Do It Now.

I think I've made my views on this clear in the past, but you need to go get emergency contraception. Right now. Plan B is now available as a single pill. In the past, it was necessary to take two pills, twelve hours apart. This is a great step forward (anyone who thinks having to wait 12 hours to take a second pill is no big deal has never been, or had to deal with, someone who actually needed to use EC...the condom broke, or there was an assault, or there was a night of drunken irresponsibility, or whatever; waiting 12 hours to take the second pill and 'be done with it' can seem like torture).

It's available over the counter if you're over 17; with a prescription if you're younger. Buy some for yourself, and encourage your friends to do the same. If you have a teenaged daughter, take her to the doctor for a prescription and get it filled (assuming, of course, that if she's sexually active you've already been a responsible parent and taken her to an OB/Gyn to get on the Pill, had a long talk with her about the importance of taking charge of her own sexuality, only being sexual with someone when she's ready, not when some sixteen-year-old Lancelot starts panting about 'If you really loved me...' and, for the love of all that is holy, USING PROTECTION).

Oh, and obligatory myth-busting--EC doesn't cause an 'abortion.' In fact, it won't work if you're already pregnant. So, on this particular point, right-to-lifers--chill. Also, EC is safe--safer than aspirin (though the more I learn about NSAIDs in med school, the more terrified I am by the prospect of using ibuprofen, or aspirin, or any of those ilk anyway).

When/if the need arises, you'll be glad you have it in your medicine cabinet.

Exploding Stomachs

...or, as a professional would say, 'gastric rupture.'
I was cleaning out our fridge and idly picked up the box of baking soda that's been in there for, oh, six months, and which is no longer absorbing odors (and which I rather suspect of harboring rogue odors of its own--the Yemen of my refrigerator). And as I looked at the box, you know how you do, I saw a paragraph on the back describing how one might use it as an antacid. Why, in the era of proton pump inhibitors, one would do this...well, it's cheap, I guess. But it also contains a buttload of sodium (yes, that's the SI unit of measure), and there was a severely worded, bold warning on the side of the box: TO AVOID SERIOUS INJURY, DO NOT TAKE UNTIL POWDER IS COMPLETELY DISSOLVED. IT IS VERY IMPORTANT NOT TO TAKE THIS PRODUCT WHEN OVERLY FULL FROM FOOD OR DRINK.

Being of the science-y persuasion, and remembering the vinegar and baking soda demonstration from fourth grade, I conjectured: Baking soda + stomach acid = internal volcano? But could a slug of baking soda after a big meal (and really, isn't that when you have indigestion anyway?) truly cause your stomach to explode? After a few minutes Googling around, I found my answer:

NM Downs, PA Stonebridge, Department of Surgery, Royal Infirmary,
Edinburgh. "Gastric rupture due to excessive sodium bicarbonate ingestion"
Scott. Med. J. 34(5) 534-5 (1989)

Around the same time, apparently (the late 1980s were evidently as bad for stomachs as they were for fashion), a young man in Denmark had a large meal of sausages and soda pop, took some sodium bicarb to help settle his tummy, and caused HIS. STOMACH. TO. EXPLODE. So be careful out there, kids. Even the most innocuous things, used in a--comment se dit?--stupid manner, can kill you. Pay the extra money for Prevacid--or (and here's a concept) don't eat so many sausages that you are literally at risk of rupturing your internal organs. Cheers!

Finals Week Poetry Breakdown

Reflecting on this block's learning experiences, with a poetic form suited for each.

Pathology (the haiku, a form of infinite subtlety, that nonetheless comes down to just a handful of words--much like a path report).

Bridging necrosis
and Mallory's hyaline:
cirrhosis, but why?

Kill the eponyms?
But won't we hurt Cushing
and Virchow's feelings?

If I never see
One more liver biopsy
It won't make me sad.

Bullous pemphigoid
or mycosis fungoides?
Which one looks grosser?


Dermatology (couplets--short and sweet, and simple to write, just like prescriptions for Retin-A and steroid cream).

Your autoantibodies to desmoglein three
mean pemphigus vulgaris. Better you than me.

I'm sorry to inform you, your mole's cellular division
has crossed the line, and now it's time for a complete excision.

The necklace hubby bought you has given you a rash;
it's called contact dermatitis; next time, tell him, blow more cash.

(Especially for Dr. A. C. L. of dermatopath):
If the lesion is pigmented but the biopsy's a shave
expect at best an angry phone call and at worst an early grave.


Endocrine (Limericks--because everyone knows endocrinology is funny. Right? Um.)

A woman who hailed from Tacoma
had a sizable prolactinoma.
She started lactating,
but more devastating,
Her leg hair required a comb-a.

The doctor she saw told her, "Well,
I can see something wrong in your sell'
turcica--if you're keen,
Try this cabergoline,"
And she did, and it all turned out swell.

GI still to come...

African albinos

Part of a physician's duty, one could argue, is to help protect the vulnerable--whether that means reporting child or elder abuse, ensuring informed consent, or preventing the possible leak of someone's HIV/AIDS status. Currently, health care workers (among other social service personnel) are busy in Tanzania, trying to provide safety and care for albino individuals. See here and here.

There are two main threats to albinos in East Africa: one is skin cancer (what happens when you take a phenotype already prone to cutaneous malignancy and add tropical doses of UV light); the other is 'poaching,' a term usually reserved for animals, but which seems to capture the brutality of the attacks on these people. Local...um...I don't think there's really a PC word for witch-doctor...local animist and Voudoun practitioners claim albino body parts are powerful charms for luck and riches; others use albino blood in their spells. The world is a wide and strange place. But lest we assume that these people are (to quote a commenter on one of the sites) "superstitious, bestial savages," let's remember that--killing aside--a lot of people in the US still wouldn't want to shake hands with an HIV positive person, or someone with psoriasis. Suprisingly, albinism is exponentially more common in Tanzania than in the US.

What got me started on this train of thought? Why, studying vitiligo for my dermatology exam, of course.

Basically, Everyone's Crazy

It's like that song from Avenue Q, "Everyone's a Little Bit Racist."
Today we talked about 'functional somatic syndromes' in our doctorin' class. These are syndromes, ahem, "defined more by suffering and symptomology than by any consistently demonstrable pathophysiology." Which sounds a lot like saying "it's all in your head." Which, to me at least, sounds kind of paternalistic and dismissive--medicine as an entity and doctors in particular putting the burden of 'un-understandability' on the patient rather than admitting that Western medicine doesn't totally have its shit together with the whole mind-body connection. A little like hubris, I feel. In one of the articles we read for today, the authors listed 'side effects from silicone breast implants, irritable bowel syndrome, repetitive stress injury and vaginismus' as among these functional somatic syndromes. The paper was written ten years ago. In 2009, we have official diagnostic criteria for IBS and fibro; everyone and their sister knows that carpal tunnel DOES, in fact, exist; and I'm gonna go out on a limb here, but I doubt that even in 1999 a reasonably intelligent person would say, "Have 500 ccs of potentially allergenic, if not carcinogenic, material pumped into each of my breasts? Don't mind if I do!" As for vaginismus being an issue of mind over body--yeah, possibly, but that doesn't mean the suffering isn't real, and telling women to just relax about it doesn't address the problem. I guess what I'm saying is, we don't know everything there is to know about the world, and it's kind of pompous to say that if we don't, it's the world's fault. After all, just 50 years ago doctors were still telling women that dysmenorrhea was all in their collective heads (and had, apparently, been a form of mass female hysteria since time immemorial).

Our group leader described his thought processes well--when prescribing a tricyclic antidepressant for a woman with irritable bowel, it's common to be met with the dismayed cry, "Doctor, you think I'm crazy! I'm not crazy!" At which point he then points out, "Your gut is very special--it's the only organ system that has a complex 'brain' of its own...(explain about the enteric nervous system, neurotransmitters, la ti da ti da) and I think that these drugs, even though they were originally prescribed for depression, might have some usefulness here." Meanwhile, he says, 'I'm thinking, yeah, I do think you're a little bit crazy, but so's everyone.' So that's a nice message to keep in mind next time someone's acting like a whack job and being really frustrating--everyone has their own particular flavor of crazy. It's like the world is a huge Baskin-Robins, but with neurosis instead of ice cream.

Healthcare professionals make the worst patients

So after the heady delight of yesterday's clear liquid diet and colonoscopy prep (read the details here, if you're inclined--it included 1) a grand total of 17 trips to the bathroom, 2) the drinking of 2 liters of a substance whose foulness could probably be approximated by mixing together 2 liters unsweetened lemonade, a cup of salt, and a few tablespoons of rancid butter, 3) my internal organs producing rumblings and gurgles more commonly associated with active volcanoes and hot springs)--came the event itself. The things I remember, after the glorious sedative/miracle that is Versed:

1) The anesthesiologist was kind of a jerk. Not mean; just not real heavy on the people skills. Example: "Did you eat or drink anything today?" "Yes, some diet coke. A few ounces." "When?" "To take my Synthroid this morning..." (interruption) "I said when, not why." Maybe I'm hypersensitive, but slow your roll there, Dr. Feelgood. I flushed a little bit at this--because hey, I'm here in a 2-ply paper gown about to have someone spelunking in my colon; I'm worried about my own asshole, so I don't want to worry about what you've got wedged up yours right now. "You've got a sort of rash on your chest. Have you noticed that?" Poking my chest, checking to see if it blanches...poke, poke, poke. Hey, why not ask before you start prodding? Just a thought. And I'm flushed because I'm pissed off but I'm not good at verbalizing anger.

2) The nurses were awesome, as nurses usually are. Warm blankets, and this hose that essentially blew warm air through the blankets I had on to keep me toasty while I waited. Someday I'm going to make friends with a medical supply rep and get one of those for my house. Or, you know, an electric blanket. Probably cheaper.
There was one bit of an awkward moment--the nurse was explaining things to me in that reassuring way that nurses have, while I was looking at the pulse oximetry reading and trying to consciously lower my heart rate to sub-tachycardic levels (have I mentioned I'm kind of tightly wound? And that I've been obsessed with controlling my heart rate and blood pressure since I read an article on biofeedback in sixth grade?). "And you can just relax--we'll have machines to keep track of your heart and your breathing, and the doctor will give you some medicine to make you nice and sleepy...now what grade did you say you were in?" (I'd mentioned being a student.) "I'm a second year medical student."

3)Apparently the doctor came into the recovery room and explained everything, but damned if I remember anything. Thanks again, Versed!

Nazi doctors: read with caution

A lot of what I write is relatively...light in nature. I've been told I'm funny, at least (which is better than just being funny-looking--what I'd be left with otherwise). Recently, though, the question of just what the ethical standards of physicianship are has come up at WUSM. There was a presentation on the atrocities perpetrated by the Nazi 'doctors' (I put doctors in quotes because those who so demonstrate so clear and complete an absence of conscience, so utter a disregard for humanity and decency, no longer deserve the title), and--understandably--there has been some upset, mostly related to some not-so-sensitive questions that were asked afterwards. Namely, whether the Nazi doctors were subjected to peer pressure, and whether this in part explained their actions. I will add that I was not at this talk, and so am at best dealing with secondhand information about said upset...realistically more like third or fourth-hand, with the attendant reliability issues that entails. Nevertheless, this seemed like fertile ground for exploration, and something about which I must make my opinion known.

As most people (I hope?) know, the Nazis' crimes against humanity included 'medical experimentation' conducted chiefly by 'Drs.' Josef Mengele [Auschwitz, all manner of horrors], Carl Clauberg [Auschwitz, both forced sterilization and forced impregnation, ie rape], Sigmund Rascher [Dachau, especially high-altitude and hypothermia experiments], and--killing any naive belief one might have that women are always nurturing and incapable of such vile inhumanity--Herta Oberheuser [Ravensbrueck, creating 'battle wounds' and infecting them with gangrene and staph]. To call their undertakings 'research' is to defile both that word and the memories of those who were tortured. Mengele is perhaps the most infamous of these doctors; his experiments, particularly on twins, are the stuff of nightmares. He injected solvents into twins' eyes in attempts to alter their color, performed surgeries--like intestinal resections--without anesthesia, and allegedly attempted to 'create' conjoined twins by sewing a pair of Romani twins together. These are not the acts of a scientist, however depraved, and they are most certainly not the actions of a physician. They are what happens when an already sick individual is given such power that his perversion becomes florid, all-consuming, utter. They are what happens when a psychopath is not subject to the slightest judicial or societal restraint.

I've known about these things since middle school, when the Holocaust was first mentioned in our history classes and I found myself appalled that such things could have happened; not so much that Germans 'allowed' it to happen (there is something to be said for what someone does under duress, the ways in which a totalitarian state twists the mind and the soul--read Alice Miller for an in-depth exploration of this from a psychoanalytic perspective). Reading and hearing about them has an effect on everyone merely by virtue of their humanity: it is impossible not to be repulsed. As a medical student I find that my response, while essentially the same, is still more profound.

As a physician-in-training (not even yet a doctor) I took an oath on the day I got my white coat; more importantly, I made a promise to myself and to the world when I chose healing as a profession. I swore that above all, I would do no harm; that I would always put the needs of my patients foremost. I promised that I would act with humanity, compassion, and humility, and that I would work for the preservation of human life and dignity. There are circumstances in which this is not easy--when, indeed, it might even seem unfair. As a specialist in Jewish medical ethics said at a talk I once attended, if a terrorist and three of his victims come into your ER, and the terrorist is triaged at a higher level than the victims, he gets care first (ideally, of course, everyone's getting it at the same time). Or, to paraphrase a little-heard B-side of Alanis Morissette's, if a man's in the emergency room with a bleeding head because he was beating his kid and she hit him back...you still stitch up Dad's head. WITH adequate anesthetic (not, of course, that I would think of doing it any other way).
L'olam lo suv. Never again.