Push

He sprawled on his hospital bed in the shadows, a 17 year old boy trapped in a body that combined the worst features of gangly youth and old age.  He had the eerie look of a body that had not withered away, but failed to ever grow.   In the dark he desultorily watched TV, a sneer on his face and a distinct lack of enthusiasm writ small in every move of his body. His disease had held him back at every stage of his life, stunting his growth, forcing him into hospitals instead of school.  He has crohn's disease, an auto-immune debilitation of the intestines.

He has been in the hospital for three months already. We have tried everything, from steroids through genetically engineered antibodies to attack the inflammatory factors riling up his system.  We had long since moved on to experimental treatments.  His current attack is brutal, and when he is off the toilet enough to let us examine him, we see signs of only worry.   This attack is strange, eschewing the normal focus on the small intestine, zeroing in on the colon.  Its weakened, and we worry that he is at risk for a rupture, for the dreaded peritonitis with its risks of death and debilitation.   We are concerned that he could develop a condition ripped straight from the title of a B movie: Toxic Megacolon.   For all his diarrhea and pain, he is still holding residual volume.   In the spirit of the B movie, toxic megacolon has a distinct limit, a line across which if we pass, lies only disaster. 10 cm.  10 cm dilation of the colon, and he is at risk for popping like a feculent grape, for dying feverishly, destroyed from the inside out.  

He needs surgery.  He needs controlled removal of a chunk of his colon, a surgery that leaves the possiblity of re-attachment and normal function in place for later.  The surgery will, for right now at least, cure him.  It will also leave him with an ostomy, his life even further removed from normal.  He resists, he pushes back.  Every day for him is guerrilla warfare against his physicians.  He demands different meds, he antagonizes providers, and refuses to let nursing staff weigh and help him.   Its all for his own rage, and for the one man audience of his father, the one who gets to make all the decisions.  He fights for a normalcy that has been denied him, for a fairness he has never known.  We can't help him against his father's will, and his father wont help him against his.   So we push, and he pushes back harder, and we hope against science and experience that we are wrong.  

Garbage

I marked the leg at one thirds and two thirds of its distance.   I drew a roadmap for our sharp implements, our knives of metal and electrocautery.  In silent curiosity, I watched as the gowned and gloved man applied a knife of furious electricity to the skin, burning through it in the quick of a blinking eye.   He cut down to deep, exposing the rust filled sartorial red of relatively healthy muscle.  Moving the tool with deliberate ease, he marched along the map I had drawn, etching it out in eerie relief.  

Pulling back the flap of skin so recently relieved from its tense duties, we expose muscle, cutting and detaching until the bones are visible.  They hand me the instrument, a giant parody of garden shears, meant for cutting of thin bones (of which the fibula counts).    A slow alignment, and I have the bone in my grip, tenderly squeezing the shears.   My touch does nothing, and I slowly increase the pressure, eventually squeezing with all my strength until I hear a crunch both satisfying and revolting.  

"Good Job," notes the Fellow, regaling me with scarce praise.   "Now saw through the Tibia."  He hands me a loop of sharp toothed wire, a Jigglysaw, the jigsaw in miniature.   In my best impression of a ghoulish lumberjack, I saw through the thicker tibia.  The others are clamping and burning bleeds, the sparks of their electrocautery refracted in a spray of white bone chips.   With a lurch, the saw come free.   The Fellow picks up the leg and hands it to me.  

"Get rid of this."

I stand there, momentarily bewildered.  I hold the leg firmly, the business end of fragmented bone and gore facing firmly away.   I'm meant to get rid of it.  I have no idea how.   The circulating nurse is holding a giant biohazard bag for me, a clear invitation to dispose of my post-apocalyptic zombie trophy.   I have a momentary flash of incongruity, and I throw the leg in the bag.  The nurse walks to the trash, and throws it out.  

A Simple Guide to Birth Control

Birth control has been the key to the modern era, to the liberation of women.  In the pre-birth control era, a woman with a sexual partner could expect an 85% chance of pregnancy in ANY GIVEN YEAR.   Imagine attempting to get an education, to build a career, to live your own life when constantly interrupted by the exquisitely messy apocalypse that is child birth.   Yet, in a phenomenon that crosses all economic brackets (although localizes heavily to young people of all types), birth control is fundamentally misunderstood.  The mythology and mysticism that surrounds a medication over 50 years old at its root is almost perplexing.   Even my most intelligent and well-informed female friends, women who handled law school and big business like they were playground games, struggle to stay fully abreast of their reproductive options.  American's in particular are terrible at planning pregnancy, with a rate of unplanned conception almost 20 percentage points higher than our Canadian neighbors.   

Accordingly, as a public service, I wanted to create a simple list of contraception, an encapsulation of current information about the available types (at least any that should ever be used).  DISCLAIMER:  none of these methods protects from STDs.  ONLY CONDOMS PROTECT FROM STDS.   Thank you.  Second disclaimer:  this list is grossly simplified.  I only include key points.  Please follow up with your health care provider, but if you have an asshole for a doctor who doesn't want to inform you of your options, planned parenthood is a wonderful resource.      

1) THE PILL!   Classic Style 

Efficacy: 0.8% failure rate when used appropriately (8% in actual use) 

Pros:  decreases odds of many forms of cancer (endometrial, ovarian), decreases odds of pregnancy when used appropriately (1 pill/day, hiatus period, don't miss any days).   

Cons: You can't smoke.  (thats not really a con medically, but for some), you have to take it reliably.  Cannot take if you have migraines.   

Myth: OCP causes cancer:  mostly false.  there is an increase in breast cancer, but a larger decrease in ovarian and endometrial.  overall, decreases cancer.   

2) IUD:  Uterine Border Patrol:

the intrauterine device is a marvel of medical engineering.   The choice of almost all female practitioners I know, the IUD, my friends, is the best thing short of not ever getting laid for not getting knocked up.   

Efficacy: 0.3% failure rate/year

Pros: one insertion, and you can forget about it for 5-10 years.  Less estrogen exposure means less increased thromboembolic risk.   Tends to decrease periods to almost nonexistence.    

Cons: insertion can be painful, a small fraction of women get abdominal cramping and pain for 3-6 months after insertion.   Increases the risk of pelvic inflammatory disease (from gonorrhea and chlamydia), so don't sleep around.   

Myths: the IUD has spawned a myriad of myths.  The first launch of the product in the 80's tended to cause sterility.  This is a phenomenon of the past.   The IUD is as reversible as any product (assuming no PID).   Second, there is a myth that this product works by "stabbing infants"   IUD's work by preventing conception, blocking sperm from getting where they are going via some complicated biological remodeling that is not worth discussion.   Let me just reassure you:  In all studies, no fetus has ever been found "stabbed" by an IUD.  in fact, no fetus has ever been found in a uterus with an IUD.  IUDs fail by falling out.    This is NOT an aborting agent.   

3) Nuvaring:  If you like it, you better put a ring on it.   

Efficacy: 0.8% failure rate/year.  

Pros: easy to use, very effective.  

Cons: vaginal discharge, awkward insertion.   

Myth: partners can feel it:  FALSE.  very rarely can partners feel the ring.  Unless your partner is wearing Magnum condoms (for good reason), this is extremely unlikely.   It also does not fall out with sex.   

4) Injections:  Baby Immunization

efficacy: 0.5% failure/year

Pro: You only have to show up for a shot.   

Con: you have to get a shot!  but seriously, progestin only medication has several serious side effects, and Depo Provera should only be used for approximately 2 years straight.    

5) The patch:

I don't like the patch.  Don't use it.  

6) Anything else:  any other contraceptive (except condoms and variants of things described above) is NOT WORTH YOUR MONEY OR YOUR BODY.