great book of stories

Y'all will remember how I love Richard Selzer's book, "the Doctor Stories": so now I found another great book, called "The Orange Wire Problem, and other tales from the doctor's office" by David Watts, MD. He is a gastroenterologist and plays the french horn in San Francisco, and his book is earthy, poignant, warm, fabulously written, and interesting/riveting. He talks about making jazz riffs, and how one needs to know the melody, as well as how to make music, to do it well, as a model of practicing medicine. I think his patients are really lucky to have such a great doctor. I love the introduction, which ends "... change suffering into art and dissonance into music". You could do worse, in trying to understand how a doctor thinks. You also could hardly do better. His writing is fine, insightful, and fast-paced. And "balanced!"

missile defense

Dear Friends,
Here is a great answer to anyone who doesn't understand why the President decided to withdraw support from the non-functioning and expensive missile shield. Again, I urge you to check out the Friends' opinion-- here is the link:
From 2C: Obama Suspends Misguided Missile Shield
What can history can tell us about the future for nuclear weapons and diplomacy? In this blog post , I look back to the Clinton administration’s attempts to ratify the Comprehensive Test Ban Treaty and reflect on the implications of President Obama’s recent decision to end the European missile shield project: http://action.fcnl.org/r/86747/76229/0.

The Friends Commitee on National Legislation

Dear friends,
If you want to understand a political issue and are bewildered by it, a good place to start is with the FCNL. The organization is by the Quakers-- who call themselves "Friends". I believe them-- they are true friends of Jesus, and each other. There is no hierarchy to support, and so they do not skew the data or twist the truth. They can be believed, and their opinion is both ethical and valuable. I am praying that what they have said about health care reform will be more widely heard. They have been pointing out that it will lower the federal deficit== and that should appeal to EVEN the most ardent Republicans! Please check it out. Love, Martina

More on Health Care Reform

Recently, I got a page from a blog talking about how the whole reform will be at seniors' expense. It is obvious to me that it is part of the big misinformation campaign being spread by powerful interests who do NOT want reform, because they are making billions of dollars, siphoned off the top of the cost of health care. I worry about how this kind of stuff is being spread, and by whom. It seems guaranteed to cause radical paranoia, which will thwart the needed changes, and will allow the robbers to keep robbing the screwed up system.
One problem is that the "Medicare advantage" program is spending 15% more of taxpayers' money, paying Large Insurance companies, for Medicare patients. If we could regulate and stop the robbery from these insurances, we could use that extra money, which is NOT being spent on actual care, but is being given to wall street profiteers, to take care of patients.
The systems which are getting put into place will utilise medical care differently. Every thing will be much more "cookbook"-- which means, you get the mammogram, labs, colonoscopy, bone mineral density, and a short visit to follow up on all of the "screening" tests. More nurse practitioners will be utilised by docs to do the quick blood pressure checks, and follow-up visits, at the "medical home" office. The patients who have congestive failure of their hearts will be getting phone calls daily or weekly, and will be going to the clinic for anti-coagulation follow-up fine-tuning on a routine basis. But overall, there will be less holes in the system this way. Patients will be followed more meticulously by every screening parameter, in standard ways. There will be more teamwork with social services, home nurses, in-home caregivers, and all the ancillary testing groups, and specialists working with the primary care docs in a more concerted and coordinated way. You won't have so many right hands not knowing what the left hand is doing.
The insurance companies are spending millions to try to block this bill. They already have bought the blue dog democrats, and they took the pearl from the crown-- the national malpractice reform which is the MOST important piece of how to save the TAXPAYERS' money. They are so devious, and so rich! It is pathetic; and the country is full of people too ignorant to see what would be best, or good for them, because the issues are complex, and easy to manipulate. The fearmongers are going to the 9th circle of Dante's inferno, if I get my way with the heavenly authorities!!
The two main issues we need to have are a public option, and malpractice reform. That will save all the needed money, and distribute it where the care is needed, to the actual caregivers. What we need is a public option which will take care of the sick and the poor. The public option should be the same as what the congress gets. And if anyone wants to pay more, they can buy a private option, which will cost more, but hopefully deliver more. It should include the perks, like plastic surgery, and infertility, and advanced treatments still considered experimental, and drugs with no generic equivalent, yet. Everyone will WANT private insurance, but not everyone can afford it.
For the sick and the poor, who are going bankrupt and losing their homes, and unable to hire in-home help to take care of their children as they struggle to pay for chemotherapy, there will be the "rescue net" of the public option, I sincerely hope and pray. Medicare doesn't pay enough, but it is better than nothing. What has happened is that the private insurances are now paying docs Medicare rates, and using the extra money they get for their policies to pay these exorbitant salaries to their CEOs and investors. Physicians are screwed by the system, but we have to remember that the sick are poor and the poor are sick, and that the job is also partly a vocation, not just a business. Docs who are making huge amounts of money as entrepreneurs are not always respected and loved by their patients or colleagues. Patients know when we have their best interest at heart, not our own. Humility is needed in any profession, and ethics always apply. Doing the right thing should always be built into the system as the best answer. We have to take a hard look at greed and profit-making, and make an effort to discern where the common good of our communities lie.
Real reform is going to be costly, and yet, citizens should be satisfied that the safety net for all our families is in place. That is absolutely the best guarantor for any person who falls ill, that the right thing will be done in their case. A few years ago, there was a ballot measure to pay about 50 cents for each cell phone user per year, into a fund which would cover 911 calls for emergencies throughout the state. The private phone companies defeated it, with smearing tv ads. That money would have helped coordinate ambulance, police and fire services. When we look at the state budget, and we see bankruptcy, we need to realize that the citizens have to push for better use of the tax money. We need to overcome lobbyists for special interest groups that warp the discussion, and help themselves rather than the "common good". My vote for state funding is to spend FIRST on healthcare and schools. I do not want to see us spending more on prisons than on education. I believe it is worth our efforts to have a healthy populace. Please see my 10 points of health reform, for a more coherent "big picture".
Love, martina

new book

My new book, called "Bread for the Stardust Pilgrims" is out! I am posting the title poem here, in case you want to get a little taste, and if you are interested in the book, check out the webpage at the publisher's-- http://www.oldmp.com/martina.htm


Bread for the Stardust Pilgrims

Holding the dandelion seeds
Of our own resurrection,
We are the stardust pilgrims:
Oxygen, nitrogen,
Carbon and hydrogen,
Kissed by sunlight,
Remixed and reborn.

Flesh blossoming from the muddy earth,
Barefoot on the journey,
Bones (sometimes weary) singing the truth:
We are stardust,
we are pilgrims;
Calcium and amino acids,
Air and water.
This bread is ours,
Wheat from the fields,
Golden as grain in summer.
This wine, transforming us
As we walk along,
On the way to the wedding feast,
Hoping for miracles,
Laughing for joy.

Good-enough leadership

This week's TIkkun magazine had a great article about the idea of good-enough leadership. The basic idea was that if it is not so "heroic" or seemingly perfect, there is more room for collaboration and contribution from the governed, to help smooth the concept or execution of an idea. It was interesting to consider this in the era of multi-cultural diversity, when there are such a plurality of opinions, and no easy consensus. We are starting to truly have a democratic discussion, in which many possible answers are given, and maybe one will be a better idea, but there are slim margins of which might be the best of these options.

Cervical Ripeness and Induction of Labor

Ripening the Cervix, and Induction of Labor
a discussion for patients by Martina Nicholson, MD, FACOG


WITH MANY THANKS to Dr. Aaron Caughey, MD, MPP, MPH, PhD, at UCSF, for the expert review of the data and nuances of this topic.

When we wonder about the "best" time for delivery of a pregnant woman, there is now sufficient data about how long the cookies should stay in the oven, so they will come out golden brown, not underdone or overdone. And the answer is 39-40 weeks. There is the lowest chance of morbidity at that time. So now we are trying to get as many babies as possible to deliver within that window of opportunity.
After the edge of "term" there is more risk of the baby being surrounded by inadequate water, so the cord can become squeezed in labor, as the contractions intensify. The cord brings oxygen to the baby, and if it is too "vulnerable" it will not deliver enough, so that the baby gets stressed, and then distressed". This makes it important to try to get through labor when there is still enough fluid around the baby so that the cord can float freely, and pass oxygen in and carbon dioxide out. The placenta is "breathing" for the baby, until delivery.
Also, the baby can go poop in the water, which is called meconium. If the baby takes deep gasping movements, the fluid in the baby's lungs can be so noxious, covering the insides of the lung surface, that the baby can not breathe air when it comes out. The baby has to make a transition from being in a watery world, to being in air, and learning to breathe, rather than get all its oxygen from the placenta, through the umbilical cord. So it is very important for the baby not to gasp and inhale deeply the meconium. We now know that babies gasp as a reflex, when they are inside and there is not enough oxygen. So we want them not to have long or deep fetal heart beat decelerations, which cause them to feel less oxygen, and gasp. Babies can tolerate some stress, some low-oxygen, for awhile. But labor can be long and hard, and if it is getting harder and harder to get enough oxygen, the baby will become "distressed"-- and need to be bailed out.
So a big part of the work of doctors, in watching labor, is to gauge how much stress the baby is under, and whether the baby is bearing up under it. In a fast, easy labor the water is abundant, the cord is not compressed with contractions, and mother's pushing allows a natural squeezing which may help the lungs be less full of water, and more ready to take in air when the baby first breathes.
In a long hard labor, there is also the risk of infection, which can rise from bacteria which naturally live in the vagina, up into the uterus. So it is really important for the mother to be delivered as promptly as possible, to reduce the risk of infection passing to the baby. The mother also can get a deep infection in the walls of the uterus, which is called "chorioamnionitis" (infection in the bag of waters) and later, "endometritis"(infection in the lining of the uterus)--and this causes the walls of the womb to be less capable of contracting efficiently, both in labor, and afterward, to keep from bleeding from the raw site where the placenta was attached.
When a baby is post-dates, and has meconium, and has infection, it is like 3 strikes against them. For this reason, we want to get them delivered when they are ripe but not at risk.
Some women look askance at us, for trying to talk them into being induced at term. They need to understand that this is the underlying reason. For most moms and babies, it is safer, and there is more chance of a successful vaginal delivery, if we don't wait till two weeks overdue.
In general, I try to "let the river flow, rather than trying to push the river". But sometimes we need to nudge someone into labor to get them to deliver in the best window of opportunity for safety.
What stops us? The last process of pregnancy before labor is cervical ripening. If the cervix is like a green apple, it is much harder to get it to open. It needs to be like a ripe peach. The soft, squishy, mushy tissue will more easily begin to open up. So what we now use, to get the "ripeness" we need, is prostaglandins. The medicine Cytotec, or misoprostol, was invented for ulcers, but it was found to be exactly what is needed to make the cervix ripen. This is what does it naturally, in most women. But some women don't make enough. So we can give them this medicine, vaginally or orally, and the cervix will respond by ripening.
After the cervix is ripened, which may take around 24 hours, the uterus can begin to open up the cervix, by contracting. The contractions are like a castle opening a heavy drawbridge. The drawbridge is drawn up and into the castle walls. We sometimes have to use pitocin, a medicine which is dripped into mom through the iv, to help this process of lifting open the cervix.
Another thing that has to happen is the baby has to come down deeper into the pelvis, and make it through the outlet of the bones. Some babies are just too big for the bones of their moms. Others are lying in a position which makes it harder to get through the pelvis. And some have a tight loop of umbilical cord holding them up. Sometimes we can change the mom's position to help get the baby to turn and come through the pelvis. Sometimes we can actually reach in and turn the baby's head a little, to get it to do this.
When the baby is distressed, or there is thick meconium, or the baby has a body which is too big for the mom's bones, we do a Cesarean Section. This surgery has helped millions of babies to be safely born, with lungs which can breathe, and not having severe infections, and so they can stay with their moms and breastfeed, and not need to go to the nursery in exhaustion and need tubes, iv's and oxygen to help them get out of trouble. A lot of people think doctors are making unnecessary interventions, because they do not understand these facts. All our monitoring is to make sure the baby and the mom are both safe through the process of labor. We want to help babies be born safely, and in optimum health, like golden brown cookies!