Bread Between The Legs

English: Candida albicans
We call these ‘branching hyphae’

Yeast infection: Yuck-central to the average vagina owner. Discharge like milk curds, funky smell something akin to old toes floating in rotten vinegar, and an intense itch that you can’t actually itch because if you try, it hurts. Cool, huh?

When you’re talking about this fun experience, what you’re largely talking about is overgrowth of a specific type of yeast called Candida albicans, which is actually a fungus. Pretty gross.

Truth is, there’s probably a few of these little guys hanging around the average human vagina all the time and it’s no big deal, but too many of ’em and you’ve got a problem.

Candida albicans
Same as the above pic, just the DANCE version.

Of interest, Candida is kept at bay by another creature that you want hanging around in your vagina called, as a group, the lactobacilli. These guys don’t fight candida, they’re much more suave. They simply produce an acid (“lactic” acid…get it?) as part of their normal life cycle that subsequently keeps the vagina acidic. This makes things real tough for most other creatures, except for the odd Bear Grylls of the Candida world who eat acid for breakfast.

Yeast infections result when the acidity levels in the vagina drop. It’s hard to predict when and how the pH will change in that region of the world, but often it does.

Historically, yeast infections were easily treated with anti-fungal creams or a single pill of the drug fluconazole. But the “easy” part is going away. Increasingly, I’m seeing patients who have recurrent yeast infections despite the usual treatment.

Often, these patients have a history of heading to the doc for “that pill.” And often, docs (or the “provider”) just fire the pill at them and everyone calls it a visit. It’s quick for the patient, saves the doc time, everyone’s happy. Unfortunately, the happiest of all in this equation is the yeast.

Fluconazole
Fluconazole

Fluconazole works by blocking an enzyme. That enzyme facilitates reactions that create the yeast’s cell wall. With the drug around, their cell walls get floppy(er) and don’t hold together as well.

But that doesn’t mean the bug is dead. Fluconazole isn’t some flaming thunderbolt from Mt. Olympus that blasts yeasts back to the Elysian (bread) Fields. The drug is fungastatic, not fungicidal. The weakened yeast is then susceptible to other bugs our our immune systems. Like a mob boss of the pharmaceutical world. It doesn’t do the killing, it just arranges, eehh, ‘tings.

These days, fluconazole isn’t as tough as it used to be. It doesn’t work like it did, often not with the strength it had. So tossing this pill at a yeast infection is a bad idea. Real bad.

Certain types of yeasts make poofy bread and good beer and they keep Jewish people busy (some would say crazy) during Passover. So they’re not all bad. But it’s an organism that we could do without. Fungal infections, when they become systemic, have always been tough to treat; more so than bacterial. And systemic anti-fungals have always been tougher on the body than antibiotics.

Under these circumstances, the best approach to recurrent yeast infection is NEVER to just go get another pill. You should firmly request that your doctor not only get a wet prep (which is merely looking for the presence of yeasts on microscope slide), but also order a culture of the yeast should any grow on the prep. From that culture, not only can the species of yeast be determined, but it can also be tested for sensitivity to fluconazole and other anti-fungals to see if the right drug has been chosen.

Recurrent yeast infections are beatable, but not if you’re lazy about it. For reasons that most men can understand, yeasts really, really like the vagina. If you don’t like ’em there, you’ve got to put more than just a little effort into getting ’em out.

Advertisements

Interview with A Virus

SW101: I’m sitting here today with Herpes Simplex Virus, type 2.  It has agreed to answer a few questions for SW101 Nation.  Thanks for joining us today, um, is it…Mr. Simplex?

HSV: “Mr.” Simplex.  Sure.  I’ll go with that.  (rolls eyes, muttering “humans”).

SW101:  Tell me, what do you regard as some of your greatest accomplishments, to date?

Mr. Simplex: We’re awesome, basically.  We like to consider ourselves ubiquitous, yet cosmopolitan.  We are particularly fond of the human idea of “make love, not war.”  mmMM.  Huge for us, that one.

SW101:  Ubiquitous?

Transmission electron micrograph of herpes sim...
Self-Portrait: Mr. Herpes

 

Mr. Simplex:  You got an ulcer on your nether-parts after a groovy night wearing nothing but beer goggles?  Probably us.  Any version of sexually active with any version of human being (we don’t like animals)?  Excellantae!  30% chance we’ll be right there with you.  Me and my posse are hanging out with 30-45 MILLION Americans.  And that just in the, ah, “middle” parts of the human landscape.  We got some cousins who live in the windy North quite happily.  We cross paths from time to time.

SW101:  Wow.  Qute a party.

Simplex: Yep.  And we’re inviting picking up around 300,000 new groupies every year.

SW101:  How’s that?

Simp:  We’re launching out all over the atmosphere much more often than people realize.  Those blistery sores we cause?  Well call ’em “pleasure domes,” referring to what they do for us as well as how our gracious hosts acquired them in the first place.  Anyway, we don’t just blast out from the popping penile blisters.  Usually, we send out early drones before the sore even forms.  We’re terribly proud of this tactic.

SW101:  Soo, when does the ‘party’ end?

Simplex:  That’s the best part.  Pretty much never.

SW101:  Like, never?

Simplex:  Oh sure, we take a break sometimes.  Lots of times, actually.  We hide most of the time.  But once we’re in a body, we don’t really ever leave.

SW101:  What do you hide from?

Simp:  There’s two things we don’t like in this world, and the Great White Army is the main one.

SW101:  Um, you refer to Tsar Ivan III‘s anti-Bolshevik Imperial Russian Army in the 1920’s?

Electron microscopic image of a single human l...
Human Lymphocyte. Non-friend to HSV's everywhere (everywhere it thinks to look, that is)

 

Simp:  What?!  What kind of freak-show wonk are you?  No!  The human immune system.  All the cells in that army are white.  Or clear.  Or something.  Scary, those guys.  They can blow us up, eat us, chew us up, spit out pieces of us so their comrades can eat the rest of us…it’s disgusting, really.  It’s like a bad horror movie.  Ugh!  Look at that picture of the immune cell!  Don’t you have any shame?  I didn’t walk in here holding up pictures of car accidents, or guys who accidentally fell into meat grinders, did I?  Why don’t we just sit around and ponder Charles Manson, and all his fabulous exploits?  Oh, actually, that guy was pretty good for us, as I recall.

Anyway, where was I?  (fans self, leans back weakly).  Oh yes, when it’s up and running full-bore, the human immune system it a giant headache for us.  We try to lay low.  No sense in getting our heads knocked off.  The good news is that it gets stretched pretty thin trying to cover all the problems that come up in those unnecessarily complex organisms of yours.  It’s pretty easy to come out and play once the person is stressed, sick, too hot or cold or with some disease that naturally keeps the White Army back in the barracks, so to speak.

SW101:  So, you hide in the nerves, right?

Mr. Simplex:  (looks left and right conspiratorially) Yep.  Broadly speaking.  This is the secret to our survival, by the way.  Our lair.  Your nerves.

SW101:  And, specifically?

Simplex:  Well, you guys have no hope of actually finding us, so I’ll just go ahead and tell you.  My guys hang out in the roots of the nerves that extend from the sacrum.  S2-5, usually.  In the ganglion.  It’s nice there.  Our version of what you’d call waterfront property, I’d imagine.  Our cousins hang out in similar nerves in the face.

SW101:  You mentioned two things you don’t like, what’s the other?

Simplex:  Condoms.  We hate ’em.

SW101:  That bad, huh?  Your great nemesis?

Simplex:  Well, actually, our relationship to them is a bit complicated.  Maybe like Ariel Sharon vs. Yassir Arafat.

SW101:  Surely you’re referring to the Israeli-Palestinian former leaders…both dead now?

Yasser Arafat at 'From Peacemaking to Peacebui...
Ariel Sharon thinks I'm a punk. I told him the feeling was mutual over tea this afternoon.

 

Simplex:  Dead?  Really?  I don’t think we had anything to do with that.  We try not to kill our hosts…bad for real estate, as you can imagine.  But yeah, them.  They hated each other, but at the same time, they created lots of business for each other too.  Get it?  People don’t like using condoms, for some reason.  But those that do are WAY lax about concerning themselves with us.  Since we don’t just hang out in areas covered by those suffocating, smothering latex udders, we get around pretty well when condoms are in the mix.  People jump into their illicit affairs, thinking they’re safe…and forget to ask anything about us.

So, it’s a love-hate thing.  Overall, condoms are probably pretty good for business.

SW101: So, you hate condoms.  What do you love?

Simples:  Promiscuity.  We’re BFF’s.  Make love, not war, dude.  Preferably, don’t even look down at what you’re doing.

It’s not personal, by the way.  We’re just doing what we are meant to do…which is reproduce.  Everyone who is living with us now should understand that.  It’s one big happy family of organisms doing what they were meant to do…mate, and reproduce.  It’s natural.  When you’re mating…so are we.  All I can say is, sorry for the inconvenience.

Half A Delivery

I wouldn’t say we’re competitive, me and ChinaDoc.  If you don’t recall, she was the other FP resident on our trip to Haiti.  Although I’ve mentioned her actual name before, in true blogging fashion I will heretofore call her by a nickname.  Being Chinese, and very small and elegant, I’ve settled on ChinaDoc.

True, she plays Hearts to the death.  And we’re constantly harassing each other about who has more deliveries.  But that’s not real competition…is it?  Just friendly banter.  Or so I thought…

Just as we’re closing up shop on the 4th night of our adventure in Haiti, a woman arrived in labor, but dilated to only 3cm.  Since she needed to get to 10 to be “complete”, we knew she had some work to do.  We thus set up a makeshift labor room out of the flight-line of the bats that inhabited our clinic at night.

Our stellar OB nurse – with something like 30 years experience on a labor ward; one of the best I’ve ever worked with – stayed with the patient to watch her, while the rest of the team walked across the courtyard for dinner.  ChinaDoc and I each had one delivery since arriving in Haiti.  It was thus my turn for this one.

Stretching nonchalantly as we headed up the stairs, I just mentioned to my illustrious colleague, “Hmmm.  Looks like this will be TWO for me.  How many do you have again?  Sorry, I forgot.  Something like…uhhh, ONE, isn’t it?  Don’t feel lame, dear ChinaDoc.  Some doctors are just, you know, more successful than others.”

I can’t recall what mean, snide thing she said then – MUCH to my surprise since I was just trying to make personable conversation (and gently help her feel better for losing the delivery race).  It was something along the lines of, “At least I’ll sleep, loser.”

She made a good point, actually.  I was probably in for a long night.

Since I was “on”, I found a perch along the edge of the balcony where we ate our meals.  From that vantage point, I could see through the door of our OB room and observe things as they unfolded.

About an hour later, my nurse stuck her head of the room and yelled up to me, “She’s 7.  Won’t be long!”

Good, I thought.  7cm.  Our patient had delivered numerous other children, which we medical folk term “multiparous” (multip, for short).  Multips don’t usually hang around at 7cm for very long.

To my surprise, a short time later I saw our patient wander away from her hastily constructed labor room.  Accompanying her were the two friendy/family types who arrived with her.  No nurse.

Here’s the thing about walking while in labor:  It almost always helps things progress.  We encourage it most of the time.  How it works is something of a mystery, but it has to do with gravity, and mental distraction and pain control.  However, I can NOT envision a time when an experienced labor nurse would encourage – nay, allow – a multiparous mom at 7 cm to walk around.

Welcome To Your Delivery Suite, Ma'am
Welcome To Your Delivery Suite, Ma'am

Babies have been known to drop right out of multiparous women.  Into toilets, showers, cab seats, soccer fields, gondolas, dog bowls, ferris wheel benches, classrooms, ski slopes, two-seater airplanes, office cubicles, hot air balloons, the space shuttle, those suction chutes at banks that kids love…

…OK, so I made some of those up, but you get the point.

But for some reason, this woman wandered away from our clinic room – ambling slowly with one hand in the small of her back – into the front courtyard of the building we use daily for the clinic.  From my roost on the ledge, I watched our patient virtually evaporate into the pitch-dense maw of the rural Haitian night.

To describe just how dark it was in the front courtyard, I’ll refer you to the ’80’s classic movie “This Is Spinal Tap”, where at one point the question was, “How much more black could it be?”  And the self-evident answer: “None.  It’s none more black.” (stated by a band-member describing the cover of their new “black” album).

Thomaseau has no street lights.  Or, maybe a few odd ones here and there, but realistically there aren’t any.  Furthermore, the power for this village comes from Port Au Prince, which shunts electrons out there based on some whimsical benevolent prescription that befuddles even the least logical among us.  On this night, there was no power.  So the courtyard was…black.

None more black.

Nervous by this point, I figured my OB nurse had been taken captive and thrown to the yapping Haitian dogs.  She would never walk a multip at 7cm.

Just then, the two women who walked out with our patient came running back into the halo of generator-powered light from our clinic, frantically yelling in Creole.  I knew exactly what they were saying, “YOU LET OUR MULTIPAROUS SISTER WALK AT 7cm AND NOW WE’RE HAVING A BABY IN THE PITCH-DARK!  WHAT KIND OF TWISTED FREAK-SHOW OF AN EXCUSE FOR OB DO THEY TEACH YOU IDIOTS IN AMERICA?”

Already I was bolting down the stairs and running for the courtyard.  I was armed with only 1 tool, perhaps the most valuable physical item a doctor can have in Haiti:  A headlamp.

I rounded the corner, flipping on the light and arriving at a scene that would make the prop crew of CSI envious.  The mother was sitting on the top step of our clinic porch, with a wide pool of blood mixed with clear fluid and thick meconium shimmering from between her legs.  Lying right in the middle of this stark lake of glistening life was a motionless baby, still connected to the umbilical cord, which still curled it’s way into the mother’s body.  The picture of that initial visual moment still glistens realistically in my mind’s eye – the image etched and harsh under the chill glow of my headlamp.

My first concern was the baby.  Motionless, caked in blood meconium and mud from the dirty courtyard, I worried about hypothermia (a real risk for a wet newborn even at Haitian temperatures), and I knew that tactile stimulation would be the best way to try to get “it” (I never even noticed the gender) breathing.

Since I had nothing but the headlamp and clothes on my back, I pulled my shirt off and wrapped up the baby in it.  “It’s dark, I reasoned, nobody will see my rotund beer-gut anyway”.  In the process, I scooped a good amount of the birth-goo onto my bare hands.  I’ve done nearly 100 deliveries, and never touched a newborn with my bare hands.

For the record: it feels exactly like it does in gloves, so there’s no sense in trying it at home, boys and girls.

Dropped Out of my Mom Onto Concrete.  All Good.
Dropped Out of my Mom Onto Concrete. All Good.

Eventually, we got the baby and mom back into their rightful places.  Turns out our OB nurse had been unable to talk the patient out of a walk, and so asked her to wait while she ran up to her room to get her shoes.  The patient didn’t wait, and off she went before our nurse could return to walk with her.  So, no fault of ours, ma’am.

The baby did great.  No head wound from a drop onto concrete.  Breathing fine.  The mom had no vaginal lacerations, and did great too.  We sent them home that night.

ChinaDoc arrived as we were settling the mother back into her cot with the baby, now wrapped in a blanket.  She seemed completely uninterested in the fact that I was shirtless and covered in blood.

“So, I heard the baby was on the ground when you got there.”

“Uh, yeah.  Blood and stuff everywhere.  All I had was my headlamp.  I’m incredibly awesome.”

“So, you didn’t actually deliver the baby, then.”

My eyes grew wide.  “WHAT?”

“Yeah.  It doesn’t count.  All you did was pick it up.  We’ve both delivered one baby in Haiti.  We’re still tied.”

“Here I am, shirtless, covered in blood – look, LOOK AT THAT POOPY, MUDDY, SOAKING FORMER-SHIRT I JUST THREW AWAY – I don’t get credit for a delivery?  I could have AIDS!  I could have an alphabet of hepatitis!  I didn’t even use gloves for God sake, woman!”

ChineDoc sniffed, unmoved.  “You wrapped up a wet baby.  Brilliant work.  But anyone could have done it.  Don’t need a doctor for that.”

Quickly I determined the best way to bend my itinerant classmate to my will was to smear my contaminated hands all over her face.  She backed away quickly at my advance, “OK!” She relented, “Maybe you can have a half a delivery.  Nice job…I guess or whatever.”

Partially gratified, I made my way to the showers to clean off the painting of real, human blood from my body.  Turns out Port Au Prince didn’t deign to allow running water that night, either, along with electricity.

Faced with laying around for the next 8 hours in that blood, purified only with a Wet Ones shower, I realized the bald injustice of my colleague’s proclamation.  “Forget it, ChinaDoc!”  I yelled to the parched shower.  “That’s one WHOLE delivery!”

It Takes A Village…And Cash

Hilary Clinton popularized the phrase ‘it takes a village’ a few years back by using it to entitle”her” book (actually written by Barbara Feinman).

Today I participated in my first group visit for pregnant adolecent teens.  I must say I loved the experience.  Included in the group of providers are residents like myself, a family medicine faculty member, a social worker, a nutritionist and one of our extremely competent medical assistants.

Into this healthcare provider mosh-pit are thrown anywhere from 2 to 15 pregnant teenagers.  We sit in a circle and spend the first half-hour talking to them in a group about any of a number of topics germane to teen pregnancy.

We then break up the group and the patients are seen individually.  The residents evaluate their medical issues.  Then the social worker checks in, helping with other issues such as depression, abuse, post-partum care and support networks.  At some point the nutritionist sees them to offer advice on how to take care of themselves and eat right, etc.

The kids really seemed to like the program, and I enjoyed feeling like like I might actually be helping someone instead of just making insurance millionaires richer.

That said, I was struck by how much such a program must cost.  Doctors, each with at least 12 years of education, a social worker with Master’s level education, and a nutritionist with at least as much education as well.  Plus, all of our salaries, the facility, the ultrasound machines, etc.  It’s quite an operation, and all of it costs money.  Just thinking through our collective salaries for that day is an exercise in money-pondering (pun intended).

Sitting there watching these patients, it became clear to me that premarital sex isn’t just some arcane religious dictate.  It costs YOU money.  Think of an average day at work (for those of you still at the grindstone).  Think of all the crap you deal with because of the pressure you feel to afford your life.

I don't drag myself to work at too-early in the morning so I can pay for kids to do this.
I don't drag myself to work at too-early in the morning so I can pay for kids to do this.

Now think of a couple of bored, hormonal, overly-sensual teenagers romping on any horizontal surface they can find.  Think of the fact that, according to ‘Village’ theology, you are partially responsible for the fruit of that short-sighted quest for pleasure.

Teenagers have a hard time thinking about much other than self-pleasure.  I’m not blaming them; I was no different.  But their pursuit of pleasure does need to be met with some societal consternation.  It isn’t judgemental to be critical of promiscous behavior; it shouldn’t take a village very often.

The right thing to do for these sweet but immature and penniless patients is exactly what we did.  But millions of teenagers who aren’t in need of our high-intensity service don’t deserve to be told that their actions don’t matter.  They do.  And often the cost of their actions are unfair to everybody.

Review: Juno

The movie Juno, released in 2007 and directed by Jason Reitman, enjoyed wide popular and critical acclaim despite a minuscule production budget. Like the Blair Witch Project, it became a sleeper (no pun intended) hit, eventually winning an Academy Award for best original screenplay. The show deals with teen sex and pregnancy, which obliquely involves family medicine, so I guess I have some reason to talk about it other than the fact that I did like the movie.

Juno is a 16 year old girl who gets pregnant after a tryst with her longtime best-friend and occasional boyfriend (depiction of the act is repeated, but tasteful and not gratuitously revealing). She initially chooses to have an abortion, but decides against it after a rather uncomfortable experience at the only local clinic that performs the procedure for free. Instead, she decides to put the baby up for adoption, and chooses a wealthy couple desperately seeking a child. The story dispenses with much of a dramatic climax – other than to require some very adult-like decision making by Juno. It turns out that the rich have their problems too, although their kind often crouch behind over-sized front doors, huddle in spacious breezeways or waltz softly in cellars devoted to past wishful glories. Juno’s parents weather the shock of her predicament well, with an admirable balance of reasonable judgmentalness and loving support. “I was hoping it was cocaine or shoplifting,” the step-mother confides to Juno’s Dad after they hear the news.

I can see why the screenplay beat out other brilliant scripts at the Awards. The writing credit goes to Diablo Cody – that’s a woman, not a an eternal being from the outer realms of darkness, or perhaps somewhere in Wyoming – who started her writing life as a stripper. Her imminently popular blog about the skin trade led to her contract to write Juno. Some wonderfully witty moments pepper the script, and deserve the attention they received. However, the actors rescue some lines that with lesser players would have devolved into jarring triteness. Credit the director for drumming up Ellen Page to play the title role, who herself borders on unbelievability, but is rescued in turn by moments of incisive honesty in her script. This symbiosis – script and actress relying the other – occurs regularly through the movie and probably saved the enterprise as a whole.

The depiction of the family planning clinic probably did not depart far from the reality. State-supported medical clinics tend to run heavy on the documentation and short on things like staff and, say, furniture. Given the number of teen-pregnancies my clinic deals with, I found the depiction of Juno fair and respectful. Not every teen is a bimbo with no grasp of consequences; there is nuance to many of their situations. That said, Juno exhibited a more sophisticated persona than most teenagers. Her sense of self and values was decidedly adult. In fact, we should be so lucky to have teens work through complicated issues like sex and pregnancy in such an honest and careful way. Many adults don’t rise to the level of emotional acumen we see in Juno. Frankly, much of America worships ardently at the altar of pleasure to the exclusion of anything or anyone else. Juno, like few of us at 16, and maybe even 35 or 65, spends most of her time focusing on her problems and solving them. Nary a misstep does she make after her single afternoon of what was, likely, something like 33 seconds of coital bliss in an over-stuffed red chair.

Fair or not, I enjoyed a cathartic moment when the step-mother – in the room with Juno and her best friend during her ultrasound – dresses down the tech for denigrating Juno’s situation. Chatty ultrasound techs have caused problems for more than one of my patients. In one case a tech hinted to my pregnant patient that something was wrong with the baby, “but I can’t tell you about it, you’ll have to talk to the doctor” (scan turned out to be fine but the woman had nightmares for the rest of her pregnancy). In other countries, OB ultrasounds are performed by the doctors themselves, and so can give an official read right there in the exam room. In the US, we have techs do it, who understandably become tempted after their 1000th scan to give the patient their own interpretation. Some techs are good enough that they’re usually going to be right, but legally they are required to keep their traps shut. Interpretation and commentary is NOT their job, acumen in that area be damned.

Humph! Anyway…

As a father, I watched the movie hoping I would know my daughters well enough to prevent them these kinds of dilemmas, knowing in all honesty that I won’t be the one doing any such thing. Hormones and pubic maturity arrive around 13 years of life, and from there I will be but a distant guide – one mild tenor in a chorus of influential voices. I also envisioned myself behaving quite like the father in the story – angry and protective but ultimately on-line and ready to help. God only knows if I could really manage such levelheadedness.

Politically, I knew that anti-abortion types would love the grim clinic scene and applaud the choice made by Juno to keep the baby. Many in the conservative right believe that pro-abortion forces are out to talk the rest of the planet into having the procedure – men too, if possible – and would DIE before they even discussed the alternatives to it such as adoption. My own experience with pro-abortion people suggests much more balance and pragmatism among them. Still, I did feel a sense of satisfaction on behalf of my pro-life friends in seeing a viable alternative to abortion played out step-by-step to a tenable – and preferable to all possible worlds, in this case – conclusion.

Juno glossed over the considerable emotional toll something like this must put on a young girl. The end scene is of Juno, back with her boyfriend (one assumes, also back in the sack, this time with a more proficient prophylactic). They sit idyllically in dappled sunlight on stairs leading into his front yard. Whimsically, they play guitars together and sing a melodic paean to teenage life. Consequences, perhaps lingering in soft shadows at the corners of the closing frame, hold no sway in this myth.

We should all be so lucky.

You Be The Doc – Gestational Diabetes

One of the more difficult things to deal with in medicine – I think – is borderline lab values. A huge component of most medical decisions relies on the patient’s latest labs; often the decision is almost perfunctory. But what about times when lab values are just barely positive? For example, a normal blood pressure is 120/80. What if a guy has 122/80? Is that hypertension? Should I put this disease on his problem list…there for insurance companies to see and thus charge him more for life or health coverage?

gdm6.jpgMost lab values can be manipulated to some degree. The entire field of biofeedback starts from this premise. In biofeedback models, the lab values can be changed by effectively willing your body to change it’s own parameters. If effect, you can think yourself to a lower blood pressure, lower cholesterol, more hair…maybe even bigger sexual organs I suppose. Go for it. Imagine big, big gonads if you want. See what happens.

Anyway, some people consider this mere quackery – I think it will be considered a fad in a few years – but some swear by it. And yeah, I’m sure there is some bridge across the Cartesian mind-body quagmire we’ve been wallowing in since Modernism awoke, but I’m not sure biofeedback is that bridge. Aside from whatever volitional input we may have on our bodies, there is the fact that all lab tests have margins of error associated with them. You hear about “sampling” error in all these perpetual polls in the presidential primaries. Obama leads Clinton 47 to 42 percent…but the margin of error is plus or minus 8 points. So Obama doesn’t lead anybody. He and Clinton are tied. Many of the good polling companies actually do some real statistics to come up with these numbers, brainball.jpgbut it doesn’t really matter much because none of us voters really care. All we care about is who’s gonna win the stupid thing? Who’s the prez gonna be? And, (for me) WHO’S FINALLY GOING TO PUT AN END TO DYNASTIC, BOURGEOIS RULE IN AMERICA?

Sorry, this is a blog, so I can digress and feel only a little bad. The points are that lab values are manipulatable both physiologically and statistically. The statistical manipulation – the margin of error, for example – exists because determining something like the amount of glucose molecules in a sample of blood isn’t exactly easy. There’s 2 major ways to do it, and a 3rd less-popular way as well. Each way is different from each other, so if you determine glucose values using Type 1, and then use Type 2, you have to convert one to the other’s value to even determine if they’re equivalent. The conversion is a math equation, not observational science.

Why does an average doc like me care about all these details? Well, these facts play out in my mind when I get a lab value that is juuuussst barely out of range. A positive value means the patient has a new disease that can affect their ability to get health insurance (a quaint little reality of this American health system I admire so much), but also can affect their care. One little lab value can determine if a person suddenly needs to take expensive medicines – brand-name cholesterol-lowering meds are a couple hundred bucks a month, for example. Or it may mean that they now qualify for surgical exploration to find a possible tumor. Some people have had things cut off of them – like breasts – only to find that they didn’t have cancer at all. This is called the false-positive rate and is one of the biggest reasons why I try very hard NOT to do even little tests on patients unless it really looks like they need it. Breast self-exams are a classic example of dangerous false-positive tests that lead to sometimes catastrophic interventions occasionally for no reason. **Disclaimer on this one: major controversy exists about whether or not breast self-exam are good or bad. This was just an example. Keep doin’ em if you do ’em.**

When pregnant, one of the things we screen for is gestational diabetes (we call it GDM). This disease only shows up during pregnancy, and often vaporizes just after the baby is born. It more resembles Type 2 DM than Type 1 in that it won’t really kill you in the short-term, but deranged glucose values give the patient headaches and lots of nausea and makes them feel pretty much miserable. The problem is that high glucose in the mom can lead to huge problems with the baby. First of them being that the baby can be, in fact, HUGE. But they can also end up obese in life. They usually end up with REAL diabetes. Being so big, there are risks for the delivery that aren’t pretty too.

gdm4.jpgSo, we need to avoid GDM. We screen for it by giving the mother an oral glucose test at 28 weeks. She drinks this sugary solution – absolutely disgusting…I’ve tried it – and then testing her blood sugar levels an hour later. This is a classic screening test: It has lots of false-positives, but fewer false-negatives. It’s reasonably good for catching GDM. But because of the fasle-negatives, we do a second test to try to filter some of them out, which is basically the same test with more sugar solution and blood tests every hour for 3 hours. People who have out of range glucose values for both tests, probably have GDM and need treatment which can include testing glucose values 3-5 times a day (rather painful, a bit bloody, and not cheap). The might also get insulin shots, based on the glucose values. They are usually sent for nutrition counseling to teach them how to eat basically no-carb foods. They also get regular ultrasounds every month or less to determine if the baby is getting too big, which may lead to C-section. And while we’re on the topic of false-positives, ultrasound becomes less and less accurate for determining weight as the pregnancy progresses. By the end of the 3rd trimester, the US could be off by as much as 2 lbs! An alarming US can easily lead to surgery when in fact the baby is of normal weight.gdm3.jpg

So, my patient had a 1-hour glucose test of 199. The cut-off is 150. That’s obviously positive – she qualified for the 3-hour test easily. The first test of the 3hr is a fasting glucose test (arguably the most important) and she was well under the limit. Her second test, at one hour, was also well below the threshold for GDM. Third test – at 2 hours – also negative. Then, at 3 hours, her test was 164. The cut-off was 160. She has a positive value. She may very well have GDM.

You be the doc. What would you do?

Here’s some possibilities:

A.) Bring her back for another 3h test, since they can be falsely positive (and, actually falsely negative). In other words, they aren’t always accurate.

B.) Give her the full-monty: regular US, daily glucose monitoring, insulin, diet counseling, weekly visits, evaluation for c-section

C.) One or two elements of option B – a partial intervention, so to speak

D.) Tell her the test is “fine” and leave it at that. Effectively, regard the test as negative, and tell her this.

E.) Bring her in and just test her glucose twice a week. Treat her if one of those values is out of range.

**I’ll describe what I did in a week or so.**

Hopping The Border

I cultivate a keen interest in politics in spite of myself.  Every election cycle I look on with – I’ll admit – bated breath.  My horse this time is Obama.   Last time it was McCain.

So I’ve been a little surprised at myself when it comes to the immigration debate.  I know conservatives are REALLY into this one, but I just never cared about it.  Who cares?!  My ancestors probably hopped a fence (or Ocean, as it were) to get here, and they probably didn’t meet with much of a warm reception when they arrived either.  So let ’em come, I figured.  They’ve got as much right to this place as me.

fence1.jpgToday, my lackadaisical opinion on the matter was surely challenged, if not changed.  I was called to see a patient in antepartum early this morning.  She was 26 weeks along in her pregnancy with cramping and reports of bleeding.  I was told to hurry there because she had 4 kids in the room who all needed to get to school and she needed to know if she was staying in the hospital or going home.

It turns out that this woman speaks only Spanish.  She doesn’t have 4 kids, she has 7.  She lives in a shelter.  So do some of the kids.  Others are in foster care.  She is pregnant again, with her 8th.  While seeing her, we notice a significant deceleration of the baby’s heartbeat.  The baby recovers, but it could be an ominous sign so we decide to keep her for another 2 hours to see if there are more problems.  There is also concern that although she has stopped bleeding, she will start again.  So we order an ultrasound for fetal viability and placenta placement.  We add a biophysical profile to that – another test.

Antepartum is basically a set of exam rooms that function like an ER for pregnant patients.  The cost of running an antepartum unit is eye-poppingly expensive, especially with all the tests we ordered.  Also, to make sure our communication with this patient was perfect, we made sure an in-the-flesh translator was in the room with her.  Since we decided to keep the patient for an additional two hours, we made sure the translator also stayed with her.  The cost for this whole thing was probably in the range of $4000-$8000.  Maybe more.

This woman has no insurance of any kind.  Not even state funds for her kids.  This is because she is here “illegally” and has no documentation to allow her to get support for her kids.  Furthermore, she refuses birth control, and has lots of children.  She effectively has state employees working just for her to get her kids shuttled off to public school, which is also not paid for or contributed to in any way by her.

This patient had no further decelerations and was sent home.  But if she had bled significantly again, she probably would have needed to deliver the baby.  The standard of medical care in this case is to ship her by helicopter to a higher-level hospital with a neonatal ICU where the odds of her 26 week baby surviving are better.  The level of care required to save a baby that age is tremendous.  The cost would rival my medical school debt.

Last week, more school levies were proposed for our neighborhood.  I want to support them, but property tax in this area is already a heavy burden.  Trying to support 4 kids on a resident’s salary, paying taxes even on the loan repayment grants I get because I’ve sold my soul to the Army Reserve, I found it hard not to be resentful toward this woman.  I’m happy to say that I didn’t really come to this conclusion until after she had left and so I think I treated her with equality and good medical judgment.  But after she left, and I thought about how much she is taking from this system that really does survive on actual dollars from real humans like me, I was angry.  My daughter has been asking me to teach her to ride her bike now all week long.  This is because her two other friends just got bikes and are starting to ride with their Dads.  I leave my house in the dark in the morning, and come trudging home still in the dark, usually late for dinner.  I missed it altogether tonight.  Patiently, my sweet little girl hasn’t continued to ask me about bike-riding lessons.  She knows it’s hopeless.  Her dad works from dark ’till dark and if she wants to learn how to ride a damn bike like her friends, it’s up to her.

I work this hard because I – yes – generally like my job.  But it’s also true that I work this hard because to really build a community of mutual benefit is expensive.  Nobody can freeload.  The whole thing falls apart if everybody doesn’t do their part.  This is how the kibbutzim failed in Israel.  Freeloaders – the achille’s heel of communism.

fence2.jpgSo, I know, I’m complaining instead of proposing a solution.  Do we build a HUGE fence?  Seems inhumane, somehow.  Do we brand undocumented immigrants, give them some sort of societal scarlet letter?  Do we round them up and deport them?  I want to be fair to everyone who needs help.  But I want to be fair to me too.

I guess I don’t know the answer.  I do know that staying home and playing with my kids, teaching them to ride bikes and read and do math while other people provide food, housing, transportation, cable T.V. (high-def, if possible, please), education and clothes is in many ways an enviable life.  It is the life of a king.  But to provide this to thousands of people pouring into this country every day is impossible.  It is certainly demoralizing to me.

When Can I Swat the Tot?

Never.

That’s the answer from the AAP (American Academy of Pediatrics). ‘Course, these are the same hardliners who can’t just come out and say what they really think about circumcision. If you really managed to nail them down, I think they’d say circumcision is a medically useless. Most would say it’s somewhat barbaric and the practice is rooted in outdated cultural norms long abdicated by the rest of the developed world. Instead, they say they have “no recommendation for or against” the procedure, but that it isn’t terribly “medically necessary.” So I kinda think of them as softies who take the most expedient position on any hot topic. The Hilary Clinton of the medical world, if you will.

Thus, I’m a little dubious that their recommendations about spanking are just as expedient. Or maybe they just can’t appreciate the magnitude of what they’re actually recommending. When they say you shouldn’t spank a spoiled brat as he throws paint and smashes china, I immediately imagine just who comprises that “academy”. I see lots of gray hair. Kind faces. Serene smiles.

I see grandparents.

car.jpgIt’s hard to imagine that anyone who strongly says you shouldn’t spank your kid – they like to call it Corporeal Punishment, which sounds so much more severe and dire – has many kids. It’s easier to imagine that they had a single kid who was born with reading glasses, a 6th grade vocabulary and a keen interest in impressionist art. Then I imagine that their single kid grew up and miraculously managed to generate enough coital passion with someone of the opposite sex to birth, say, 5 kids.

Now suddenly grandparents, these ACPA’s (anti-Corporeal-Punishment-Advocates, I’ll call them) find themselves surrounded by the love and adulation of all the best that children have to offer: Grandkids are all smiles and no poop. Beautiful, creative…they like imagination and building blocks. They’re the future. Even if they disobey a little bit…hey, they’re just kids, right? Oh, look honey, time for the 4pm buffet at Shari’s, better move along just before dinner-time at the 15-ring circus (since each kid has 3 issues to deal with at all times). Oh, and don’t spank them, dear precocious daughter. That’s called Corporeal Punishment, and we never used it on you.

I grew up in fear of The Paddle. Spanking was routine in my world. Knowing I’d messed up big time, I once put on every pair of underwear I owned – and a couple pairs of my brother’s too – in anticipation of the big Swat…and it still hurt like mad when my backside met that inevitable swooshing wood. Did it keep me in line? I don’t know. All I know is that spankings were part of my life. They hurt. They ruined my day. But by the time I was in high school, I didn’t even have a curfew because I just sorta did what I was supposed to do all the time. My parents didn’t even worry about me.

The AAP held something called a “consensus conference” specifically on this issue (read their policy statement here). They concluded that the word discipline comes from the a root word that means to teach or instruct. Specifically, it refers to preparing children to achieve competence, self-control, self-direction and empathy. Sounds good, right? I think I got all that from The Paddle.

These AAP grandparents go on to say that every discipline “system” must contain 3 elements:

1.) learning environment that is positive and supportive between parents and kid,
2.) a strategy for teaching wanted behaviors – this is considered the “proactive” part, and
3.) another strategy for stopping crappy behaviors – that’s the “reactive” part.

When I think of those 3 things – again – El Paddle Grande comes to mind…hovering in my peripheral vision like a specter of Mother Mary Joseph, Stalin and Javert combined into one terrifying henchman.

Let’s be honest. Most parents have 1 and 2 figured out, or at least they usually aren’t asking their docs about those. They’re asking about #3. And here’s my personal – and I guess professional – opinion on the matter: The best way to address #3 – spank or no spank – is with consistency. While allowing for times when you actually are in error, in general, you have to follow through on what you say. Discipline should be loving, without anger, in control and cause no harm. And most of all, it should be consistent. Don’t say you’ll do something you have no intention of really doing, “Jimmie! If you swallow that slug, I’ll cram 50 more in your mouth and hold it shut ’till they’re crawling out of your eyes!”. Keep your threats small, realistic and fair. If the child merits the punishment, be extremely committed to following through on your threat.

I think AAP can’t advocate for corporeal punishment, because there are a tragic few parents out there that take the practice way beyond the bounds of normal. I also harbor the opinion that just about every parent gets some catharsis out of spanking their kid, which is why most parents regret how hard or how much they have spanked their child at some time in the past. I think the AAP theorizes that if spanking is not one of the options for parents, the potential for abuse or simple over-use is diminished or eliminated completely. Equally effective, they say, are strategies like being consistent, calm and firm and using punishments such as time-outs and removal of privileges. These approaches work just as well as the violent, corporeal approach employed, no doubt, by the likes of Osama Bin Laden and Charles Manson, had either of them ever managed to have kids and stick around to raise them.

Research says that more than 90% of parents spank their kids. And I think that easily 90% of that group have no intention or inclination to abuse their kids. But keep in mind that if a mark – other than just red skin – is left on a child after spanking, it is reportable to child protective services (read: a crime). A bruise of any kind is considered abuse. One report won’t get your kids taken away, but a few of them will.

scream1.jpgMany people in my church a few years back were influenced by a small book called “To Train Up A Child” by Michael and Debi Perle, which describes a religious-oriented approach to discipline that advocates very light spanking for any infraction. When used exactly as he prescribes, I can see how it might work. But most parents can’t stay in control of themselves all the time, and often end up spanking too hard, or too often. Better, then, say the grandparents at the AAP, to simply never spank.

Whether or not you agree with the “no-spanking” approach – which puts you in a 5% minority of parents – one thing most do agree on is that spoiled kids that don’t obey their parents are one of life’s singular annoyances. Furthermore, our nation in general is regarded by most other nations as one that won’t share, never wants to be “it” in tag, has to be first in line, wants the most toys and never wants to wait its turn. Could it be that part of our low standing in the world is a direct result of bad parenting?

Everyone can agree that a major component of good parenting is good discipline. The question is how it’s done. I think using controlled consistency – spank or no spank – is the secret.

Pregnant with Hepatitis C…A Problem?

I have a pt. who is about 15 weeks pregnant. She has Hepatitis C. She’s one of my favorite patients, although I suppose I’d like her more if she knew less about medicine. It’s always a bit unsettling to try to help a patient who basically knows more than you about her medical conditions. Actually, I’m kidding. Patients who educate themselves (she lives on the internet…she’ll probably read this within the first 10 minutes of posting) are the best to work with because they often partner with their doc in taking care of themselves.

So the two of us are working on taking care of her Hep C problem at the same time as her pregnancy. The question is whether or not Hep C while pregnant is a problem.

The answer – from what I’ve gathered after reading and talking with GI specialists – is that Hep C is a problem in general, but pregnancy doesn’t have much bearing on it. The only big issue is trying to prevent the new baby from getting it. And like most things with Hep C, we humans don’t have too much control over that outcome.

blood-virus_hcv.jpgHep C is a virus (see funky-cool pic), so we can’t kill it. There is hep A, B, C, D, E and probably F,G, and who knows how many others, each quite different from the others. Hepatitis infects the liver, as the name suggests. It causes an acute infection, which isn’t usually a big deal and is over in a few weeks. But it also causes a chronic infection that isn’t a big deal either…for about 20 years. Then it’s a real drag. Imagine being told that – as of today – you just swallowed a time-bomb that might or might not explode sometime in the distant future. Bummer for you, dude. Have a nice day.

That’s Hep C.

El Problemo is that the acute infection usually leads to a chronic one, which over time causes cirrhosis (basically, a rotting liver). Hep C is the most common reason for liver transplantation in the the U.S. And in case you’re wondering, the liver is important. If you want me to talk about how your liver does positive things for your life, I’m happy to do that. Suffice it to say that the liver is not like a fibula, or funny bone, or navel or second testicle. It’s called the liver ’cause you can’t live without it. And when a person goes into liver failure, the experience is disfiguring, painful and often very bloody.

“Hmmmm.” You think, “So, what’s the bad news, Dr. A?”

The bad news is that the baby can get it too. There isn’t good information on how the infection happens (called vertical transmission), or what causes it to happen to some kids and not others. Currently, smart researcher types believe the biggest risk for vertical transmission is when the mom is also infected with HIV. Another problem is if the mom’s viral load is high (it usually isn’t if the mom is chronic). If neither of these things are present, the limited studies done on this topic suggest a relatively low transmission rate…something like 4-8%. On one hand, this is nice, because you can flip that number around and say that there is a greater than 90% chance that the baby won’t get Hep C from mom. On the other hand, it’s still close to 1 in 10 babies who get it. It’s a half-empty/half-full perspective kind of thing.

The virus has been found in colostrum (part of the breast milk), but there’s no evidence that babies become infected by breastfeeding, e.g. if you swallow a gnat, it doesn’t mean you’re now infected with gnats. “What about C-section?” You might ask. “Can’t you just zap the kid right out of there and keep it from all that birthing mucky-muck?” There has only been one small study comparing C-section to vaginal delivery and, statistically-speaking, there was no difference. It makes sense to keep the baby away from mom’s infected blood as much as possible. But if you’ve been in on both vaginal deliveries and C-sections, you know that until the day when we can just reach up there and put the kid in a zip-lock bag and pull ’em out, birth is just going to be a bloody affair no matter what route you choose.

So, after all that, what I can say is that we aren’t going to do anything for my patient. We’ll test her new baby for Hep C during the first year of life. But that’s about it. It makes for an intellectual but otherwise normal pregnancy.

After talking up the bad, here’s some cool stuff: The few studies on this subject show that infection doesn’t affect pregnancy. One small study suggested, actually, that pregnancy was beneficial to the long-term odds of mom progressing to liver failure. Also, it appears that even kids who do manage to pick up the virus from their moms tend to do pretty well. Some clear the virus entirely. Those who don’t usually aren’t affected at all during childhood.

There’s lots more that can be said here about Hep C, about pregnancy…about how smart my patient is (she’ll probably write in correcting me on something in this post). But those are the basics. Hep C is the social security of medicine…we worry about it blowing up in the future, but we have this sneaking suspicion that if we take care of things now, things will turn out ok.