Development

Nhi Dong I (literally children's hospital 1 in Vietnamese) seethed with humidity, crying children, and stoic families. The corridors colonized with cots and tents, clothes hang drying in the absent wind. The ICU, as it were, stood behind a curtain, with individual beds and incongruously modern monitoring equipment marking it as the domain of the truly worrisome. I stood head and shoulders above it all, unable to follow the oscillations of foreign speech, physically removed by my alien shape, size, and coloration. I was there, theoretically, to learn and to teach, to bring my foreign viewpoint and education to work with the local pediatrics residents for four days out of a month otherwise spent in a cool office space, researching newer and better ways to promote helmet use. I sat down with my partner to hold clinic, his rapid fire interrogation in Vietnamese and 30 second physical exam directly in contrast with my slow translated questions and protracted study. His throughput was nearly quadruple of mine, and given the remarkable size of the line waiting as we broke for lunch, the reasons why were obvious. One side of my brain wondered at the brevity of his exam, the fact that there is no way he truly hears anything through his stethoscope in the amount of time he listened. The other half marveled the fact that all his poor form, the discrepancies in what I believed to be a truly good exam and what he performed, and he still arrived at all the same conclusions, all the same diagnoses and treatments. The diseases ranged from the familiar to the bizarre, and I left the day tired, sweaty, convinced that I was definitely going to get Dengue Fever while in Vietnam, and intrigued by the skill and savvy with which my Vietnamese colleagues had overcome their disadvantages in education time, resources, equipment, and ancillary support to provide care well beyond an american provider in a similar position. It left me to wonder, what was the merit of our protracted education? Why did we need 8 years of higher education, of which the majority of the final year was spent doing educationally questionable things like going to Vietnam and eating copious amounts of noodle soup. What had all my training and experience provided me that he didn't have? The answer, in the end,comes down to systems. A system like Nhi Dong, built on throughput and insane numbers of patients, leaves no room for higher level thought, for making that "great catch," or the "tough diagnosis." The numbers just don't pan out, and the system lacks the money, the doctors, and the space to truly investigate a difficult case. American Physicians are trained the way we are because we are expected to operate at a higher level, to be perfect in a way no human being truly can be. We are meant to think critically, to assess the whole of each patient, to move beyond complaints and systems to a practice model in which each patient can receive the whole of your attention, to where you can make that critical early catch, and start treatment before there is even a problem. This training is inherent in the entire model of our education, and is probably why so many of us have so much trouble facing real-world practice models. We hate the fact that you can't have our whole attention, the benefit of 20 odd years of education. We hate that even in the resource-rich United States we are still stuck with issues of access, throughput, and time.

Malignancy of Youth

She sat primly on the exam table, ignoring the indignity of the thin gown with an air of casual familiarity. An older woman, she was not at all put off by two men in white coats, despite her lack of attire. She was here for a complaint of repetitive vaginal bleeding, a phenomenon typically standard for the female of the species, but not at the advanced age of 65, not 14 years after her menopause. We probed for details, asking about volume, frequency, color, consistency. She had undergone an endometrial biopsy, which came back anomalous, not for cancer (our biggest concern in this situation), but for its health, a far more well developed endometrium than should exist in a post-menopausal woman.

We took another look with the speculum, examining her in the indignity common to the needs of feminine health maintenance, and again found anomaly in her health. We found health, abundance, a complete lack of the atrophy that is the stigmata of age. We asked further questions, attempting to get to the bottom of this mystery. She reported no pain, no nausea, no vomiting. In fact, the only difference she had noted was a tightness in her bra. Stumbling over words, she noted an increased "perkiness." A breast exam was inconclusive, yet another finding notable only for its overstated health.

We walked out of the room, the resident and I, stumped by a bizarre presentation. The standard treatment for dysfunctional uterine bleeding (which we presumed this to be) was a dilatation and curettage, the literal scraping of the uterus clean. We walked back to present to the attending with this idea in mind, only to find an less than receptive audience to this plan. The word malignancy came up, a granulosa cell tumor that revives the lost and forgotten estrogen key to endometrial growth and menstruation. An ovarian malignancy that has different effects at the extremes of life, serving as a rapid introduction to puberty for young girls, and a sexual fountain of youth for older women. Estrogen increases breast size, maintains menstruation, and prevents vaginal atrophy, and this malignant packet of cells had provided a fountain of youth in a faustian bargain ultimately ending in death if untreated.

We went back in, planning imaging and an eventual laparotomy to remove the disease. We discussed the situation with the patient, who lowered her silvery head to consider the situation. When she looked up, a mischievous smirk stole across her face, and she asked "is there was any way to keep the big tits?"

Turn away

Medical School in the modern era has undergone a metamorphosis in how it deals with "feelings."  Gone are the days of total repression and stolidity, replaced instead with an overcorrected idea that it does us some service to explain to our professors (who are just as poor at reading papers as most scientists) how some of the horrors we see make us feel.   Most specifically I was asked to reflect on a series of videos and articles discussing the horror that is human trafficking, specifically children, and specifically sex trafficking.  While it doesn't fit the vein of most of my normal work, I thought it worth putting up.   (mostly for my forty year old self to marvel at my righteous indignation once I am suitably jaded):  (sorry for what is most likely a substantial lack of editing)

The hardest thing to face in my medical education has not been illness, has not been disability, has not been mortality.   People get sick, they get crippled, they die.  Often these events are direct consequences of life decisions the patient made to their own benefit or detriment.  This is an impersonal war to fight, doctors vs disease, the human equivalent of building dikes to keep out a rising sea.   The hardest thing has been the evil, the raw, visceral darkness that afflicts our species, the casual cruelty that brings abused children to our ER, gun shot wounds to our OR, and the ignored and deathly ill elderly to our palliative care.   It is hard to think about.  It hurts to think about.   Without fail ,when faced with the reality of abuse, of neglect, of vicious intentional evil, I want nothing more than to retreat to my bunker of middle class comfort, where my kind and patient parents treated me with nothing but love, and shielded me from the dark vicissitudes of mankind.   I can, and have, wallow through spurting arteries and disconnected body parts in the OR.  I can watch people die, feeling nothing but compassion and a desire to help.  But I squirm and twitch when made to look upon belt and burn marks on an innocent child, when asked to watch videos of helpless children forced by an uncaring world to advertise their skills at oral sex.  

Human trafficking, for instance, is the sort of problem that makes me want to curl up and hide, to withdraw from the position I have long sought as one of the people who makes things better.   Huge and intractable, it is a monolith of sin and depravity that is hard to even think comfortably about, reflecting as it does the darkest parts of human nature.   One shrinks back it, loath to try to understand how it is that members of your species engage in something so soulless, cruel, and disturbing.   On a personal level, I have no response to this issue.   I can’t even deal with it without resorting to defense mechanisms, the intellectualization and derealization that protect me from the considerable pain of empathy with the millions of children right now being torn apart by greed and sickness of adults who were meant to shelter and raise them.   In a way, those defense mechanisms are what you ask me to employ here.  The dry context of how this information will affect my practice is a well-meant question, designed to raise the issue in my mind, to encourage me to help.   But I find it hard to answer, each thought, each theory, about how I can help falling flat in the face of the sheer volume of pain.  

I could talk about the policy of it all, of the overarching need to drain the swamp, to promote education, civil society, and local development in order to eliminate the crushing poverty and insecurity that provides the source of so many of these slaves.  We could push for increased enforcement of laws, for political and economic pressure on the countries most known for being purveyors of sex tourism to enforce common international rules.   I could promote local efforts to track down the operators of local brothels and the kidnappers and slavers who run them.  I can make high minded policy arguments about legalization and regulation of prostitution in order to ensure that only the 11% of women who don’t want out remain in the business.   I could talk about the increased vigilance I will employ in my practice, looking for signs of abuse, asking questions no matter how painful or rude.   I can talk about how I will be involved in physician lead efforts to improve healthcare for sex workers, to mitigate the pain and destruction that this life inflicts on them.  Of course, I could state my intention to provide money and support to organizations that help rehabilitate the victims.   All of these are good ideas, all of these can help some of the 27 million people living in shackles, literal and metaphorical.   Any of these is a valuable use of time, effort.  But none of these changes what is happening now.  None of them changes the vast quantity of wrong that touches my life only tangentially.  None of those efforts improves the life of a Filipino woman held hostage by two disgusting examples of our profession in our own state.  None of these efforts wipes clean the stain of  seemingly normal people using  craigslist, the internet, cell phones, and the comfortable framework of modern American life to repeatedly rape a 14 year old girl in a motel I drive by every time I fly out of Milwaukee.  Even the discomfort, the cringe that I feel when talking about the issue seems a mockery of what those afflicted by this blight are going through. 

The one thing I can do right now, for those currently in pain, is to bear witness. To be stronger than my weakness, than my avoidance, and to recognize both the sin in the world and my, and our, current failure to solve it.  Of course I will resolve to work in the highly unsatisfactory and slow effort to fix these problems, to fix whatever it is in humanity that lets us do this to a subset of our children.   Of course I will be vigilant in my practice, and I will give money and time to efforts hoping to resolve, if not this problem, then others that bear on it.  I will use my knowledge and energy to promote policy helping the third world and impoverished areas of our own nation to grow out of the diseased poverty that spawns issues like this and so many others.   But most importantly, I will recognize this evil abroad in the world.  I will care about its victims as much as I can.  I will not shy away.  

 

Patience

Wild hair flying, sullen eyes narrowed, the overweight woman barreled through the hall on her motorized wheelchair.   She left the floor every day to smoke, fleeing her hospital bed for he relief of nicotine.   Her body had ravaged by polio, caught in the last gasps of the disease before the herd immunity of an immunized body politic saved almost all US citizens from the ravages of the disease.  She had diffuse neurological damage and was barely able to walk.  The polio combined with the stress of 50+ years of partial mobility to create diffuse and excrutiating pain.  She had been on immense quantities of painkillers for years, and had developed an opiate resistance to rival that of Keith Richards.  

She was here for no particular reason.  Her pain had acted up, fall storms driving her to seek solace at our hospital.  She had health issues enough that she could always get herself admitted, tearfully pleading for someone to fix her.   She got sullen every time, blaming us for not trying, for not helping.  Pleading evolved to a more strident beast, eventually culminating in demands for a neurosurgical procedure that she felt CERTAIN would fix her pain.  She ranted about her family, a victimization complex seeing every slight as a salvo in an orchestrated campaign to put her into a home.  She demonized the public health service, declaring her need for more than an hour a day of government sponsored home assistance.   She lectured us on our hard natures, blaming our inability to meet her demands on the fact that men never respect women.  Every day I saw her was a struggle, trapped in a room with a person whose struggles I felt for, and whose personality defied affection.  

She had disease, but her pain was magnified tremendously by her inherent depression, and her cultural biases shot our treatment plans in the foot.  She refused all the practical suggestions.  I spent hours talking to her, convincing her that chronic pain like hers is not curable, that there is no surgery,  no pill.  I reinforced that her opiates were maxed out.  I suggested trying medications like neurontin and amitriptyline, both of which could have helped her pain (and amitriptyline her depression), only to have these suggestions rejected because, of course, "I ain't crazy."   In a similar vein she rejected any suggestion of assistance from chronic pain psychologists.  

It came time, after a week, to discharge her.  We tried earlier, but were met with strenous resistance, accusations of not caring, threats of complaints and lawsuits.  The hospital, by nature a risk-averse institution, elected to let her stay until her coverage ran out, adding thousands onto an already astounding bill she was never going to pay.   When finally we called security to escort our most trying patient out, we were met with a barrage of profanity, and a week later, two malpractice complaints (the first of my career). 

I didn't like her.  I didn't like her because she wouldn't let us help her.  I didn't like her because she didn't like me.  I didn't like her because she was a waste of precious healthcare dollars.  I didn't like her because she was just intrinsically not likable.  I don't think she taught me any lessons (outside of showing me a post-polio syndrome, which is fairly interesting).   I have no great insight from this episode.  I didn't care for her, and I did my job.  I tried to help a demanding, uncaring, selfish disaster zone from hurting herself any more.  Because thats what I signed up for, and thats what this job is, and for every delightful person in the world, there is one like her, and they all deserve our effort.    

Those Eyes

My girlfriend's response when I informed her of the role of fungus in seborrheic dermatitis (aka, Dandruff) reeked of incredible disinterest.  "Really?" she asked me, with an incredulously malicious glint in her eye, "that's common knowledge to anyone with a beginner's understanding of hair care."  Despite my argument that this means approximately 1/2 the world's population is completely unaware of this phenomenon, I still had been thoroughly put in my place as late to the scalp health soiree.  She regaled me with a robust explanation of why dandruff shampoo included selenium, an active ingredient that disrupts fungal cell cycles.  She lambasted my poor understanding of how to keep a scalp healthy and flake free.   She gave me the treatment that I usually reserve for all my otherwise intelligent friends when it comes to healthcare. All this she did with a look in her eye, a patient but condescending look that I imagine I wear all the time.   Man, do I hate that look. 

The long and short of the facts of dandruff is that it results from a persistent fungal skin infection causing seborrheic dermatitis, a fatty flaky rash that generates the pseudosnow dappling some of our dark shirts and jackets.  The shampoo's and medications used to get rid of it are all antifungal in their function, and the one real take away message is that you need to rotate your antifungal shampoo in order to fully clear a fungal infection, as they will grow tolerant to monotherapy with head and shoulders (active ingredient: selenium). 

But I knew none of this.  It wasn't covered in my pathology class. I had heard of seborrheic dermatitis, but only in connection to HIV (which increases the incidence, as if HIV patients needed the insult of dandruff on top of the injury of HIV).  We don't educate well on the annoyances, the minor medical mysteries and problems that confound people on a day to day basis.  You pick that up in residency, in practice.  On that fateful day my girlfriend taught me two lessons.  First, a strong preliminary course in haircare.  Second, a lesson in humility.  Next time I give a patient or a friend a lecture, it will definitely come from a place of better understanding.  

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.   

Steampunk

The boy sits on the edge of his bed.  A metal frame surrounds his chest, plastic tubing covering him in tendrils of oscillating white.  A mask covers his face, flushing him with medicine laced steam.  The device rumbles and jerks, steam pulsing out of its joints with each movement.  He watches Law and Order quietly. 

He had come in with complications of cystic fibrosis, a disease that boiled down to a few faulty sodium transporters, most often a single faulty digit of genetic code.  Without this sodium transporter, his cells don't push water into mucus, creating a thickened, nasty product that makes the normal kind seem delightful. He cannot get rid of this mucus.  It accumulates, filling his lungs with a rising tide of congestion.   It serves as a platform for bacterial colonization, the thick substrate impeding his immune system from properly fighting back.  It clogs his intestines, it destroys his pancreas, his kidneys, whose ducts are as dependent on mucus as his nostrils.  It stunts his growth, ramping up his metabolism hugely with the physiologic effort of clearing mucus.  It will kill him, on average somewhere in his twenties or thirties.   He is 17.   His sister died of the disease at 18.  He is terrified.  

The device torturing him was a CF vest, a vibrating, oscillating, beating of a treatment, designed to free up mucus in the lungs, letting the child cough up some of the phlegm that was drowning him.  This contraption of steam and metal had him for hours each day, a shuddering, clanking mechanical replacement for a process his body could not do.   We doused his circulation with antibiotics, we gave him sprays of albuterol, steroids, and toxins designed to help fight his chronic infections.  The volume of his medication was so high we had cut a port into him, a ready made venous access normally meant for chemotherapy.   

He plays football for his high school.  He has a girlfriend. He wants to go to college, to med school, but thinks he will become a rad tech because it takes less time.  He doesn't feel like he has that much time.  I can't argue.  But he has a life, even inside the abusive steampunk hug of his vest.    

Nosebleed

I don't even touch his nose before it starts gushing.  I'd looked in his ears, an invasion that any four year old knows is worthy of the most potent vocal rage he can summon.  His tearful howl literally burst a vessel in his nostril, the sudden surge of pressure and agitation proving too much for a vessel that had assuredly been picked clean by his questing tiny fingers.  

The blood pours out in gushes that seem literally unimaginable for a child this tiny.  It sprays onto the ground in sartorial geysers, staining his pale freckled face with ghoulish warpaint. He stops bawling for a second, confused momentarily by this painless wet.  The blood slows down, the decreased pressure drawing the flow back to a trickle.  But he knows blood is bad. So he does the worst thing, he bawls more, ramping up the gusher in his sinuses once more.  Blood is pooling on the floor, a sticky mess of coagulation and snot running through corrugations in the tile.  

I sit there momentarily frozen, astonished by the sheer volume, stunned by the ultrasonic scream of a confused (but not wounded) child.  He grabs his mother, spreading gore across her shirt.  I hand her a paper towel for his nose, and think about what to do.  Tilting your head back is wrong, they say.  You just swallow blood, it doesn't actually stop the bleed.   I'd been told you use a tampon to stop nosebleeds.  I ask the nurses, but none of the available feminine hygiene products will fit up his nasal passage.   I tell her to tilt his head forwards, to put pressure on the outside of the nose.  I tell her to hold this position for ten minutes.

Those ten minutes are long for me.  He had come in for frequent nosebleeds.  Nosebleeds in kids can be nothing. But not always.   My mind stutters out fears like acute lymphoblastic leukemia, a possible death sentence for this friendly, albeit vocal, little man.   The bleed has to stop in 10 minutes.  Longer, and it begins to get worrying.  Shorter, and we can chalk it up to a youthful obsession with boogers.   A terrible fantasy sequence rolls out in my head, the guilt of possibly diagnosing this child with leukemia crushing, the idea of this mother losing her boy...but no, its just a nosebleed.  Its almost certainly just a nosebleed.  Right?

I look at the clock, begging for the right answer.    

Pseudo

The baby boy had horns. Two big round lumps growing from his brow, two cephalohematomas, bruises of the soft infantile skull that shrank with each post-natal day. His horns, a birth accident, but not one of any consequence, seemingly marked him from birth as a troublemaker. And in a way, he was trouble. Not that he behaved poorly, quite the opposite in fact. He was, to put it mildly, quite adorable. His round eyes took in the room with that innocence that rarely seems to last even weeks, and he rarely fussed. He took everything in stride, from the hospital crib he lived in to the tubes we fed him with. Even the two loops of his small bowel protruding from his side in a man-made point of access couldn't perturb this little guys day.

He'd been here for a month. He'd been on Earth for two. He was born happy and healthy, but with a distressing tendency to vomit. This isn't unheard of in babies, so his pediatricians weren't too worried. Not, at least, until each succesive test kept coming back negative. It wasn't the usual things, the pyloric stenosis, the duodenal atresia. There were no visible obstructions in his intestines, no problem we could point to, nothing to say "here. this is what we need to do." They pulled the ostomy (the loops of intestines) out to try to correct a problem, try to further diagnose. They ran test after test, all the while feeding him a mix of fats, sugars, proteins and salt through his minature veins. But every time they tried to feed him, every time they tried to get him back to normal, he threw up.

They took a sample of his intestines. Perhaps its an extremely early onset inflammatory bowel disease. Perhaps he has a strange infection. Either of these we could work with, work on. Instead, they found only an absence: he didn't have any nerves. You might think this wouldn't be a problem, but you need nerves in your intestines. They drive things forward, onward and downward, from stomach to the porcelain throne. Pseudo-obstruction, we said with a grimace, the word Pseudo belying the severity of the problem. Almost-obstruction, not-quite-obstruction, seems like it wouldnt be as bad as the real deal right?

But a blockage we can fix, a blockage we can clean out, set right. Even dead intestine can be removed and tied back together, leaving a shorter but functional system behind. He had no nerves, anywhere. His intestines would never work.

He lay there in his crib, wiggling happily in my powerless care. His parents asked question after question, hoping and praying for options, for prognosis. We tell them he will survive on TPN (IV feeding) for many years until his liver gives out. We tell them that Pittsburgh does a total small bowel transplant. We tell them that the outcomes have been improving. We mention, but do not focus on, the fact that the improvement is from 100% mortality to a 3-5 year life span post-op. And each day I check up on my newly alive and slowly dying patient, and each day he looks at me like I am something new and marvelous.

Case 1

The first thing that struck me was the room. Tiled in aquamarine, with a latticework design of grout, the procedure room struck me more as a YMCA shower than a site for finely tuned medical activity. Shelves lined the walls, crowded with individually packaged sterile equipment. A black portable surgical bed stood in the middle of the room, self important, if not proud. Next to it lay a sterile tray of surgical tools, a rack of dully shining medieval metal and sharp edges. The OR team (as it were) consisted of myself, the attending surgeon, and a single circulating nurse, as this establishment was only for minor surgery. This unassuming room was to be home to my first case on my first day of surgery.

Minor surgery or not, VA policy dictates full sterile procedure, and given the lack of personnel, it was my responsibility to scrub, gown, and glove myself, using the half remembered, half heard instructions from a 3 hour OR orientation. The patient was already in the room, lying on the surgical bed having his arm prepped methodically. A 50 year old vet with a stunning mustache and a slightly bored look on his face, he apathetically took in my relentlessly self-conscious efforts to lacerate my hands into sterility as the nurse lathered his arm in betadyne. He enjoyed my inexperienced efforts to don the uniform of a surgeon, laughing out loud as the nurse patiently helped walk me through the final steps, amused by the gyrations that kept my lanky frame sterile in the cramped space.

The attending finished his note and in moments was scrubbed and fully wrapped. In the meantime, the patient had been fully prepped and draped, and the attending stepped up to the tray, grabbed a syringe of lidocaine/epi, and announced that we were ready to start. The patient was here for a triple lipoma removal from his left arm, and in moments the attending had anesthetized, incised, and dissected the largest fat tumor. In a whirlwind of motion we were left holding a fatty sac and suturing, with my main experience being some supremely impressive retracting (if I do say so myself). I wasn’t really sure what I had learned, except that I don’t faint at the sight of blood. I looked up at the patient, who had been chattering away through the whole thing, looking on in fascination at the bloody mess we were making of his arm.

“Here” the doctor said, handing me a syringe, “you do the next two.”

He plopped the syringe down on my palm. I reflexively grasped it and stared it down, plastic clasped far too firmly in my sterile and double latex clad hand. The patient’s arm remained outstretched, visible bumps calling out for minor medical attention. My own inexperience shouted back that this was almost certainly a bad idea, my entire surgical career to this point having consisted of a single afternoon of suture clinic. As I tried to recall how to sew (no…the surgeons like to call it suture), I tentatively stabbed him, working the needle tip under the skin and injected the sodium channel blocking delight that would keep him blissfully uncaring when I sliced him.

“Minor burn here” I said, willing cheery competence into my voice with every ounce of my frame. I pushed on his arm, poked his skin to see if I had successfully applied the local anesthetic.

“Can’t feel a thing doc,” he said, as I mumbled something almost under my breath about being a medical student, and not a doctor. The attending handed me the scalpel, and for the first time in my life I was seriously about to cut someone. I put the knife to the skin, drawing downward across the protuberant lump I was about to remove. The skin split apart almost eagerly, tiny rivers of blood sliding out as it parted like the skin of a ripe orange.

“OWWWW” yelled the mustachioed man with his arm now wide open. I froze, scalpel in hand, agonized with the knowledge that I must have failed with the anesthesia. I looked up, saw the patient smile, and heard him say “Naw, just fucking with you kid.”

The attending laughed. I didn’t.

Hair of the Dog

Not all alcohol's are created equal. Defined by the telltale -OH group, alcohol ranges from deadly toxin to delightful intoxicant, all dependent on the number of carbon atoms it carries. Ethanol, the friendly molecule in vodka, cause of merriment and only a modicum of increased cancer risk and cirrhotic liver damage, is the safest of all these. But we have not always restricted ourselves to consumption of this only moderately toxic iteration. Prohibition carried with it an epidemic of blindness, a side effect of cheap bootleggers using woodchips in their fermentation process. Methanol, you see, that solitary carbon alcohol, is acutely toxic, both in the pleasant warming nervous system depressant way, and in the terrible formaldehyde producing metabolism kind of way.

We still see methanol induced blindness. We see it mostly in suicide attempts, but the acute (drinking methanol to end it all), and the long form (alcoholics who are too broke for regular booze). The toxin starts off like regular alcohol, inducing inhibitory effects throughout our brain, slowing our breathing, making everything just a bit distant and complicated. The issue arises when we try to get rid of it, our cellular machinery breaking it down into component parts. The components, with methanol, are worse than the whole, and formaldehyde courses through us, blocking our energy metabolism at every step. The damage to our cellular resources can be staggering, and deadly.

We can help though. We can decrease the metabolism of methanol, forcing it into a slower elimination with less acute toxicity. We do this with alcohol. Ethanol, to be precise, straight into your veins. You will be drunk as a skunk, and the ethanol will block the metabolism of methanol, using up all the available alcohol dehydrogenase.

How is that for hair of the dog that bit you?

Better Know Your Hermaphrodites

We all began this world as girls. The male genome differs from the female in the key fact of extra genetic material (well, extra expressed, less overall). A tiny Y chromosome, with a tinier gene known as SRY, informs the masculine fetus that the uterus and vagina they were developing are of no use, instead growing a second set of tubes (our former embryonic kidney), into a new, more standing up to urinate appropriate set of equipment. This duct, known in medical circles as the appropriately manly "wolffian duct," is activated by Testosterone, the overproduction of which is the definitive physiological trait of manhood. The external genitalia, the organ on which we of the far less fair sex place so much importance, is derived from signals using dihydroxytestosterone (DHT), otherwise known as the hormone that makes you go bald and get a swollen prostate (about 40-60 years down the road). At the same time, mullerian inhibiting factors are obliterating your once promising female genital tract, obliterating the paramesonephros.

But remove these signals, and we develop along the baseline, into someone that is almost a women. You see, we still express baseline levels of estrogen, so in the absence The signals can be broken in several different places, causing several different outcomes.

One breakage can be in the production of testosterone. A 17-alpha hydroxylase deficiency we can't manufacture the copious testosterone needed to inform our bodies what to do, and without the testosterone, there is no DHT. Depending on the damage, the XY fetus would develop as either a partial hermaphrodite (small penis, blind vaginal pouch), or as a women. This all depends on the degree of insufficiency, a sliding scale of gender.

A 5-alpha reductase deficiency will block the production of DHT, leading to an entirely male form, except for that ego and gender defining locus, the genitalia. Ambiguous at best, these infants force the doctor to say "I'm not sure" when announcing the sex. They are male, of course, but will need hormone shots, and possibly a bit of surgery, to function normally.

Androgen insensitivity implies a child whose cells blithely ignore the flood of testosterone, developing quitely into almost female. These children are sterile, presenting with complete lack of internal genitalia. The testicles do develop marginally, and have a distinct tendency to get stuck in the inguinal canal (the site of the hernia), where they also need to be removed to prevent any cancerous development. They are the simplest, because genome aside, they are essentially girls. Typically tall, slender girls, with symmetrical bodies, larger than average breasts, and no body hair. (think about that next time you look at a model)

The true hermaphrodite, the fully formed penis and vagina, is the rarest of breeds. In class, one day, discussing this phenomenon, we heard a professor utter the most odd of screeds: "Its easier to dig a hole then build a pole." These children are almost always forced into feminity, regardless of their intention, because thats the way our society directs the outcome.

Masculinity is a narrow thing. Perhaps we shouldn't take it so seriously?

Mythomania

They want your blood. The beasts of our unruly imaginations, the vampires and werewolves of our gothic past, they want that vital stuff that drives you. The myths have existed for centuries, these dark companions of humanity. Our shadow siblings have survived ages in the comfortable dark, serving as the stuff of nightmares for all of us who have ever started at an unknown shape in the night. These creatures represent our collective fear of the black, the unknown. But these creatures, oddly enough, are based on reality. In fact, they are based on biochemistry.

It all comes down to the blood. Uroporphyrinogen decarboxylase, a simple (well, not so simple) enzyme, designed to help break down you assemble your hemoglobin. Hemoglobin, of course, is the wonderful material that serves your blood so ably as a sherpa of oxygen. Oxygen, however, is the hazardous trade of biochemistry. We need it to drive the reactors that keep our cells flush with energy, but like any source of energy, it comes with risks. As a substance, it loves to attack us for our electrons, to damage the infinitely delicate material that makes up cells and DNA, our molecular identity. To tame this unruly resource we have harnessed equally dangerous materials, locking reactive intermediates into a closed ring, our own tamed beast: hemoglobin.

Each stage of hemoglobin assembly has an intermediate flush with potential destructive capability. It is this chain of manufacture, this biochemical supply line, that gives us our favorite myths. The vampire involves a form of porphyria (a breakdown in the enzymes for hemoglobin assembly) in which a byproduct forms that is extremely reactive to sunshine. This leads to someone who is constantly anemic (and thus hungry for the salty iron of blood), and prone to immediate and dramatic burns upon exposure to sunlight.

The werewolf suffers from hypertrichosis, hair growing from every surface. These poor individuals might suffer from a slightly different porphyria, that of cutanea tarda. They also burn, but the more dramatic side effect of failed synthesis is an overgrown thatch of hair. everywhere.

These deep dark myths, these reflections of the lost soul of humanity, are merely the deranged impressions the sick leave on the uninformed. This extends to our other monsters in human form, the zombie (most likely suffering from hansen's leprosy), the cyclops (holoprosencephaly), and the mermaid (sirenomelia).

Funny how understanding makes it less mysterious, but more disturbing. These creatures aren't the stuff of legend. They are the sad reality of disease.

Make Room for Dinner

One of the most disturbing and odd facets of masculine culture is the reflection and embrace of our digestive systems, particularly the strange communion many men have with the porcelain throne. Beyond the establishment of gaseous expulsions as a hilarious form of art, men commonly seem to want to discuss the quality, quantity, and enjoyment of eliminating solid waste.

Descendants of this fascination include numerous euphemisms and contexts for when one really has to take a shit. Dropping the kids off at the pool, the deuce, and a myriad of others have become commonplace, if unpleasant, phrases. One of the more common concepts of this milieu is the idea of "making room for dinner." The concept underlying this is that if one was to use the facilities, dinner would be better received, as one would have "made room."

It always bugged me when people said this. In general, I never really enjoy hearing about folks fecal fun. It bugs me only slightly less now that I know that this mythos of masculine misanthropy is actually a legitimate fact.

The gastroileal reflex is a system by which distension of the stomach actually triggers increased movement in the ileum (part of your small intestine), and dilates a sphincter allowing food to pass from the small intestine (where it is absorbed into the body as nutrients) to the large (where it is prepared to be expelled). A natural peptide called gastrin, released to increase stomach acidity and break down the various products you consumed, teams up with your autonomic nervous system to literally "make room for dinner."

Which doesn't actually make saying it any less tacky.

Party Trick

The patient perched on the corner of the exam table. He stood up gingerly, a snap and crackle underlying his every move. An younger man, his delicacy was premature, the cautious movements of a man twice his age. His eyes could have used a good cleaning, the whites anything but. Grey orbs with a brown center, he looked at us nonchalantly, a cup of fresh urine in his hand.

The doctor takes the cup, places it on the table, and tells me to keep an eye on it. Nonplussed, I examine the urine, looking for the typical marks of illness. It wasn't cloudy, or discolored. It didn't smell sweet, or musty. I saw no crystals, no blood. So I looked away, taking in the interview, wondering what the doctor thought was going to happen.

After the final reflex hammer falls, the doctor looks up at me, asking for a diagnosis. The only thing I noticed was arthritis, the reason for his care in movement. Gambling, I toss out rheumatoid arthritis, and receive for my trouble a slow shake of the head, and an extended arm pointed at the cup of urine, now sitting there rather dark shade of black.

The patient had alkaptonuria, a fairly benign metabolic disease, a failure of tyrosine metabolism. His buildup of homogentisic acid has stained his connective tissue, darkening his eyes and causing pain in his joints. He eliminates it in the urine, and on exposure to air, it turns itself black.

As diseases go, its a fairly innocuous one to be stuck with. Unless you are the guy at the urinal next to him.

French Pox

Kurt Vonnegut used to discuss the lurching old men of his youth, ambulating irregularly about downtown Indianapolis. His wandering examination of the terrifyingly possessed men, mumbling and bumbling in their confusion and discordance, paints a fairly terrifying picture of the disease once known by names varying from the French Pox to the scourge of royalty: Syphilis.

Treponema Palladium, a gram negative spirochete, has brought down rulers and vagabonds, and remains today one of the most prevalent (if slow moving) sexually transmitted disease around. It's readily treatable (simple penicillin does the trick), but if you let it go, it begins to run amok in your cerebellum, corkscrewing its way through the all important cognitive matter. Over years, you slowly go crazy, lose your ability to sense your arms and legs (except for pain and temperature), and develop a series of unsavory skin conditions.

The trick with syphilis is that it spends so much time with no clinically apparent symptoms. (although also decreased chance of catching it). The diagnosis can be tricky because the little spirals are adept at avoiding tests, and the symptoms are erratic and transitory. Perhaps the best (not most effective, just most hilariously named) diagnostic technique for the final stages of syphilis is the the eye exam. A person with late stage syphilis will have normal eye constriction with general eye use (known as accommodation), but not respond to light. This is known as the "prostitute's pupil," although in deference to modern terminology, it has recently been rebranded the Argyll Roberston pupil. Which honestly just makes me associate syphilis with sweaters for some reason (perhaps its because the human race most likely got syphilis in the first place by having inappropriate relations with sheep?)

Recruitment

At some point, something threw a wrench in your machinery. Cosmic rays, bad food, invading microbes, or piss poor protoplasm, but somewhere along the way, something in you got knocked out of place. Your roadmap, your building blocks, got altered. DNA alkylation, cross-linking, deletion.

It had happened before, but this one, this one was different. That single mistake happened to be in just the right place. It amplified, expanding in flawed protein designs, processes erroneously instantiated or failed. The mistake prospered, through luck and tenacity. It defeated or ignored your internal defenders, hiding behind a protective mask of your own flesh. It made a place for itself, even as it made more of itself, reinforcements in its desperate effort to expand.

You have a tumor. Reproductive drive incarnate, an invasive expanding riot of your constituent cells, demanding that the rest of you be more like them. These renegade cells, in their zeal to expand, have lost what defined them. Increasingly ill-shaped and deformed, the multiplying cells have lost their function, their irreplaceable role in the community that is your body. They swarm, they hustle, and dedicate resources in one vast effort to outcompete everything around with sheer numbers.

I’m here to stop them. I have an arsenal of methods, from futuristic rays to simple reinforcements for your beleaguered immune system. But this mistake, it is crafty. It hides itself behind the hostages of your healthy cells, component human shields staying my hand. Its hustle is it’s weakness, its sheer drive to reproduce differentiating it from your more sedate and helpful cellular citizens. Its growth makes it a target for my toxins, my rays. Some cells hide, biding their time, hoping I will accept the elimination of their more eager brethren as total.

I pump you full of poison, indiscriminate and wild. But I have been careful. My agent won’t kill you or your unruly cellular mob, but it will hurt. The tumor shrinks under the onslaught, even as your hair wilts and your immune system surrenders, casualties of friendly fire. When I withdraw my horsemen of alkylation, my carmustine, my mechlorethamine, the tumor will spring forth, hustling to reproduce and replenish, secure in the belief that it has resisted modern medicine. It doesn’t see me, waiting in the wings, an army of specific anti-neoplastics chomping at the bit. It was a trick you see, a con, a bamboozlement.

Your tumor got hustled.

Honeymoon

At the heart of medicine lies the proposition "everything in moderation." A core premise of every aspect of practice, from pharmacology to preventative medicine, homeostasis (our fancy word for balance) is what keeps you going.

Excess is the enemy, a destabilizing force that introduces openings for all of our natural enemies. Even natural acts like sex can be intrinsically damaging (beyond the potential for spread of disease). Honeymoon cystitis is a bladder infection induced by bruising damage to the bladder from repeated or forceful sex. Yes. We named it honeymoon cystitis.

These days, the honeymoon isn't actually the main source of this cystitis. As times changed, and the honeymoon and loss of virginity have diverged, a more experienced population has managed to avoid the pratfalls of their elders. But the name has stuck, an institutionalized giggle at the expense of a population that is enjoying themselves far too much.