By Nicholas Fogelson, M.D. and Chukwuma Onyeije, M.D. Early reports described the story of Tracy Hermanstorfer as a “Christmas Miracle”. It has also been described as inspiring, heartwarming, and “wonderfully appropriate for the season.” Others have referred to her saga as a nightmare with a happy ending. On Christmas Eve 2009, Ms. Hermanstorfer was admitted to Memorial Hospital in Colorado Spring, Colorado after her water broke. Ms. Hermanstorfer suffered a cardiac arrest during labor with her child Colton. After immediate resuscitative efforts failed, nearby Maternal Fetal Medicine physician (Dr Stephanie Martin) performed an emergency cesarean section. In the minutes following the delivery, Ms Hermanstorfer regained circulation and breathing, and is now doing well. Her infant also went on to survive and is apparently well… The case of Tracy and Colton Hermanstorfer continues to baffle and amaze those who learn about it. Over at the academicobgyn.com website, Dr. Fogelson and I review the case and provide our ideas regarding the possible causes for this miracle. Do you agree with our assessment? Is there anything we forgot? You can read the full article at : http://academicobgyn.com/2010/01/10/an-obstetrical-analysis-of-the-christmas-miracle/ Thanks!
I’m continuing to read about technology and its relationship to the propagation of ideas. An excellent source in this regard is “Content” by Cory Doctorow. I originally thought the following quote was written by Mr. Doctorow regarding digital rights management and contemporary intellectual property concerns. Imagine my surprise when I discovered the actual author. QUOTE:
“If nature has made any one thing less susceptible than all others of exclusive property, it is the action of the thinking power called an idea, which an individual may exclusively possess as long as he keeps it to himself; but the moment it is divulged, it forces itself into the possession of everyone, and the receiver cannot dispossess himself of it. Its peculiar character, too, is that no one possesses the less, because every other possesses the whole of it. He who receives an idea from me, receives instruction himself without lessening mine; as he who lights his taper at mine, receives light without darkening me. That ideas should freely spread from one to another over the globe, for the moral and mutual instruction of man, and improvement of his condition, seems to have been peculiarly and benevolently designed by nature, when she made them, like fire, expansible over all space, without lessening their density in any point, and like the air in which we breathe, move, and have our physical being, incapable of confinement or exclusive appropriation. Inventions then cannot, in nature, be a subject of property.” — Thomas JeffersonSent from Onyeije’s BlackBerry Storm
It’s official. I’m in love with Prezi!
Prezi is something like PowerPoint except simpler, fancier and based on Flash. Embedding video into my presentations was quantum leaps easier than with PowerPoint. Prezi also represents a completely different way of looking at presentation software, since Prezi is a service delivered entirely online.
You can learn more about Prezi here. And you can see my other Prezi presentations here:
These lectures can also be found at http://preeclampsiaonline.net in a post which I’ve placed here:
The presentations below are for medical students at the Morehouse School of Medicine. Any lecture of this nature is always a work in progress. These unfortunate students will be my guinea pigs. I’m sure the lecture it self as well as the audio/visual presentation will improve, since a new set of students will be getting this lecture every 6 months or so.
I’m also glad to finally spruce up my old preeclampsia lecture which is (gasp) about 5 years old.
Please enjoy and feel free to comment.
I found this image while reading “What Matters Now” by Seth Godin.
Seth Godin writes about marketing, the spread of ideas and managing both customers and employees with respect. “What Matters Now” is a collaborative effort by a number of social media and marketing experts. The e-book and the above image represent a fascinating perspective on marketing but I think it is an even more appropriate metaphor for how to view medical communication in the information age. I also recently had the opportunity to review an article in the British Medical Journal in which C.O. Hawthorne takes issue with a plea by another physician ( Dr. Hempson) to conform to accepted practices. In his correspondence to the journal, Dr. Hawthorne states:
The suggestion implied in these warnings (by Dr. Hempson) plainly is that somewhere within the province of medicine there exists a recognized and authoritative standard of ” orthodoxy ” – that is, a body of doctrine and practice presented by authority and received and adopted as true and valid on the word of authority, with, as a corollary, and for the contumacious, the penialty of exclusion from the ranks and communion of the faithful. Possibly there are professions to which these propositions apply. But most certainly they do not apply to the profession of medicine.
This was written in 1926; but I completely agree with Dr. Hawthorne as we enter 2010. Many of the discussions on this blog have detailed the dangers that can result when we in the medical field accept things “as they are” and do not question how we can improve them or make them work better for patients.
This is true for reform efforts, specific procedures live VBAC, communication technology and the participation of patients in their own care. Given the drastic changes in technology and the ability these provide us to radically change what we do for the best; we owe it to ourselves to question everything and seek to optimize patient care rather than do what we have done in the past.
Recently, I participated in a minor uproar on Twitter regarding VBAC.
The discussion arose from a story on CNN regarding Joy Szabo. The story detailed the fact that Ms. Szabo had been told that she could not have a VBAC at the hospital where she planned to deliver. As a result, she ultimately moved nearly six hours away from their home in Page, Arizona, to Phoenix to give birth at a hospital that does permit women to have VBACs.
And, thus, one woman’s quest for a vaginal birth after a cesarean became national news. How did it come to this? The fact that hospitals are refusing to even offer the option of a VBAC (with apparently no discussion of options or alternatives) is striking to me.
But, then again, I completed my OBGYN residency in the mid 90s when VBACs were at their peak. “The Golden Age of VBACs”. I also had the honor to work with the Midwifery Service at North Central Bronx Hospital after finishing my fellowship. In 1998 (when I finished my fellowship) the Obstetrics service at NCB boasted a C-section rate of 7-10% for first time mothers. Also, over 90% of women with a previous Cesarean had trials of labor and the vast majority had successful VBACs. Interestingly, I never experienced a uterine rupture during a VBAC attempt at NCB.
The conversation that developed around the case of Szabo spawned a number of tweets (and retweets) as well as lively blog posts by Nick Fogelson (@academicobgyn) and the blog Mom’s Tinfoil Hat . One of the thing that everyone agreed about was that in order to reduce the number of repeat cesarean deliveries, it would be important to decrease the number of first time cesareans. But how can that be done? and what is an unnecessary cesarean?
A quick story should provide some context. When I was a chief resident at Harlem Hospital, the team of physicians reviewed a fetal heart rate strip with clear evidence of fetal distress and decided to proceed with a cesarean section. As we prepared for the case, we sent the intern to the room to get consent from the patient for surgery. Several minutes later, the intern returned to tell us that the patient had refused the cesarean. The response from myself and other physicians was unanimous and immediate. “Nonsense. She *can’t* refuse a cesarean. Obviously the intern did not know how to “counsel” the patient regarding her “options”. I went to the room, spoke to the patient and within 2 minutes the consent was signed and the patient was on her way to the OR for the cesarean.
I use this story to remind people of the awesome power that a physician wields where an unborn child is concerned. Patient’s trust physicians to make tough calls by virtue of our expertise, training and because they believe that we want what is best for them. My fear is that physicians risk losing the trust and goodwill we have with patients if we steer them away from safe vaginal deliveries toward unnecessary cesarean deliveries for questionable reasons. The current trend towards not offering VBAC may have begun due to concerns regarding safety or even medico-legal exposure; however at present, it has metaststatized to inordinant levels that I have referred to as PVH (physician-VBAC-hysteria).
The reversals in the rate of VBAC have clearly increased the Cesarean rate in the US, but have not (in any definable way) improved maternal or fetal outcomes. Therefore, presented for your review is my most recent slideset on practical ways that patients can avoid some of the pitfalls which may result in an unnecessary cesarean delivery.
Enjoy.
Recently, I participated in a minor uproar on Twitter regarding VBAC. The discussion arose from a story on CNN regarding Joy Szabo. The story detailed the fact that Ms. Szabo had been told that she could not have a VBAC at the hospital where she planned to deliver.
As a result, she ultimately moved nearly six hours away from their home in Page, Arizona, to Phoenix to give birth at a hospital that does permit women to have VBACs.
And, thus, one woman’s quest for a vaginal birth after a cesarean became national news. How did it come to this? The fact that hospitals are refusing to even offer the option of a VBAC (with apparently no discussion of options or alternatives) is striking to me. But, then again, I completed my OBGYN residency in the mid 90s when VBACs were at their peak. “The Golden Age of VBACs”. I also had the honor to work with the Midwifery Service at North Central Bronx Hospital after finishing my fellowship. In 1998 (when I finished my fellowship) the Obstetrics service at NCB boasted a C-section rate of 7-10% for first time mothers. Also, over 90% of women with a previous Cesarean had trials of labor and the vast majority had successful VBACs. Interestingly, I never experienced a uterine rupture during a VBAC attempt at NCB.
The conversation that developed around the case of Szabo spawned a number of tweets (and retweets) as well as lively blog posts by Nick Fogelson (@academicobgyn) and the blog Mom’s Tinfoil Hat .
One of the thing that everyone agreed about was that in order to reduce the number of repeat cesarean deliveries, it would be important to decrease the number of first time cesareans.
But how can that be done? and what is an unnecessary cesarean?
A quick story should provide some context.
When I was a chief resident at Harlem Hospital, the team of physicians reviewed a fetal heart rate strip with clear evidence of fetal distress and decided to proceed with a cesarean section. As we prepared for the case, we sent the intern to the room to get consent from the patient for surgery. Several minutes later, the intern returned to tell us that the patient had refused the cesarean. The response from myself and other physicians was unanimous and immediate. “Nonsense. She *can’t* refuse a cesarean. Obviously the intern did not know how to “counsel” the patient regarding her “options”. I went to the room, spoke to the patient and within 2 minutes the consent was signed and the patient was on her way to the OR for the cesarean.
I use this story to remind people of the awesome power that a physician wields where an unborn child is concerned. Patient’s trust physicians to make tough calls by virtue of our expertise, training and because they believe that we want what is best for them.
My fear is that physicians risk losing the trust and goodwill we have with patients if we steer them away from safe vaginal deliveries toward unnecessary cesarean deliveries for questionable reasons.
The current trend towards not offering VBAC may have begun due to concerns regarding safety or even medico-legal exposure; however at present, it has metaststatized to inordinant levels that I have referred to as PVH (physician-VBAC-hysteria). The reversals in the rate of VBAC have clearly increased the Cesarean rate in the US, but have not (in any definable way) improved maternal or fetal outcomes.
Therefore, presented for your review is my most recent slideset on practical ways that patients can avoid some of the pitfalls which may result in an unnecessary cesarean delivery.
Enjoy.
David Harlow has an excellent post over at HealthBlawg, which summarizes recent discussions regarding patient control over health data over at his blog:
He also does an excellent job at posing two questions which require further consideration.
Below are some of my initial thoughts to his queries. I would encourage my readers to take a look at HealthBlawg and join the conversation at David’s Blog, er Blawg.
The two questions are:
#1: Are patients now ready to insist on having their health care providers upload their health information to PHR systems such as Google Health or Microsoft HealthVault? Answer: Yes. Absolutely, and the person who finds the most seamless way to do this will reap immeasurable financial and reputational rewards. See details below… #2: Are PHR platforms and health care providers prepared (and equipped) to act on these requests? Answer: No. And that’s too bad. (See my answer to #1). A quick reference point. In my practice as a high risk pregnancy specialist, I am often asked to evaluate patients who have had a previous stillbirth. This is a difficult situation and (of course) the first question that a patient has for the next pregnancy is; “Will I have another stillbirth?” In many cases, the answer lies in the cause of the initial stillbirth. Invariably, at the time of the initial adverse outcome, there are a large battery of tests done to determine the cause of death for the first child. Unfortunately, many patient’s do not have or know the results of these tests when they come to see a specialist like myself with their next pregnancy. A large part of my job is putting on my Sherlock Holmes cap to search through records from other hospitals. In some cases, I can call and have records in (literally) 5 minutes. In other cases, I have to fax multiple signed requisitions and then wait days or even months to get the information I have requested. In one case, I received records from a hospital in Brazil faster than I received records from across town. This would not be the case if patient’s had access and control to their own health data. My hope is that this bottleneck will one day become archaic. I’m hopeful that this will happen quickly due to the nature of disruption and progress in a digital age. Consider this. There was once a time when to make a withdrawal from a bank you had to physically present yourself to *your* bank to do so. We now take for granted the ability to have immediate access to our funds from any ATM or grocery store. Any bank that did not give it’s customers access to funds immediately would (in the current setting) rapidly become obsolete. Dave DeBonkart (@ePatientDave) has popularized the phrase “Give me my damn data,” and I clearly think he is on to something. In this day and age, no one would tolerate non-realtime, non-interactive silos for their financial resources. When banks realized this, they bent over backwards to make sure that consumers had constant access to their funds. Eventually, health care systems will realize that patients will not tolerate silos for their health information. When that happens, (soon) I see rapid development of the type of real-time access to transportable health data. The current barriers will fall only when someone realizes that the old system is inefficient and ultimately less profitable.From The Decision Tree Blog Based on new research, Dave Dobbs introduces the idea of two types of people, “dandelions” and “orchids”. Dandelions can thrive anywhere, despite their environment or upbringing. Orchids, however, are more temperamental, and require a stable environment to survive. At first glance, the orchids may seem like a liability, and in fact, they often carry genes that make them susceptible to mood disorders and psychological disease. The astounding part of Dobbs’ report is that he shows that given the right care, or environment, the orchids don’t just do OK, but far surpass the dandelions in perfomance. In other words, given the right training, orchids may in fact be destined for greatness.
See the complete Blog post by Brian Mossop here: http://thedecisiontree.com/blog/?p=1093 The original article by Dave Dobbs is here: http://www.theatlantic.com/doc/200912/dobbs-orchid-gene Sent from Onyeije’s BlackBerry Storm
Earlier today, a patient that I saw for an ultrasound asked me a peculiar question.
“When am I going to have my baby?” A review of her medical records revealed that she was 30 years old and pregnant for the first time. Her estimated due date was in the second week of January. She has had no medical problems and has had an uncomplicated prenatal course.
On one level, my answer to her question should have been pretty clear. ”I don’t know when you are going to have your baby. Your baby will arrive whenever it is ready to come…”
If pressed, I could have responded with a little more definition, as in “Well, I doubt that you are going to have the baby within the next hour. And I am very confident that you will not be pregnant on Valentines day…”
But of course that type of glib irony is not appreciated by most pregnant women. Trust me. I know.
After further questioning the patient I discovered her OB-GYN had told her that she was going to have her baby “about 2 weeks early”.
Amazing. I wonder if that OB-GYN could help me out with some lottery numbers…
One of the things that I have noticed during my years of practice has been the way in which increasing numbers of patients and doctors are unwilling to allow the natural birth process play itself out prior to the birth of a baby. It is very common for patients and their doctors to plan an elective induction at a pre-arranged date not for medical reasons but because it fits their schedules.
As a father of three boys, I can relate to the angst and anxiety that comes at the end of a pregnancy and the desire to “get the baby out” at a time is convenient. There is also the nagging concern that something might happen to the baby “in there”; but that the baby will be safe when it is “outside”. I understand the reasoning behind delivering early.
This would be fine if the process of labor induction was the same as the process of spontaneous labor. But it is not. When a mother undergoes induction of labor, there is always the chance that the induction process will fail and that a cesarean delivery will be necessary. Indeed, a large part of the increased cesarean rate in the US is due to failed inductions of labor. This is important because, although a cesarean is very common and very safe; it is not (and never will be) as safe as a vaginal delivery (statistically speaking).
Furthermore, once a patient has had one cesarean delivery the prospects for a vaginal birth after cesarean (VBAC) are becoming vanishingly smaller since many physician (unfortunately in my opinion) do not offer a trial of labor for VBAC. The risks of a previous cesarean are not limited to repeat cesarean deliveries either. Patients who have had one cesarean are at risk for abnormal placement of the placenta (placenta previa), bleeding problems and surgical complications with future children.
The birth process is amazingly efficient. I often tell patients that for 90% of pregnancies a high risk pregnancy specialist like myself is not necessary. (Oops. Should I be admitting that?). But it’s true. We provide high risk perinatal services to a large group of the uncomplicated pregnancies to catch that 10% because we have made the decision that it would be unacceptable to discount those babies. However, it does not change the fact that for the most part, women with uncomplicated pregnancies tend to do better with less rather than more intervention.
So, my point for consideration today is this. Certainly, there will be cases where there is a medical reason for an expedited early delivery. But such cases are in the distinct minority. Perhaps one of the best “low tech” ways we could improve health care outcomes for women in this country would be to allow babies to do what they have done for centuries. Come when they are ready!
This is a case where we as doctors and our patients should sit back and allow things to occur. In the end, I suspect the outcome will be better for everyone involved.
