Guest Blogger: Lights, camera and a whole lotta action in the Gynae Theatre & Here I go again on my own

Third installment from Dr. Katy Rivlin, NYU resident blogging from Ghana!

5/17---> Lights, camera and a whole lotta action in the Gynae Theatre

    Well, the GI monster finally defeated Maala, who sent me a message through Paka that she has been vomiting all day and night and is out for Cape Coast this weekend. Me on the other hand, I’m still game. It’ll be a nice vacation from my bleating, dying goat friend. Oh, and I’ve since learned that Paka’s name is actually Parker. Let this be a good example of why the Ghanaian accent can really throw you for a loop. 

    I spent the day in the Gynae Theatre, or the operating room where I assisted Emmanuel in a myomectomy, taught some deer in headlights medical students how to put in a foley, and then talked them through the hysterectomy that Emmanuel and Henry did together. I found them every appreciative and they flocked around me like I was a steaming pot of free rice (Ghanaians LOVE rice. They call it riiiiiiiiiiice). 

    The OR is truly a theater, teeming with house officers, residents and medical students who place their chins on your shoulder while you operate. All the while the woman is awake behind the drapes, with only spinal anesthesia. Her uterus becomes the plot of the show. 

    On the walk home, as per the usual all the school kids ran up to me in their red and orange uniforms, shrieked “obruni!!!” (which means shiny one) and ran away giggling. I’ve associated the phrase with children mainly and some taxi drivers, until the anesthesiologist said it to me today. I guess it crosses age and socioeconomic boundaries. The correct response is a big smile and wave and everyone walks away happy, even anesthesiologists. The obruni feels a mixture of happiness at being acknowledged and ridiculousness for being, well, caucasian? American? Wealthy? A salad eater who sometimes goes on runs? A daily shower taker and multi-daily toilet flusher? It’s a little unclear. 

5/18--> Here I go again on my own

    Last night we went to Osu for dinner, a neighborhood that the New York Times called “upscale” in its “Places to go in 2013”.  As far as I can tell, there are just as many goats eating garbage there as here, but I get the idea. We drank beer and fermented cane alcohol at a bar that somehow is very appealing to western sensibilities. It had little plates, outdoor seating and kicking tunes. There were more obrunis there than I’ve seen since I left New York and I felt a bit of an urge to touch their skin and hair, just like a school child. Sari and I got pretty drunk, and the evening ended with a wild beef-fest about health care in America and the world and how Barbara Kingsolver is the only one who gets it. 

So now I’m off to Cape Coast, trying to push through the diarrhea, goat still hasn’t died, and I’m starting to get a weird chest rash. 

Until next time!

Guest blogger: And besides it was the hottest part of the day & Fellow fellows!

Two more updates from guest blogger Dr. Katy Rivlin, NYU fourth-year Ob/Gyn resident writing from her Global Health rotation at Korle Bu Hospital in Accra, Ghana.

5/15 --> And besides it was the hottest part of the day

    Lured more unsuspecting victims into my snare today, Titus the resident who giggles a lot when questioned by his “bosses” (or attendings) and Brittany the 2nd year resident with a gap between her teeth and red tinged hair. As far as I can tell, she is the only one on rounds who know anyone’s gestational age. The biggest (and most obvious) success was Maala, the other sort of white woman. She just finished medical school in London and goes for a jog at 5 am every morning. Once we’d spotted one another across a crowded room, what could we do? Now we’re semi attached and already have plans to visit Cape Coast together this weekend. Sadly for Maala, the long ward rounds in the midday heat are taking their toll on her. I’ve kept her alive with sips of water from my Nalgene and Chocolate Mint Cliff Bars. At least I’m providing some kind of medical care. 

    As for myself, I have the thickened (or thinned?) blood of a Southerner and can hold my own on post partum and antepartum rounds with the strongest, most heavily clad Ghanian.  I even laughed at the right time once or twice!

    I ate red red with fried fish tail and plantains for lunch today. This is very likely the dish Evangeline tried to teach me yesterday, and I see now how far off I was. My first forage into Ghanian cooking was about as successful as my first bucket shower, except the consequences may last longer for myself and for Sari.  Also in my lunch was a white powder that looked like quikrete. Dr. Samba said it’s made of maize and meant to thicken my red red. But I feared spilling red red and quikrete on myself and all the bosses, so I kept everything to itself. In other gastric news, all milk is  condensed or sweetened, tomatoes come as a paste, and spices end up lumps of chalk in their bottles. I must bend my brain and my stomach, if they aren’t bent already. 

5/16 --> Fellow fellows!

     Dr. Samba extracted me from Maala’s hip after M&M this morning and took me to the Center for Reproductive Health and Family Planning. I was shown into Emmanuel’s office, air conditioned with a computer. It didn’t take us long to realize that the fellowship I will be starting next year is the same one he is doing now!  He even had the Family Planning fellowship pamphlet to show for it. Unfortunately for Emmanuel, the American donors who used to fund his fellowship and the fellows before him now expect Korle Bu to be self sufficient. He has little to no access to up to date information on contraceptive practices. Dr. Ades has already promised to help me put together a curriculum which Emmanuel can adapt to Korle Bu. My first project that feels useful!

    Then we spent the better part of the day swapping stories about the Ghanaian and American health care systems. I wowed him with stories about bariatric bend extenders and Big Gulps, he parrying with a house officer who caused arm necrosis in a baby by forgetting to remove a tourniquet. Geeeeeze. 

    Every once in a while a nurse entered, asking if it was safe to put an IUD in a woman 8 weeks post partum after a c-section and whether or not a woman’s blood pressure was too elevated for depo provera.  Emmanuel would give his answer and she would leave, off to plan families, the two of us still giggling about teen pregnancy and diabetes. Then we went to the wards, saw one post partum patient and calmed down a panicked house officer who had just seen a cervical foley “drop out” of a woman’s (very dilated) cervix. I’ve learned quickly that this is a pantsless, drapeless society when it comes to women and their doctors. No one seems to mind too much, it’s all smiles when we come around. 

    In other culinary news, turns out it’s true, mangoes in Africa are unbelievably good. Also turning out to be true, if you travel here, you will get diarrhea. In the grand tradition of ending on the state of my intestines, I will end here. Oh, and there is a goat just outside of my window who may be in the throws of death. Or just making normal goat noises. 

Guest Blogger!

I've been inactive on this blog because I've been at home in New York and no one wants to hear about my boring life here. But now I'm excited to announce a guest blogger, Dr. Katy Rivlin.
Katy is a chief (4th year) resident at NYU, where I am an attending physician, and the Director of Global Women's Health. Katy is spending 2 weeks in Ghana as part of the Global Health rotation. She's working in the Obstetrics & Gynecology department of Korle Bu Hospital in Accra.
I have been really enjoying her daily updates from Ghana, and I thought you all would too. She has been there for a few days now, so I am going to post a couple of days' worth at a time to catch up.

Hello Veronica’s blog followers! My name is Katy, I am an Ob-Gyn resident at NYU who is lucky enough to spend 2 short weeks at Korle Bu Teaching Hospital in Accra, Ghana. Veronica, or Dr. Ades is my attending and she asked that I guest blog a little. I’ve adapted my daily emails to my friends and family for the blog, so please forgive some of the, well, personal parts. 

Hope you enjoy!

-Katy

5/13 --> under the mosquito netting

First bucket shower and flush by bucket, already got dirt on my newly cleaned sheets (a perfect black footprint). Bucket shower was a moderate failure, I left filmy residue on the surface of the water and my nether parts are still stinging with Dr. Bronner’s mint. Hot and dirty, full of starches. This is Ghana. 

5/14 --> sort of an honest days work

Woke up with my hair in a fluff of its own choosing and some distant rumblings in the stomach. Unclear which direction these will head (hair and GI motility). 

On my walk to Korle Bu, I got 4-6 honks which seems manageable. My first Grand Rounds was hard to hear and steamy, still learning the language of the land. Everything has a lot of “eh!” and “ay!”s thrown in and often jokes happen without my knowledge until the room erupts in peals of laughter. 

We rounded on a woman with cyanotic heart disease and polycythemia in pregnancy (Hemoglobin of 22) who was pretty and passive, not on oxygen. She’s a florist who was able to recite her usual Hemoglobin level to us (19, normal is about 12.) I don’t know that I’ve ever asked a patient that before. According to Sari (the American ER doctor I am living with), oxygen is very expensive and an ICU is a luxury only for the wealthy. 

Then I scrounged around for new friends and succeeded in luring Mustafa and Sylvia into my snare. Mustafa is a first year resident from Nigeria who kept asking me when I qualify and when I do if it’s as a member or as a fellow. I never quite figured out his meaning and just did a lot of smiling, nodding and wild gesticulating. 

Sylvia was a bigger success. One of two female residents that I’ve seen so far, she immediately became a bosom friend. She has kids, likes the beach and laughed every time a cab driver honked at me. 

On my way home, Evangeline the bean maker convinced me to add a strange red sauce to my purchases of black eyed peas, green peppers and digestif crackers. She wrote down a recipe for me that goes a little something like this: 

CP: 

1.) Cook beans+salt to your taste

2.) Ripe plantain 

    Fry to your taste +salt

    Put in oil

3.) Put on small red oil

I don’t know what CP stands for (other than cerebral palsy) but Evangeline asked me to return with a report on how it went. I’ll ask her then.

Got home to no electricity or gas on the stove, so instead I ate a can of corn with cut up spicy green peppers in it (sure to worsen the GI distress) and digestif crackers (sure to negate the effects of the peppers). Ending the day feeling net even. 

Your Birth Control Should Be Free

Do you get prescription birth control - the pill, the patch, or the vaginal ring?
If so, make sure that you are not charged a copay when you pick it up at the pharmacy. Many people are still being charged erroneously - I was, until I complained to my insurance company.

Under the Affordable Care Act, women no longer have to pay a copay for prescription birth control. (I wish it didn't require a prescription, but that's a whole different rant). This change officially took place on January 1, 2013.

When I picked up my birth control last month, I realized I was still being charged a copay, and I wasn't sure when I was supposed to stop. I asked the pharmacist, and he told me that about 80% of women at his pharmacy are no longer paying a copay, and I shouldn't be either. (My pharmacist rocks.) He advised me to contact my insurance company to find out what was going on.

That day, I called the company. The representative had no idea what I was talking about. When I explained that under the ACA, I should not be paying a copay, he scanned through my information on his computer screen, and said "I don't see anything about that in your account."

"It's not in my account," I said, "it's the Affordable Care Act. It's a law."

He was totally clueless. He kept scanning through my account. I asked to speak to a supervisor and, not surprisingly, he stalled me, and kept insisting that "my account" shows nothing about eliminating the copay. "Look, I'm a doctor, I know what I'm talking about," I told him. HELLO.  It didn't help. He played dumb.

Frustrated, I gave up. I thought about complaining - maybe to the Better Business Bureau, or maybe the ACA has a provision for insurance companies playing dirty tricks? But first I tried one more time. I called again later that day, and spoke to a woman, who knew exactly what I was talking about. She agreed that I should not be paying a copay, and that, in fact, I should be reimbursed for the 2 copays I had already paid since January 1. She was very helpful, and very apologetic. She said she would register a complaint and it should be fixed within 3 business days. She took my phone number - my cell number, which I never give out - and my email, and assured me someone would contact me.

Two days later, I got 2 telemarketing calls to my private, unregistered cell phone, and several spam emails to my email account that rarely gets spam. Thanks, insurance company. I sent them an angry email, and got an autoreply informing me how I can look up their privacy policies. pbbbtth.

An entire month went by, and it was time to pick up the next prescription before I realized I had never heard back about the copay. I called again, and the person said that my account now shows that I do not need to pay copays (yay), but said nothing about being reimbursed. He submitted another ticket, told me I would hear back within 3 business days, and asked for my phone number. I told him Hell No You People Sold My Number Last Time. He claimed that they don't do that, and I called bullshit. I said I would call them back, even though it means going through that awful robot lady who can't understand anything I say and yet insists on requiring voice commands instead of numerical options until I end up yelling "I WANT TO SPEAK TO A %&#@$ HUMAN BEING" and then I finally get transferred to an agent.

In summary, if you pick up your birth control at a pharmacy, you should NOT be paying a copay.
If you are paying a copay, call your insurance company immediately, and demand that they fix it, and that they reimburse you for ones you have already paid.
If they try to give you a line about your plan being "grandfathered in," do the research yourself and verify whether or not this is true - it may be a stalling tactic.

Here's the government website where you can read about the ACA.
Here's information on how the ACA improves access to preventive care services for women, and makes many of them free.
Here's the information about grandfathered health plans.
Here's the consumer assistance program.

What Happened to Lady Sybil on Downton Abbey?

(WARNING: This entire post is a spoiler if you are not watching Downton as it airs in the US)

**************

On tonight's Downton Abbey, Lady Sybil died of toxemia of pregnancy. What does this mean?

Toxemia is the older name for a disease now known as preeclampsia/ eclampsia. Sybil felt unwell, and complained of headaches and swollen ankles. Sometimes this happens in normal pregnancies, so it can be hard to differentiate between disease and normal. She also looked pale and uncomfortable, which had me nervous from the beginning of the episode.

At one point in the episode, Dr. Clarkson can be seen checking her blood pressure. The illness usually first starts with elevating blood pressure. A normal blood pressure in pregnancy generally ranges around 100-120/60-80, and can be as low as 90/50. When it gets above 140/90, that is when disease is present. It can get even higher, above 160/110, and the higher it gets, the more the danger. It's not clear whether the blood pressure connection was known in the era of Downton, as none of the doctors mention it.

Dr. Clarkson also mentions that Sybil's baby seems small. In toxemia, or preeclampsia, there is an abnormal placental attachment - the arteries of the placenta and uterus don't adapt in a normal way to pregnancy, and there is increased resistance to blood flow. When this happens, the baby doesn't get quite enough nutrition and oxygen, and might be growth restricted. It would be born small, even at full term (9 months).

During Sybil's labor, Dr. Clarkson insists on checking Sybil's urine for albumin, or protein. The phenomenon of preeclampsia is now known to manifest first in elevated blood pressure plus protein in the urine. This combination makes the diagnosis, and often predicts the poor outcomes associated. Women with preeclampsia are at risk of seizure, stroke, fetal death, and maternal death.

Dr. Clarkson insists on bringing Sybil to the hospital for a cesarean because the only known cure for toxemia (preeclampsia) is delivery. That remains true today - delivery is the only cure. However, we have another tool in our arsenal these days, which is the administration of a high dose of magnesium sulfate, an electrolyte. It's not know why, but magnesium is extremely effective at preventing the seizures associated with preeclampsia. It doesn't cure the problem, nor prevent the other outcomes like stroke or fetal death, but it makes a huge difference in preventing seizure. It can also be rapidly administered at the time of an eclamptic seizure to stop the seizure and save the woman.

Sadly, it seems that the benefits of magnesium sulfate were not known during the era of Downton, because once Sybil begins to seize, Dr. Clarkson says that there is nothing he can do. When seizing starts, the disease is called eclampsia - the combination of elevated blood pressure, proteinuria, and seizure. Sybil seizes to death in a matter of minutes. The scene was devastatingly accurate, and horrifying.

In the United States, we still see a lot of preeclampsia, but very little eclampsia. That's because we are able to detect the warning signs - elevated blood pressure and proteinuria - and give magnesium and induce labor before the dangerous outcomes occur. Intervening in preeclampsia is one of the most important developments of modern obstetrics.

In developing countries, preeclampsia/eclampsia is one of the most common causes of death. As was noted by the downstairs Downton staff, many women before Sybil have died in childbirth. We still haven't eliminated this problem. I was gratified to see it portrayed in such a popular show. Although it meant losing one of my favorite characters, it is important to highlight this tragically common problem.

No Excuse

If you haven't read about the death of this woman, you should:

Woman "Denied A Termination" Dies in Hospital

A 31-year-old woman presented to a hospital in Ireland in pain, and was diagnosed with a miscarriage in progress (what we call inevitable abortion - "abortion" being the medical term for any pregnancy that ends before viability). There was no doubt that she was going to lose the fetus. Nonetheless, the doctors were barred by law from removing the fetus or inducing labor because the fetus still had a heartbeat. The woman suffered for 2.5 days, and then died of sepsis.

Non-medical people might wonder whether this outcome might just be a rare, unexpected outcome. You might wonder whether the doctors could have known what would happen.

So, let me be clear: this outcome was entirely preventable. This woman should not have died. Her risk of sepsis was well-known, and predictable. Women who have spontaneous miscarriages are at risk of infection, and the longer the miscarriage goes on, the higher the risk. Women in second trimester (which she was, at 17 weeks) are at even higher risk, because the cervix has to dilate more, and because the reason for the miscarriage could easily be an infected pregnancy. Pregnant women are highly susceptible to infection, and less able to fight it because their immune systems are suppressed. When a woman comes in with a miscarriage that doesn't end spontaneously within 1-2 hours, we evacuate the uterus to prevent the development of complications - specifically, hemorrhage and sepsis.

Her death is not a mystery, and it is not surprising. It's hard to blame the doctors, as their hands were tied by law and they risked losing their license to practice, or going to jail, by intervening. The doctors were prevented from providing adequate medical care by the law. The people responsible for the law are the Irish lawmakers who created it.

If they had done their jobs, the lawmakers who created this law would have looked at the implications of it. They would have learned that the law would inevitably cause the deaths of women. (Who knows how many others have died that we haven't heard about?) In fact, women die every day as a result of pregnancy and of lack of access to safe abortion. Anti-choice individuals who argue that such outcomes are rare, people such as our recent nominee for vice-president, are lying, or they are speaking ignorantly. I think it's the former, because if you spend 1 minute googling maternal mortality, you can easily see that 800 women die every day in pregnancy from preventable causes.

When lawmakers dictate what physicians can and cannot do, they are presuming that they can practice medicine better than doctors can. If they want to pass laws dictating medical practice, then they should take responsibility for these patients' lives. Lawmakers who pass laws that prevent abortion even when the pregnancy is a threat to the mother's health or life are knowingly causing the deaths of pregnant women. This is murder, and should be prosecuted as such. There is no excuse for having a law like this.

Unsung Heroes

I have been helping out with disaster relief the last 5 days, and working hard. The last 3 days, I was working with Médecins Sans Frontieres (MSF), and finding myself astounded to be doing MSF work in my own city.
I have gotten a lot of moral support from everyone, and I am grateful for that. But while I think I have done some good and helped some people, I actually think that my contribution has been minimal in comparison with some of the other people out there that get less attention. I want to take a minute to highlight these ordinary people being heroic in a time of need.

1. Sanitation Workers
The city is a mess, and can't become functional until it is cleaned up. Sanitation workers are working long hours of backbreaking work to get New York back in shape. I saw sanitation workers lifting up huge pieces of furniture all over the place, and somehow getting all of it into their trucks. They were in the Rockaways today, on the streets that are covered in piles of sand and broken crap, hauling it all away.

2. Social Workers
Everyone realizes that doctors and nurses would be needed in a crisis, but few appreciate the desperate need for social workers. These amazing people can do everything from therapy to logistics to coordination. I had social workers tracking down people's insurance information to get them emergency prescription refills, comforting people with anxiety and depression that was worsened by losing their homes and being trapped in chaotic shelters, replacing broken eyeglasses for people without insurance, and basically doing everything they were asked. One of the days I was in a shelter, I was exploding with stress until a wonderful social worker arrived on the scene, and took some of the work out of my hands, handling everything with grace and perseverance.

3. Pharmacists
So many people have chronic conditions now, and many people did not expect the storm to be what it was. They brought only a few pills with them, or they didn't refill the prescription before the storm hit, and now they're stuck with no meds. Their pharmacies and doctors' offices are under water, and their insurance information is lost in the flood. Pharmacies all over the city are accommodating the need for emergency meds by urgently refilling meds, delivering to shelters, accepting partial insurance info and figuring out the rest later, waiving copays and offering 3-day emergency refills without any insurance information whatsoever. One pharmacist, when he realized how much need we had at a shelter, drove over in his car (kids in tow) to drop off not only prescriptions, but soap, lotion and other toiletries he thought people might need.

4. Nursing Home Staff
Several nursing homes and assisted living facilities were located in areas that were evacuated. These facilities had to move all of their residents, many elderly and with chronic medical and/or psychiatric conditions, into shelters. Some of the staff from these facilities worked 12-18 hour days in the shelters to stay with the patients they know, and make sure they get the meds they need in the middle of a chaotic situation. Without the staff from these facilities, caring for these patients would have been nearly impossible.

5. Home Health Aides
In the shelters I worked in, there were home health aides staying on a cot in the shelter (sharing a room with 20-100 other people) to care for their patients - changing their diapers, checking for bedsores, requesting wheelchairs, giving them medications and staying with their patients 24/7 to make sure they were well cared for.

6. Community Organizations
In many of these communities, we are outsiders; unfamiliar with the surroundings and the people. Preexisting community organizations stepped in to collect, organize and distribute donations, as well as information about where to get food, shelter and medical care. In the Rockaways, a youth organization became a hub for donations, and got so many donations (and needy people looking for donations) that they started distributing to other donation sites. These inspiring young people (in their early 20s) were the most organized and efficient group that I saw in this entire experience.

7. Good Samaritans
People came out in droves to help. Many were turned away from several sites, only to keep traveling to other ones until they found a place to help. These volunteers became essential, and many found a very specific task that they became very good at, and helped bring a chaotic situation more under control. Most were working outside their comfort zone, or even below their level of expertise. But no one balked, everyone pitched in to do whatever was necessary. Some people triaged medical patients; others climbed epic flights of stairs to knock on doors and bring water and food to trapped people; others still cared for patients in shelters too sick or old or incapacitated to fully care for themselves.

The aftermath of this storm has made me realize how much we need everyone in our city and our community to pitch in. But it also made me realize that there are people out there who do really good, hard  things every single day, who deserve our appreciation. Please take a moment to thank them.