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.