Monday, December 16, 2013

Guest Blogger: Day 8

Dr. Terri-Ann Bennett, writing from Korle Bu Teaching Hospital in Accra, Ghana. She contemplates some of the differences in obstetrics between the US and Ghana, and encounters her first DOA patient: Day 8

Guest Blogger: Terri-Ann Bennett

Dr. Terri-Ann Bennett, a chief resident in Obstetrics & Gynecology at NYU, went to Ghana recently and had her own blog. It was insightful and well-written, and I want to share it here.

Here is her first post, in which she reviews her first few days on service at Korle Bu Teaching Hospital: The Introduction

Tuesday, July 9, 2013

How To Clean Your Vag

This post is going to be exactly what it sounds like. If that grosses you out, click to somewhere else.

In the office, I get a lot of questions about how to clean "down there." There are a lot of cultural influences that lead us to think of vaginas as unclean. Feminine hygiene products are marketed to women in a way that lead us to assume that we are inherently unclean. So many religions and cultures have mythology surrounding menstruation and women's bodies that imply a contamination or lack of cleanliness. Meanwhile, where are the testicular hygiene products?

Many of my patients come in thinking that any discharge means they have bacterial vaginosis (BV), a bacterial overgrowth that can lead to odor. While BV does exist, in my opinion* it is wildly overdiagnosed and overtreated, especially given that its presence has almost no spontaneous adverse consquences**. It can be very annoying, but it's not dangerous. It's not like Chlamydia, or HIV. It's not even as painful as a yeast infection. If you have BV or think you do, it's important to confirm it with a doctor, and not just assume you need antibiotics over and over. Those antibiotics can actually lead to a yeast infection, so be cautious.

First, a terminology clarification:
The outside female genitalia is called the vulva. The inside female genitalia is called the vagina. So even though we use vagina as a general term to refer to the entire female genitalia, the medical term only refers to the inside.

So what is the truth about the cleanliness of vaginas? 
First of all, yes, the vagina is full of bacteria. It needs to have that bacteria in order to stay healthy - they are the "good" bacteria. When you eliminate the bacteria (by taking antibiotics, for example), that allows overgrowth of other things, like yeast. Yeast can exist in the vagina, but when they grow too much, they can cause itching, burning, pain with sex, redness, or odor. There are certain bacteria that shouldn't be in the vagina - like Chlamydia (a sexually transmitted infection), or E. coli (a bacteria found in stool). Another bacteria that can exist in the vagina, Group B Strep (GBS), does nothing to the woman, but can cause a serious infection in infants, so if a pregnant woman has it, we give her Penicillin in labor to get rid of it before the baby comes out.

Should you clean your vagina?
Bottom line: not really. Most women have a small amount of daily mucous discharge. That discharge is produced by glands in the vagina. That mucous traps any untoward elements, and pushes them out. That's why the vagina is "self-cleaning." An increase in the amount of discharge isn't very concerning - usually it is related to the hormonal cycle, or random chance. A change in the color of the discharge can sometimes come with an infection, so you should see your doctor in that case. But using a douche doesn't really help. It pushes things up when you really want things to come down. And what is up? Your uterus and cervix. If there is anything dangerous in the vagina, you would be pushing it up toward your uterus, and potentially your fallopian tubes. That means that if there is "bad" bacteria in there, like Chlamydia or Gonorrhea, that bacteria would then be pushed upward into a sterile area, and cause Pelvic Inflammatory Disease, which can cause tubal scarring and infertility.

Should you clean your vulva?
Yes, this is OK. The vulva are on the outside, and so have the tougher external skin that covers most of our bodies. However, I have found that the vulvar skin, being hidden from the outside world most of the time, is more sensitive than the skin on your arms or legs. It can often become very irritated by shaving/waxing, or the detergent in soap, which strips off the natural oils. This can cause a vulvar dermatitis, which can be extremely itchy, and looks like dry patches of a lighter color than the rest of the skin. When this happens, I advise women to stop using soap or removing hair at least temporarily, and I usually prescribe a cream to help with inflammation. If you think you have vulvar dermatitis,  see your gynecologist. If you want to stop using soap on the vulva, I recommend washing with water and a washcloth. This can remove the dirt/discharge without irritating the sensitive vulvar skin.

Should you shave your vulva?
Meh. You can, if you want to, but stop if it causes problems. Hair removal pulls the hair from the shaft, and can introduce bacteria into the hair follicle. When this happens, a woman can get folliculitis, which looks like a small pimple, and is painful. If this happens, I advise women to stop hair removal at least in that area. It's important to remember that hair removal is entirely cosmetic, and has no medical benefits, so if it's causing irritation, it's time to stop, at least temporarily. Not every culture thinks women should be hairless.
One potential alternative is trimming the hair instead. This can avoid the folliculitis complication while still feeling neat/clean.

What should you do for the occasional itch?
If you are having persistent itch or pain, you can try an over-the-counter yeast cream, or see a gynecologist. But if you get the occasional itch down there, and you are pretty sure it's nothing, I recommend a cream like Vagisil (or its generic alternative "Vaginal Anti-Itch Cream"). It has a pain reliever and a soothing ointment, and can take care of the occasional itch, or pain from folliculitis. If it doesn't help, see a doctor.

How do you know if you need to see a doctor?
Occasional mild symptoms, like itching or odor, can arise with changes in cycle, especially around the time of menses. Something that does away quickly on its own, especially once your period is over, is usually no big deal. Symptoms that are severe, or that are constant and persistent, mean that you should be evaluated by a doctor.

These recommendations are not hard and fast rules. They're just my attempt to answer questions that it seems like all women have. Feel free to leave questions in the comments section, and I'll try to address them.

*This is my opinion, based on my professional experience, not a scientific statement. Others would disagree with me, but they can write their own damn blog.

**BV has been associated with some negative outcomes, like preterm birth or infection after surgery, but attempts at prevention and treatment have been mixed or have often failed, and it's unclear whether it's a cause or an association.

Monday, May 27, 2013

Guest blogger: Full Of Hot, Dusty Air

The last blog entry by Dr. Katy Rivlin as she prepares to leave Ghana. Many thanks to Katy for sharing her experiences in Ghana. Stay tuned - I plan to have more residents blogging in the future.

5/24 -->  Full of hot, dusty air
    I’m packing to leave, just watched my last Ghanaian uterus extracted from an abdomen and gave a pile of NYU scrubs to Parker and Henry. I picked up my dress from Constance (definitely gonna wear it to my next garden party/wedding/Kentucky Derby) and made a salad of all the leftovers in Sari’s fridge which may have involved tuna fish and beans.
    Along with my dress, I had a pair of patterned pants with a drawstring made for Ari. I envision them also at the Kentucky Derby, or perhaps when he meets with an important client at his law firm. Constance surprised me with a matching shirt. She asked me again who it was for and I told her “It is for the man I am going to marry”.
“Ah” said Comfort (Constance’s co-seamstress), “But is he a tough man?”
“Umm, yes” I said, Constance and Comfort both nodding approvingly.
“But not too tough” I added.
We all three laughed hard. Surely any woman can agree on the value of a not too tough man.
    On my last day in the Family Planning Unit, I listened to a lecture on abortion put on by a few senior medical students. While abortion is technically only legal here if a certified health care provider decides that the maternal or fetal life is at risk, Emmanuel says they interpret that law very liberally, at least at Korle Bu.
     I watched this big group of medical students (not Ob-Gyn residents mind you, just plain old medical students) passing around manual vacuum aspirators, or suction devices used for early abortion, and cheering every time they did it right. I listened to them debate the perfect combination of medications for a medical abortion. The attending doctor gave a moving talk about the horrors of septic abortion (something they see frequently here in Ghana) and he praised cytotec, a medication for abortion that is now cheap and easy to get on the black market. This has completely changed the face of illegal abortion here in Ghana. “Thank God for cytotec” he said. Never thought I’d hear God and cytotec used in the same sentence.
    I can’t imagine an equivalent scenario in the US, even at a place like NYU and certainly not at the University of Mississippi where I went to medical school. We tiptoe around abortion, we apologize for it, we neglect to teach it. With septic abortion a thing of the past in the US, we’ve forgotten what it means. And don’t blame religion, because believe me, Ghanaians are as fiercely evangelical as any bible belter worth his spurs.  It’s funny how things go in circles.
    One more bucket shower, one more semi toilet flush, one more mouthful of dirt on the car ride to the airport. Thank you Sari, plastic chair lady, Dr. Ades, Maala, bleating sheep-goat Paka-Parker, bean maker lady,  Korle Bu Teaching Hospital, Emmanuel and his family, thank you Ghana. You’ve breathed your hot, dusty air into me and I hope to have it with me always.

Sunday, May 26, 2013

Guest blogger: If you like pina coladas and other speculations on death

Dr. Katy Rivlin feeling morbid in Accra, Ghana.

5/23 --> If you like pina coladas and other speculations on death

    Drunk again, this time Sari, Maala and I commemorated my last night in Accra at Labadi Beach Hotel, a swanky obruni heavy spot with a pool, sweet cocktails, and food not cooked in palm oil. No yams, no rice, no beans. Aside from the buzzing mosquitoes and the High Life band, I could have been in Miami. 
    In my revery I started to think (and blab) about death in Ghana and death in the US (who wouldn’t over a couple of ice-cold pina coladas??) Sari tells stories of family members blessing her and kissing her when she decides to withdraw care from a patient in the emergency room and the stillbirth I saw delivered on labor and delivery lay alongside its mother for hours, both of them lodged between rows and rows of healthy, newborn babies. I’ve already mentioned the open aired coffin markets on the drive to Cape Coast, and while I never got to visit it, I read in Sari’s guidebook to Ghana about Kane Kwei Carpentry where you can be fitted for the fantasy coffin of your choosing, with shapes like airplanes, whales, boats, birds, even uteruses. 
    It feels unnecessary to provide the US counterpoints, but good luck finding a uterus coffin worth its salt south of the Mason Dixon. My point is that people die here in Ghana. A lot. We die in the US too, but man it drives us (and our doctors) nuts. I’m not saying let's learn to die from the Ghanians, I’m just saying a uterus coffin might be a start. 
    Ok ok, it’s enough already. Either the malaria has set in or I have dysentery of the brain. To bed!

Friday, May 24, 2013

Guest blogger: Any way you want to tie it

Dr. Katy Rivlin writing from Accra, Ghana

5/22 --> Any way you want to tie it

    In the mornings, I awake to the sound of a traveling saleswoman from the North (Sari says you can tell by her accent). She cries “plaaaaaaastic chairs, PLAAAAAASTIC CHAIRS!!!” The metal worker beats out his offerings with a wooden stick on a wooden box, and the shoe repair man has a little metal clanger. The goat (who turned out to be a sheep) has gone to a better place and bleats to me no more. 
    In the family planning unit this morning we did a tubal ligation. It’s a surgery that I’ve only done laparoscopically in the US, so using a mini abdominal incision was new to me. Only later in the case when I jabbed my finger into the woman’s abdomen to fish out her fallopian tube did I realize she had nothing but local anesthesia and some IV sedation. Geeeeze!!  It’s a whole different skill set here: low cost, fast surgery, as gently as you can. Turns out there’s a special instrument other than your finger that you can use to snag the tube. My apologies to you and your peritoneal cavity Madame. 
    After work, Emmanuel drove me out to a suburb of Accra to meet his family and to see the house they just built. His oldest daughter, Ama is 15 and away at secondary school, but his son Naana is only 5 and came with us to dinner. We ate Chinese food spiced Ghanaian style, talked about the contested election here, Chinese immigrants and how to lose weight. Well, I think we did. The conversation was half Twi and half English so as usual, I did a lot of smiling and eyeball crossing. When Emmanuel’s wife packed me off at the end of the night, she made sure I had a half gallon of strawberry ice cream to take with me. 
    In other news, I think Maala has finally gotten her sea legs. She told me a story about the water and electricity running out at her house (a fancy gated expat community with AC and running water). It happened right as she was taking her post call shower, and “my hair was full of lather” (don’t forget, she’s British). With no other water around she resorted to rinsing her hair out with mouth wash. All day today her scalp was tingling. Bravo Maala, this makes my bucket showers seem like a Carnival Cruise. 

Thursday, May 23, 2013

Guest blogger: Duty

5/21--> Duty

Last night was my “duty” night or 24 hour shift. Well, sort of. There was a random 3 hour break in the middle of the day in which Sari took Maala and I fabric shopping and then to Constance the seamstress.  She works from a wooden shack in the middle of a field and has a steady inflow of obruni doctors coming to her thanks to Sari. Maala played it safe with a light blue fabric covered in tiny blue flowers, I went for a very African yellow, orange and black print that will bring tears to your eyes. I hope my dress has lots of ruffles. 
    With rounds in the morning and Ob clinic in the afternoon (two patients and two doctors to a room, pelvic exams and all) we didn’t get to L&D until 5pm. Sign out involved the outgoing resident telling Parker about all the patients on the floor (this one, she delivered, this one, she has imminent eclampsia, this one, she has a stillbirth, this one, she is for an elective c-section for a bad obstetrical history) and then leaving. Not much to go on.
    Other than the heat, the lack of water for scrubbing (someone pours it over your hands for you before a c-section), and the colorful fabric sheets that each patient brings for herself and to wrap her baby,  L&D in Ghana is quite similar to L&D in the States. Babies come, some from the vagina, some from the abdomen. Sometimes women bleed and you try to stop it, sometimes their blood pressure gets really high and you try to stop it. Lucky for us in the States, there is never a magnesium shortage and we always have IV antihypertensives. I guess that’s a difference too. 
    I tried to teach Maala cervical exams and how to rupture membranes with limited success. They use a Kocher clamp to rupture here (in other words, a heavy metal instrument with wooly mammoth like teeth) which I think left Maala more traumatized than the non flushing toilets.  We spent the whole night doing c-section after c-section, until everyone got tired of it and went to sleep. Then we woke up and did some more.
Finally Emmanuel sent me home to “take a bath” and I am to be back for a Family Planning meeting this morning. I think I’m getting too intolerably pungent for anyone to stand anymore. 

Guest blogger: A list of lists

Dr. Katy Rivlin, guest blogger writing from Ghana, travels to Cape Coast, the site of former slave trading posts.

5/19--> A list of lists

I learned from my Daily Themes class in college and Tim O’Brien’s The Things They Carried that some things are best said in lists. So here is my trip to Cape Coast, in list format (at least until it gets too contrived). 

1.) Things that hawkers carry on their heads and sell to you through the windows of the tro-tro  (or terrifying minivans packed to the brim with fellow travelers)

Laundry bags
The Jesus Collection DVD in Twi (Ghana’s local language)
Phone cards
Dish Towels
Fried plantains
Bags of water
Bottles of water
Bottles of yellow/pink/orange/purple drinks
Cell phone holsters
Royal primers
Fried balls of starch

2.) Things that I saw through the window of the tro-tro on my way to Cape Coast

Many pregnant dogs
The Brainy Child Learning Center
“Do no urinate here” spray-painted on a huge concrete wall
Many many goats
A sign reading “Life Donkey for Sale”
Some chickens, one pig
Open markets with rows and rows of pimped out coffins, people perusing the aisles. 
Even more very pregnant women

3.) Things Ghanaian men say to you when you are a female traveling alone

Is your husband black or white?
My name is _____________ (fill in biblical sounding name here, examples include Ishmael, Nicholas, Emmanuel, Anthony, Isaac). Will you be my friend? 
I love you. Will you marry me? No? Then please, your number. 
Are you alone? Are you happy alone? (this one hurt a little)

4.) Things Ghanaian women and children say to you when you are a female traveling alone

Miss! Miss! You like fabric?
Afternoon obruni. God bless you. 

In other news, Sari steered me to the Anomabo Beach Resort, which made possible a real shower (I took 4 in my one night stay), a flushing toilet (I flushed it just for the sake of seeing the water swirl) and the most peaceful beach I’ve seen in a while. 
Though it took all my wits and cedis, I made it to Cape Coast Castle, or the holding place for captured slaves headed for Brazil, the Caribbean and the Americas in the 17 and 1800s. My fellow obrunis and I fell under the spell of Stella our pretty and low voiced tour guide as she weaved us harrowing tales and showed us dark, cramped dungeons where at one time 1000 men and 350 women lived in darkness and filth, awaiting export. Ari (my fiance back in the states) has already called it the birthplace of America and I think he’s right.

I’m back in Accra, the effects of the shower long lost on the tro-tro ride back. Getting ready for “duty” or our overnight shift tomorrow.  

Tuesday, May 21, 2013

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!

Monday, May 20, 2013

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. 

Sunday, May 19, 2013

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!

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: 

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. 

Thursday, February 21, 2013

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.

Sunday, January 27, 2013

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.