text:
That's oh-be-GUY-n, not oh-be-GIN, as some (primarily people from Texas) would like to refer to my chosen profession. Although, working in this field can sometimes cause one to develop a penchant for gin...hmmm.
Thursday, January 15, 2009
It can be very hard for the patient however, after having the doctor be wrong numerous times over the years with drastic consequences to your life. I don't watch Oprah, and the articles you mentioned irritate me, but yes, I do look for reputable internet sites, and before the internet was available, I researched.
sarai, I realize that your postings are coming from a place where you have been burned by the medical profession, but I certainly do not believe that physicians are anything more than fallible human beings who will make mistakes. That was not the point of the post.
That doesn't mean that I approach the doctor like I know more, and like I expect them to act as my puppet. But if I go to an OB appointment and say my baby isn't moving as much, and I am concerned about placental insufficiency, for example, I DONT want to hear "you're baby is moving just as much, it just doesn't feel the same because he has less room". Excuse me, doctor, YOU are not the one that's actually pregnant here, DON'T tell me how much my baby is or is not moving. YOU are not the one that will have to live with a dead child if there is a stillbirth (which the medical world is completely unable to understand how to prevent) I and MY HUSBAND ARE.
I think you are misunderstanding me. I *do* appreciate an informed patient. As I stated before, I practice collaborative medicine, not paternalistic care. I take my appointment time with patient to educate them and talk about treatment options. I even have a list of reputable internet sites on which to research information. That is completely different than someone coming in (or better yet, just calling the nurse line) and telling me that they have already diagnosed themselves, and now would like me to prescribe this medicine or order this test for them.
Again, I know that you've been hurt, but I am not the doctor that didn't listen well enough to you when you knew something was wrong, so please don't cyber yell at me. Just because I may vent my spleen on anonymous blog about things that irritate me about patients does not mean that I quickly dismiss them or am rude to them, quite the opposite actually. I take my patient's complaints seriously and act quickly on alarming symptoms. The dismissive attitude you are attributing to me does not apply in real life. You only see the seedy underbelly of my brain here.
You doctors don't always know how many times in person's life a previous doctor missed something important and the patient paid a heavy price. The doctor may have done nothing wrong, they may have met the standard of care, but to the person living with the consequences, it just doesn't matter, and they will do anything they can (watch Oprah, read really stupid Reader's Digest, surf the net) to try to make sure they get more observant care next time around.
Yes, as I said, "we doctors" are not omniscient. I did already know the patient about whom I posted, and have been doing her GYN care for 3 years now ( and each time I did her pap, her small speculum was warmed and lubed). She is not new to me or my practice. My care of her has been as observant as can be. Doctors are human, we do our best, and sometimes, despite our best efforts, it just isn't good enough. It sucks, and we try hard so it won't happen, and it bothers us perhaps more than you will ever know.
As a nurse, I've seen term babies stillborn, (decreased fetal movement, doctor ignored, or minimized), diarrhea was actually Ecoli, which turned into HUS, by the time treated (after being sent home 3 times) kid had stroke and ended up needing kidney transplant, a "viral upper resp infection" was actually a bacterial pneumonia, doc wouldnt believe patient couldn't breathe well 'cause sat was OK, vomiting and increasingly decreased LOC was actually juvenile onset diabetes (also sent home a few time before ER doc figured it out -- kid almost died.) This may be why some people are reading articles and trying to advocated more vigorously for their own care. I know I am. Even as I feel sincere empathy for you as I see the look on your face when you see my internet sheets........
See above, and there are even term stillborn babies where there were *no* warning signs. No decreased movement, no pain, no bleeding, sometimes babies just die. We do everything we can to prevent it, but despite our best efforts, babies still die. Yes, there are physicians that dismiss patient concerns, or miss pertinent signs, but we are not all the same person. Advocating for your own care (what you are talking about) and telling the doctor what to do and how to do it (what my post was about) are two different things entirely.
And here's something that just kind of bothers me about your blog, which, BTW, I otherwise enjoy reading.........it's judgement both from you and commenters, about women's birth choices.
Well, I can't speak for my commenters, but part of my job is to regard "women's birth choices" with my own clinical judgement. That's my job. If women come to me for care, they are, in fact, asking me to use my clinical judgement in their care.
If I'm reading your blog right (and correct me if I'm not), the "ideal" expectant mother in your practice wants to go into labor naturally, not mind being past due date, and not object if you feel at the last minute she needs a crash c-section. Moms who want to be induced (God forbid a week or two early) prefer a c-section straight off, or "insist" on a "happy vaginal midwife birth" even if things don't go according to plan are subjected to the eye roll.... Kind of a tall order, Dr. Whoo.....
I don't know if there is a "right" way to read my blog, so who am I to say who is "reading it right" or "reading it wrong?" I do think that you may perceive my words in a more malicious way than they are intended, and this is probably only highlighted by your bad experiences. I vent on this blog when things get tough to take, a safety valve, if you will, so that I do not blow up in the presence of an actual patient. There is no actual eye rolling going on in the presence of my patients. No matter their circumstances, personality quirks, or clinical needs, they are treated fairly and equally.
Loosely speaking, my "ideal" patient (as you put it) doesn't exist. My guidelines for delivery, elective or otherwise, are dictated both by the standard of obstetrical care, my clinical judgement, and the individual aspects of each patient. What I expect of my patient is a relationship of mutual respect and trust. Those are things that must be earned...by both parties. There is no "laying down the law." There is a give and take that is natural in these kinds of professional relationships, and quite honestly it doesn't merit many blogging entries because it is so routine. I don't think that you understand, you only see so much of me here.
One thing I did NOT NOT want with my first child was a crash c section. Either a vaginal birth, or a planned section, didn't care which. Of course, doc wouldn't do a c-section just because I wanted one, so we had a crash vag delivery with vacuum, (baby crashed too late to get c-section) where I got to experience watching my firstborn be revived, separated for her for hours after birth while she stabilized, and was so sore and torn up that I didn't want to have sex for months and months, and still deal with stress incontinence since that delivery well over a decade ago.....but because I didn't go to med school I didn't get to decide what would be better for me. I would like to argue, both as a nurse and as a mom which was physically better for me -- ugly vag birth or planned c-section. Yep, I'd choose c-section. Sorry.
I'm sorry that you had such a traumatic experience, and that it still haunts you. There is no way to predict when something like that is going to happen. Crash deliveries of any kind are heart stopping, but it *is* the physician's decision, in that moment, what will lead to the best outcome for mother *and* baby. If there is a terminal deceleration, and the baby is on the perineum, it is much more likely you will get a better fetal (and maternal) outcome with an assisted vaginal delivery.
I'm sorry that your bottom got torn up, and you had to undergo the trauma of seeing your daughter (successfully?) resuscitated. But, if I'm reading correctly, your baby survived. If your physician did what you wanted them to do, what you *perceived* to be "physically" better for you, and did a c-section, your baby's brain could have been deprived of several additional minutes of oxygen, with possible disastrous consequences. Whose fault would it be then? Yours? No, it wouldn't, it would be the physician's fault, who let the clouded judgement of an overly involved party (read, you) make the call. Instead of a torn up bottom, you could have hemorrhaged and required an emergent hysterectomy, precluding any future deliveries. Would you take the responsibility of zero future fertility, just because you *wanted* a surgery? Or is that the physician's responsibility? So yes, when you put your medical care into the hands of your physician...in that critical moment...you may not get to make that final call on what you *think* may be best for you. That is what a physician is there to do.
The recovery from next delivery was even worse, crash section, nobody's fault, but if I had it to do over again, possibility of crash section or planned section, well, I'd choose planned every single time. The crash carries psychological scars --- many of them. If you are lucky, you get to go to sleep and miss your baby being born. If you are unlucky, you have to stay awake, with no one talking to you, while your baby gets CPR. and your husband is God knows where. Physically, its a lot harder, too, and wound healing is not nearly as good than it is when the surgeon has time to take his time.
Agreed, but the point is the same, you cannot always predict these things. You said yourself, nobody's fault. Precisely. Planned surgeries are often more controlled than emergent surgeries...but not always. There are exceptions to every single "rule." Again, I sympathize that you have had such traumatic experiences, but the neither medical profession at large (in general) nor I (in particular) are to blame for this. I didn't have the perfect, ideal, rainbows and orgasms births that I would have loved to have, either, but I was fortunate and had 2 viable, healthy babies. I wouldn't trade that for any "experience."
The reason that patients want to run the show is because THEY have to live with the outcome!!!!!!! Tell yourself over and over and over again, its not about me, its not about me, its not about me!!!! especially in your profession where the stakes are so so high.......
But in order to be safe, objective, and effective the patients cannot feasibly run the show! They can (and should) be involved in the decision making process and development of a treatment plan, and they can consent or not consent, but they *cannot* "run the show." That is what a physician is supposed to do. Run the health care show.
This blog *is* about me! How I feel about the things that I do and that I see. Here, in this little corner of the internet, it *is* all about me. That doesn't mean that I disregard what my patients want. It also doesn't mean that I haven't had to make a decision that a patient was not capable of making on their own.
Maybe they really want to be induced when they know YOU, whom I'm sure they all really like, will be there. Maybe they are tired. Maybe afraid of late 3rd trimester stillbirth. Maybe they are struggling financially and need tax break. Maybe already not able to work anymore and trying to maximize maternity leave. Wanting to be induced at 38 1/2 weeks is not a sin.
Perhaps it isn't a "sin," per se, but it isn't valid medically. There is a lot of research to read about elective inductions, especially prior to 39 weeks. Often the outcomes are less than stellar, both maternal and fetal. Wanting your own physician, or "being tired," or "being afraid," or "needing a *tax* break (!)" are not viable indications for medical procedures that can have lasting impact on fetal and maternal health and well being. Elective induction of labor is associated with higher rates of cesarean deliveries, fetal distress (and dreaded "crash deliveries"), and fetal hospitalization for various immaturity issues.
Take a page from your midwives book. Listen to your patient. Ask questions. Try to figure out what the patient is afraid of. What she values. Try "why is this so important to you?" instead thinking "I can't believe she wants to have her baby by Christmas!" Find out what other experiences she has had with other health care providers. Maybe the last doc that did a pelvic jammed a large cold speculum where the sun does not shine, and she thinks you respect Oprah more than her. And remember, if she wanted a midwife, she'd probably be seeing one, so try to tactfully ask what she wants from your expertise, if you feel like she is treating you like her puppet.
Not to beat a dead horse, because I'm already feeling nuts for defending myself for talking about the way I feel on my own freaking blog, but how do you know that I *don't* listen? You don't know. You don't know me. You don't know how I treat my patients. The last doc that patient had for a pelvic exam was *me*, and I did not jam a cold, extra large speculum into her.
I've found that being a patient and having really horrible medical experiences makes me a lot less offended by my patients. Because if a patient asks me "will the doctor use a small, warmed speculum like it says to in Oprah's magizine?" my first thought is not to roll my eyes, it is to ask, "what has your past experiences with pelvic exams been like...."
Unfortunately, having really horrible medical experiences makes you a lot *more* offended by the things that I say, anonymously, on this blog, and causes you to extrapolate and frame my commentary in a less than favorable light. I hope my response has given you some insight. And truly, for all the snarking on the blog, I never forget that my patients are just people, just like me, with a different frame of reference. Even if it doesn't translate in text, I'm certain it translates well in person. I wish you healing as you attempt to move forward from your painful past experiences.
44 comments:
- Somenurse said...
Love you! You do not need to defend yourself to her. I think she took your words, twisted them around and made the whole issue about her. Like you I am sorry that she had such a horrid experiance. No one but she and her doctors know why or what contributed to her issues. You are not to blame. Don't let some anonymous, bitter poster upset you. This is your blog, your ranting grounds, your place to talk about how you feel. Keep up the good work!
- Lisa said...
Um. Wow. That was crazy that someone left you a comment that involved. Sheesh.
- Rebecca Berger said...
I appreciate your sharing this dialogue. I'm sorry you were the object of this poster's pent up anger and frustration; I thought you responded diplomatically and eloquently. Thanks again for a great blog.
As a medical student who is starting to realize exactly why physicians get burned out in this profession, my heart goes out to you. how quickly women forget that pregnancy used to often result in one or two deaths, before modern medicine and surgical intervention. People have been swept up into a cloud of mysticism to the point of thinking birth is not a risky event. How quickly we forget how many women died from hemorrhaging to death or infection before all of our so-called heartless medicine. I'm sorry that you are just trying to get things off of your chest, and this is how people respond to your blog.
hugs from a female med student, who would rather be cut and have a healthy, viable baby, then otherwise. - 1/16/2009 12:32 AM
- Cindy said...
That was truly a yeoman's job of responding to all those comments! It did make for great reading. Cheers.
- What The Hell Is This? said...
Long time lurker..
To the commenter:
At 23 weeks I went into premature labor with my twins, 1 week prior, I had been to 2 doctors, neither caught my cervical change even though I was having contractions. I had 1 baby girl born 23 weeks and die 10 minutes later in my arms. The other baby girl was born at 23 weeks and 4 days and died 30 minutes later in my arms. I get not understanding how some doctors don't listen eventhoguh you have suffered so much.
I am sorry you experienced all that you did, and it sucks, and coming from someone who watched her first 2 born daughters die in her arms at the hospital, I know how you can feel somewhat "I need to be in charge"... but there is difference in being incharge of your own care and putting the doctors license at risk... if she does what you tell her and she is wrong and something happens, it is still her fault.
If you can't trust your doctor again, don't go to one.
And why attack people over the internet? sheesh.. just quit reading if you don't agree.
Hugs and you should be able to vent. - 1/16/2009 9:35 AM
HOLY MOLY!!! I think she has issues.
I started reading your blog while I was pregnant with my third child. I love it and really enjoy getting a physician's perspective. Please keep it up.
I can even add that I was a patient who begged to be induced early this time because I was on bedrest and my second daughter weighed 10 pounds, 5 ounces (no gestational diabetes) and had to be delivered with a vacuum (she is fine although later developed craniosynostosis that needed surgical correction). I desperately wanted to deliver early to avoid another such delivery. I was lucky though because I have a physician, who like you, understands the science and was great in explaining why inductions really should wait until 39 weeks and aren't always the best option. I did get my wish to be induced at 39 weeks, but it was medically necessary and everything turned out fine. Thanks again for sharing your perspective! We need to keep good physicians like you so I'm going to say something you probably don't hear enough: THANK YOU for all of your sacrifices! - 1/16/2009 11:10 AM
- alanaransley said...
Please don't quit writing your true feelings because some commenter took you the wrong way. Your blog is one of my favorites, and I love the way you lay it all out there. Just like any other blog, I read yours as your opinion.
- btschulze said...
Well said, Dr. Whoo, well said.
You are not the one that needs to question your motives. Sarai is. And while I sympathize with her over her traumatic experiences, she needs to know that not every crash C-Section (which I believe saved my son's life) and every crash delivery (which I believe saved my Godson's life) is a traumatic experience, but sometimes a blessing. - 1/16/2009 11:21 AM
Oh Dr. Whoo, I'd take you for my doctor anytime.
I have come to appreciate that doctors are people - well, that came from having them as church members and playing in the symphony with them and when one of my doctors got a horrible perm to cover up his thinning hair... ANYWAY! I try to get others around me to think about doctors simply this way, they are experts and they are fallible, they do what they can but they have a limited time to figure out what is going on with you at any appointment so you need to help them by being straightforward with what's going on and not expect them to ask all the right questions. I think expecting my doctors to be perfect and always get it right is too much and not fair, but expecting them to be right most of the time is a fair expectation.
As for the speculum I'd wish they'd start with the biggest first since I prefer as few insertions as possible, but they never believe me when I say get out the big guns (I'm tall, that cervix is far from the end...). Guess I should be glad my uterus is staying so high up in my pelvis.
Anyway, chin up! Most of us appreciate your blog and the insights that we'd otherwise never get, at least I do. I'd like to think it makes me a better patient too. - 1/16/2009 1:49 PM
- DoctorMama said...
I've got your back, dr. whoo.
Anyone who hasn't figured out that you're an awesome ob is a lost cause. - 1/16/2009 2:48 PM
- ~Ashley said...
i'm constantly amazed by the people who comment about "not liking your blog" or "being in disagreement on most issues" or whatever... i usually just yell at the computer-- "WELL, WHY DO YOU CONTINUE READING IT THEN? DUH." Seriously, if people get so upset by reading it, they should just stay away, or get a grip and have a reality check, sheesh.
I think your blog was great! I even did a blog about it and put a link to that blog you wrote! sorry you had to defend yourself so much, she obviously has things to deal with. I hope she is never my nurse :|
I completely agree with coffeeandtea above that there is somewhat of a delusion in society as a whole that birth is not as risky as it really is. I would include myself in that category until I had my third child. Although my complications were minor compared to some of the commenters (my heart truly goes out to you), it was enough for me to get a reality check. Birth is risky and sometimes things happen that are no one's fault and could not have been prevented.
Don't feel like you need to defend yourself. If people can't tell you are a wonderful doctor from reading your blog, then no amount of defending / explaining will change their mind.
With that, I will go crack open a bottle of wine for you :)
Amy in OH - 1/16/2009 4:16 PM
- Foster Mom to Many said...
I've been reading your blog for quite awhile now and I enjoy it very much. I had a horrible and very traumatic preterm delivery with my first child. I had the unfortunate experience of being delivered by a first year resident who was completely unprepared for the hemorrhage that followed. My OB couldn't make it in time, I went from 4cm to 10cm in 6 minutes and the baby almost shot out on her own! I came very close to dying.
I chose my OB for my second child with more care. I am sure that if she has a blog in which she vents about pain in the butt patients- I feature prominently in it for at least 7 months out of that year LOL! But she was never anything but courteous, attentive and professional with me. She listened to my obsessive compulsive fears and never once called me a loon. Because she listened, she caught my preterm labor immediately when it started at 28 weeks. She aggressively managed my care and my son was born at 37 weeks on the nose. I did have a scary delivery cause once again I went from 4cm to 10 in minutes and baby's heartrate went down and stayed down. Never have I been so grateful for my OB- she was calm, steady and encouraging even while I was panicked. Because of her, my son is perfectly healthy.
I'd take you as my OB any day, just from reading your blog. Thanks for sharing. - 1/16/2009 5:00 PM
- Fizzlemed said...
Holy personal attack, Batman.
Doctors are human, and I think we all forget that. My family has been repetitively subjected to doctors who cannot figure out what is wrong with them. It is overly frustrating to me, a premed undergrad, because when they don't get better, they call me-- a girl with 7/8 of a bachelors degree to save the day. Sometimes things are not easy to diagnose, and even more difficult to treat-- it is the way of the land. But we have to keep in mind that our doctors have our best interests at heart.
Keep up the happy blogging... you keep the rest of us happy :) - 1/16/2009 6:20 PM
- Jen @ the mama years said...
What I love is that the commenter is saying that basically you should give patients whatever they want - that early elective induction, that scheduled primary c-section without any indication - but yet you should be more like a *midwife.* Correct me if I'm wrong, but aren't the midwives the ones yelling at us OBs for doing all these elective, non-indicated procedures?!?
Also, if she wants to run the show she can either (a) go to med school or (b) figure it all out herself, without us. Wouldn't that be dreamy. - 1/16/2009 7:13 PM
I know that all these people say doctors are just people and I agree, but, you my dear, are definitely superhuman in my book. I love you.
Let the lot of 'em give birth in the third world. Docs will start looking a whole lot better. Chin up, Dr. Whoooo. I'm just sorry there's not more like you.
Dr. Whoo, continue to use this blog as your outlet for the things you feel you need to rant about. People forget that pregnancy/childbirth can be potentially hazardous. People died (and still die all the time in developing nations) from something as natural as giving birth. All those interventions sarai named(the induction, the elective cesareans) can lead to complications, something she would have known had she and her physician had a discussion about them. This is the only speciality where everyone wants a perfect outcome. When it doesn't happen, it's the doctor's fault. I say hell no to that. I, as an OB, am sick and tired of the misinformed, the skewed info from people like Ricki Lake and even Lady O, dictating how I am to practice my field. Do not let this obviously uninformed witch (but i wanted to say the other word) sway you from the right to blog the way you want. She doesn't like what you have to say , she doesn't have to read. Congrats again on board certification =)
- natalie said...
Go get 'em Dr. Whoo!! I think you're friggin fantastic and would take you as a doc any day!!!
- Lizard said...
wow. and may I say again, WOW. I hadn't read the comments on the last post, and his blows my mind.
I am from what would appear to be the opposite camp, in that I am a naturopathic physician and midwife, so I do home births. I am often the person people come to when they have had unpleasant experiences previously, or worse when they have read and watched scary things that tell them they *will* have one if they aren't careful.
I agree with everything Dr. Whoo says in both of these posts, and in general. Everything. EVERYTHING. I am the supposedly touchy-feely "hippie vaginal birth" midwife, and I can't and wouldn't pick a single point.
One of my biggest problems these days is that women think that being educated and choosing, say, a home birth, means that they will get one. It doesn't work that way. Sometimes we have to go to the hospital. Some babies need to come by c-section. Some even need to come by crash c-section, which is certainly no one's first choice.
However, to say "I want to schedule a c-section so I can avoid a crash c-section" is insane. Really. No responsible physician will say yes to that, especially for a first time mom. It pretty much guarantees her repeat c-sections, and every doc I know around here will work his or her butt off to protect the vaginal birth, especially for the primip.
Doctors do make decisions. Just because you have researched and read about the choices doesn't mean you get to choose what your birth will be. It doesn't work that way. This is not buying a damned car, people, it is an entirely unpredictable event and you can hope for the best and have lots of dreams, but I have news for you, from the hippie midwife: giving birth is NOT about the mother. It is about the baby, and what the baby needs. The mother's desire for a vaginal birth does NOT trump the baby's need to get out right now, or suffer brain damage. It just doesn't.
So now I sound like a cold, unfeeling, um, female dog. But you know what? I'm not. I think that my biggest job is to make women OK with birth, no matter what happens. My best successes are the women who transport to the hospital and have c-sections and don't feel traumatized by them. Who feel that they were heard and that they tried and that they made the best decisions they could for THEIR BABIES. Who really understand at the end of it all that the most important decision they made as a mother was when they ignored everything they wanted and dreamed about in the face of evidence that their baby needed something different.
So there we are. Feel free to tell me what a terrible midwife I must be. - 1/17/2009 10:37 AM
- Victoria said...
Wow Dr. Whoo. I'm sorry that you had to respond to that. I cannot begin to imagine going into a doctor's office (ob or any) and demanding to be treated as I desired. I think my favorite part of this comment from Sarai was the part about down on their luck people needing a planned delivery for a tax break. Right. That's a great reason to have a child.
I hate how people assume that they can always do someone's job better than they can. It seems that no matter what field we go into, they way society has shaped people into having an inflated sense of self worth makes them think they are the know all and end all. It seems no profession is exempt from this! - 1/17/2009 1:48 PM
- Dr. K said...
I think that your responses to these comments are very reasoned and logical. Well done, Dr. Whoo, and thanks for sharing.
Great reply, Dr. Whoo.
I think it is ironic that someone would post on your blog that you should take a page out of the midwives' book, and then tells you to do early inductions because the pregnant mom is tired. I can't believe she tells you to know that they will live with the consequences of your actions for the rest of their lives, and then tells you to do unindicated care with statistically worse outcomes (elective cesarean, early inductions).
And, I can't believe she would tell you that you don't listen to your patients. Sorry about that. It's hard to put it out there and be subject to people's reactions.
I have all the sympathy in the world. I think informed consent is sacred, but as long as both parties know (practitioner and patient) what the risks are of a procedure, the practitioner gets to decide what to do, and the patient gets to decide whether to accept that decision or to shop for another practitioner.
Obviously this isn't possible in all situations, if there is an emergent condition or the patient doesn't have the financial or social means to shop around. But, otherwise, that's how it should work. - 1/17/2009 3:46 PM
- Theresa said...
Many times I feel sorry for my docs. You are damned if you do and damned if you don't and if the results are less than perfect then you are always at fault. Keep doing what you do and remember that most people are reasonable and not as judgemental.
thank you thank you thank you. I am a small town doc who struggles daily with so many of these issues you so eloquently post about on your blog. I was feeling so alone and just plain sad until I found your blog and the mothers in medicine blog. Thank you because I now do not feel that I am alone!
This post is just why I find it so hard to do medicine some days and wish I was doing something else - anything else! But, it's the responses above and people who do appreciate my expertise and respect me that bring me back to why I'm here - out in the prairie, doing my best, and trying to be patient when my patient asked about their hemorrhoids in the grocery story last night, and trying not to take it personal when a patient I have worked so hard for asks to switch to my partner.
so, keep venting, and sharing why this is one of the toughest jobs out there - thanks again!! - 1/18/2009 8:11 AM
Wow....well not to restate the obvious but...
(1)It's your blog and you can really write whatever you want, no one is forced to read/agree with it...in fact rather than leaving rambling messages they can not read it
(2)people seem to forget that pregnancy is more than cute maternity wear and weight gain the list of things that can go wrong in the peri and postpartum period are huge
(3)childbirth is very natural and naturally remains a major cause of death for women and infant in the developing world.
(4)as for calling the shots, I'm an M.D. and when I delivered while a discussed options with my OB I inherently trusted her to make objective decisions that I knew I couldn't do
(5)It's easy to play monday morning quaterback but much harder to call the shots as its happening
(6) this won't be popular BUT..I've heard nurses complaining in hospital about they're plan for patients not being followed and guess what....ITS MY ASS ON THE LINE...it's easy to complain and wax poetic when the responsiblity for outcome doesn't ultimately falll on you, so spare me. - 1/18/2009 2:00 PM
- Milk and Two Sugars said...
Wow! All support from this med student who seconds coffeeandtea and anonymous' opinions.
God Love you Dr. Whoo...you are freakin' awesome.
- Unknown said...
Dr. Whoo,
I am another fan of your writing and points of view.
My only but is that I think that MD venting can sound awfully harsh to non MDs.
Yet venting is a critical in order to keep us sensitive physicians who can truly hear our patients needs, both physical and emotional.
So keep venting in ways that are restorative to you. - 1/18/2009 11:18 PM
- Return Of Saturn said...
Aww, your Mr. Whoo is so sweet!
I just wanted to chime in and agree with all the previous supporters. What the hell is the point of going to a physician if you're just going to make demands, regardless of medical indication. I do like the idea of my doctor keeping me informed and seeking my opinion/preference when possible. That said, the initials after my name aren't MD or Do, so I will defer to them...
Finally, it's your blog, and you can say what you want!! Based on the way you write (i.e., your philosophies regarding the practice of medicine), I'd let you do my pelvic any day of the week. ;) Keep up the great work, Dr. Whoo! - 1/20/2009 2:35 AM
Is there any way to block that nut job from reading your blog?
Great response! Go Dr. Whoo go!
I hope her comments don't discourage you to post. I would miss your blog!
Mrs. Mom - 1/20/2009 3:25 PM
- MI Dawn said...
Dr Whoo..I've been lurking a lot more than commenting, but WOW. This post was amazing. I can't understand where this woman is coming from (actually, as a CNM I have run across it, but still don't understand it).
@Lizard: You are very correct. It's about the baby. A safe delivery for both, and a healthy baby. I went to a great lecture by Ina May Gaskin several years ago. She said many of the things you did. - 1/20/2009 6:05 PM
- Taking Heart said...
Oh. My. Goodness.
She's a peach. - 1/20/2009 6:57 PM
where are ya now sarai! where are ya now?!
Oh my god, Dr. Whoo. I cannot believe this woman wrote all of this stuff - and I'm SO FREAKIN' PROUD of you for responding in this way.
ALSO - holy crap, that mention of the tax break reminded me - my co-worker knows a woman who insisted on a c-section super-early (or tried to insist; I can't remember whether she got away with it or not) because she "HAD to have this baby in 2008 for tax purposes". SERIOUSLY??? Who ARE these people? - 1/21/2009 11:18 PM
- Cindi said...
Wow - this is the first time I've read your blog. I have quite a few questions for Sarai - If you read a cookbook, can you compete with Bobby Flay? When you got your driver's license, did you tell Richard Petty that he should ease up in the corners?
I have nothing nice to say, except I've instantly become a Dr. Whooo fan. - 1/26/2009 6:37 PM
wow, ob-gyn, this is why I dont vent my really seep personal thoughts on my blog, when I started to it attracted email from people who had all sorts of projections and expectations of me. On top of it, I am a psychiatry resident and have my name on my blog, and it just took a few annoying comments to make the whole thing unpleasant! it bordered on harassment! so i just stopped the semi personal soft (no less!) commentary which I have butt-loads of to begin with.
Bless you for even going as far as you did in your response, you know you didn't have to... because these complaints had NOTHING to do with you. And there was nothing you could have said to make it better for her. I am sorry she is in pain. - 1/29/2009 11:06 PM
I appreciated the dialogue here. Thanks for your comments, Dr. Whoo. To Sarai and other patients: Like many, I became a physician to help people. It's a hard job to do. We are trying to make our decisions on the best evidence available. That's because, believe it or not, we actually want what's best for you, our patient. We are trying very hard not to miss anything that could cause you bad long-term consequences. We don't want any harm to come to you or your baby. At the end of the day, if we schedule you an early induction, and then your baby has transient tachypnea and spends 3 weeks in the NICU, we are grieved, too. Or we hesitant to do an emergency C-Section because you don't want one when our experience and knowledge tell us that your baby is in danger and your baby dies or has long term damage, we don't ever forget about it. Yes, you as the patient, have to live with it. But we have to live with how our decisions affect you, too, and we've worked too hard, spent too much time away from our family, and gotten too much grief in our altruistic persuits to also loose sleep when you run the show and have a bad outcome. Not to mention the million dollar lawsuit that we might end up with. We are doing the best we can for you. We do a good job most of the time. Bad things happen enough even with our best showing. Sure, continue to keep us on our toes. But don't be too hard on us either.
-OB resident - 1/31/2009 12:44 AM
- Dragonfly said...
Dr Whoo, I loved what you, Lizard and coffee and tea said. Couldn't agree more.
And my being here (and my mother still being here) is a testament to all that has been said - a crash Caesar was needed to deliver me (2.3kg and with lots of scary decels), saving my life, and half an hour later my mothers life was saved by the anesthetist when she VFibbed on the table. We have a great relationship despite often being separated geographically (despite many people telling me that Csections can interfere with bonding), and even though she didn't see me for 8 hours after I was born because we were both in ICU. And she went on to deliver my sister the natural way. So hooray for the anaesthetists, midwives and obgyns who were involved. - 2/04/2009 8:47 PM
- prachi said...
Hi Dr Whoo
I really really enjoyed reading your blog and am happy that such doctors exist in the USA.
I received horrible OB care and is described on my blog but all doctors arent good doctors and some are not even good humans. - 2/13/2009 3:49 PM
Honestly, you sound like my ideal OB. Willing to wait and be patient but ready to jump in if there's a problem. Willing to listen to my preferences, but never at the expense of my safety or my baby's. You don't happen to practice in the Kansas City area, do you?


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Thinly cut, red skin potatoes, tossed with olive oil and a variety of seasonings and baked. |
Homemade Baked Potato Chips
Another one of those No-Recipe-Recipes ... yummy, crisp homemade potato chips that you bake yourself, season yourself, and coat with healthy olive oil. So easy and just delicious!Break out the mandolin for this one because you really do need the potatoes to be thin (not too thin though) and uniform, and a mandolin does that with ease, making a super speedy job of it too. I went through these two potatoes in literally seconds. Toss the potato slices with some olive oil.
By the way, as noted in the recipe, I'm using unpeeled, red skin potatoes here, rather than russets. Russets are too starchy and don't perform the same, so do use the larger sized red potatoes, not the small new potatoes, for these chips.
Once slices, spread them out in a single layer on a baking sheet that has been brushed with a bit of olive oil. Here's where you can really have fun! Season them however you like! I used Bacon Salt seasoning, Slap Ya Mama Cajun seasoning, and salt and pepper on this tray. Try some BBQ seasoning, Lawry's Seasoning Salt, garlic salt, Parmesan cheese, paprika, chili seasoning, cayenne, popcorn seasoning, fajita or taco seasoning, rosemary, powdered ranch dressing mix, dry Italian seasoning, Greek seasoning, Old Bay seasoning, or whatever you like!
You'll bake them at about 400 degrees F for right about 20 minutes, or until they crisp up. Remember all ovens vary, so your time may differ. I highly recommend using an inexpensive oven thermometer to ensure that your oven thermostat is accurate for baking purposes. Remove the potatoes from the baking sheet to a paper towel to soak up excess oil, then transfer to a serving bowl and enjoy their lovely crispiness! Yes, they should be crisp - just like the ones you buy in the bag.
Here's how to make them.
If you make this or any of my recipes, I'd love to see your results! Just snap a photo and hashtag it #DeepSouthDish on social media or tag me @deepsouthdish on Instagram!
Recipe: Homemade Baked Potato Chips
©From the Kitchen of Deep South Dish
Prep time: 10 min |Cook time: 20 min | Yield: About 4 servings
- 2 medium sized red-skinned potatoes,unpeeled
- 1 tablespoon of olive oil
- Kosher salt
- Additional seasonings (see below)
Lay out two layers of paper towels. Preheat oven to 400 degrees F. Slice potatoes very thin, preferably with a mandolin and lay onto the paper towels. Top with another layer of paper towels and press to remove water. Place into a bowl and toss with the oil. Brush a baking sheet lightly with oil and lay the potato slices out in a single layer on the baking sheet. Sprinkle with salt and any additional seasonings, and bake at 400 degrees F for about 20 minutes, or until potatoes have browned and are crisp. Because there are hot spots in ovens, check frequently and pull off any that are already browned. Use a metal spatula to transfer the potato chips to a paper towel to cool, then to a serving dish.
Additional seasonings: Bacon Salt, Cajun seasoning, Creole seasoning, cayenne pepper, lemon pepper, BBQ seasoning, Lawry's Seasoning Salt, garlic salt, Parmesan cheese, paprika, chili seasoning, popcorn seasoning, fajita or taco seasoning, rosemary, powdered ranch dressing mix, dry Italian seasoning mix, Greek seasoning, Old Bay seasoning or any of those hundreds of seasoning blends on the market these days.
To Deep Fry: While I like these much better baked in the oven, you can also do them in the fryer. If you're frying, try Yukon Gold potatoes, but soak them a bit before frying and then pat them very dry. This helps to remove some of the starch that makes them soggy. Preheat fryer to 375 degrees and drop potato slices in the fryer basket, shaking to make sure the chips separate and do not stick together. Fry until light golden brown and transfer to paper towels to dry. Sprinkle immediately with salt and/or desired seasonings.
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subset: commoncrawl


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Patriot Tactical Multi-Threat Vest
Introducing the Body Armor Direct wrap around Scalable Patriot Tactical Enhanced Multi-Threat Vest NIJ Certified Level IIIA. Manufactured in the USA it features adjustable shoulders for improved fit, front and back 10" x 12" plate pockets, 11" x 3" area for a patch, and comes with our NIJ Certified armor that slides in from the bottom allowing you to fully wash the carrier. Adjustable cummerbund for secure fit. The removable inserts also fit our t-shirt and concealable carriers.
➠ View Ballistics Test Report
➠ View Ballistics Specification
➠ View Compliance Letter
➠ Professional Tactical Vest Datasheet
Weight in Lbs. |
Size | Light | Lighter | Lightest | Sq. Inches of Ballistics |
Small | 5.6 | 4.3 | 3.1 | 374 |
Medium | 6.2 | 4.7 | 3.4 | 421 |
Large | 6.5 | 5.0 | 3.6 | 447 |
Thinness |
Light |
0.35 inch |
Lighter | 0.25 inch |
Lightest | 0.21 inch |
- 1 Qty. Patriot Tactical Carrier
- 1 Set of Certified Level IIIA ballistics (front and back that fully wrap the sides)
Yes, we do! High-quality products are non-negotiable, which is why we work exclusively with the best protective product manufacturers.
Because of this, products may not be cheap, but we guarantee that they are reasonably priced.
However, we want you to have confidence that you are getting the absolute best price for your product.
So to show our confidence in our prices, we offer a price guarantee to our customers. If you find out within six months of your purchase that our company offered an item for a higher price than a competitor, we will refund the difference.
To get a refund, all you need to do is e-mail us a link to the product on our website and the same product on our competitor's website within six months from the date of your purchase, and we will process the refund accordingly. (Terms Apply)
Terms and Conditions of our 100% Price Guarantee:
- You must have purchased the item from our website before requesting your Price Match Guarantee
- Discounted goods and goods received as an Ad on such as; buy one, get one free offer are not eligible
- The item must be in stock on the competitor's website
- The 100% price guarantee is only valid within the first six months from the date of purchase
- The competitor must be an online store; they may not have a retail location
- The competitor website cannot be a discounter or an auction website (i.e., eBay, overstock, etc.)
- The competitor must be an Authorized Retailer of the product in question
- The Price Match Guarantee includes the item price and the shipping charges; it excludes sales tax
Order Confirmation:
As soon as you place your order, you will receive an order confirmation e-mail. This means that we have received your order in our system and pre-authorized your credit card for the purchase.
As soon as we receive your order, we automatically reach out to our suppliers to confirm that it is in stock and available for immediate shipment. If your item is on backorder or unavailable, we will reach out to you via e-mail to see how you'd like to proceed. If your item(s) are available we will process the charges and submit the order for shipment.
Order Shipment:
If your order is stock and we process the charges to your credit card, it will ship within the time frame specified on the product description page (which varies depending on the item & manufacturer).
We will send you tracking information within 24 hours of your order leaving the warehouse to the e-mail address you provided when checking out. If you do not receive tracking information from us within six business days of your order, feel free to follow up with us at firstname.lastname@example.com
Damaged Packages
Please inspect the packaging of your item(s) when they arrive, if you notice any damage you should make note of it when signing for delivery. If your item(s) do arrived damaged, please send photos to email@example.com and we will process an insurance claim on your behalf.
Order Cancellations
All orders cancelled after 48 hours are subject to a $20 administration fee, whether or not your order has shipped. If you order has shipped, you (the buyer) will also be responsible for actual return shipping charges.
In 99.9% of cases, refunds will only be issued as in store credit because of the nature of the products being sold and manufacturer specific policies.
All body armor sales are final.
Additional terms may apply (see "Vendor Specific Return Policies" below).
General Return Policy
Pivotal Body Armor accepts returns within 10 business days of product receipt for most products.
All body armor sales are final. Body armor includes but is not limited to soft armor, hard armor plates and helmets. These items cannot be returned as neither Pivotal Body Armor nor its manufacturing partners retained chain of custody of the item and cannot guarantee that after we have shipped the product that the structural integrity has been maintained.
Defective Product Returns
We stand behind our products 100%! Should an item be returned because it was defective, mis-represented, not as described, etc.
Please notify us immediately if you discover a manufacturing defect with your item. Pivotal Body Armor will issue a full refund and provide a return shipping label.
Return Instructions
If you would like to submit a return, please fully read the Return Policies on this page, submit a claim within 30-days of receiving your items, and follow these instructions:
- Email us at firstname.lastname@example.com to have an agent review your request and see if you qualify for a return. If you qualify, please use the link provided by the customer service agent and go to the "Submit a Return" form on our Shipping and Returns page of our website to submit your claim.
- Provide your name, email, order number, ticket number, and the reason for your return.
- An agent from Returns will review your claim and send you a confirmation email stating it was received along with a digital copy of a return label and instructions. The cost of return shipping will be deducted from the credit amount.
- Upon arrival and inspection of the product, within 5-10 business days, you will either be issued a store credit, or an exchange of product will be shipped out.
Some exclusions apply (see "Vendor Specific Return Policies" below).
Vendor Specific Return Policies
Each brand/vendor may have their own specific return/refund policies. Please refer to the following list to see if your item has any special instructions before making your purchase.
By purchasing any of our items, the buyer certifies they have read and agree to our shipping, return, refund, and privacy policies.
Armored Republic AR500 Armor
At AR500 Armor®, 100 percent customer satisfaction is always our goal. We understand that issues with orders may arise from time to time that need to be addressed.
Sales of promotional, seasonal, discontinued, and clearance items, as well as e-gift cards, are all final and cannot be returned or exchanged.
Please note: If a claim was not submitted via web, email, or by phone, the return will not be valid for store credit or exchange. Please make sure to contact us in advance to ensure the most timely and appropriate response.
If you think there may be a defect with any of the products you purchased from us, please contact us for store credit or an exchange of the product. AR500 Armor® will accept requests for store credit or exchanges on all products, excluding medical items and level IV body armor, within 30 days of delivery.
Refunds will not be issued for products that were delivered as described on our website. All armor plates must have the original manufacturer sticker on the plates or they will not be accepted for return claims. The cost of return shipping will be deducted from the return credit amount.
Once a return request is submitted, a customer service agent will review the request and send a return label via email. If you prefer a return label be mailed to you, please let us know in advance. Include the return shipping in-process form, within your package, and follow the return instructions page which will be provided with the return label. Failure to fill out the return shipping in-process form properly and include the form with your return may result in a longer processing time for your return or denial of your refund. This form helps the staff in our warehouse file your return more efficiently, allows us to notify you quickly with updates about your return, and assists us in getting you a faster credit/refund/exchange.
After the product arrives at AR500 Armor®, it will be inspected, and your request will be processed. You will receive your store credit within 7-10 business days upon your returned item (s) arrival at our facility. Any items exchanged will ship out with a new Ships in About time frame and will depend on the highest Lead Time within the order.
Body Armor Direct / National Body Armor
We do not accept returns, refunds or exchanges on any items for any reason.
Caliber Armor
Caliber Armor guarantees the proper fit of your body armor. If you feel your vest does not fit properly, you can exchange it within 30 days of purchase in its original condition. All return shipping costs are the sole responsibility of the customer. If no exchange is made a 10% restocking fee is applied.
Caliber Armor provides a five (5) year warranty on all of our ballistic inserts and two (2) year warranty on all of its armor carriers.
In your email include order number and reason for return. You will be issued an RMA# number and form to be included in your return package. Cost of return is based on reason for return. If the return is being generated with no fault to Caliber Armor the customer is responsible for the return. All return shipping costs are the sole responsibility of the customer. A 10% restocking fee is applied.
Elite Survival Systems
Please do not return any merchandise without prior written authorization - no credit will be issued for any such unauthorized return. All claims of return merchandise must be made within ten days of date of invoice. Product must be returned within 30 days of invoice date to avoid a twenty percent (20%) restocking fee. All shipping charges incurred by the customer as a result of items returned for refund or exchange are the responsibility of the customer.
PPSS Group / SlashPro
The Consumer Protection (Distance Selling) Regulations gives you a cooling off period that allows you to return your item for any reason.
- Your right to cancel an order for goods starts the moment you place your order and ends 14 days from the day you receive your goods.
- If your order consists of multiple goods, the 14 day period runs from when you get the last of the batch.
- This 14 day period is the time you have to decide whether you wish to cancel and return your order.
- To be eligible for a refund you must notify us in writing via email to firstname.lastname@example.com that you wish to return an order within this first 14 days.
- You then have a further 14 days to return the goods to us from the date you contacted us about the return.
- Please note that goods must be received back within this second 14 day period.
- You must include in the package our returns form and include your full contact details and the reason for the return.https://www.slash-pro.com/terms-and-conditions
- You will not be entitled to a refund if you have not advised us of the pending return/cancellation within the first 14 days, however we will consider an exchange.
- All items must be returned unworn, undamaged and in the condition they were sent to you with all labels and packaging intact.
- The cost of return postage will be at your expense unless we dispatched the incorrect item or the goods are faulty.
- Any agreed exchanges or refunds will be processed within 14 days from the date we receive the goods back.
- Goods that are returned will be inspected for any sign of use, damage, misuse or neglect. A deduction can be made if the value of the goods has been reduced as a result of you handling the goods more than was necessary. If there is any doubt we reserve the right not to exchange or give a refund.
- Credit card payments will only be refunded to the original card If there are any problems with your order please contact us immediately.
Customers are reminded that we are not liable for returns that are lost or damaged in the postal system.
Customers should always ensure that the appropriate level of insurance is purchased from the carrier.
Predator Armor
We strive for 100% customer satisfaction. Our products are potentially life saving products and we want to make sure you get what you need. We understand that on occasion issues with orders may arise. All products are eligible for an easy return or exchange as long as the return is initiated within 30 days of receipt, and the product is in new, unused condition. Shipping and handling charges are non-refundable. There is no restocking fee for returns or exchanges. The customer is responsible for any return shipping costs associated with returning the product. Returns must include an invoice or information regarding the return.
If you would like to make a return and your product is new, unused condition, and submitted within 30 days of receiving your items, follow the steps below:
- Email us at email@example.com with your name, order number, and reason for return. We will review your submission and respond to you with a document to print and include in your shipment.
- Ship the item back to us at the address provided to you by the customer service agent once your return has been approved.
- Once we receive the returned product and review that the product is new, unused condition, we will proceed with the exchange or refund. Please allow 5-10 business days from the time the item is received to process a refund.
Self Defense Company / Bulletproof Bodyguard Backpacks
You have 30 days after you receive the item to return it for a refund or size exchange.
You must email firstname.lastname@example.com
Return postage is at the customer's expense and shipping costs will be deducted from the refund – this is includes all FREE SHIPPING. The cost of shipping the original order to you will be deducted from your refund.
You may be charged a restocking fee if the item is damaged or dirty and not in 100% condition.
The return of armor plates is at your own risk due to the nature composite material. Plates may be internally damaged if not shipped or transported correctly. If you return plates that are packed improperly you will not receive a refund.
Up to 90 days of purchase under normal usage. This does not include damage due to rips, tears or breakage of backpack clips. This includes seams or velcro fasteners coming loose. If you return an item that looks damaged you will be notified and you we will return the item to you.
The Self Defense Company has a right to replace any damaged or defective items.
If your package is damaged please immediately get a note from the shipper, take pictures of the package, the damaged item and email them to firstname.lastname@example.com for an exchange. In this case we will issue a priority mail return label for a large priority box from the US post office.
The Self Defense Company can only ship orders to certain countries. This is subject to change based on export laws. If you want to see if we can ship to your country email email@example.com.
The Self Defense Company is not responsible for any duties, taxes or fees. This is the responsibility of the customer.
All returns are shipped at the customer's expense.
Shellback Tactical
Shellback Tactical stands behind their products 100% and want you to be satisfied with your purchase. If you are unhappy with your item you can request a return or exchange up to 30 days after order delivery.
Items must be in new, unworn, or unopened condition and free of any signs of wear in order to qualify for a return. Items must be shipped in their original packaging and placed inside of another box when shipped.
All items returned for a refund are subject to a restocking fee up to 25%. All exchange items returned for exchange are NOT subject to a restocking fee.
The following items can not be returned or exchanged - body armor, ballistic helmets, customized items, closeout items, special order items, or medical supplies.
All body armor sales are final. Body armor includes but is not limited to soft armor, hard armor plates and helmets. These items cannot be returned as Shellback Tactical no longer has chain of custody of the item and cannot guarantee that after we have shipped the product that the structural integrity has been maintained.
Spartan Armor Systems
The buyer is responsible for inspecting their products within a reasonable amount of time, which we consider to be 10 business days from item receipt. If there is a discrepancy discovered with the buyer's purchase during this time period, Spartan Armor Systems, The Target Man will be fully responsible for resolution and all associated shipping and product costs. After the inspection period, discrepancies will be resolved at the discretion of Spartan Armor Systems, The Target Man, and on a case by case basis. After the 10 day inspection period, all costs associated with discrepancies will be assumed by the purchaser.
Should the item be misrepresented, not as described, or the wrong item was sent to the buyer, Spartan Armor Systems will pay all costs associated with the return shipment to Spartan Armor Systems.
Spartan Armor Systems will ship only completed orders in full. For example, if you purchase three targets and one of the targets is on back order, we will have to wait until the last target is ready before we can ship out your product. To continue to provide you with the best pricing possible, we must wait until your order is fulfilled 100% before shipping.
Should you need your partial order urgently, we will review your order on a "case by case" basis.
Spartan Armor Systems accepts returns within 10 business days of product receipt for all products.
Defective Product Returns
We stand behind our products 100%! Should an item be returned because it was defective, mis-represented, not as described, etc. Please notify us immediately if you discover a manufacturing defect with your item. Spartan Armor Syst


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Thursday Night Football Recap — Vikings Hold Off Redskins, 34-27 [GALLERY]
The Vikings scored 20 points in the second half and avoided a game-tying touchdown in the final seconds in a 34-27 win over the Washington Redskins in Minnesota on Thursday night.
Washington (3-6) had an opportunity to score a game-tying touchdown in the final minute, but Robert Griffin III's fourth-and-goal pass into the end zone with 32 seconds left was caught by Santana Moss with only one foot in bounds.
Trailing 24-14 at the half, Minnesota (2-7) rallied in the third quarter. After a Kai Forbath field goal put the Redskins up 27-14, the Vikings surged ahead on a 28-yard touchdown pass from Christian Ponder to John Carlson and a 1-yard TD run by Adrian Peterson in the third quarter.
Two fourth-quarter field goals by Blair Walsh helped give Minnesota its eventual margin of victory.
Peterson finished with 75 yards rushing and two scores, while Ponder passed for 174 yards and two touchdowns before leaving with a shoulder injury late in the fourth quarter.
Griffin threw for 281 yards and three touchdowns for Washington. Redskins' running back Alfred Morris carried 26 times for 139 yards. Pierre Garcon caught seven passes for 119 yards and a score in a losing effort.


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CH391L/S13/Cell Scaffolding and Printing
Cell Scaffolding
Cellular scaffolding is used in biomedical engineering to support tissue growth, usually during the process of tissue regeneration or tissue engineering. Scaffolding has been in use since the 1980's in an effort to support tissue growth and early structures used sponge-like biomaterials, which were useful, but limited for a number of reasons. Modern fabrication techniques have been developed over the past few decades to create new kinds of scaffolding that are more suited to grow a diverse number of tissue types. Modern scaffolds need to fulfill several requirements to viably support and guide the development of cells and tissues in vitro [1].
1) The cells need to be able to be placed precisely onto the scaffold. Tissue-specific stem cells need to be placed in the right location onto or into a scaffold or else the cells may develop abnormally [2]. The cells also need to be able to adhere to the scaffold through secretion of extra cellular matrix (ECM) proteins and saccharides [3].
2) The cells need to be able to survive on the scaffold (the scaffold should be biocompatible). This includes that the scaffold should be able to facilitate cellular signaling by signaling molecules or mechanical cues. One challenge faced by tissue engineers is the lack of known biocompatible scaffolding material with the particular properties needed in applications such as tissue printing and rapid prototyping techniques [3].
3) The scaffold needs to be rigid enough to support tissues, but porous enough to diffuse oxygen and nutrients to the cells inside. If the scaffold is poorly designed, it could collapse or starve the cells growing inside the scaffold [3][2].
4) The scaffold should be able to guide the development of new tissues. Pore size is a major factor in guiding tissue development. Most tissue cell types differ in size and, consequently, will not grow as well on scaffolds with pore sizes that are either too small or too large for that particular type of cell. For example, if the pore size is too small then the cells will not be able to migrate inwards and won't allow nutrients to flow through the scaffold. If the pore sizes are too large, then the surface area for cells to attach decreases which limits cellular adhesion [4].
5) The scaffold should degrade in a controlled manner as the developing tissue becomes able to support its own weight.
Cells can also be grown in vivo onto scaffolds by implanting scaffolding directly into the patient. This has been used for bone regeneration if large parts of bone are missing [5].
Year | Event |
1887 | One of the first known examples of electrospinning demonstrated by C. V. Boys [7] |
1974 | First biologically active scaffold is made |
1977 | First patent for a scaffold is granted |
1981-1982 | Induced regeneration using a scaffold is achieved in animals and humans |
Scaffold Fabrication Methods
These methods for scaffold construction are just a few of the many techniques used in tissue engineering. Other techniques in use but not discussed include: phase-separation, freeze dry, self-assembly and fused deposition modeling scaffold construction.
In this process, high voltage is applied to a capillary tube filled with a polymer solution. The polymer is charged by the electric field and when the field is intense enough, the polymer solution flies out the end onto a collector with the opposite charge. The solvent evaporates and the polymer hardens into a tangled web. The diameter of the threads can be adjusted anywhere from the nanometer to micrometer range [8][9].
This process is easy and simple and the resulting topography is similar to the ECM. It is widely used to engineer scaffolding for tubular tissues, like vascular or urethral, and other tissues [8][9].
3D Printing/Rapid Prototyping
The scaffold is designed in a CAD program and printed using a 3D printer. This process is also called "Additive Manufacturing" since structures created by this process are built layer by layer. This method is relatively quick and cheap in that it greatly reduces the cost of creating a single copy of a particular scaffolding design and the scaffold can be created within a day. A drawback in 3D printing is that it is difficult to deposit material over an empty cavity, so a scaffold for the scaffold is needed. Another is that this process is limited by the number of available biomaterials that can be used to create these scaffolds [3].
Decellularized Organs
In this process, organs are extracted from animals (sheep, mice, ferrets, etc) and the cells are removed by washing with mild detergents (usually by pumping the solution through the vascular system). This kills and washes away the cells without damaging the extracellular matrix (ECM). The ECM is then reseeded ex vivo with human or animal cells. They repopulate the ECM and create a new, functional organ that can be transplanted. A limitation for this procedure (semi-xenotransplantation) is the lack of scaffolding for solid organs. Animal experiments, such as transplanting functional rat penile tissue, have been successful but this technology is far away from entering clinical studies [12].
Hydrogel is a network of superabsorbent polymer chains immersed in a fluid solution. They can used in combination with cell printing to use as a scaffold for tissue growth. Since hydrogels are not water soluble, they can form a sort of mesh like scaffolding when immersed in solution. They are currently used mostly in connective tissue studies, such as cartilage tissue engineering, since they are more compliant (easier to bend and transfer mechanical forces throughout itself) [3][15].
Cell Printing
Cell printing is the process where cells are placed onto a substrate. Cell printing is advantageous in that it allows for the cells to be precisely placed onto a surface. This gives greater control over the individual cells and their development in a way that other methods cannot offer. This is especially true in terms of the quantity of cells that are able to be placed at a time using cell printing. An exciting area of research in cell printing is in situ cell printing, or printing different cells directly onto or into a wound. The methods below are several different ways to print cells.
Laser Printing
Laser Direct Write (LDW) printing is where cells suspended in solution in a medium are kicked down to a collector slide underneath it using a laser pulse. The laser creates bubbles and the resulting shock waves propel the cell downward. This allows the cells to be patterned on to the collector slide. LDW printing has also been used to print cells onto hydrogel scaffolds to create a stacked pancake type structure: the cells are patterned between layers of hydrogel. LDW printing has also been used to print cells that were placed in vivo in mice [18].
LDW printing takes a relatively long time to produce a bed of cells. 3D printing with LDW printing is difficult, but 2D laser printing is extremely precise [19].
Inkjet Printing
Inkjet printing has been in use since the 1980s, but it wasn't until until about the year 2000 that this technology has been adapted for printing cells. Inkjet printing uses an inkjet printer and replaces the ink for cells suspended in solution, then seeds them onto scaffolds. The actual ink dispensing nozzle uses an electrical current to cause a piezoelectric element to restrict the diameter of the ink nozzle, squirting out the ink. This can be done in either a push-pull or pull-push fashion, shown in the picture to the right. Inkjet printing is cheap and versatile: a cell printer can be made from a commercial inkjet printer and multiple cell types dispensed by multiple ink cartridges. Cells can also be printed on curved or wavy surfaces allowing the cells to be printed in situ.
Inkjet printing suffers from cellular damage and cell death due to the mechanical stresses placed on the cells while being printed. Additionally, the cells tend to clump near the nozzle, resulting in clogging. The shape of the droplets are also relatively hard to control [19].
Extrusion Printing
In this printing method, cells are suspended in a gel, placed in a tube and squeezed out of a nozzle (using a plunger) while being moved around by a robotic arm. This cell printer type is, relatively, not harmful to the cells dispensed, but if the cell density of the effluent is too high, shear stress will cause significant cell death. There are a limited number of biomaterials that are available for extrusion based printing, limiting the number of applications this technique can be used for. Extrusion printing has been used to print a number of tissues, such as vascular tissues [19][21].
In situ Printing and Future Directions
The Skin Spray Gun
The "skin spray gun" has been designed to treat second degree burns by using skin stem cells from the patient by a biopsy. With this device, hopefully, skin grafting can be replaced. Grafting takes weeks to accomplish, has a much higher risk of infection, leaves much more scarring and is more painful. Currently, the "skin spray gun" is still undergoing clinical trials for the treatment of second degree burns [22][23].
iGEM Connection
The University of Illinois iGEM team wanted to create an RNA "scaffold" to create an "enzyme conveyor belt" to increase enzyme efficiency.
The University of Missouri iGEM team wanted to use a membrane protein that could be used as a sort of scaffolding in order to bind to other proteins to the cell surface.
- jinlee pmid=23355718
- Derby pmid=23161993
- Lu pmid=23345979
- Jirsak Jirsak O. et al.: Polyamic Acid Nanofibers Produced by Needleless Electrospinning. Journal of Nanomaterials, Article ID 842831, 6 pp. (2010)
- Sill pmid=18281090
- Atala pmid=23152327
- Slaughter pmid=20882499
- Seck pmid=20659509
- Ozbolat pmid=23372076
- Yamaguchi pmid=23075800
- Norotte pmid=19664819
- Michael pmid=23469227
- skin http://en.wikipedia.org/wiki/Skin_cell_gun
- Chan pmid=19005702
- Scaglione pmid=22355786
- Peppas pmid=11701505
- Murphy pmid=19819008
- Schulte pmid=23420664
- Gerlach pmid=21334816
- Koch pmid=23570054
- Ma Scaffolding in Tissue Engineering, By: P. Ma and J. Elisseeff, CRC Press, Dec 12, 2010
- Boyswiki Biofunctionalized poly(ethylene glycol)-block-poly(e-caprolactone)
nanofibers for tissue engineering, J Mater Sci: Mater Med (2008) 19:1479–1484 DOI 10.1007/s10856-007-3299-8


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Creating a rewarding search experience for users can be integral to successful site design, but few books address the process. Here, co-author Tony Russell-Rose describes the conception and creation of Designing the Search Experience: The information architecture of discovery (Morgan Kaufmann). You can download a sample chapter here and enter to win a copy of the book below.
Remember the Yahoo! Directory? It was a hand-built taxonomy that allowed users to browse and discover Internet resources. By categorizing sites by topic and location, it became the definitive map of the World Wide Web. But at the turn of the millennium, Yahoo! transformed itself from a directory into a search engine. The task of organizing so many disparate items into a single coherent structure had simply become too overwhelming.
A decade later, this story is all too familiar. Online stores sell hundreds of thousands of items, social networks host millions of users, and Flickr hosts billions of photos. Navigation is no longer the future: Search is the key making sense of the digital universe.
Despite the growing influence of search on our daily lives, relatively few non-academic books have been published on the subject. While there are dozens of titles about designing web navigation, those on designing search can be counted on the fingers of one hand.
That's why Tyler Tate and I set out to write Designing the Search Experience: The information architecture of discovery. For the last year and half we have been researching, drafting, and editing—striving to transform our ideas and insights into a coherent narrative.
To help maintain our focus we established three fundamental principles to guide the writing process:
- Integrated: Theoretical frameworks for human information seeking should be tightly integrated with practical design solutions, helping readers understand what, why, and how.
- Holistic: individual design patterns should be related to the overall user experience, and search itself re-framed within the broader context of analysis and discovery-oriented problem solving.
- Readable: The tone of voice should be informal and approachable, and the narrative driven by examples.
Plenty of amazing folks—Ann Blandford, Karen Church, Rory Hamilton, James Kalbach, Joe Lamantia, Greg Nudelman, Louis Rosenfeld, Ian Ruthven, Daniel Tunkelang, and Martin White—contributed essays to the book, enriching it with their expertise and enhancing our mission. Designing the Search Experience weaves together the theories of information seeking with the practice of user interface design. This definitive guide will enable you to:
- Understand how people search and how the concepts of information seeking, information foraging, and sensemaking underpin the search process.
- Apply the principles of user-centred design to the search box, search results, faceted navigation, mobile interfaces, social search, and much more.
- Design the cross-channel search experiences of tomorrow that span desktop, tablet, mobile, and other devices.
We hope you find it useful and insightful, and welcome any feedback.
So you want to win this book, right? Well, all you need to do is answer a question for us:
How do you search for jobs online?
There are three ways to enter the contest:
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Five winners will be chosen from amongst the valid entries. The giveaway ends on Friday, January 25th.


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Yes, alright, I suppose I can humor you for a little longer.
Behold, some of the sweetest ships to sail the seven seas!
These first two have the added bonus of being fondant-free. It's nice to know you can still craft a tasty craft using only buttercream.
Those of you who enjoyed my "Boston in the fall" line yesterday will appreciate this one:
Yep, it's the Pirates Who Don't Do Anything! Love it. The wooden planks and overall design of the ship are simply superb, too. Clearly this baker does far more than stay home and lie around.
Here's the most elegant ship design I've seen:
Wowza. That hand painting is exquisite.
This amazing pirate chest was Felicia Day's birthday cake, and is posted on her Flickr stream. Melissa G. submitted it, but I don't see a baker listed. Anyone know?
Oh, and as usual, if you know who made one of today's sweets (and it isn't already listed) be sure to let me know.
Have a Sweet to nominate? Send it to me at Sunday Sweets [at] Cake Wrecks [dot] com.
- Similar Sweets: (Dr.) Horrible Sunday Sweets