…that I actually sharpened the blade on my electric pencil sharpener.

As someone who both loves to walk and is moving in about 2 years, the 2007 “most walkable cities in the US” is interesting. Right now Portland, Seattle, and San Francisco all seem pretty cool…

Top 10 most walkable cities in the US.

Dear Readers:

If there is one thing you should know about me, it is that I can be thorough to the point of being OCD. After the landmark Supreme Court decision today (in case you missed it, SCOTUS upheld the “Partial Birth Abortion Ban” of 2003), I went ahead and read the original law, the entire SCOTUS decision (all 73 pages of it, including every judicial opinion and the dissent written by Justice Ginsburg), several first-hand accounts by women who had D&X procedures for anencephaly, looked through Dr. Tiller‘s statistics on when and how he performs late-term abortion, and lastly educated myself on how to perform both D&E (Dilation and Evacuation) and D&X (Dilation and Extraction AKA IDX AKA Intact D&E AKA Partial Birth Abortion). I’ll refer to the procedure as D&X for the purposes of this article to maintain continuity.

Now that I’ve advised you of my credentials, we can chat in relatively plain English.

The Origin Of The D&X Procedure

For starters, let’s point out that none of these procedures are possible without dilation of the cervix. This is usually done by inserting several pieces of dried seaweed into the cervical os, which over the next day or two will soak up fluid and expand, dilating the cervix to allow the doctor access to the uterine cavity. This is a notoriously erratic procedure, and the amount of dilation varies highly from woman to woman, depending on the tone of the surrounding muscle, the amount of fluid absorbed, and just about everything else in between.

Frankly, the easiest way to remove a fetus is simply to grab and pull. Since everything is still forming, pieces start coming off, and before you know it, you’ve dismembered the fetus in utero and everything is gone. Fetal parts get discarded in a dish, and mom wakes up minus one pregnancy. This is the basis of the D&E. The problem with this procedure is that occasionally pieces go missing, which can lead to infection and possibly death. It also means repeatedly introducing instruments into the uterus, which carries a risk of perforation, contamination, and infection. This leads us to…

… Dr. James McMahon, who in 1983 decided that there had to be a better way of doing things. He realized that occasionally (if the dilation went better than planned), a large part of the fetus will come out, leading less to an evacuation of fetal parts, and more of an extraction of the whole fetus. By pulling the baby through the dilated cervical canal feet-first, everything could be removed from the uterus with the exception of the head, which is the largest part. There are then several ways to reduce the size of the head, notably vacuum-suctioning the brains out, crushing with forceps, or poking holes with curved scissors. The fetus is then removed, whole, and again, the mother wakes up sans pregnancy. Safer, faster, fewer bad outcomes – now we have the D&X. All clear? Moving on to…

The 2003 Partial Birth Abortion Ban

I’m going to paraphrase and highlight the really important bits here.

Doctors cannot perform the D&X procedure on a living fetus unless mom will die without it, on penalty of jail & fines. –Congress

Simple enough?

The 2007 SCOTUS Ruling

Now this is where things get really interesting. Quite a number of states, patients, and doctors immediately sued to overturn the 2003 law on several grounds: that it was too vague, that it was unconstitutional, that it breaches the terms set out in Roe v. Wade – specifically that of undue burden. The Supreme Court decided to hear it. They debated, and on April 18, 2007, delivered the 5-4 landmark decision: in short, the ban stands.

Opinion of the Court
* * *
Respondents have not demonstrated that the Act, as a facial matter, is void for vagueness, or that it imposes an undue burden on a woman’s right to abortion based on its overbreadth or lack of a health exception. For these reasons the judgments of the Courts of Appeals for the Eighth and Ninth Circuits are reversed.

It is so ordered.

This all being said, there is some very interesting language in the preceding 45 pages of the opinion.

What It Explicitly States

For starters, if the doctor’s INTENT is to perform a D&E – that is to say, removal of the fetus in parts – but the cervix is dilated enough to allow the whole fetus to come out, the ruling states this is expressly legal (and is termed in the opinion an “accidental D&X”). This extends as well to D&E’s that procedurally turn into D&X. Secondly, a huge amount of the discussion centers around what is meant by “living fetus” as it pertains to the law. Specifically, injecting potassium before performing the D&X- thereby killing it before the procedure – is also legal. Lastly, a distinction is made expressly condoning the practice of routine D&E.

What It Means

D&X is still a valid medical procedure, provided that the fetus is already dead – which means killing the fetus beforehand in any way completely circumvents the ruling. Therefore, a very minor change is required by medical staff providing such abortions. Obviously there’s more to it than that- but since the mother usually needs to come in a day beforehand for the cervical dilation, on the surface this is a relatively simple thing to do.

Of course, the scathing dissent written by Justice Ginsburg brings up several important points. Why does the law single out D&X? What makes this procedure so much more inherently gruesome than, say, dismembering a fetus limb by limb in the original D&E procedure? How is this anything other than a veiled attempt to decrease access to abortions? Furthermore, what right do politicians have to interfere with a doctor’s choice of which procedure to perform, especially when D&X is demonstrably safer for the mother? Certainly political meddling was widely condemned during the Terry Schiavo fiasco.

My Own Personal Opinion

I don’t think this is going to change the practice of abortion in a substantial way. As of today, standard medical practice for a D&X will be preceded by a lethal injection to the fetus, making it as legal as it was yesterday. Hopefully no maternal deaths will occur from the deadly cocktail leaking back out into mom’s bloodstream. Planned Parenthood will distribute information to every OB/GYN and family doctor who provides abortion, informing them of the continued legality of the procedure. On the plus side, euthanasia of the fetus is now required before performing a D&X (though, I think this is more a side effect of the law than the intended outcome).

So to me, this ruling bears the question: exactly what was the point? If nothing has changed but a slight procedural variation, how is this anything other than a political message?

I hope this was informative for you all. Please take note- I’m not a lawyer, so get my facts checked if you’re going to use any of my arguments in a legal sense.

References:
The ruling itself, along with opinions and dissent.
The original 2003 Partial Birth Abortion law.
Dr. Tiller’s late-term abortion for fetal anomaly statistics.
A first hand account of partial birth abortion for spina bifida.

I got an email back from the woman with the Right To Life group today. Unfortunately it was neither filled with inflammatory invective (fun to argue!), nor well written and convincing (worth my time!). If it were a breakfast food, it’d be that soggy bowl of cereal that you really don’t want to eat but you’re hungry, dammit! Try to imagine the most vapid, worthless email you’ve ever gotten… and then add some misspellings and grammar errors. That’s what it was.

What I will say is that she’s doing an extremely good job of convincing me that your average pro-choicer is more intelligent, well-read, thoughtful, and compassionate than she is. And she’s the head of the entire state-wide pro-life organization.

Zing! I just dissed her entire pyramid scheme! I’ll keep you posted, loyal readers.

Alright folks, in anticipation of hitting the wards in less than 3 months, it’s time to start racking my brain about what I want to do with my life. We’ll start with my big no’s first- it’s easier to rule out than in.

Aww hellz no!

Pathology:

The good: Amazing hours. Get techie enough and you could probably even work at home while sipping lattes from your own personal espresso machine. Zero malpractice.
The bad: Much as holding rotten, gangrenous penises gets me going, I’m going to pass on this one. Zero patient contact, zero procedures (autopsies / CSI:Miami excepted).
The ugly: See “rotten penis” above.

Radiology:

The good: Nifty images, lots of diagnoses to be made, great hours, good pay.
The bad: No patients, except on screen. Could quickly move to “good” category as I actually start seeing patients.
The ugly: Sitting in a dark room all day and slowly developing a thirst for human blood.

General Surgery:

The good: Cutting people open and not getting arrested for it. Boy’s club.
The bad: Angry coworkers, gunner med students (you know who you are), overworked attendings, shitty hours, bad pay, high malpractice …
The ugly: All of the above, combined with a sheer lack of sleep and the realization that your life is the definition of misery.

General Peds:

The good: Cute, cute kids. Adorably cute. It makes you want to pinch their cheeks… which you are fully within rights to do as a “diagnostic test”.
The bad: 2 seasons: Physical Exam season (AKA the ol’ grab ‘n cough) and ‘Flu season (AKA eat some chicken soup, you’ll be fine).
The ugly: Parents who Nair their babies.

Vascular/Cardiothoracic/Transplant Surgery:

The good: Ridiculous pay (mostly). The knowledge that you can out-asshole anybody you’ll ever meet.
The bad: Hours that make God look like a slacker for taking 6 whole days.
The ugly: See “out-asshole”.

Psychiatry:

The good: Comfy couches, finally a use for Aunt Myrtle’s knitted sweaters.
The bad: Developing a googly-eyed stare (please, tell me more!).
The ugly: Psychoanalyzing everyone you meet. Knowing you’re a shrink.

I could be swayed on:

OB/GYN:

The good: Delivering babies (joy!), being a primary care doc for the mother, seeing kids you’ve delivered in grocery stores, GYN surgery.
The bad: Malpractice/hours blow harder than almost any other specialty.
The ugly: Moms poop during delivery. Guess whose face is right up in there?

Orthopaedic Surgery:

The good: Seeing patients doubles as working out. Consulting for major sports teams means free skybox season tickets.
The bad: If you don’t watch sports, you’re way out of your league (ba-dum!)
The ugly: Hip replacements on 70-year-old women. Yikes.

Family Practice:

The good: You’re the definition of “doctor”, lots of continuity of care, huge variability in day-to-day routine.
The bad: Fine, if nobody else will, I’ll say it- you don’t make very much, and I really, really want a waterproof plasma TV in my shower.
The ugly: Dealing with specialists.

You have potential, young padawan…

Ophthalmology:

The good: Sharks + laser beams are finally a reality.
The bad: You look at eyes all day. Half your patient base is diabetic / hypertensive / both.
The ugly: Screw up and people go blind.

Internal Medicine:

The good: You have 3 years to figure out what you want to do, and most internal subspecialties are interesting and pay well.
The bad: Old people smell funny.
The ugly: Cultivating an unhealthy interest in shit, piss, and vomit.

Otolaryngology (ENT):

The good: Sooooo much cool stuff in Ear / Nose / Throat. Similar to ophtho in that the pay is insane and the possibilities after residency are endless.
The bad: I mean, you specialize in picking other people’s noses.
The ugly: Boogers were gross before. Now they’re infected and oozing everywhere and all over your hands and you can never get clean again no matter how hard you scrub AAAaaaaaaa……

Urology:

The good: Nifty toys, killer stories at cocktail parties (and future blogging!), hysterical coworkers.
The bad: You’re a pee doctor. People will always giggle behind your back for that.
The ugly: Rotten penises. Dammit! They’re EVERYWHERE!!!

Pediatric _______:

The good: Kids rule. Adding Pediatric + Anything would be kickass.
The bad: When you diagnose cancer, it’s in a kid. Suck.
The ugly: Parents.

Emergency Medicine:

The good: Dude, you’re an ER doc. As far as badasses go, you’re it (also on this list: trauma surgeons).
The bad: Shiftwork can be good or bad, depending on how you look at it.
The ugly: Drug seekers, being the primary care doc for anyone who can crawl in the door. There’s a lot more ugly in EM than most fields.

Dermatology:

The good: There’s a reason this field is hard to get into: lifestyle. Derm is the definition.
The bad: Seinfeld already made fun of you; it’s downhill from there.
The ugly: Oozy, weepy, pustular sores. Actually, I really like this kind of stuff… I wrote my application essay on how much fun it was to pop a perianal abscess.

I wish I could take the credit for this brilliant analogy, but I can’t.

CJD is just like the underpants gnomes*.

Step 1) ingest protein
Step 2) …
Step 3) profit!

Explanation:
Creutzfeld-Jakob Disease
South Park’s Underpants Gnomes

For more particularly interesting reading on prion diseases, how you get them, and why you should never, ever eat Haggis, see this and this.

*Before I get reamed for being crass and heartless, I should point out that this analogy is about our understanding of the disease process, and not what it’s like to get it.

There has been an awful lot of banter lately about big pharma and its massively deep pockets. There has been more banter about how we, as doctors, may effectively climb out of said comfortable, velvet-lined receptacles of ethical ambiguity. And, from the other side, banter about how really, its the physician’s personal responsibility to stay straight in a sea of crooked money. I might also add that there is a rather predictable lefty/righty leaning to the individuals sharing these points of view.

I’m not going to weigh in on the debate, because doing so would probably be rather middle-roadedly obnoxious of me, much like my last post (to which i have not yet gotten a response, might I add. Pro-life? More like Pro-crastination!) What I will say, however, is that I feel truly sorry for what happened in class today…

…which was that one person tried to fight a very unpopular battle against a particularly well-spoken professor. This blog has run afoul of said person before. Anyhow, I won’t say that I wasn’t part of the jeers, the malicious laughter, and the booing as she talked herself into a train wreck for the better part of 5 minutes, but I will say that I feel pretty guilty about the whole thing.

Must be losing my edge.

I’m sick of the abortion debate. I’m sick of it because pro-choicers are unapologetic and unwilling to face the reality that they are aborting a potential child. I’m sick of it because pro-lifers throw emotionally charged rhetoric and are so caught up in saving the life of the fetus that they ignore the life of the mother. Obviously this blanket statement isn’t true for everyone, but from the speakers we’ve heard, that’s exactly what you’d think.

The pro-life talk yesterday was horrible. I really, really wanted it to be good. I wanted it to present a coherent argument that called attention to the life of the unborn child. I wanted it to challenge my beliefs as an open-minded pro-choice future doctor. I think there is a huge potential for a dialogue between the pro-choicers and the pro-lifers, because honestly folks, each side has some really valid points.

Here’s my letter to her organization.

—

To whom it may concern-

I’m writing to express my disappointment with the presentation given by xxxx at the College of Medicine yesterday. A bipartisan group turned out to hear her speak, including representatives from both Medical Students For Life and Medical Students For Choice- as well as several students who have no affiliation at all.

I should first mention that I consider myself open-minded about the whole debate. I have never set foot in a planned parenthood, and I’m not sure that will change in the near future. I find the concept of an abortion repellant, though my medical training has convinced me that there are certainly times when it is, in fact, necessary. I truly believe that there is a lot that can be accomplished from an open dialogue between pro-choice and pro-life sides.

All this being said, the presentation given yesterday was an embarrassment to the pro-life cause. Among the reasons I feel this way:

• For every 300 doctors you can find who claim “there is never a medical reason to perform an abortion”, I guarantee I can find you more who disagree wholeheartedly with that statement.
• Claiming that planned parenthood “gives away the bottom 2 rated condoms as rated by Consumer Reports, and therefore is clearly trying to get women pregnant so planned parenthood can abort their unborn babies” is both slander and absolutely untrue. Nobody would ever be this inhumane and I couldn’t believe you would say such a thing.
• Hinting that pro-choice people are “terrorists” is a horrible thing to say. Furthermore, trying to link slavery, the death of Matthew Shepard, and the extermination of Jews in the holocaust to pro-choicers was particularly offensive, especially because if you strictly play odds on the political spectrum, those events are much more closely tied to the right wing.
• If you are going to make the argument that life begins at the meeting of sperm and egg and ANYTHING that destroys that baby after the union is tantamount to murder, please do not wholeheartedly endorse “removal of ectopic pregnancy” 5 minutes later “just because it isn’t viable”. That is a complete contradiction. Remember, you are talking to highly educated medical students, not impressionable high-schoolers.
• Whenever a pro-life point was given, every quote included all the “ums” and “ahs” to try to make them look stupid. It’s a minor point, but served very well to emphasize that there was no respect for anything other than your opinion.
• When asked not to use pro-abortion and pro-choice interchangeably, if you claim you “don’t recognize that rhetoric”, don’t turn around and say “partial birth abortion” instead of “intact D&E” to a group of medical students. Especially don’t claim that you don’t believe in using the medical term, because believe me, we certainly do. If pro-choice rhetoric isn’t valid, then neither should be that of pro-life.
• Abortion is, like any other medical procedure, potentially unsafe. That being said, statistically speaking, carrying a pregnancy to term is more dangerous, and therefore presenting abortion as a highly dangerous procedure with many side effects is incredibly misleading.

I firmly believe that the facts speak for themselves on both sides of this debate. When you resort to rhetoric and invective you lose any ability to have an open dialogue, and you certainly ruined a perfectly good opportunity to present a coherent argument arguing for the sanctity of life.

Thank you for your time,
Zac, MSII

Placing an IV is hard. Really, really hard. It’s even harder because every time you practice, you practice on real people, who experience real pain. Much like the pain that I was in today.

Today we had clinical skills practice, where we learned – ha! – how to draw blood, place IV’s, and give subcutaneous shots. Now, the subQ shots I can already do, because of all the kids vaccine stuff last year. But the IV’s are really, really difficult. Lets see if we† can’t give you a feel for it.

So you’re looking at someone’s hand. The vein is bulging out, thanks to the tourniquet you’ve so expertly placed. That was the easy part. Needle in your right hand, vein trapped under the thumb of your left. In passing, you realize that you’re about to drive a sharp needle directly through someone else’s skin, at a vein that is so distended and huge it looks like it’s laughing at you.

You poke. The vein, like a greased-up hog at a redneck barbeque, dodges. You start rooting around, hoping to see the flash of blood that will tell you your needle is in. None comes. Pain is written all over your victim’s face. Tissue is swelling. You have no idea where the vein is in relation to your needle. It could be up, down, left, right, and you would never know. It’s like a drunk guy with a blindfold trying to hit a pinata.

Meanwhile you know full well that if you push too far in, your needle will pierce muscle, fascia – or worse, nerve – and the pain they’re in now will be dwarfed in comparison. So you carefully tool around for a few more seconds, ripping up more tissue as you do. Then you pull out, discouraged, and silently curse your stubby fingers.

And that, friends, is what it’s like to learn how to perform a medical procedure.
Tomorrow: NG tubes.

†the royal we…

If you’re a fellow meddie and like radiology images – and, lets be real folks, who doesn’t – you’ll really enjoy this. My good friend Lyle (loyal reader, friend of the show) sent it to me a few weeks ago and I can’t get enough.

Radiology Picture of the Day