Your Brain is Green
Of all the brain types, yours has the most balance. You are able to see all sides to most problems and are a good problem solver. You need time to work out your thoughts, but you don't get stuck in bad thinking patterns. You tend to spend a lot of time thinking about the future, philosophy, and relationships (both personal and intellectual).

Sunday, February 17, 2008

That Old Black Magic Has Got Me Under Your Spell

Actually, I can't use a title like that in a post about the current political situation in the US without being extremely politically incorrect.

And that's a shame, because Barak Obama's cafe au lait skin has nothing to do with what I'm writing about.

What is largely forgotten in presidential election years is that one-third of the Senate, and all of the House of Representatives are also up for grabs. All the rhetoric in the world won't change the fact that an unfriendly Congress can tie the hands of any new President. In fact, it can darn well choke him/her.

My middle daughter, a.k.a. The Curly-Haired Monster, asked me, a few years ago, when she was about 21, if I had ever heard of a singer by the name of Bob Dylan. It seems she had just heard "The Times, They are A'Changing" on MTV.

Every generation thinks it reinvents the wheel, and usually thinks it does it better than before. I hear Obama trotting out all the Kennedy-isms, and I feel very old. ("Yes, dear", I told the CAM, "we smoked, and we inhaled".) I remember what happened to JFK when he tried to get any legislation through a Republican-dominated Congress. The only reason LBJ was able to rescue JFK's programs was because of the public mood after the assassination and--this was actually the more important reason--LBJ had over 25 years of wheeling and dealing on the Hill, and he was one sly SOB.

Obama's hands are completely empty. Oprah likes him. I probably would, too, if I met him. But he's barely been in national politics long enough to know how to find the right washroom.

Should Obama get the nomination, I predict the following:

  • McCain will win the election because most Clinton Democrats will either stay home or vote for him. I cannot see many Clinton supporters transferring to Obama. Hillary could beat McCain, both on her own virtues and because I think she would get some swing votes from McCain, and certainly from Obama's people. It wouldn't be easy, but it could be done.
  • Obama won primaries in the South because the total number of voters in many places were blacks. However, this may not be reflected in Congressional districts where there is a majority of white voters. I don't want to use the term "backlash", but if the poorer and more conservative Southern whites see any threat in an Obama Presidency, they will vote for the "lesser" of two evils: a Republican.

Let us assume that Obama does get into the White House but control of the House, and/or Senate is only very narrowly Democratic. It has to be remembered that while Bush is personally very unpopular these days, many Republican Senators and Congressmen aren't. Neocons and the Bible Belters can't abide the liberalism of Obama, and with the country not in the best economic situation, conservatives in Congress will take an awful lot of convincing to embark on radical, vague, changes.

And he has no power base. He hasn't been a Senator long enough to do much of anything, let alone create a cadre of supporters who can call in favors and swing votes. What the public sees on the Senate and House floor is the end product of many meetings in corridors and offices, clubs and other venues. Oprah Winfrey, in this regard, probably has more real clout than Obama does.

And now for the unmentionable "color" issue: should Obama get to the White House, and turn out to be a President like Jimmy Carter was, a nice man way over his depth, the advancement of blacks in the US will be harmed for another generation. I can only wish that Obama had chosen to wait another 8 years before running, when he'd been more seasoned and tested in the ways of power. As it is, I think he's going to be roasted.

Saturday, February 16, 2008

Yo Mama! You is BIRTHIN'! Part 1

The internet is an obsession of mine, no, it's an addiction. I belong to groups discussing various aspects of living in Israel and making aliyah, literary groups which discuss Dorothy Dunnett's novels, Dorothy L. Sayers mysteries, Laurie R. King's Mary Russell books, the Outlander series by Diana Gabaldon.

And I read a lot of blogs. Most of these are medical, and quite a few are written by nurses, several by midwives. The one which is taking up most of my time currently is Homebirth Debate, hosted by Dr. Amy Tuteur. There are times when the comments quite frighten me.

Dr. Tuteur herself is a retired obstetrician/gynecologist. Her contention, and it is quite accurate, is that home birth is more dangerous than hospital birth. The women (and occasional man) who enter the forum and leave comments, cover the full spectrum of reactions. Some of the women have had home births, without incident; some have had extremely high risk pregnancies--including a few bad outcomes; some commenters are direct entry midwives. I think I'm correct in saying that currently I'm the only certified nurse-midwife contributing to the discussions.

There are a number of recurring themes. One is that birth is a normal physiologic process; logically it there follows that no special expertise is needed by birth attendants. Indeed, attitude rather than specialist knowledge is adequate, if not preferred. Over and over again the view is expressed that women don't get sufficient "respect" from doctors and nurses, whereas midwives (usually direct entry midwives are meant in this context) do "respect" their clients more.

"Respect" usually means two things: allowing the woman to conduct her own labor and birth as she sees fit, regardless of medical necessities, and improved communication between care provider and patient. There is a certain degree of just complaint. Communication--what used to be called "bedside manner" is often pretty bad. Doctors don't have courses in "how to be nice to patients"; they're too busy coping with the medical side. Nurses can be better at communicating with patients, but just as there are all kinds of patients, there are all kinds of nurses. "How are we this morning?" one of my co-workers used to ask every patient, and was rather shocked one day when the patient so addressed snapped back, "I don't know how you are, but I'm f**king terrible!" Outside the room the nurse asked me, quite upset, "Should I ask for a psych consult? She's so aggressive!"

Women may be experts in being women, but they're not experts in obstetrics. Another recurring theme is that a basic nursing education is superfluous in being a birth attendant, because nursing implies illness and birth isn't. Why, after all, should a midwife have to know such things as the names of the 12 spinal nerves or the symptoms and treatment of subacute bacterial endocarditis? Especially a midwife who is never going to take care of a woman who is having a high-risk pregnancy?

Unfortunately, even the lowest-risk pregnancy can become a massively high-risk one literally in a matter of hours. Then, direct-entry midwives argue, in that extremely rare possibility, expert help should be summoned. But how will they identify the situation, if they've never learned it exists? It should be noted that some conditions are less common than others, but many are more common than this type of midwife is willing to admit. But a certified nurse-midwife not only can identify them and instigate initial measures, she has experience with all sorts of conditions not directly related to the obstetrical situation. A pregnant woman can have appendicitis. A pregnant woman can have an aneurysm, or a perforated ulcer, or be at risk of a detached retina.

One of the commenters, on Homebirth Debate, has written:

The question we are left with is the wisdom of assigning
primary care of normal birth (admittedly a time-consuming,
physiologically-based management skill) to a surgical

Aren’t we
working against ourselves by not being more
realistic about these issues? Could
it be that we are barking up the wrong
tree by confusing the topic of midwives
and planned home birth with the
general problem of a maternity care system that
in general needs to be

Americans have a few odd quirks. Individualism is
carried to absurd lengths. In spite of medical advances, quite a few women
jealously maintain they have a right to endanger themselves and their babies in
the name of personal freedom. Inadequately educated persons labelling
themselves as obstetric professionals jealously guard their right to be
allowed to endanger others in the practice of their entirely unregulated
"profession". As I write this, those Americans who think the Constitution
gives them the right to own guns are claiming that the students gunned down in
various campus shootings only died because they didn't have guns to protect
themselves against their assailants, rather than trying to remove guns from easy
access by the assailants.

We wouldn't allow doctors to practice medicine without being licensed, by a responsible authority, to do so, because lives are in the balance. Why do we allow "midwives" to do so? The first step to making reforms in our maternity care system is to make the practitioners of midwifery uniformly worthy of the respect of the medical community, as a unique branch of it. This would require, however, legislation on a Federal level, both of educational requirements, of the curricula of schools of midwifery, and of standards of practice. It would be necessary to create a governmental department responsible for the training, certification, and oversight of practicing midwives. Midwives would have to be, just as nurses and doctors are, graduates of accredited institutions meeting certain standards, be legally obligated to keep records, hold malpractice insurance, and do continuing education in order to maintain their licensure.

It ain't gonna happen. That would restrict "freedom". At present the demand for midwives is so small, and by such a fringe group that they don't exert any real pressure. Despite all their propaganda, DEMs account for less than one-half of one percent of births in the US.

The US is a very big and diverse country. European countries, on the other hand, are much smaller, more urbanized and centralized, and don't fear central government the way Americans do. European countries can, and do, regulate midwifery much more than will ever be feasible in the US. Also, the European homebirth model would be resisted vigorously in the US. Not all women are eligible for home birth in Europe (indeed, the majority deliver in hospital even in those countries held as models by homebirth advocates). One of the "rights" demanded by the homebirth lobby is that just about anyone who chooses a home birth must be allowed to have one, as a matter of personal choice, no matter how irresponsible that choice is. There is currently one DEM blogger who supports homebirth in a number of instances which are, by any criterion, not low risk (she even claims to have delivered a woman whose baby was in a position which is impossible to deliver vaginally). There is another DEM whose opinions have appeared on the internet which are completely refuted by all reputable statistics. Some women will be convinced by these women because they want to be .

"Empowered" is another term often bandied about. My guess is that it means that one is attempting to control an essentially uncontrollable process. The very unpredictability of birth is frightening. But whereas, if we were indicted on a capital charge, or if we needed to take an airplane to another city, we'd not hesitate to retain the very best criminal lawyer or put our lives in the hand of an experienced pilot, women who need this feeling of control over birth do the exact opposite. They choose not to trust medical professionals but deliberately want an amateur, who can't or won't contradict them, to be their birth attendants. Fear of hospitals is combined with fear of doctors, who are accused of being virtual sadists, bent on forcibly restraining women and subjecting them to gratuituous, painful procedures deliberately to wreck the "birth experience" (another phrase in the lexicon of those who want to reject modern science).

Oh, I could go on and on. Dr. Tuteur has written extensively about all of this. It is, to my mind, very odd.

Saturday, February 02, 2008

Some Anecdotes from an Old Midwife

Someone, over on Homebirth Debate, has suggested that I should write a book. Hah!

It will have to wait for my retirement, and only if some really crazy publisher will give me a giant advance, but...
When I reminisce about my 40 years' work in maternity care, of course there are cases which stand out. Generally they are not the simple, easy ones, although quite a few have more to do with the foibles of the women or couples in labor rather than complicated labors or bad outcomes.

There was the Black Muslim Birth, where several Afro-American (as they were called then) men, dressed in business suits, arrived with a very pregnant woman in the "uniform" of floor length skirt, long sleeved tunic top, and head scarf, all in the same pastel color. (This was back in the days of Elijah Muhammad, when the Black Muslims had not yet become standard Sunni Moslems and whose main tenet was hatred of the whites). One of the men informed the (white) OB resident that "no damn white man was going to examine his wife", let alone deliver her. But as she was obviously in labor, we could hardly send her away. I was not yet a CNM, but I'd done quite a few deliveries when the residents were otherwise occupied, and it was agreed I'd take care of this woman unless something began to go wrong.

After all the normal admission preliminaries, the husband informed me that it was essential, when I cut the cord, that the stump attached to the baby be anointed immediately with grain and oil and certain prayers said. Fine by me, I said. I was hardly going to argue with a very large and rather aggressive black man. He seemed satisfied, and unrolled his prayer rug, and began his version of the standard Moslem prayers, even though I could have told him that he had the Arabic all wrong and he was bowing with his backside facing Mecca. Couldn't see much point in it, frankly. I was a devil to him.

The delivery was uneventful. As I tied and cut the cord, with Daddy at his wife's head, I used the drapes on the mother's stomach to hide the baby's end, which I'd left quite long, and held up the placental end. "Here", I said, "do your thing" and with much "Allahu Akbar"-ing and other gibberish he anointed the placental end of the umbilical cord with his grain and oil and I saved the baby from septicemia.
Afterward, he thanked me, and told me that it was a huge relief he hadn't had to fight "Whitey" for his religious beliefs. "It's a real shame", he said, smiling pleasantly, "that when we take over the world we're going to have burn all you kikes along with all the other whites."

And then there was the hysterical lady who arrived on a stretcher, flinging herself around and generally behaving as if she was delivering imminently. She was thrashing so much that it was impossible to listen to the baby's heart, but it didn't seem as if she was having any contractions--the abdomen was entirely soft, although she was screaming in Spanish as if in agony and didn't stop. Severe, constant abdominal pain is a sign of premature separation of the placenta, a major complication. One of the residents, suddenly inspired, ran to the delivery room down the hall, and brought back a mask from one of the anesthesia machines, and put it over her face, connected to nothing but room air. "Breathe deeply!" he urged her, in Spanish. Instaneously she went completely limp. So limp, in fact, we had trouble "waking" her up to find out her name. From that time on, whenever we had a patient who was screaming but not in labor, which was quite common among certain cultural groups, we would say "Get THE Mask, quick!" and we all knew what was meant.

My hospital had a lot of women delivering who were in drug detox programs because we had bought a small hospital a block away and turned it into a detox center. One of the problems we had was knowing exactly the drug status of these women, who often detoxed in pregnancy intending to get high when labor began. They knew that normal amounts of painkillers wouldn't help at all with labor pain, unless they reduced their tolerance levels. So we really couldn't give them anything lest we depress the babies. On our blackboard, where all the patients were listed, we would write "DA" after their names, to alert the staff. A new, and very politically-correct, supervisor, objected to this "labelling" as being prejudicial. Thereafter, in the "analgesia" column,, where we could list the patient's request for an epidural, local anesthesia , or other pain medication when it was needed, we wrote "vocal". The lady in question could scream, and having injected herself prior to admission, usually did, flying around the ceiling without any inhibitions.

When I was at the very beginning of my career as a delivery room nurse, we had a patient who, every two minutes, would let out the most bloodcurdling screams: "Ay, dios mio!! Ay, Santa Maria!!! Ay-ay-ay!!!" Every time this happened, I'd jerk, and start to get up to go to her, but my comrades in the nursing station would tell me to sit down, that she was nowhere near delivery. "But listen to her!" I'd exclaim, and they would smile and shrug. Then we heard "Ay, dios mio! Ay, Santa-----" followed by silence, and everyone stampeded toward the patient. You can't scream and push at the same time.

Baby, It's Cold Out There (and inside too)

Snow fell in Jerusalem this week, or what passes for snow, in this Mediterranean country on the same latitude as Miami, Florida.
Of course, Israelis in general and Jerusalemites in particular don't have a clue what to do when a white flake or two begins to fall, and everything--everything--comes to a screeching halt. Snow is rare even in our mountain regions--Jerusalem only gets a dusting every 5 to 7 years on an average, and the coastal regions never see it. The ski "resort" at Neve Ativ on the Golan often opens (barely) for a month or so. Jerusalem is one of the few places in the country where central heating is needed at all in the winter, and even then, the temperature usually dips to freezing for maybe a couple of nights in the entire season (days tend to be, at worst, in the 40s Farenheit, usually in the 50s). Below freezing is very unusual, and really hated because the solar panels which provide hot water year round tend to crack if the pipes in them freeze; an expensive repair.
Nevertheless most American olim find Jerusalem winters very cold. Homes here are built for hot summer weather; insulation is virtually nonexistent, cracks around window frames let in cold air, the method of building itself (cement or cement block with plaster on the inside, stone facing on the outside) is cold, and most apartment buildings that do have central heating only turn it on for about 4 hours a day. There's no point in heating a building when everyone's at work or in school, especially since heating oil is now about $6 a gallon.
Israelis cope in a number of ingenious ways. They sit in their living rooms bundled up in anoraks, scarves, hats, clutching hot water bottles or electric foot warmers, or just don't get out of bed. We have electric underblankets, called "electric sheets" in Hebrew, which are pads put on top of the mattress, beneath the bedding, and which you switch on for a few minutes before getting into bed but do not sleep with them on. Delightful! Israelis also use portable gas or electric room heaters and relate to them rather like having a campfire in the middle of the living room. The latest craze is for dual-purpose air conditioners, which can heat in winter. The result of all this has been an unprecedented strain on the national electric grid.
Since Israeli winters are short, beginning (usually) toward the end of November, and ending by March, there's not much reason for investing a lot of money in long term solutions to the cold. Most of the winter the days are nippy but bright, indeed, it can be quite warm in midday. Then a front arrives, from the north (now you know what the references to the north wind mean in the Song of Songs), blowing wet and frigid from Russia and/or Turkey. First it gets overcast and very windy, then the rain begins, and if there is snow at all, it starts after the ground is absolutely saturated, which is why snow in Jerusalem is really slush. I find it very unimpressive, but parents bring their kids from Tel Aviv and other warmer places just to see it.
Israelis don't really have the necessary clothes for winter, since they need them so seldom. In the "big" storm of 1992, I found myself tying plastic bags over my kids' feet, since they only had trainers and no boots, and letting them use the oven mitts for lack of gloves. I also had to teach them that, if they were making a snow man, not to roll the giant balls of snow for the body uphill from the base of the garden but to begin from higher up and roll down. (I was rather surprised that this wasn't obvious)
So, life stopped for two days this week. Husband didn't drive his taxi, not because he doesn't know how to drive on slick streets but because at least 90% of the other drivers don't, and he didn't want to be hit by one. No one but myself went to work, and I only went on the second of the two days, as my clinic was running on an "emergency only" schedule. I was very glad to go as all of us had cabin fever badly by the second day. The only one who seemed happy with the weather was our sheep-sized Samoyed, Sheleg (which means "Snowy, davka). He was born here, so he copes with hot weather better than his breed does in its natural habitat of Alaska or Siberia, but he really gets frisky when winter begins.
No one's been complaining much, however. This winter has been unusually dry (but unusually cold) so far, and Israel's water reserves are very low. All the rain there is falls during the winter--from May to October there isn't a cloud in the sky--and what doesn't run into the Sea of Galilee or get soaked into the ground and winds up in an aquifer is a total loss. So snow, which melts slowly and doesn't run off saturated ground, is good. But what fell isn't enough, and we can only hope for a lot more stormy weather before the rainy season ends. The farmers, however, who are almost always unhappy (too dry, too wet, too windy, etc.) have already started lobbying the government for compensation on their spoiled crops and the price of strawberries this year is horrendous (the fact that it's a shemitta year, during which the land is supposed to lay fallow and the Orthodox won't eat the produce thereof unless certain methods are used, has jacked prices up anyway on just about everything).
Now that I'm diabetic I'm feeling the cold much more than I used to. And my computer is in a kind of storeroom that doesn't have any heating so I'm typing this with numb fingers. Could be worse, of course--last night, just as we sat down to Shabbat dinner, the electricity in our neighborhood went out for about 15 minutes. Very romantic.
And now I'm going to end this and put my hands back in my armpits to warm them up.