Nov 25, 2009

The Custom Baby

I saw a woman today for her annual well-woman exam. She had her husband with her, an older guy, and a ring that was at least 4 carats on her hand, with a matching necklace. She was wearing a shirt with my high school's logo on it, so we chatted about that and about her son who goes there now. Near the end of the exam, she asks about what her options are for getting pregnant. Since she is 40 and her husband is 67, it doesn't seem like a great idea, but we talk about in vitro fertilization, artificial insemination, etc. Since the dad will probably be dead by the time the kid is in college, it doesn't seem very fair to the kid, but whatever. But then it gets weirder. They look at us and say "How can we guarantee that we have a boy? We only want a boy. It would be a shame to go through the trouble and expense of in vitro and just have to abort it because its a girl."

I was just floored. I had always thought that most parents in America maybe wanted one sex or the other, but adjusted to love the baby they got. But they were serious.

As the doctor explained the process by which the sperm could be separated out by chromosomes, and how only the Y chromosomes could be used for the fertilization process, I was thinking. They want a boy, but they assume what they get will be a healthy child. In any pregnancy, disability is a possibility, but especially when the baby develops from older eggs. I couldn't imagine that they would tolerate a disabled child if they weren't willing to have a normal girl.

Furthermore, is it okay that we can make that happen? Would you like a boy or a girl? Blue eyes or brown? A cup of smart, a tablespoon of athleticism, and a pinch of musical talent? Because we can custom make a baby, just for you.

That line is blurring; what we can make versus what God (or whatever higher authority you prefer) gives us. I know that I don't feel comfortable as the physician being in the position to choose one viable embryo over another. I don't have it all figured out. I don't think there is a clear answer. For most educated and difficult dilemmas, things are not black and white but shades of gray.

Speaking of, would you like gray eyes?

Nov 22, 2009

A Heart Restart

A funny story from my time in family practice...there was a patient that I saw for about two weeks while he was in the hospital recovering from a cardiac arrest and technical death. I got to know him and his wife, who was a nice lady but an eccentric, rather intense individual. When I asked him about the sequence of events related to his heart attack, he said that he had been feeling chest pain and shortness of breath, and the "blacked out." His wife then took over the story, saying "And I was so mad at him! I hit him squarely on the chest and yelled "You're not going to die on me, you son of a bitch!") The punch to his chest, called "precordial thump" in medicine, restarted his heart to a normal sinus rhythm and he lived. She wasn't trying to save him, just really mad. And he lived.

Nov 12, 2009

Five Again

Twenty years ago, I was in kindergarten. Like many classes, we had 3 "cards" on display for each student- yellow, red, and green. When the green card was showing, you were on good behavior and doing well. Yellow signaled you needed to slow down and shape up. I don't even know what happened when you had the red card showing. Probably a sentence worse than death (ie benching, principal's office, etc).

I was a conscientious student, even at age five. My card stayed green the whole year, except for one day. I was screwing around a little, off task with a friend, when my teacher turned my card over to yellow. In an instant, my world screeched to a halt, my stomach dropped out of my shoes, and my throat closed as I tried not to cry. Eventually my card turned back to green, and life went on as usual. But I never forgot that feeling.

At age twenty-five, I was on my first medical rotation, in my first operating room. I carefully scrubbed in and was watching the surgery from a ringside seat. The surgery went on for an hour, and stretched on to two, and I absentmindedly scratched my nose. (When you scrub in, you can't touch your sterile gloves to your mask or hat, which are considered "clean" but not "sterile.") One nurse caught me, and I was thrown out of that OR faster than I knew what had happened.

And suddenly, I was five again. Horrified from head to toe at the consequences of my thoughtless action. Throat closed, I waited for the surgeon from outside the sterile doors. He came out, and was actually very kind about the incident, saying that it happens to everyone, and provided more specifics on sterile procedure. But I just remember that feeling being exactly the same, twenty years later.

My dad often quotes Paul Simon, saying "After changes upon changes, we are more or less the same."

I am.

Nov 5, 2009

Happy Turkey Day!

Just a short thought...

Closing a c-section really reminds me of stuffing a turkey. Seriously. It has exactly the same motion. You have the opening, you grab the uterus, and stuff it back into the abdomen, pushing all the stuff (intestines, etc) back with it til you've got it far enough in. Then you close the abdomen.

Happy Thanksgiving.


Today I had the privilege of helping with the birth of twins. A lady that I've been seeing for about a month came in for her weekly check (35 weeks gestation), complaining of some mild back pain. I decided to check her cervix, and she was 5 cm with membranes bulging through the opening! I called in the attending and he scheduled her for a c-section over our lunch break.

Note: normally lunch is a sacred time for me, as my blood sugar drops into subhuman levels in the late morning. It was a sign of how exciting this was that I was thrilled to not eat lunch.

We brought her in to the OR. The doctor let me be his first assist again. He carefully cut through all the layers: skin, fat, fascia, muscle, and finally the the uterus. There was one twin, head poised and ready to be born. He eased that baby out of the uterus, and I peered into the uterus, expecting to see the other babe. Instead, all I saw was a milky colored balloon with what appeared to be a lizard inside.

Honestly, I had never seen an intact amniotic the time I get to the mommies they are either already ruptured or the water bag has been cut during the c-section incision. I really wondered if everything was all right. The doctor knew what to do though, and he incised the water bag, grabbed the kid by the feet (he was breech), and lifted him into this world.

The babies both cried right away, and were a great size for 35 weeks (7 lbs and 6.5 lbs, I later found out). Such a blessing.

However, mom's belly looked like a war zone. One open uterus, two placentas, two bloody gushes following the placentas, two ruptured membranes...carnage. The surgeon was moving fast, removing the placentas and suturing, and I was helping him dab and suction and suture...until mom's uterus once again resembled a uterus. We tied her tubes (can't blame the lady after having twins), and we put it all back in the abdomen and begin to close her incision. Slowly my heart rate began to fall to normal.

I am so thrilled I got to see a twin birth, right before my ob/gyn rotation ended. SO worth not having lunch!

Nov 3, 2009

An (Unintentional) Funny Story

Last month, when I was in my second month of Family Practice training, I saw a young man with a cold. I had been with my attending long enough that she trusted me to manage uncomplicated patients on my own, including taking the history, doing the physical exam, and writing the prescription under her license. This guy seemed like a perfect case for me; midtwenties with a cold. Upon taking the history, I learned that the man had a bilateral lung transplant a few years ago, and with the physical exam, it seemed to me that this was a case of bronchiolitis obliterans, not a simple cold. Awesome. I called the attending in to come see this guy, as he was so not an appropriate patient for management by a medical student.

Leaving the attending to treat the patient who was autodestructing his lung(s), I went into exam room #2, a sinus infection. Easy enough. Confirm the diagnosis by physical exam, write out a Z-Pak or some Bactrim, and we both would be on our way. Upon questioning as to why he was missing his nasal septum, he admitted to me that he regularly snorted cocaine. Again, awesome. I waited for the attending to finish admitting the first patient to the hospital, and explained the situation. She came in, and unleashed a lecture which would not be allowed in a managed care facility.
"You stupid asshole. You think you can just get away with this habit? You will lose your job, your wife, your kids, and end up in jail. If you are lucky. If not, you will end up in my ER and die, because there is not one thing I can give to to treat a cocaine overdose. Or worse, you will end up a vegetable that can't wipe his own ass."

I guess that's an advantage of being in private practice. You can say whatever you want to the patient.

"Also," I added, "your sinus infection will never clear up if you keep snorting."

The attending and the patient both stared at me, and then laughed and laughed. The guy said he understood what we both said, and left with a prescription and resources on treating cocaine addiction.

I was not trying to be funny. I know in the scheme of all the (true) life-threatening adverse outcomes the attending told him, the minor matter of sinus trouble was laughable. But it seemed to me that the reason this man had taken time out of his day to see the doctor was because he was bothered by his sinuses. So, if that was what mattered to him most, then that's how I would point out how his cocaine use affected his life. Plus, it was true. They wouldn't clear up if he was using, no matter how many antibiotics I gave him.

Nevertheless, it was a funny story out of a very un-funny situation. And a very good reminder that patients are often much more complex than how they present.

Why is the Doctor's Kid Always Sick?

Today I was the first assist on a c-section...very exciting for me. Usually a surgical nurse does that job, but today the obstetrician let me be the one to help him with the instruments, and help suture and staple the patient closed, layer by layer. The baby was big (over 9 lbs) so I had to push hard on mama's belly to get enough force to help baby come out of the incision. When she came out, I suctioned her mouth and nose, and she began to scream.

And scream. And scream. All through the closing procedure, through her measurements, and through our dictation of the surgery. All through daddy holding her (saying "it's okay, daddy's here"...melted my heart...), and mama trying to breastfeed. She screamed through the nurses taking turns holding her and reassuring mommy and daddy that yes, this was normal, and yes, everything was all right.

I came over to check on mom, as I always do after a surgery, and she grabbed my arm and asked. "WHAT is wrong with her??!!). "Nothing" I said. "She's got a great, healthy set of lungs." Dad laughed, and mom just looked at me. I heard the nurse sarcastically comment "Boy, that's a doctor comment if I ever heard one. This one's learning early."

The thing about being a doctor is, you know what can truly go wrong. You worry when the baby is silent. When they cry for a long time, you have peace knowing that the lungs are well-developed and they have created enough intrathoracic pressure to close the fetal circulation, allowing baby a healthy heart to start their life outside the womb.

My mother, who works as a speech-pathologist in a school, says that doctor's kids are always the sick ones. Maybe it's because the parent brings home patient germs, maybe its because they are too busy to deal with keeping them out of school. But I'm inclined to think that its because they know nothing is really wrong. They see so many health crises per day that one simple cold doesn't even fall on their register of illness, and they send the kid off to school.

I think most doctors are not cold people with indifferent comments. I just think they have seen a lot, and tend to tell it like it is. This is not to say that most are not compassionate; on the contrary, most doctors that I've seen care a lot about their patients. They may not be the most user-friendly professionals, but they do care. I sure care about my patients. And I'm oddly kind of pleased with the nurse's comment, because I feel like I'm learning to be an effective doctor.