Reader Q: Take A Laxative Before A Rectal?

Bob Asks:

Hi doc! I have an appointment with a urologist in a few days for an enlarged prostate.

I know the doc will probably need to do a digital rectal exam. Should I take a laxative or something else similar to what you’d take before a colonoscopy in order to make sure the rectal cavity is empty?

This is rather embarrassing and I don’t want to make this any more unpleasant for myself or the doctor than it has to be.

Also, if you think I should use a laxative, which one should I use, and how long before the appointment should I use it?

The Ignominous Future of Every Human With A Prostate
The Ignominious Future of Every Human With A Prostate

Bob –

It’s good for me to get questions like this because I often forget how much anxiety a physical exam can cause.  I only recently learned that many women shave their legs, and often wax their pubic areas, in preparation for their pelvic exams.

One woman, just as I was about to insert the speculum, said something along the lines of, “See doc?  No hair!  Isn’t that nice?”

The truth is that performing physical exams – the scientific evaluation of the of the human body – is the job of every doctor.  By the time we’re fully-trained, we’ve done thousands of them.  This makes non-medical things like smell, hair, feces, dirt, grime, growths, etc, decidedly uninteresting.

There really is a disconnect between the medical and non-medical parts of a physical exam.  This is part of the bigger question about how a male Ob/Gyn, for example, can see breasts and vaginas all day and then go home and be sexually attracted to his wife.  To most Ob/Gyns in that situation, it’s a strange question.  They’re two totally different worlds.

Plus, after you’ve done so many physical exams, you’ve seen some pretty crazy things.  Most ER’s have a “butt box”, for example.  This is a place where all the things people have inserted – in a state of sexual arousal, or out of just plain curiosity – into their rectums.  I had a patient once who came in with a full-size can of deodorant in his rectum.  “Fell on it in the shower, dude.  Can you get it out?”

So, it takes a lot for a PE to be memorable for a doctor.

That said, yes, a laxative might reduce the fecal matter in your rectum prior to the exam.  Over-the-counter laxatives won’t clean you out like the stuff they give you before a colonoscopy, but honestly dude, you don’t need that.  I’d do the laxative – any over the counter brand is fine – about 6 hours before your appointment, and make sure you’re near a bathroom!

It Could Be Worse..
It Could Be Worse..

Remember that a rectal exam takes all of 8 seconds.  The doc then quickly pulls the glove off and tosses it in the trash can.  Even if covered in something icky, you barely see it and rarely smell it.  I’d just recommend a good shower prior to your appointment.

If you’re really worried about this issue, you could do an enema.  There are over the counter versions you can do yourself, or you can have them done by a pro…which probably would not be helpful in your case!  An enema the day before your appointment will remove most of any material in your rectum.  So, you might feel less anxious prior to the appointment.

But again…all we ask is a good shower.

What, Exactly, Is A Unit?

blood1
The Quizzically-Named Blood "Unit"

Packed red blood cells are measured in the odd units of…”units”. 

There is very little meaning to this term.  Typically, we measure liquids by the King’s pleasure with terms like “quart” and “gallon”.  Or, if in a scientific mood (as we are in the hospital most days) with terms like “mililiter” or “deciliter”.  Of course there are similar words for solids. 

Each term boasts about as much tangible meaning in this world as any in the English language.  Similar to the idea that a dollar is actually a representation of a chunk of gold in some vault somewhere, so too are the words we use to describe matter backed by very specific – material – standards.

But a unit?  Even the guy I called at our hospital blood bank didn’t know what the term meant, exactly.  So, I done did me some research…

The term relates to the fact that blood is only partly liquid.  Really, human blood is nearly 50% solid matter – blood cells, clotting factors, platelets.  Lots of cool stuff, actually.  Blood is so complicated, doctors regard it as a human tissue.  

I also imagine that we describe blood in units because the substance looks so stark and bright and scary;  it just demands mad respect.  One of the most spectacularly beautiful things I ever saw in medical school was microscopic slides of red blood cells.  I used to stare at them for hours (which is why I nearly flunked histology).

A unit of blood typically is about 450 mL, which is about .95 pints.  If you order a unit of some component of blood, say, plasma, you will get the amount of plasma that would be found normally in a unit of blood.  Again, not especially exact.

BLOOD_0125_JRH_19516Here’s the thing:  A human body contains, roughly, 12 units of blood.  12.  That isn’t much.  So, when a person gives blood, they generally only give about 1 unit.  Any more than that and they’d have a pretty tired week.

The other day, we gave one patient 24 units of blood. It took 24 people deciding to take time out of their day, endure an IV, sit around with an outdated shallow magazine about surgically-enhanced humans…and donate part of their living body tissue to help this one person.

I order 2 to 4 units of blood for patients on a semi-regular basis.  I’d say I do it every other time I’m on a medicine week in the hospital.  As a doctor, I look at the patient’s needs; rarely do I actually think about where the supplies that I order come from.

Really, if you’re sitting around wondering what you can give away that genuinely, truly helps humanity.  Give a little blood.  It’s gross, the IV hurts and it takes up a not insignificant amount of your day.  And it’s measured in weird amounts that have no meaning so you won’t really know what it is that you actually donated.  

But you really do help others in dire need when you give blood.  Nobody “just kinda” needs a blood transfusion.  I’m not sure what we’d do if people didn’t donate regularly.  We really do save lives with the stuff.  So, when you get the chance, give it a try.

CDC Officials Upset About Champagne Return Policy

logoATLANTA – Officials at the Center for Disease Control are contesting the return policy of the Korbel Champagne Company in what many here are calling “a classic swindle.”

Effervescently giddy a week ago at the start of the Swine Flu outbreak, senior officials at the organization approved a “full-out partaaay”, says CDC spokesman Greg Thereou.  “But things didn’t work out like we had hoped.”

“Look, the swine flu thing….we were gonna be important again!”  Says Geoff Davis, senior epidemiologist of the Floating Particles and Peanut Dust Unit and lead researcher of viral gene sequence XD449Cd.

building“I was gonna get to make all the bus and cab announcements.”  Interjected another scientist – Dr. Franklin Sumpsen – as he passed by.  He then added wistfully, “Sure beats tracking the sperm count of banana slugs in the Mississippi Delta.”

Amy Forsythe, lead statistician on the Women with Bizarre Sexual Histories Who Also Smoke Crack project, agrees.  “We had a lot going for us this time.  I mean, the SARS scare didn’t pan out at all like we’d hoped.  I think we only got 3 or 4 press conferences out of that before it was all over.

“This time – ”  Amy interrupts herself to hold up a newspaper on her desk, “Look at the London Metro Newspaper..’Swine flu could kill up to 120 MILLION’.  I think they did that all by themselves!  It’s like they were working for us or something.”

Dr. Davis did admit to some involvement the story, “Yeah, well, I photoshopped some surgical masks on a picture of a group of SWAT team guys enacting a raid for a public promo in Tulsa.  Then I put little Mexican flags on their uniforms and sent it to the Metro.  But what’s the big deal?  It could have happened like that.”

bubbly1“We bought 128 cases of Korbel Champagne.”  Said Jody Flannagan, auditer of the Nosocomial Urethral Cath Infections Tracking bureau, and under-secretary of the party planning committee.  She quietly pulled down a giant banner that read:  We’re relevant Again!  Have a drink on us…hell, have two!

“We mostly went with the Brut, but also threw in a smattering of Extra Dry and some Rose too.”  She continued glumly, popping a balloon under her sensible office shoes.  “Now the upper brass have called off the party and Korbel won’t even talk to us.  It’s like we’re dead to them.”

All employees agree that coming back to reality after these heady past few days has been quite a blow.  “It was shaping up to be the most powerful moment of our lives.”  Said Dr. Forsythe, “If we could have nudged our pandemic indicator to ‘Crimson-blast deathblood of innocent millions’ level, we would have enjoyed utter domination of planet United States.”

space-suitA warehouse on the CDC lot is now filled with unused supplies including 48 million square feet of rolled plastic, sterile body suits, goggles, bright blue gloves (“they show up better in the pictures” said Dr. Forsythe) and miles of biohazard taping.  Teams were already prepared to take over airports, schools, bus lines and other places of public congregation.

“True, they only gave us daycares.” Said James Dickson, a tech in the Toe Fungus lab.  “It’s no JFK International..but still.  We would have gotten to do a press-conference or two.  I could have printed up lots of directions and mandates and plans and I’m sure we could have overseen the arrest of some itinerant parents who wouldn’t submit to our authority.”

Sighing sadly, Dickson threw a box of round stickers in the trash that read, “It’s for your own good.  One day you’ll understand.”

“We’re sending an official letter of complaint to the champagne company,” says Dr. Forsythe.  “They should understand that we have no use for the stuff now.  It would be like popping corks at a funeral.”

Then she laughed conspiratorially as a man in a white coat whispered something in her ear.  “Oh, that’s right…on the back of the letter, we’re attaching a sticky note that says we’ll release Vibo0t778-XM2 into their heating vents if they don’t give us our money back!

“That’ll teach ’em to ignore the CDC!”

Swine Flu UPDATE!!!

Deaths from swine flu world-wide:  Approx 147

Death from normal flu every year in the U.S. alone: nearly 36,000

It would be nice if the media kept it in perspective. 

The concern at the WHO and CDC is that the virus is a novel strain combining elements of human, swine and bird influenzas that humans MAY not have any natural immunity to.  But so far there’s no evidence that the virus is particularly virulent or more deadly than boring, non-newsy, every day  influenza.

So, it’s too soon to worry much. 

Wear your seatbelt.  Eat your vegetables.  Do the usual, proven, stuff  if you really want to protect yourself from bad things. 

Oh, and go ahead and ignore Joe Biden’s advice to avoid airplanes and subways.  What a tool.  If you really want to protect yourself…I’d avoid him.

I Want It Thaaat Way

“Just…look under your seat.  I’m sure it’s there.”  Said Bobby, my driver.  We were rushing my ailing patient from Thomaseau to the general hospital in Port Au Prince when Bobby suddenly stopped our car to find a CD.

He made me get completely out of the car so he could check all around my seat, under it, inside the faux fur cover.  Nothing.

bobby“Daang, MAN!  I borrowed that from a friend.  Now I lost it.”  He sighed, “Ok, get in.  We’re in a hurry here.”

Thus began my first experience with the most famous man in Thomaseau.  Bobby grew up here.  His parents owned a general store that apparently did extremely well.  But with the rise of an anti-aristocracy movement when he was young, Bobby’s family found themselves in the grim cross hairs of a violent revolution.  So, his father pulled some strings (one very convenient perk of wealth in Haiti) and immigrated to the United States.

“I’ve never been to a public school,”  Bobby said as we bounced over a stretch of land that might be described as smooth for a Siberian rock quarry.  With Jedi-like reflexes, he swerved around some of the the bigger pot-holes and cranium-sized stones.  “Always private.  Even college.”

Bobby has a smile like a sun-flare and fashion sense straight from New York.  He knows English well enough to drop innuendo and colloquialism into his jokes.

“S-s-s-s-oh you went to c-c-c-c-c-ollege-ege?”  I chattered out as we pounded the Haitian “road” into submission.

“Yep.  Boston University.  Was getting a degree in…beer.”  He laughed.  “It was such a waste.  I dropped out and started my own contracting business.  Made a fortune.  I had money everywhere.”

But now he runs an orphanage in one of the poorest villages in Haiti.

Bobby's Mom
Bobby's Mom

When his parents decided to return to Haiti, Bobby followed.  Soon after returning, his Dad died and Bobby stayed to take care of his mom. Just like that.  Shut down his business, sold off the valuable parts and stayed.  It’s a family thing, I guess.

Bobby and his wife have been unsuccessful at having children, so they closed the family store and opened an orphanage in that building.  Mom lives in what was their house.  Lemons from lemonade.

“So, can you even make a living as an orphanage director?”

“A living?  HA!  Tell me another joke.  I don’t even know where I’m gonna get the money to pay my friend back for his CD.”

“Then,” I pressed, baffled, “clear this up for me: you left a few hundred-thousand dollar a year job to come back to Haiti and live on donations?”

Something like that, he responded.  “You do what you gotta do.”

I once heard a missionary talk about why they lived on pork and beans in a hut in Gambia.  “Love constrains us,”  he asserted.  Sometimes the call to service overwhelms the call for comfort and the pursuit of happiness.  Bobby seems to think the same way.

slum1That said, I myself do not believe in true altruism, with perhaps the exception of one perfectly selfless act somewhere around A.D. none.  Even the great works of Mother Teresa and Father Damien, most probably, have some selfish motive tied up in them.  The great Christian missionaries like Hudson Taylor and Jim Eliot were as much promoting their own worldview as providing service.  They probably would agree with me in this assessment on some level, too.  Great Christians are constantly in touch with their need for salvation.

And I wasn’t about to let some Haitian guy restore my belief in completely sacrificial love, but he certainly got me thinking about it, especially as we entered the inner city of Port Au Prince…

I wasn’t prepared for the hopeless destitution I saw there.  The place is a singular universe, filled with the dank and putrid entrails of human suffering.  The streets teem with staring hungry, lifeless eyes.  Hollow, gaunt faces watch expressionlessly as our car blisters by.  Breathe too deeply and you will retch, but you won’t know if it’s because of the stench or the scene.  Maybe both.  These slums fester like an abscess, limitless human pestilence stewing within the wound.  And instead of drinking with his buddies at Boston U, Bobby drives through this nearly every day.

orphankids
Some of the orhpans

As we bounced along, Bobby described some of the problems that led to such squalor.  I noticed his voice drop a pitch in the effort, and I could feel the sorrow in his countenance.  He described the floods, the fires, the rebellions and litany of misguided UN and WHO initiatives.  He outlined some of the self-serving and catastrophic policy choices by the French, and lately by – you guessed it – the United States.

We stopped at a stoplight and a child came to the window, asking for money, food, anything.

“Say something in English.”  Bobby told the child in Creole.  “If you want something from me you have to earn it.”

“Gim me dullah.”  Said the boy.

“Allright!”  Bobby exclaimed, “You’re on your way!”  He flashed his fantastic smile, the display of mirth some sort of anachronistic throwback to better times, handing the boy a US dollar bill.

Then my escort looked at me, reading my thoughts.  “I know about the handout thing,” he said.  “It just perpetuates poverty and dependency.  I know.  But you gotta remember…this is Haiti.  That kid isn’t going to go buy drugs or something stupid with that money.  He and a good portion of his family will eat with it.”

He paused as we asserted ourselves – alpha-wolf style – through a melee obliquely described as a roundabout.  “And anyway,”  He said swerving around a donkey and accelerating into oncoming traffic, “It’ll get that kid off the street for at least one night.”

Just as he said this, the expansive grill of an impressively huge white truck bore down upon us; clearly with no intention of stopping.  Deftly, Bobby yanked the steering wheel to the right at (what felt like) the very last moment, the blare of the truck’s horn bending into lower tones as we passed by.

But in avoiding certain death with the truck, even the Bruce Lee reflexes of Bobby couldn’t avoid two giant potholes now in our path.  I gasped slightly and dug my fingers into the IV bag I was holding for our patient.

Blam!  Followed quickly by BAMBAM!!

“No problem,”  he started to say, “we-…”  Bobby stopped, looking at me as he drove.  “Do you hear a crowd cheering?”

bbbExtracting my fingers from the ceiling, I listened.  “Actually, yes!  I hear it too.  Like, a real crowd.”

Just then the band kicked in, “Tell me WHYii!”  And then the crowd REALLY roared (screams, actually…it was mostly girls).  “III want it, thaat way!”

Bobby laughs.  The sound reverberates through the car, energetic and infectious.  “THERE’S my CD!  I knew I didn’t lose it.”  Apparently the shock of foot-deep potholes jarred the CD player loose from some track fixation and it just spontaneously started playing again.

I never, in the imagined space of 10,000 lifetimes, thought I would find such joy in a Backstreet Boys song.  But I did.  There we were, driving through a sorrow I will never forget, singing one of the cheesiest pop songs in American music history…together.

This child would not survive the Spring.

Later I would tour Bobby’s orphanage, a jewel of glimmering hope for forgotten children.  I would see the 40 foot well he dug through the hard dirt and rocks in his back yard.  I would listen to him describe his days that start at 5am so he and his wife can care for nearly a dozen kids with no home, no family and no safe keeping.  I would meet one of his orphan boys with cerebral palsy that would be dead within a month.

Through it all – with so much emotion and despair pressing me into ineffective stillness – Bobby is belting out American pop tunes, driving like Andretti with a midichlorian infusion and trying to save lives.

Sure, some part of what this guy does is self-serving.  He’d laugh if anyone called him a saint.  He’d probably ask that you dispense with the titles and donate t0 his orphanage instead.  But his life reflects a near-image of genuine altruism in ways that might inspire even the most jaded.

And he’s a perfect fit here.  This place is destitute and tragic to me.  But this is Bobby’s home.  He can see the hope that I can’t.  He waves to friends he knows as he barrels down the street; he looks with affection on the same things I see as symbols of misery and suffering.  With just a little help from people like me – so ill-fitting here – guys like Bobby will change the world.  They will change Haiti.

Even in a place like this, he still sings.

Left To Die On A Tile Floor

“Dr. SW101,”  said Father Larry, “There’s a woman lying unconscious in the church courtyard.  Can you go see her?”

With little more than a quick nod, I grabbed my interpreter and headed out the door. How, I wondered as harsh sunlight spilled into my eyes, is a doctor supposed to help an unconscious patient?  In Haiti.

I tried to think of all the reasons a woman might collapse, and what sort of assistance I might be able to offer.  Again…in Haiti.

Quickly, I reviewed ACLS in my head.  I tried to revise the arcane algorithms based on the fact that we probably did not have ONE SINGLE med used in a typical code.  I thought through hypoglycemic coma, and stroke signs and symptoms.  I tried to recall how I might distinguish between ischemic and hemorrhagic types (and would it help to know the difference?).

haiti4
Our team working on the patient

Also on my list of worries were seizures, pulmonary emboli, electrolyte disorders, dehydration and the difference between heat exhaustion and heat stroke.  Distantly, I pondered the probability of this being a simple “waiting delirium” where people fake a collapse to get to the front of a line.

I approach what must be the patient but of course I can’t see her.  All I see is a giant throng of people hovering in a circle; a shark frenzy of curiosity.

My interpreter helps me push through the crowd to a thin elderly woman lying with eyes half closed on a tattered blanket.  She was placed in the half-shade of a skinny, leafless tree on dusty cobblestones just outside the church offices.  People are yelling and pointing in all directions.  They give me space grudgingly.

I learn that the woman had a seizure sometime in the night, passed out, and has been seizing regularly ever since.  She is completely unresponsive.  Someone tells me she’s around 70 years old.  Someone mentions that she’s a grandma.  Someone says it’s hot out.

After a brief exam, I have her brought into our clinic and placed her on a army-issue stretcher.  I rummage around our supplies with the help of a spectacular nursing student named Kim.  Together we come up with an angiocath (for IV’s), a bag of normal saline…even some gauze.

We place the IV and get some fluids running to treat possible dehydration.  Kim and an OB nurse place a foley urine catheter we happen to have too.  Clear urine runs into the bag, ruling out dehydration.  We find urine test kits and note that there is no blood or glucose in the urine, thus arguing against diabetic problems or UTI.

The immediate problem was the seizures.  And we had no medicines we could give a patient who, every 15 minutes or so, had a full seizure on the entire left side of her body.  Kim and I riffled through the meds again and found some dilantin (good for seizures)…but in pill form, which made them totally useless.

Knowing the patient would die in her current state, I wrestled with the problem of how to get some sort of sedative – ANY sedative – into her tortured body.  At one point a group of us seriously considered IV Haitian Rum.  I thought about crushing up the dilantin and trying to trip a slurry down her throat, or pushing it rectally.

We eventually found liquid dilantin; made for oral administration.  The discovery felt like a ray of sunshine in a mausoleum.  Now all we needed was a naso-gastric (NG) tube.  Gotta be lots of those lying around, right?

None.  The patient is seizing again, Dr. SW101.  The family is getting frantic.  People are looking in at the patient through every window.  What do we do?

Kim and I did find a feeding bag. Looking at it, I envisioned how we could fashion some version of an NG tube out of the tubing from the bag.  I talked up my plan to Kim.  Seeming like this kind of thing was a daily occurrence for her, she retrofitted the tubing, reversed the adapter connections…lubed the thing up and slid it right down into the patient’s stomach.  Perfect.  I had my tube.

I dose out my best guess for the patient’s weight, not knowing her renal function, her hepatic status, her chronic diseases or her current metabolic state.  I gave it my best guess – shooting for safety and efficacy – and we started a regimen of dilantin.

Along with trying to treat this patient urgently, we knew this woman needed to be in a hospital, and Father Larry had been working on the weirdly complicated logistics of transporting a critical patient to General Hospital in Port Au Prince.  Father Larry also supported my desire to stay with my patient to make sure that someone on the receiving end knew the story and could adaquately take over for us.

haiti11
Our best effort at an ambulance

Not ungently, we put the woman in the back of a tough Isuzu jeep and then blasted out of Thomaseau over rocks and roots and dusty country roads, headed for the thriving city of Port Au Prince.  Nearly 2 hours later, sweaty and dusty, we pulled in through the hospital gates.

My driver and translator is something of a celebrity in the village and knows many people in Port Au Prince also.  He did some quick talking at a back entrance to the ER, and ran back to our car and told me to, “help me pick her up…quick!  They’re letting us in the back.  Otherwise we have to go through the front and it will be at least 8 hours until she is seen.”

We carry the woman through wards teeming with people.  I sense many stares as I pass as quickly as possible through hordes of sick patients, family members, hospital staff and equipment.  We enter an austere room made of tile and bricks, with windows high above us grudgingly tossing some light to the floor.  A kid of about 15 is walking back and forth, tears streaming down his face as he intermittantly screams and jams his hands down his pants (psych?  testicular tortion maybe?).

“Lay her here.”  Instructs Bobby, my interpreter, the celebrity-guy.

“Right here?  On the tile?”  I reply, looking around anxiously.  “Where’s the bed?”

“No beds.  There won’t be one for hours.  Maybe days.  It’s leave her here or we take her back.”

We lay her on the floor.  Two of her family members that came with us huddle on the cold linoleum next to her.  I tell her story to a bored and tired looking orderly.

“Ok.  They’ve got it from here.”  Says Bobby, already heading for the exit.  “Stay any longer and they’re going to demand more money to keep her.  We need to get out now while we can.”

Fighting a sense of revulsion at the place where I’m leaving my patient, and vicerally wrestling with nearly-overwhelming waves of guilt for abandoning her, I snap a quick photo and leave.

As we walked away, I knew she would die on that cold, lonely floor.  Her family trusted her to me, and I left her lying in a tile grave.

haiti21
Her Final Moments

Not long after we returned to Thomaseau, after a harrowing drive through some of the worst slums in Port Au Prince – and in the entire Western Hemisphere – after hours and hours of efforts to save a life…she died.  Probably from a stroke that occurred before we found her in the courtyard.  Within 2 hours of our return to the village we were notified that the patient was gone.  Please come collect the body.  We wouldn’t have given her a bed in the hospital anyway because you didn’t pay for food and supplies.

We did calm down the seizures, by the way.  By the second dose of dilantin, the repeated convulsions faded away and our patient clearly became more peaceful. 

A small consolation.

The news of this woman’s death was somehow devastating to me, even though I knew she had no chance.  I couldn’t help but get emotionally involved in something that required so much effort and focus. 

And for all that work, I ended up with a dead patient; her last moments spent in squalor, destitution and abandon. 

I have now spent hours trying to frame this experience in some sort of meaningful context; actively resisting raw emotions of fury and hopelessness and sheer nhilism.  So far, I know only this:  all I can really do for Haiti, is care about the suffering there. 

And never, ever forget…

Le Flip-Flop Be`be`

Journal entry after the 1st day of clinic work:

A garrulous, ebullient, colorful people.  Haiti teems with energy and noise.  The creole language sounds like a brook hurriedly scrabbling across smooth stones.  At first, you think you hear French; those soft contoured and drawn-out vowels.  And you are.  But more, too.  It’s French plus native.  Plus pride.  Plus individualism and cultural distinction.

Creole is French drenched in the personality and attitude of a people.

**********

I achieved the pinnacle of my profession on my first day in Haiti.  I practiced clinical medicine while wearing my Reef flip-flops.  Every day, including for the delivery of a baby.

Long have I pondered where in the world I might have the chance to be a doctor and still wear the greatest shoes ever invented on planet earth, and I think I finally found it.  Haiti.

snaI think the prohibition against open-toed shoes in medical practice is probably much more about Victorian anti-sexual, social dictatorial fashion strictures than any true sterile or safety issue.  I wore my flippers every day in med school…I even wore them under my gown at graduation, flapping happily across the stage to get my powerful and awe-inspiring diploma.

My singular goal in life – if you press me – is to find a job where I can wear flip-flops with impunity.

As you can see, I found my professional soul in Haiti…through my flip-flops.  My very first case was a baby delivery, in fact, and nobody said anything about the irreverent shoes (sandals, really, footwear of Jesus, clogs of the Gods).

The case began while everyone was still sitting around the breakfast table.  We planned on getting an introduction to the mores of our makeshift clinic, led by a highly capable nurse who oversaw things each time she made the trip to Haiti.

Before I could even see my clinic area however, a voice blared over a hand-held loudspeaker from outside the church walls, crying “Le bebe!  Le bebe!”

Even I knew what that meant.

Quickly we settled the woman onto a rather uncomfortable wooden table with stirrups drilled into the sides.  Shortly thereafter, the woman’s, amnion ruptured with thick meconium staining.  Missed my exposed toes by inches.

Mec, especially when thick and gooey like this, suggests a very stressed baby. In the “real world” we call pediatric hospitalists to be present for deliveries like this because a resuscitation will likely be needed.

Just next to my exam “room”, we just happened to have a pediatric ER doc down from Miami.  While she provided a welcome level of expertise, supplies were in short supply.  We had no resuscitation equipment.  No baby warmer.  MAYBE a pediatric IV, but we would have to give adult saline.

One of the things we didn’t have was a welcome omission, however.  Adding to my joy about the flip-flops, we also were without a fetal heart tone monitor to watch obsessively.  I hate those things.  I blame them for thousands of needless C-sections a year.  It’s only because of the prolific lawsuits of John Edwards that we worship at the altar of FHT strips anyway.  No science even supports their use.

I could have done without the mosquitoes and flies buzzing around, the open window behind me (and directly in line with the woman’s exposed perineum as numerous couplets of eyes looked on), and the flimsy shower curtains that separated us from other exam “rooms”.  But overall, I could not have been happier, hovering around my new patient, waiting for new life in Haiti.

The baby came out small, stained and floppy.  One unintended benefit of malnourishment is that babies don’t get too big, and don’t often get stuck in the birth canal.  The delivery itself went rather smoothly.  Minimal tearing.  Things started off slowly for the baby, but our noble pediatrician performed some equipment-less magic, and the baby came around after a few minutes.  Eventually, he looked good enough to go home by the end of the morning.

That’s right.  3 hours later, the lady slowly tottered out the front door, heading home.  As I sent her out – consternation swirling in my chest at sending a stressed baby home on the day of delivery – I asked her to bring the baby back tomorrow so we could check on him.  The mother agreed, and appeared as promised almost exactly 24 hours later with a clearly healthy baby boy.

Only on her return did I learn that she lived 3 hours away…on foot.  The day before, the woman walked 3 hours to our clinic in labor, and then returned home the very same day, carrying her new baby.  Without complaint, she returned to the clinic again.  Another 3 hours.  Just routine for people like this, I guess.  Never a complaint.  Only dignified, quiet gratitude.

And nary a word about my flip-flops.

Pizza Hut? Starbucks? Haiti’s Not So Bad!

I play a mental game on airplanes.  I try to determine as accurately as possible when I cross the line from “likely to live” to “likely to die”.

As the plan taxis to the runway, I often think, “No problem.  Wheels could fall off and we’d be fine.”  Then the plane accelerates dramatically, the landscape begins to slide by with increasing rapidity.  “Not yet,” I think.  “Still wouldn’t die if we skidded off the runway”  Or, say, fell into a huge sink-hole nobody noticed.

“NOW!” I exclaim to myself at some arbitrary point just before lift off.  “We’re dead!”  I have no science for this, it just feels like human life probably was never really meant to achieve speeds like that.

I do the opposite on the way down, too.  I usually choose that point when the wheels have touched the ground, the wings have exploded into fins and panels to catch the wind and help the brakes slow us down.  Sometime around the point when the entire cabin roars and rattles in wind-shear friction I proclaim as objectively as possible, “Ok.  We’ll live.”

You can imagine my instant consternation when our plane lost power for a split-second after lift off from Miami as we headed toward Port Au Prince.  Some may not have noticed, but I sure did. 

We couldn’t have been more than 300 feet in the air.  Cars and buildings were still BIG.  I’d just proclaimed us “likely to die”, when suddenly the plane just seemed to sag.  The nose dipped slightly, and my heart caught in my throat.  But in an instant then the engines roared back to their previous RPM’s, and we kept climbing.

NOT comforting.

A few minutes later, the captain’s voice announced that yes we did in fact have a problem.  The landing gear did not retract into the belly of the plane.  Stuck.  The good news was that the wheels were stuck OUT, rather than IN.  “But”, the captian informed his white-knuckled crowd, “If we can’t get the landing gear into the plane, we can’t go to Haiti.”

So, we needed to turn around and land the plane.  Great.  No problem.  I don’t like this plane anymore anyway.  Unfortunately, landing the aircraft presented some uncomfortable dangers.  One problem was the huge amount of fuel we had in the tanks.  The extra weight made landing dangerous.  Unspoken, of course, was the grim prospect of just how big a flaming explosion all that fuel could make.

We also didn’t know if the landing gear actually worked.  Maybe it only partially extended from the plane.  Maybe it wouldn’t hold the aircraft under the stress of a real landing.  Maybe someone shoulda spent 15 bucks on a little internet cam down there so the captain could actually see what the gear looked like.

So, we circled Miami for close to an hour.  Burning fuel.  Losing weight with an efficiency any American could appreciate.

I spent this time pondering my choice to spend two weeks in Haiti.  I wondered if I could really provide any aid to anyone.  Was this really just tourism couched in the self-important guise of Western medicine?

How would my kids feel, 10 years after we saponified in a brilliant sun-ball of death on MIA’s runway #4?  Would they say, “My Dad died on a medical mission to Haiti.  It has been hard growing up without him, but I’m proud of what he was trying to do.”  Or, conversely, would they simply never understand why their Dad left them for what turned out to be  forever so he could go try to help a bunch of people he didn’t even know.

Around this time, the plane approached the runway, but we didn’t actually land.  Just before touching the runway, we took off again.  As we passed over, crews on the ground visually inspected the landing gear to determine if it was actually locked in place.  Things must have looked good because we then circled around, re-approached the runway and finally land the plane.

Waiting for us were emergency crews, lights flashing, posted at intervals along the runway;  each successive crew ready to pick through pieces of wreckage that flung away from the main one.  Nice image.  “Could you guys at Crew 1 look for my charred arm, please?”

Four news helicopters also hovered along the runway expectantly.  I’m not sure that a Bell-Howell chopper can lick its lips in salivating anticipation of afternoon of “news”, but I found the image easy to imagine.

Since I’m typing this, it should be clear to you that we landed without incident.  The choppers turned away forlornly, off to cover the boring Miami traffic; hoping for someone else to perish dramatically, preferably with flames involved.  We taxied to the quizzically-named “terminal” to board another plane while repair crews swarmed over our ailing one.

As we entered the airport, I felt a new lease on life although still haunted by the grim possibilities of what we “survived”.  Just then, I see Lisa, the only other resident doctor on the team.  Figuring she might be a little distraught about nearly losing her life, I walk over to check on her.  Be strong and manly, I think.  Supportive.  The rock.  Fearless, me.  The poor girl.

“Haiti’s not that bad.”  She says, looking around curiously.  “I saw a bunch of nice tiled roofs and high-rises as we flew in.  And-” She points to an airport Starbucks, “They even have coffee and pizza and stuff.”

Lisa then turns at me and beams.  “I think this trip’s going to be pretty cool!”

For a beat, I’m utterly speechless as I thickly connect the dots, “You’re serious?  What the heck have you been doing this past hour and a half?”

“Oh, I just had my ipod on and then I fell asleep.”

I think, your ELECTRONIC DEVICE?  ON?!  During TAKEOFF?

I realize that she has no clue what nearly happened to us.  No questions.  No worries.  Chilled out to music and then sleeping like a child.  No freaky captian, no fuel, no existential questions about loved ones, sacrifice and mission work.

She thinks we landed in HAITI!

“Good idea, Lisa.  Let’s get some freaking coffee.  Maybe they sell cigarettes valium too.”

Can I Breastfeed with HCV?

One of the most active posts on this blog over the past year dealt with Hepatitis C in pregnancy.  Given the interest and number of questions about it, I’ve added another post specifically addressing breastfeeding while infected with HCV.

By the way:  I do use medical resources for this post.  But you’ll just have to believe it.  I’m not spending time citing sources.  It’s a blog.  Quote me at your own risk – I could be just making this up.

The short answer to the question is “we don’t know, but it’s probably safe” to breastfeed when infected with HCV.

There is quite a reasonable amount of research about it.  Of the numerous studies looking at HCV transmission to infants, none have documented infection from breastfeeding.  However, HCV has been found in colostrum, so the baby does come in contact with the virus.  It’s just that eating HCV is a REALLY tough way to pick up the disease – especially if you have no teeth.

So, breastfeeding is probably safe.  One cavieat: this does not apply if the patient also has HIV. HIV moms pass along HCV at nearly quadruple the rate of non-HIV moms (18% transmission rate vs. 4%).

Nobody knows why HIV increases these rates, but I’m sure you can reason that since that virus weakens the immune system, the patient’s ability to suppress the HCV is limited.  A recent systematic review identified 77 studies on the topic of HCV transmission to infants published from 1992 – 2000.  Of all the variables studied, the one that correlated most strongly HCV transmission was HIV co-infection.

And what are some of those ‘variables’?  The studied variables are the other things that people surmise might contribute to HCV transmission from mom to baby.  These include mode of delivery (vaginal vs C-section), type of Hep C (yep, there’s lots of strains), rupture of birthing membranes more than 6 hours before delivery, internal fetal monitoring (if you don’t know what this is, ask in the comments section and I’ll explain it).

So, here is a basic summary what what we think we know about that tricky HCV:

  • HIV infection is the biggest risk factor for passing hepatitis C to your baby.  It more than quadruples the risk of HCV transmission.
  • A high HCV viral load is also a problem.  Moms with viral loads higher than a certain threshold (1 x 10 to the 5th power) are more likely to transmit hepatitis to their infants, although we can’t say how much more likely.
  • The effect of type of HCV on transmission isn’t clear, but probably ins’t much of a factor.
  • Breast feeding appears to be safe except in women who are coinfected with HIV.
  • Studies of the effect of mode of delivery on transmission rates are all inconclusive.  We use this 4-syllable word to describe our highly profesional feelings of ineptitude.  We don’t know whether or not we should recommend C-sections to HCV moms.  There just isn’t good data to support either method.

Therefore, what I recommend to my patients is to breastfeed.  The benefits of mom’s milk outweigh the possible risks of giving the baby Hep C.  True, the disease is no cakewalk, but some argue that its a tough life to have to grow up without their mom and all she can probvide, like breastfeeding and the intimacy of such a practice.

So, take your pick.  True, the topic isn’t really important unless you get to know someone with this kind of problem.  But then, suddenly, the situation becomes much more real.

Ill Prepared

Doctors are constantly tested on medical facts.  Advancement in any of the specialties is totally predicated on fact recall and medical knowledge.

But there are no tests of emotionial intelligence.  No evaluations of imagination, creativity, curiosity, empathy and – perhpas most glaringly ignored – a sense of humor.

I suppose it would sound weird to hear someone say, “Well, I didn’t make it as a doctor because I failed my “gets jokes” test.”  But I do wonder why doctors can be total disasters of humanity but still bestowed with all the accolades of the healing professions because they can recall voluminous arcane medical facts.

We currently have a patient with a strange constellation of neurological symptoms.  He can hardly walk and has bouts of numbness that at times make his limbs nearly numb.  But the symptoms don’t really fit any classic neurological pattern.  When I consulted with a local neurological specialist about the patient, his response was, “This case is weird.  Call psych.”

He did eventually go see the patient, but with such a preconception and general lack of curiosity in the first place, the bias came across clearly to my highly intelligent patient.  The resulting interaction was less-than-desirable.

Nobody should be required to be a stand-up comedian to be a doctor.  Many are some version of humanitarians, which is a nice asset.  But all doctors should be expected to be humanists. Like mastery of medical knowledge, this requirement – while admittedly harder to quantify and assure – should be expected and required.

The system of training doctors devalues the humanities, and continues to place greater value and emphasis on technical, or trade, training.  See a wonderful commentary on this trend in the NYTimes here.  But doctors shouldn’t be technicians only, they should be humanists, in the most challenging sense of the word.  Otherwise, they are ill-prepared to truly help the ill.