Food Recalls and Listeria
As part of my job as an Obstetrician I like to follow the news.
One thing that is frequently in the news is Food Recalls.
Not too uncommonly there will be news that the various Departments of Health will recall a particular type of food because there is some food-born illness lurking in that food. Sometimes companies will recall food on their own.
It is always something different.
Sometimes, the spinach farm is next to the pork farm, and there is heavy rain, and the pork "droppings" run into the spinach. So the spinach might be found to harbor E Coli bacteria.
Sometimes the barn that grows eggs is found to have bird droppings on the eggs, because the wrong kind of bird has flown into the barn. And those bird droppings carry bird borne infections. Egg farmers have been shut down for this.
A few years ago it was Melons. Before that it was brussel sprouts.
And recently a peanut butter company executive was charged with a crime because he didn't do enough to make sure the peanut butter was uninfected. I don't know the outcome of that trial.
Sometimes the recall is very specific. Like frozen food from a specific shift of a factory.
A few weeks ago a pregnant women informed me that she had a mild flu like illness. Then she informed me that she ate food that was subject to recall for listeria.
Listeria is dangerous to fetuses. It does unspeakable damage to them, or they die. I have seen these babies. Listeria hides because the maternal illness is very mild or nothing, but the fetal illness is extreme.
If we know of the exposure we can monitor and treat the mother and fetus with antibiotics. Ampicillin can be effective, but it takes a high dose. So high a dose that the pharmacist calls to ask if I am sure. Ampicillin is very safe, and Listeria is very dangerous, so I will treat preventatively if possible.
Most of the time we don't know of the exposure. And the baby and family pays the price. It is rare, but it really does happen. And most Obs have seen the terrible end results.
The latest recall is from a popular brand of Hummus. It was found to contain Listeria.
Do a google search for Hummus Listeria Recall and you will find the brand. It is called Sabra.
Here is the CNN link:
http://www.cnn.com/2015/04/09/us/sabra-hummus-recall/index.html
Please, if you have Hummus in your fridge, check the recall and throw out the Hummus. It is just not worth it.
I have put a poster up in my office as this particular Hummus is really good and it is really popular around here. It is my favorite brand.
So watch the news for food recalls. Especially if you are pregnant.
Thank you very much.
Dr John Marcus
doctorjohnmarcus.blogspot.com
89 North Maple Ave
Ridgewood NJ 07481
Thursday, April 9, 2015
Friday, March 27, 2015
Friday Night
Hi Everybody.
It is Friday7 about 8 pm and I just got back from rounds. I signed out for the weekend to my friend Dr Damien-Coleman. She is a very nice person and a great doctor. For my goals this weekend I am looking at about 8 hours of work going through my lab results and reports from other doctors. I will restart on this tomorrow as I have been working 12 hour days since Monday. I will get my lab results interpreted and my opinions out to my patients. I hope to use my "patient portal" for most of my results. More about that later in this post.
Today's belated blog is about the future. The future is here, and it is bringing tremendous changes to our culture and society. A hundred years ago calling on someone meant going to their door and knocking. It was like that for thousands of years. But since 100 years ago or so calling on someone meant dialing your phone. At first, 80 years ago, it was picking up the phone and asking the operator to plug your phone line into someone else's line. 50 years ago, the operator was replaced with equipment. Every person's phone had a ring with holes to actually spin to dial. Kids nowadays have no idea what that means. The next change, when I was young, a person could pay a few dollars a month to push buttons instead of turn the dial. Nowadays, I doubt if a dial phone would even work any more. Only push buttons with tones remains. Then, when I was in high school, the cell phones came. Now, people are dropping their home "land line" phones like hot potatoes. People are just using their cells. But there are two further changes that have come up unexpectedly.
The first: most people don't even answer the phone anymore. Most people don't even use the phone anymore. People have moved to cell texts to move information around. Some people still call others. But most don't. And the kids, forget it. A phone call? They don't want it. It is much too slow. In the time of one call, then could have made 20 texts. Now we are also losing email.
The second change: kids have abandoned email. The kids now are no longer filling in the email spot on application forms. They don't want email. It is too slow, cumbersome, and polluted with spam. It still has business uses. But for rapid personal connections, email is dead. Everyone is using texts and micro-blogging sites.
Why am I wasting time on a gynecology blog to say this?
Because today I received about 10 phone calls from patients asking for some information or advice. I called every one of them back before I closed up the day. And only one answered the phone. There are now 9 calls into me that are just completely unanswered. I feel awful about it.
The phone, as a reliable form of communication, is completely useless. Nobody uses it reliably any more.
But I have a solution to this awful and vexing problem.
But first, let me explain the technology changes in my office. We of Lifeline have moved our EMR software to a much bigger package called NextGen. We have been doing this for months now. Those of you who have read my blog in the past will realize the huge difficulties of moving from paper to EMR. I have described how hard it is here on this blog.
But now, the original software package was not fulfilling our needs. So we, as a group, moved ourselves, our practices, and our Electronic Medical Records, to a new software package called NextGen. The move to NextGen EMR software was just as big and just as traumatic as our move to our original EMR. But NextGen has some much more powerful functions.
One of the more powerful functions is called the "Patient Portal". The patient portal is a website. The patients can log on to this encrypted and secured website and access a ton of functions related to their health care on the portal. They can review whatever medications the computer thinks they are taking. They can ask for, get, and review their appointments. They can read their "patient plans". This is the end of the medical note that is created for them when they are in for their appointment. The patient plan function is still being rolled out so don't expect it there every time. But it is nice to see. In the patient plan people can see their "problem list". The problem list is generated by myself by the conduct of general medical practices. The problem list has already generated questions to me about something they don't understand. So the resolution of their lack of understanding is... wait for it... Their Understanding. And that is a Good Thing. And if there is a Mistake in their records (theoretically that might be possible), then there can once again be a correction, and then an... Understanding (an understanding that goes the other way, patient to doctor). And any correction to the medical records is a Good Thing.
It goes without saying that I am starting to love the patient portal.
But the biggest lesson here is that of Communication.
Today, on Friday afternoon, I made 10 phone calls and only one phone call was actually answered. I left no protected health information on any answering machine. At the very same time, I made about 15 protected email responses, some with multiple round trips both ways. And each and every one of them was at least potentially received and read by patients. And the information was received and understood in a completely secure and confidential manner. There is no way that a nosy neighbor, a jealous husband, or a worried mother, can read or hear the information in that secure portal controlled email. Remember the email never went out on a normal email server. It is only fake as an email. The email is really only served by an encrypted web site. That only one person can read. The person who holds the password for that email.
So today I made 10 phone calls, 9 of which went nowhere with no results, as I cannot leave any substantially private information on an answering machine, and 15 secure portal messages, all of which went through, and many of which were started by patients themselves. All of which contained highly valuable personally important information.
How secure is this information? I can tell you that it is as secure as NextGen can make it. NextGen is based on some very advanced encryption. It satisfies the requirements of HIPAA. It satisfies the Feds. If HIPAA is violated without due care, there is a potential for a fifty thousand dollar per incident fine. So you can be sure that I am keeping my passwords secure.
The hardest part of making the portal work is getting the patients actually started on it. Starting a portal account requires some hard work making sure that patients actually get secure access. So the account is set up with some very personal communications of passwords, followed by a round trip of emails to a pre-existing email account.
This set up process is actually too much of a hurdle for some people. There are many people out there who either will not or cannot go through this process of creating a secure account on the portal. But for those who do, there is a connection with really fast and secure access to communication between them and myself.
And that connection can do a lot to help people. I promise to do my best.
But I'll tell you what. 90 percent failed phone calls vs 100 percent successful secured emails tells a story.
I'll take the successful communications vs the failed ones any day of the week.
....
I haven't posted a blog here in some time. It has been much too long. Perhaps I need an editor who can give me assignments and deadlines. Like I've said before I have not abandoned this blog. I have been working very hard. One of the things that has been keeping me busy has the process of moving my EMR over to NextGen. NextGen is a much more complicated piece of software. It requires a tremendous amount of work to make it go. I am working and succeeding at it.
I just reviewed my side of this blogspot site. I have sort of the "back" side of the site. I have about 20 blog posts that have been started and are at some stage of completion. There is never enough time to write and complete these posts but I do enjoy writing them. And it has been very popular. I haven't looked at it in awhile but there are still thousands who find these blog posts and read them, from all over the world. I have more readers from worldwide than from the USA. There are many readers from Germany, from Africa, from Russia, and of course from Canada. Here near NY City I am only a few hours driving time from Canada. But the readership continues, even when I am not actively blogging. Thank you all for reading this. It is really rewarding.
...
Now for something new.
I have a problem that I have been thinking about for a long time.
This really should be a new blog post but I want to start it now.
One of my jobs as a Gyne is that of dealing with the problem of Breast Cancer. The problem is that about one in 8 women are destined to get breast cancer. That means if you personally know 100 women, you know that 12 of them will get breast cancer.
The good news is that breast cancer is treatable. It is something that can be removed. People can be saved. Lives saved. Wives, mothers, sisters, can be saved.
But the key is diagnosing it early.
There are three ways to diagnose it early, before it becomes an obvious and deadly problem. The first is by routine Gyne checkups. This is basic good medical care, and all women need a Gyne checkup once a year, without fail. A Gyne checkup can get a history and examine the breasts and pelvic parts of women. It is important and it is my job.
The second early diagnosis is mammograms. Mammograms have gone through a process of technical improvements through the years. They are constantly evolving. There are more improvements than you can count. Sterotactic, 3D, computer enhanced, tomographic, focal, compressed, and on and on. Then there are other imaging techniques, like ultrasound, sonograms, CT, MRI, thermography, etc. All of these may have their uses. But they have challenges too, like expenses, scheduling hassles, radiation exposure, lack of scientific proof, lack of financial resources, coverage limits, etc.
But the final and cheapest early warning system for breast cancer is "Self Breast Examinations". For the last 25 years I have been asking women to examine their own breasts for lumps. There seems to be good science that says that SBE works for women. And it can easily save lives. Once women get over the shock of finding a lump, they can get down to the hard work of diagnosing it. And they can get down to the hard work of protecting their own children's mother, who is a very important person. An irreplaceable person. Or, if they have no kids, then they can get down to the hard work of protecting their mothers daughter. Who is also very important.
There is an overwhelming problem with Self Breast Examination.(SBE). Most women recognize this problem. And they complain about this problem to me a dozen times a day.
The problem is women examining their breasts are not experienced enough to know what they are finding.
I explain to them a hundred times a day that all women go through this same problem. There aren't any women with a tremendous amount of experience doing SBE. All women who do SBE are beginners with an experience level of one and only one set of breasts to examine.
I have a solution.
It is radical and will be roundly criticized. And it will be viciously criticized.
But I believe that it will save a lot of lives.
If what I am going to propose comes to fruition, the problem of SBE might be solved.
I will propose to form an organization organized around the principle of generating a group of people dedicated to one thing and one thing only. The examination of each others breasts.
This will take the "Self" out of "Self Breast Examinations". And it will replace it with "Shared Breast Examination". I am not proposing that a women expose her breasts to the world. But that she come together with other women who have a similar goal in life, and train each other in the principles of breast examination.
I think that woman can learn how to examine breasts. And by sharing and teaching and learning, the knowledge can expand.
Women can learn how to feel the difference of glands, ducts, cysts, and tumors.
In my office I used to buy breast lump models. These were artificial breasts that had artificial lumps. They were pretty cool teaching aids but they got grungy really fast and fell apart in a matter of weeks.
But imagine instead that I had Real Breasts to show women. Well, this is what I am going to propose.
I would propose that this organization become real. With a mission statement. And a website. And all that goes with it. And some means of protecting women's privacy and rights as well.
I am in the early stages of thinking about this proposal. I have not come up with any insurmountable problems
For instance, the first probem: One needs a medical licence to examine someones breast. Solution: we are teaching women to examine their own breasts. And using many real breasts as examples. And besides, these are consenting adults. They can examine each others breasts as they need to without hassles from outsiders.
Another problem: There is no scientific proof this will work. Answer: we will not know unless we try.
Problem: woman may be harmed by anxiety and unnecessary biopsies. Solution: there is tremendous anxiety now, and lack of skill as well. And biopsies can be minimized by using needles and fine needle aspiration instead of open procedures.
I would ask the reader and the community to think about the meaning of breasts to the world. Breasts are perceived as beautiful. Boys fantasize. Girls compare. Babies love and feed. Women have surgery to make them bigger, smaller, and firmer. Breasts are part of birth. Breasts feed life to babies. Breasts are much visible to world, appreciated, and loved by everyone. But they are also one of the biggest sources of fear. Most women fear breast cancer more than a heart attack. And heart attacks are more than 15 times more likely to strike a woman dead, as her breasts. All breasts are beautiful, no matter the shape nor size. But the fear surrounding their health is so out of proportion that it is unreasonable. I don't think there is any subject in the world that has such a dramatic juxtaposition of beauty, love, fear, and danger, as human breasts.
It is time we started helping women get over their fear of SBE and bringing reason back to the subject of early diagnosis of breast cancer.
I hope to be part of the solution.
I realize this is a big dream.
But it might be possible to do better than we are doing now.
Thank you for reading.
Please pass the link to this blog on to others.
Thank you sincerely,
Dr John Marcus
doctorjohnmarcus.blogspot.com
Member of Lifeline Medical Associates
89 North Maple Ave
Ridgewood NJ 07450
Comments are of course welcome. Please post comments.
It is Friday7 about 8 pm and I just got back from rounds. I signed out for the weekend to my friend Dr Damien-Coleman. She is a very nice person and a great doctor. For my goals this weekend I am looking at about 8 hours of work going through my lab results and reports from other doctors. I will restart on this tomorrow as I have been working 12 hour days since Monday. I will get my lab results interpreted and my opinions out to my patients. I hope to use my "patient portal" for most of my results. More about that later in this post.
Today's belated blog is about the future. The future is here, and it is bringing tremendous changes to our culture and society. A hundred years ago calling on someone meant going to their door and knocking. It was like that for thousands of years. But since 100 years ago or so calling on someone meant dialing your phone. At first, 80 years ago, it was picking up the phone and asking the operator to plug your phone line into someone else's line. 50 years ago, the operator was replaced with equipment. Every person's phone had a ring with holes to actually spin to dial. Kids nowadays have no idea what that means. The next change, when I was young, a person could pay a few dollars a month to push buttons instead of turn the dial. Nowadays, I doubt if a dial phone would even work any more. Only push buttons with tones remains. Then, when I was in high school, the cell phones came. Now, people are dropping their home "land line" phones like hot potatoes. People are just using their cells. But there are two further changes that have come up unexpectedly.
The first: most people don't even answer the phone anymore. Most people don't even use the phone anymore. People have moved to cell texts to move information around. Some people still call others. But most don't. And the kids, forget it. A phone call? They don't want it. It is much too slow. In the time of one call, then could have made 20 texts. Now we are also losing email.
The second change: kids have abandoned email. The kids now are no longer filling in the email spot on application forms. They don't want email. It is too slow, cumbersome, and polluted with spam. It still has business uses. But for rapid personal connections, email is dead. Everyone is using texts and micro-blogging sites.
Why am I wasting time on a gynecology blog to say this?
Because today I received about 10 phone calls from patients asking for some information or advice. I called every one of them back before I closed up the day. And only one answered the phone. There are now 9 calls into me that are just completely unanswered. I feel awful about it.
The phone, as a reliable form of communication, is completely useless. Nobody uses it reliably any more.
But I have a solution to this awful and vexing problem.
But first, let me explain the technology changes in my office. We of Lifeline have moved our EMR software to a much bigger package called NextGen. We have been doing this for months now. Those of you who have read my blog in the past will realize the huge difficulties of moving from paper to EMR. I have described how hard it is here on this blog.
But now, the original software package was not fulfilling our needs. So we, as a group, moved ourselves, our practices, and our Electronic Medical Records, to a new software package called NextGen. The move to NextGen EMR software was just as big and just as traumatic as our move to our original EMR. But NextGen has some much more powerful functions.
One of the more powerful functions is called the "Patient Portal". The patient portal is a website. The patients can log on to this encrypted and secured website and access a ton of functions related to their health care on the portal. They can review whatever medications the computer thinks they are taking. They can ask for, get, and review their appointments. They can read their "patient plans". This is the end of the medical note that is created for them when they are in for their appointment. The patient plan function is still being rolled out so don't expect it there every time. But it is nice to see. In the patient plan people can see their "problem list". The problem list is generated by myself by the conduct of general medical practices. The problem list has already generated questions to me about something they don't understand. So the resolution of their lack of understanding is... wait for it... Their Understanding. And that is a Good Thing. And if there is a Mistake in their records (theoretically that might be possible), then there can once again be a correction, and then an... Understanding (an understanding that goes the other way, patient to doctor). And any correction to the medical records is a Good Thing.
It goes without saying that I am starting to love the patient portal.
But the biggest lesson here is that of Communication.
Today, on Friday afternoon, I made 10 phone calls and only one phone call was actually answered. I left no protected health information on any answering machine. At the very same time, I made about 15 protected email responses, some with multiple round trips both ways. And each and every one of them was at least potentially received and read by patients. And the information was received and understood in a completely secure and confidential manner. There is no way that a nosy neighbor, a jealous husband, or a worried mother, can read or hear the information in that secure portal controlled email. Remember the email never went out on a normal email server. It is only fake as an email. The email is really only served by an encrypted web site. That only one person can read. The person who holds the password for that email.
So today I made 10 phone calls, 9 of which went nowhere with no results, as I cannot leave any substantially private information on an answering machine, and 15 secure portal messages, all of which went through, and many of which were started by patients themselves. All of which contained highly valuable personally important information.
How secure is this information? I can tell you that it is as secure as NextGen can make it. NextGen is based on some very advanced encryption. It satisfies the requirements of HIPAA. It satisfies the Feds. If HIPAA is violated without due care, there is a potential for a fifty thousand dollar per incident fine. So you can be sure that I am keeping my passwords secure.
The hardest part of making the portal work is getting the patients actually started on it. Starting a portal account requires some hard work making sure that patients actually get secure access. So the account is set up with some very personal communications of passwords, followed by a round trip of emails to a pre-existing email account.
This set up process is actually too much of a hurdle for some people. There are many people out there who either will not or cannot go through this process of creating a secure account on the portal. But for those who do, there is a connection with really fast and secure access to communication between them and myself.
And that connection can do a lot to help people. I promise to do my best.
But I'll tell you what. 90 percent failed phone calls vs 100 percent successful secured emails tells a story.
I'll take the successful communications vs the failed ones any day of the week.
....
I haven't posted a blog here in some time. It has been much too long. Perhaps I need an editor who can give me assignments and deadlines. Like I've said before I have not abandoned this blog. I have been working very hard. One of the things that has been keeping me busy has the process of moving my EMR over to NextGen. NextGen is a much more complicated piece of software. It requires a tremendous amount of work to make it go. I am working and succeeding at it.
I just reviewed my side of this blogspot site. I have sort of the "back" side of the site. I have about 20 blog posts that have been started and are at some stage of completion. There is never enough time to write and complete these posts but I do enjoy writing them. And it has been very popular. I haven't looked at it in awhile but there are still thousands who find these blog posts and read them, from all over the world. I have more readers from worldwide than from the USA. There are many readers from Germany, from Africa, from Russia, and of course from Canada. Here near NY City I am only a few hours driving time from Canada. But the readership continues, even when I am not actively blogging. Thank you all for reading this. It is really rewarding.
...
Now for something new.
I have a problem that I have been thinking about for a long time.
This really should be a new blog post but I want to start it now.
One of my jobs as a Gyne is that of dealing with the problem of Breast Cancer. The problem is that about one in 8 women are destined to get breast cancer. That means if you personally know 100 women, you know that 12 of them will get breast cancer.
The good news is that breast cancer is treatable. It is something that can be removed. People can be saved. Lives saved. Wives, mothers, sisters, can be saved.
But the key is diagnosing it early.
There are three ways to diagnose it early, before it becomes an obvious and deadly problem. The first is by routine Gyne checkups. This is basic good medical care, and all women need a Gyne checkup once a year, without fail. A Gyne checkup can get a history and examine the breasts and pelvic parts of women. It is important and it is my job.
The second early diagnosis is mammograms. Mammograms have gone through a process of technical improvements through the years. They are constantly evolving. There are more improvements than you can count. Sterotactic, 3D, computer enhanced, tomographic, focal, compressed, and on and on. Then there are other imaging techniques, like ultrasound, sonograms, CT, MRI, thermography, etc. All of these may have their uses. But they have challenges too, like expenses, scheduling hassles, radiation exposure, lack of scientific proof, lack of financial resources, coverage limits, etc.
But the final and cheapest early warning system for breast cancer is "Self Breast Examinations". For the last 25 years I have been asking women to examine their own breasts for lumps. There seems to be good science that says that SBE works for women. And it can easily save lives. Once women get over the shock of finding a lump, they can get down to the hard work of diagnosing it. And they can get down to the hard work of protecting their own children's mother, who is a very important person. An irreplaceable person. Or, if they have no kids, then they can get down to the hard work of protecting their mothers daughter. Who is also very important.
There is an overwhelming problem with Self Breast Examination.(SBE). Most women recognize this problem. And they complain about this problem to me a dozen times a day.
The problem is women examining their breasts are not experienced enough to know what they are finding.
I explain to them a hundred times a day that all women go through this same problem. There aren't any women with a tremendous amount of experience doing SBE. All women who do SBE are beginners with an experience level of one and only one set of breasts to examine.
I have a solution.
It is radical and will be roundly criticized. And it will be viciously criticized.
But I believe that it will save a lot of lives.
If what I am going to propose comes to fruition, the problem of SBE might be solved.
I will propose to form an organization organized around the principle of generating a group of people dedicated to one thing and one thing only. The examination of each others breasts.
This will take the "Self" out of "Self Breast Examinations". And it will replace it with "Shared Breast Examination". I am not proposing that a women expose her breasts to the world. But that she come together with other women who have a similar goal in life, and train each other in the principles of breast examination.
I think that woman can learn how to examine breasts. And by sharing and teaching and learning, the knowledge can expand.
Women can learn how to feel the difference of glands, ducts, cysts, and tumors.
In my office I used to buy breast lump models. These were artificial breasts that had artificial lumps. They were pretty cool teaching aids but they got grungy really fast and fell apart in a matter of weeks.
But imagine instead that I had Real Breasts to show women. Well, this is what I am going to propose.
I would propose that this organization become real. With a mission statement. And a website. And all that goes with it. And some means of protecting women's privacy and rights as well.
I am in the early stages of thinking about this proposal. I have not come up with any insurmountable problems
For instance, the first probem: One needs a medical licence to examine someones breast. Solution: we are teaching women to examine their own breasts. And using many real breasts as examples. And besides, these are consenting adults. They can examine each others breasts as they need to without hassles from outsiders.
Another problem: There is no scientific proof this will work. Answer: we will not know unless we try.
Problem: woman may be harmed by anxiety and unnecessary biopsies. Solution: there is tremendous anxiety now, and lack of skill as well. And biopsies can be minimized by using needles and fine needle aspiration instead of open procedures.
I would ask the reader and the community to think about the meaning of breasts to the world. Breasts are perceived as beautiful. Boys fantasize. Girls compare. Babies love and feed. Women have surgery to make them bigger, smaller, and firmer. Breasts are part of birth. Breasts feed life to babies. Breasts are much visible to world, appreciated, and loved by everyone. But they are also one of the biggest sources of fear. Most women fear breast cancer more than a heart attack. And heart attacks are more than 15 times more likely to strike a woman dead, as her breasts. All breasts are beautiful, no matter the shape nor size. But the fear surrounding their health is so out of proportion that it is unreasonable. I don't think there is any subject in the world that has such a dramatic juxtaposition of beauty, love, fear, and danger, as human breasts.
It is time we started helping women get over their fear of SBE and bringing reason back to the subject of early diagnosis of breast cancer.
I hope to be part of the solution.
I realize this is a big dream.
But it might be possible to do better than we are doing now.
Thank you for reading.
Please pass the link to this blog on to others.
Thank you sincerely,
Dr John Marcus
doctorjohnmarcus.blogspot.com
Member of Lifeline Medical Associates
89 North Maple Ave
Ridgewood NJ 07450
Comments are of course welcome. Please post comments.
Monday, April 21, 2014
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.
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.
Thursday, November 28, 2013
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
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