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.

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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.

It’s Not Just Sex

A good approximation of how sex and intimacy is regarded by the U.S. Armed Forces can be summed up in the phrase I heard recently: “If you needed a wife…we’da issued you one.”

These days, the U.S. Army is perhaps the most chaste and constrained military organization on planet earth.  No drinking on duty, no sex, no pillaging, no cavorting…and go easy on the damn swear words.

Contrast this with the Russian Army, and German, which frequently serves beer with lunch; the harder stuff after dinner.  And numerous armies – no joke – provide prostitutes to their deployed troops.  Effectively, a little mini-platoon comprised of practitioners of the world’s oldest profession gets sent to war zones right along with the soldiers.  No doubt this idea  is regarded by these armies as a Godzillian leap up the ladder of human rights.  In the past, when victorious they just raped the women (and men) of their vanquished quarry.  At times, a veritable sexual bonanza was promised as the leading incentive to engage in vicious battle in the first place.

Members of the U.S. Armed Forces by contrast, seem expected to never have sex of any kind.  If sexual organs didn’t come already attached to the bodies of their troops, I’m rather certain the Army would have confiscated all tissue related to human reproduction – and especially the related pleasures of it – on the first day of basic training, relegating every appendage to iron storage boxes next to the gold bars in Fort Knox.  “You can have your clitoris back after your 20, soldier.  Until then, kill stuff.  And like it.”

I’m a happily-married, loyal-to-death-do-us-part, honest-to-a-fault type of husband who, with the perfectly understandable exceptions of Rachel McAdams and Jennifer Connely, can provide infinite assurances to his wife that she has minimal reason to fear infidelity (in kind, if she ever meets Johnny Depp in a smoky, sultry, bean-baggy, beatnik bar…she has my blessing).  That said, I think the “Hooker Platoon” is a great idea.  Presumably, said professionals are well-paid, in control of their lives, and free of drugs.  Like it or not, humans are sexual beings and they go about obtaining it in a myriad of ways.  Might as well make it safe, fair, protected and consensual, even if questionably moral.

But what about the ones who aren’t deployed?  Or the ones who, by choice, remain celibate as they await – with admirable fidelity – their dear lover back home?  What about the people who have returned from over a year’s deployment, waay beyond ready to re-start a healthy, loving sexual relationship with their spouses?

Unfortunately, many soldiers return from war zones with major emotional and physical damage – and major problems having sex.  PTSD, insomnia, chronic pain, depression and anxiety all affect sexual ability.  And these problems are like cockroaches…if you have one, you probably have others.  Worse, the meds used to treat the above problems often severely inhibit sexual function too.  Am I the only one who sees the Faustian irony in “You can be happy…OR you can have sex.  Not both.  Your choice.”  For many (including me), that choice is an oxymoron…emphasis on moron.

While not always the problem, erectile dysfunction is one of the more common issues I deal with.  Given the ubiquitous commercials displaying medically-enhanced virile men, one would think ED wouldn’t be such a problem.  And it is true…a pill can solve the problem sometimes.  Cool, right?  A nice, easy fix.  The problem is that sex is considered by the Army to be something of a sport.  Golf, but morally suspect and generally distrusted.  As if to clarify their position, one of the more odd policies I’ve seen is the meet-you-1/20th-of-the-way idea of providing 6 pills of Levitra per month for up to 3 months for erectile dysfunction.  6.  For 3 months.  Then…good luck.

But 6 pills?  A month?  I know they’re expensive – something like 10 bucks a pill – but who came up with a number like that?  Was he (or she…or it) ever in a loving, happy sexual relationship?  Had it already donated the entirety of its copulation gear to NORAD for weapons testing?  Turns out the decision comes from the Department of Defense.  Yep.  The guys buying fiber-plated bombers and infra-red rifle sights and inventing bombs that suck your inner organs out through your maxillary sinus, are also the ones who decided that 6 sexual encounters a month should keep the average couple happy.

Truth is, for many of my returning soldiers, sex and intimacy isn’t simply a nice addition to their lives after over a year of living in austerity.  It is life.  This seems to be especially true of the committed, married soldiers I work with.  Their marriage, and the love they share within it, is often the only salve on wounds that cover their bodies and souls.  Imagine falling into the yearning arms of your wife after 15 months alone, after encountering horrors on the battlefield you will never describe, only to have to say you’re sorry, you just aren’t the same as you were…even as a lover.

A patient recently said to me (to paraphrase), “My wife and I LOVE to have sex, doc.  It’s an every day thing, if not two or three times a day.  At least, that’s how it was.  Now we spend most of the time we would have spent in bed – or in the kitchen, or in the microwave, or in the neighbor’s tool shed, or on top of the dresser, or under the aquarium, or in the chimney, or dressed up as Tonto and the short curly-haired lady from Cheers – with a counselor, trying to figure out what’s wrong with me.”

Most (not all) healthy, vital, loving relationships are comprised of sex more than just once a week with an occasional “two-fer” on the weekend.  Especially if one of the partners has been gone for over a year.  If returning injured soldiers have anything to look forward to, for many of them it’s their longsuffering, waiting, pent-up, willing spouse.  Divorce is a catastrophe, especially when it’s between a broken soldier and the person who typically is the last one standing in their corner when the world is running down.  Seems to me that we could forgo a couple of those useless air-to-air combat fighters everyone’s arguing about and use the money to give these soldiers as many nights of intimate bliss as we possibly can.

Movie Review – Avatar

I enjoyed myself fully last night as I entered the world of ‘Avatar’, James Cameron’s new sci-fi epic that already handily broke a 1 billion-dollar landmark record of some kind.  I’d watch the show again tonight if I could.  I’d probably watch it every night for a week like my high school buddies did for “Bill and Ted’s Excellent Adventure” once upon a time.

You don’t have to care – or understand – the point of the movie to completely enjoy the stunning visual spectacle presented in wide-screen, 3D wonder.  In fact, I’d advise constraining yourself specifically to the visual effects and skip putting any real thought to the message of the movie.  In essence, just sing along with the song, but don’t think about what the words actually mean.

The story follows an ex-Marine named Jake as he becomes part of a mission to subjugate – or at least translocate – the natives on a strange new planet (a moon actually, but does it matter?).  On the n0t-so-subtly-named Pandora, the “aliens” congregate around an enormous tree set in the middle of a seemingly endless forest.  They stand about 11 feet tall, with blue skin and luminous yellow eyes and they all seem to carry bow and arrows and daggers.  These blue and tall but otherwise disappointingly human-shaped beings generally seem happiest when attending their frequent tribe-wide drum fests – with a terminally simplistic 2/4 beat rhythm that sounds like it might have been pounded out on cool Senegalese drums the Anglo orchestra bought in bulk.

These earthy aliens have a sacred, mystical, spiritual connection to the forest where they live; generally behaving like any nature-loving tribe the Europeans successfully decimated a little over a century ago in North America.  In a complete creative hiatus, at one point nature is even called a “mother”.  Why not a father, or brother, or just skip the nuclear family reference to nature entirely?  The descriptor ‘Mother Earth’ is so unoriginal, it ranks up there with Bless You and Dot Com.

Although 2 hours and something like 40 minutes, you can easily sum up the movie in one phrase: “Dances With Wolves”…but with pterodactyls you can ride.

Basically – Marine makes contact with natives through project financed by aggressive and ethics-challenged Big Business company.  Marine plans on helping his financiers destroy said natives.  Instead, he inadvertently falls in love with natives in general, and one curvaceous native in particular.  He then becomes the enemy of his former bosses, ultimately leading the meek, dumb, dark-skinned simpletons to victory over superior white man.

I haven’t decided if this REALLY tired theme of the White Male swooping down into a primitive race, seeing their genuine good, and then becoming their Great Savior is completely racist.  Some are saying it absolutely is.  I don’t really think that was the intent.  I just think it was lazy writing by a white male who deep-down believes that white men are still the best hope for the world.  That they still run it, ultimately.  But it is possible that white men really don’t have much to offer the world anymore – that we’ve had our time and made our mark.  Maybe it’s time for some non-white, non-men to run the countries, write the laws, own the companies and save fictional worlds.  Maybe the white boy has done about all he can.

Big Business takes a major hit in this movie.  It gets portrayed as the denizen of all Evil in life.  That said, it’s Big Business that has paid for every iota of scientific discovery that has occurred on Pandora.  The science taking place on this moon (and taking place on our earth) is an elevated form of existence, no question, but in both worlds it mostly exists because of Big Business, either directly or through taxes.  Scientists – and artists – need to accept the fact that to live in that enlightened world of thought and wonder and possibility depends on their benefactor’s mundane ability to sell widgets.  Big Business is rarely genuinely evil.  True, figuring out when to inject some profit-endangering humanistic principles into a business plan does takes some skill and is occasionally gotten wrong. But for the most part, if business didn’t make the poet, at least it feeds him.

The actual “avatar” is a living being made to look like the aliens, but controlled by the mind of a human.  The human links to the avatar neurologically, so it can only be controlled by one specific human.  Thus, the human lies in a coffin-like body-pod that connects him/her to their specific avatar.  Upon falling into a coma in the pod, the avatar wakes up and the mind of the comatose human controls it.

Soohh...who gets to clean this thing?

The doc in me couldn’t help but get hung up on this part of the movie.  First, all humans need to sleep.  But since the avatar wakes up as soon as the human “sleeps”, and since controlling the avatar is a conscious process, the human never actually does sleep.  For some evolutionary reason I can’t fathom, REM sleep is the foundation of all life.  This inconvenient fact defies even the mighty pen of James Cameron.  By the end of the movie, after staying awake vicariously with the characters, I felt like I’d been on call in the hospital for days on end (felt like I was back in residency again).

Also, the human lays in this coffin thing for hours and hours.  At the least, he’s gotta pee himself on a regular basis, to say nothing of the inevitable bowel movement here and there.  Plus, the main character’s avatar hooks up with the sexy female alien.  Depicted as the first consummating night of an eternal love bond – thus likely a multicoital affair – envisioning the scene (and smell) inside the pod after this particular night left me a bit squeamish.

As mentioned, the power of this movie is in the visuals.  It is a “looker” many times over.  But the general message is tired, probably slightly racist, and denigrates the U.S. Military (or at least leads the audience to exult in the widespread slaughter of American soldiers/mercenaries).  That said, perhaps our culture really should take the main theme of the story to heart.  After all, we DID decimate the Native American culture, and based on my experiences on the Crow Reservation in Montana, I’d say we continue to.  We’re also strikingly obtuse in our dealings with tribal cultures in the Middle East today.  Listening to people from a different culture – rather than melting them with daisycutters and circling drones – has some merit.

But I do wish the movie had added a little post-modernism into the mix and eschewed the evil-good idea altogether.  It didn’t have to pit the American Axis of Evil (big business + U.S. Army) against a pristine tribal culture practically perfect in every way.  Historic Native American tribes were often duplicitous, aggressive, thieving and hateful (many still are today).  They rarely trusted each other from tribe to tribe and may have been just as irresponsible had one tribe attained the raw power that the U.S. Government currently has.  The Arab tribes we’re tangling with recently have a litany of faults and cobwebby dark corners too.  But they are also a just, priceless, sacred, honorable people.  This dichotomy exists in virtually every race in our world.  Americans seem to hate this complexity in our fiction – it’s easier to hate one thing and love another and then watch them duke it out.

Yeah, YEAH! Die lame-oh Americans! Wait, didn't an American make this movie?

Thus, the conflict in the movie could have been between two parties filled with faults and frailties but ultimately imbued with genuine honor, honesty and a respect for the rights of others.  Standing between them is something they both deeply need and want (trees, mineral ore…whatever).  In life, conflicts almost always boil down to two parties who both have blood on their hands, but both are essentially good, honorable…and in the right.  e.g., Palestine wants the land, Israel wants the land, both have been evil at times, both have been angelically good at times, and each have some form of legitimate claim to the exact space of real estate.  Stick that conundrum in your avatar’s virtual peace pipe and take a deep drag, nature-brother.

Depicting this nuanced world may have weakened the sense of righteous rage as the Army went Operation Flatten Everything.  It may have lessened the gloating release when the Ultimate Bad Guy finally met his ignominious end.  But it would have made a better movie.  It would have made the written story as complex as those fantastic visuals, and created a worthy counterpart to such a sparkling, wondrous vision.

Vanished and Forgotten

I spent the past two weeks working as a stand-in for a private practice family doctor in the tiny town of McCleary, Washington.

The stirringly beautiful enclave is better described as a village.  Calling it a ‘town’ implies a bit more hustle and bustle than actually goes on here.

Evergreen trees pepper the landscape, outnumbering cars ten to one.  Wooden cabins and simple churches with peeling paint line the single main road.  A generous census – throwing in some dogs and cats to pad the number – wouldn’t put the population over 2000.

But even here, in one of the most idyllic settings in all of rural America, something wicked this way…came.

lindseyOn a soft warm night typical for Western Washington this time of year, 10-year old Lindsey J. Baum disappeared while on a short walk home from her friend’s house.

She was last seen on June 26th around 9pm wearing a gray hoodie.  Lindsey should have made it home well before dark at this latitude in early summer.  But after weeks with no leads, authorities now assume the girl was abducted.

Each day as I worked in the small medical clinic, I overheard discussions about Lindsey.  Frequently, people decried the lack of “truly effective” sex offender laws.

The one running blog I found about the situation abounds with merciless criticism of those who allowed her to walk home alone.  The posts have an annoying, self-anointed authority and certitude about them, coupled with virtually zero compassion.

townMy criticism, however, focuses on the response of the outlying communities during this tragedy.

7 years ago, about this same time of year, a similar event occurred to a young girl not much older than Lindsey in Salt Lake City.  In that case, word of the abduction spread to every news outlet in the English-speaking world in a matter of hours.  Pictures of her were posted on websites and in newspapers in ever-widening circles, to include towns and cities hundreds of miles away.

Every day, this girl’s story stayed in public view.  News of her disappearance became a dull, throbbing headache to virtually the entire Western United States.

That girl, Elizabeth Smart, survived her ordeal and was returned to her parents fully 8 months after being led at knife-point from her own bedroom.  Her abductor was recognized by someone who had seen a picture of him on “America’s Most Wanted”.  Nearly a year after the incident, this girl’s abduction was still making top news stories.  Why?

The Smart family drove this process, true.  The parents had money, were excellent communicators and kept their wits about them in a horrific situation.

But they also commanded a small army of help. Literally thousands of people lined up to join the effort.  The Laura Recovery Center and other organizations dedicated to this type of tragedy joined the effort as well.

People worked continually to get the Smart family onto national news and talk shows.  Pictures of the victim and her suspected abductor appeared on Larry King Live and Oprah.  And, of course, the show that ultimately led to the break in the case managed to make the story seem relevant months after the incident occurred.

By contrast, Lindsey is yesterday’s news.  You can’t find a current story on her anywhere.  For all I know, she’s home watching Hannah Montana and pondering boyfriend proposals.

mapMcCleary is so tiny, its presence is rewarded with a dot only on maps with an unusual commitment to cartographic accuracy.  The community there can’t make much noise by themselves; certainly nothing to approach the caucophony of a galvanized rescue movement in the heart of upscale Salt Lake City.

The only paper that has carried regular updates about Lindsey is The Daily World, which covers sparsely-populated Grays Harbor County.  A little village like McCleary needs help.  It needs the media power of cities like Tacoma and Seattle, and even here in Olympia.

Yet daily checks of the Seattle Times reveal constant updates about Amanda Knox – a case involving a beautiful college student, sex, drugs and murder – deliciously entering year 3 of drama, but nothing about little Lindsey.  Here in the capital of Washington, The Olympian seems to have the memory of a golden retriever regarding this case, and we’re only 20 minutes down the road.

The Puget Sound region should be plastered with information about Lindsey Baum.  Every 3rd street light and telephone pole should have a Lindsey Baum flyer attached to it.  Every newspaper in the region should have a running narrative of the latest updates on her case next to their logos.  Every citizen from Port Angeles to Portland, from Westport to Boise should know the name, and the story, of Lindsey Baum.

This isn’t idealistic, hyper-passionate pontificating, either.  I distinctly remember stopping for a lay-over flight in Salt Lake City during the summer of 2002.  As we made our way from one flight to another, we could rightly have called the place “Elizabeth Smart International Airport.”  Thousands of fliers and posters papered halls, pillars, windows and doors everywhere we went.

I don’t think anything will change with tougher pedophilia and kidnapping laws.  I also do not think parents need to be more vigilant about this kind of thing.  Increasing either has too many unwanted side-effects.

CandleWhat needs to change is how our communities respond to such a horror.

The abduction of any of my 4 children is the singular fear of my life.  If it did happen to our family, I can only hope that hundreds, even thousands of concerned citizens would take up the burden to rescue that child.  Even if I lived in a forgotten small town off in the hills and away from the city lights.  Even if I was poor.  Even if divorced, uneducated, bad on camera, or just plain ugly.

The way to stop child abduction is to make it really, really hard to steal a child.  An army of awareness might save Lindsey Baum from this evil she faces.  Ignorance lets it flourish.

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.

Chaperone – That’ll fix it

Chaperones in the exam room have become a way of life in residency.  Ostensibly, a M.A. will protect me from a patient who either: 1.) is trying to come up with reasons to sue and hit the lottery, or 2.) might misinterpret a normal physical exam as sexual assault. 

The idea seems to be a good one.  Between emphasizing better communicating through the exam itself – “I’m not listening to your heart…I’m going to lift your shirt so I can listen to your lungs” and having a second pair of eyes in the room, it seems that misunderstandings and craven accusations will both be kept to a minimum.

Still, the addition of another, salaried, person in the room is yet another way that costs in medicine are rising due to litigation.  Litigation itself, obviously, is expensive.  But the secondary costs – like chaperones and a host of other additions in the medical field meant to protect us from law suits – are where the real money is being spent. 

The doctor in my area who was recently tried for sexual assault apparently did not have chaperones with him during most of the physical exams in question.  On the surface, one might gape in disbelief at this lapse in standard of care…especially considering that he came from my program where this practice is drilled into us.  But I’m tempted to forgo the chaperone almost every day I’m in clinic.  It’s a pain.  It slows things down.  Half the time I’m ready to do the exam and nobody is available.  A 3rd person in our small rooms makes things cramped.  My biggest problem with it, however, is the implicit message to my patient that “I don’t trust you, and you may not be able to trust me.”

And will chaperones really save us all in white coats?  I doubt it.  This latest doc in question is being charged by patients who he saw at a chemical dependency unit.  Places like that necessitate long histories prior to or following a physical exam.  It isn’t practical – or really even possible – to have someone sit through the entire meeting from start to finish.  So, a patient could easily just charge that the assault happened before or after the chaperone arrived.

Maybe more technology is the answer.  Maybe we could rig security cameras in every exam room.  The entire time the pt. is on the premises, s/he would be taped, with the patient’s knowledge before they even enter the room.  The entire meeting would be archived, with an index to the exact start time and date of the encounter for reference later if needed.  In every chart would then be a reference to where you could watch the entire visit.  All the data could be stored somewhere “safe” and cut from the hardlines that connect the clinic to the internet. 

I don’t mind chaperones in the room, especially when they hand me stuff and remind me to do everything involved with an initial pregnancy speculum exam.  Some procedures just need assistance.  But most don’t, especially in family medicine.  And in the end, a determined litigant will find a way around chaperones.  So will a determined predator.

Mistrial II

There is a surprising amount of information about the charges against the doctor from my program who recently survived his criminal trial end due to a hung jury. The accusations are galling, and although there were 3 women listed as accusers in the trial, there are numerous others in the initial filing. You can read about it here, if you’re interested.

And why would you – loyal and growing nation of secretwave101 readers – be interested? Who would want to read stuff like this? Well…think about the astounding number of really serious allegations that can be leveled at a doctor and yet still not be enough to lead to a conviction in criminal court. And just how valuable is it to file a report if it merely leads to this? I imagine it takes some courage for a woman who has been sexually assaulted to come forward and make a claim. They have to relive the experience, endure ridicule and skepticism. They may have to appear in court and be subjected to character-withering cross examination by the defense. All of these women (I think there were complaints from woman “A” through “I”) did what they should have done and yet it ended in a mistrial.

sarlacc.jpgAnother wrinkle is that his license is suspended for a catastrophically bone-headed medical error in addition to the sexual allegations. The guy dropped a lung doing a trigger-point injection…a type of injection that shouldn’t go in more than a few millimeters. His response to the error is even more bizarro. His license is suspended as much for the error as it is for the allegations of groping and frotteurism.

The failed trial was only for criminal charges and whether or not he should go to jail. But he isn’t anywhere near being off the hook. He now is open to civil trials and…lawsuits. The standard of proof in these trials is MUCH lower and I shudder to think what awaits him now. He’s headed toward the Sarlacc Pit of the legal system (*ahem* please pardon the Star Wars reference. People who fall into this pit are kept alive for 1000 years and are slowly digested over that time). Although he avoided jail time (unless the D.A. decides to re-file charges), his life is still a mess.

Mistrial

A doctor who graduated from my residency program was recently charged with sexual assault on 3 of his patients.  Actually, I understand more women made allegations, but the trial here in town was brought by 3 women.  At one point it got pretty sensational, with a local news story about all the women he’d wronged – then the camera cut to a room of women all sitting around commiserating about how much of a punk the guy is.  I figured he was toast.

The trial began about 2 weeks ago, and was declared by the judge to be a mistrial today.  I guess this means the jury couldn’t agree on his guilt.  So, does a tie go to the runner, like in baseball?  If he hasn’t been proven guilty, then that makes him not-guilty, right?

I can’t decide what to think about this.  On one hand, people make allegations about doctors all the time, but charges aren’t often brought unless there is more evidence than just an allegation.  In this case, I remember the state licensing board saying that they were alerted because 3 women who have no connection to each other all complained within 1 week.  As much as I want to empathize with the doctor and say his actions were probably just misinterpreted, it’s hard to explain 3 women at the same time.  That’s a lot of strange physical exams.

I also don’t know what this means for him.  The prosecutor’s office hasn’t decided whether or not they’ll re-charge him.  If they don’t, does that mean he’s free?  Off the hook?  Will he get his suspended license back?  Will there be nothing on his record?