, an extension of the law of unintended consequences. When the powers that be forced the statistics out into the open, then the statistics became more important than the patients. And then some docs who provide IVF only to the easy cases, even to those who didn't even need it, became really busy. They formed giant clinics. The docs who did IVF only on young heathy women,  whe were nearly guaranteed a good result every time, had the best published statistics.  

There are some statistical methods that can tease out the success rates of the difficult cases from the easy ones, but the law of unintended consequences still holds. 

So anyway, I advised my patient to go ahead and continue the cycle with the young donor with the poor AMH. I figured the biggest loss would only be the money and the time if the one cycle failed. This would at most be a month. But...think about it... the gain would be a family maybe 5 months sooner that a cancelled cycle. And an isolated AMH doesn't mean that much anyway. I figured that statistics were 5 to 1 in my patients favor that the cycle would work, even with the low AMH. How could a healthy 27 year old donor suddenly run out of quality eggs? The statistics did not favor failure, even with the IVF clinic telling her to quit. 

Then a most beautiful thing happened...

She got pregnant with twins...

The pregancy was very eventful, with placenta previa, some bleeding, hypertension, some working bedrest, some hospitalizions, some bit of temporary gestational diabetes (due to steroids given to help the babies when they were threatening to come early), some meds to quiet the uterus, lots of MFM consultations (and using their excellent information with proper discretion to keep it real and simple), and big babies. 

Then... 38 week healthy full term, nice and big, twins. Born via a repeat C-Section, in an OR with big smiles, nice soul music playing, and a big team of very experienced support staff. 

I shared a story about the perils of believing that all that is new is better. 

What is the moral of the story?  

Don't let an isolated antimullerian hormone test wreck your life. Two beautiful living babies are proof of that. In fact, don't let any isolated test result wreck your life. 

And think about the young egg donor. She now has proven her eggs, and the worth of her ovaries. If the cycle was cancelled, she might have thrown away contraception, had an unwanted pregnancy, lost her life's partner for possible infertility, gone into a depressive spiral, or worse. Now she knows she is good and healthy. AMH be damned. 

Another even more important moral is that Statistics are Abused. Because the IVF programs are forced to divulge their stats, they become slave to the stats. And they will cancel cycles if there is even a 20 percent reduction in possible success for one woman. They live and die by the statistics numbers. Everyone does. If my patient did not call me, those babies would not have been born. 

Pretty soon Obstetricians are going to have their stats published. CS rates, mortality rates, etc. But since every obstetrician does things a little bit differently, they will be punished in what may be completely unexpected manners. And maybe rewarded unfairly. By the statistics that are misused. 

I would like my patients to retain freedom of choice. Freedom of C-Section or vaginal birth, for instance, who can take that away from them? I would not want to. I will do everything I can to make sure their decision is not only proper for them, and that they have thought about all the alternatives to what they have chosen, but I will also do what I can to support them to believe that their choice is valid, proper, and comfortable. 

So after an 18 hour labor and pushing a baby out, and a women is laying there with beautiful new baby on her chest, and she is all sweaty, and the nurses are cleaning up last nights dinner from her gown, and the floor is getting mopped up, and her vagina is sore from stitching, she will have the biggest smile of victory she has ever had. And the baby is in that comfortable spot that they love on top of her mom. Then, she will have known that it was all worth it. And she will have a megawatt smile and a beautiful relief. 

But, if she elected to have the baby the other way, because her own mother's life is wrecked by urinary incontinence and sexual disability, or her brother was strangled in labor and she can't bear the thought of it, and no one offered her mother a C-Section, or maybe she just didn't want to stretch her vagina out, then she can be confident that she will have her baby just the same. And she can be confident that her wishes were honored in a safe and caring manner. 

Who would take her ability to choose away? I would not willingly take that choice away. 

The statistics may be misinterpreted and the bean counters will get involved, and the politically active ones will get involved and make a ton of misinterpretations, and the world will change. 

I will do my part to keep it real, and honest, and proper. 

By the way, I have once again been elected to the position of Associate Director of  my Department of Ob/Gyn. It is my second stint in this position. 

In the past I have been elected or assigned to be the Associate Director, the Chairman of the Department, the Director of Education, the Director of the Oncology Committee, the department secretary, the treasurer, and who knows what else. I have also been the director of the Bergen County Medical Society. 

One of these days I will post my full CV. 

Thanks for reading. 

My blog is at http://doctorjohnmarcus.blogspot.com 

John W Marcus MD Ob/Gyn FACOG 

Obstetrics and Gynecology 

89 North Maple Ave 

Ridgewood NJ 07450 

Phone 201-447-0077 

Fax 201-447-3560