Thursday, June 15, 2017

Cholera isn't the Plague

There is a scene in the Italian movie about St. Guiseppe Moscati that gives a good image for the Catholic bioethicist.

We know that St. Guiseppe had a role in addressing the 1911 cholera epidemic in Naples. His research prompted him to make public health recommendations to prevent its spread. In the movie, this is summarized dramatically in one scene. The saint finds city officials burning the furniture and belongings of cholera victims in order to stop the spread of disease.

St. Guiseppe commands that they stop, insisting that cholera isn't the same as the plague. (Cholera is spread by fecal-oral transmission, and is therefore much less contagious than diseases droplet or airborne vectors.) The solution to the cholera epidemic was hygiene and effective plumbing, not quarantine and destruction.

I think of this scene when I am considering bioethical issues. Many theology teachers cautioned me never to think about practical ethics in terms of what I could get away with. Others reminded me not to conclude that we should stay far away from anything possibly problematic. The first approach is irresponsible; the second, Pharisaical.

I try to take St. Giuseppe's approach. His research into the true nature of things permitted him to see what he and others ought to do. That way, he could place legitimate restrictions on people while also freeing them from unnecessary burdens.

Tuesday, May 30, 2017

I post these when I put something through peer review, partially to celebrate but partially to explain why the current blog content might not have been as stimulating. Praise God!

Monday, May 15, 2017

A Plea for SSPX

My coworkers are primarily practical atheists. But even most of my Catholic friends find it hard to get all the Catholic culture right. Not everyone can keep FSSP and SSPX straight, or Miles Christi and Regnum Christi separate. I guess I should be glad they have heard of Dominicans. There are few that know about Carmelites.

Honestly, there is a spectrum of knowledge of Catholic gossip. A few of the retired virgins I know seem to be familiar with every bishop, cardinal, church scandal and church document, and they will remark on what each one has said about each other one. Honestly, I don't know what Cardinal Sarah said last Tuesday or that such-and-such did an irregular thing and now has such-and-such canonical status. Not that it's bad to care about these things. The Church is the way to salvation and the mother of souls. Of course Church happenings matter. But I don't keep track of a lot of them.

However, there is something that is near to my heart. I love the extraordinary form. Irreverent and ill-prepared liturgies make me sad and angry. I have had classmates and coworkers in SSPX. So for my part, I would love for SSPX to come back into complete union with the larger Roman Rite. Please, please help the rest of your brethren understand the majesty of the Eucharist. Please spread the patrimony of the ages built into the 1962 Missal. Breathe into us your love for chant, your attentiveness to God, and your awareness of the differences between women and men and children. It's more important than we can comprehend.

Sunday, April 30, 2017

Eleven Cents

I am struggling with a frustrating reality: a person hoping to do research to build up the culture of life has to do twice as much work as a person who hopes to do amoral clinical research. Becoming a clinician-scientist is hard enough. They have to see enough patients, do enough surgery (when applicable), and earn enough grant money to make their institution value them. This means they have to stay on top of their clinical game. And like it or not, this usually means they have to choose result- and revenue-generating research topics.

Becoming an academic physician who also builds up the humanity of the unborn or builds up the science behind FABMs is even harder. Those topics don't make money and don't make friends, so these people either can't overtly do this research (i.e. they have to cloak it as MIGS or MFM) or they have to do amoral popular research in parallel. In my limited experience of successful pro-culture-of-life physicians, there is a proportion involved: the more pro-life/pro-family research you do, the more amoral research you do. The more you cloak your pro-life/pro-family research, the less you have to lead two lives to put bread on the table.

This initially made me very frustrated. Why should I have to do twice as much work as other people in order to do the research I care about? In this age of non-discrimination, why should I be effectively treated differently because of my beliefs? Of course, I realize that I'm not alone. I'm sure there are hundreds of MDs and PhDs who have pet topics that are non-fundable because they are too obscure, too unstudied, or not flashy enough to earn grants. But still! This is different. Want to do research that builds up humanity and saves the world? Tough luck.

This makes me think of a story from my childhood. I was at a big family reunion as an early teen. I have a lot of cousins that span almost two decades in age, and we were all at the pool. There was a wading pool for the little cousins and a regular pool for the "big kids." Most of the kids who could swim were in the big kid pool. Then the reunion held an event: all the adults tossed coins into the pool and the kids could keep any that they picked up.

The competition in the "big kid" pool was fierce! I was bumping into people and the coins I was diving for would get picked up by someone else. I think I ended up with a penny and two nickels. I was actually pretty pleased with myself.

I was pleased, that is, until I went over to my dad, who was with my younger sister by the wading pool. My younger sister was with the little kids and had collected almost a dollar, just by bending over and picking up coins. She hadn't even gotten her face wet. I was so angry! I worked so hard to get eleven cents and my younger sister, who had no appreciation for money anyway, had easily collected almost ten times what I got! And I hadn't even realized that the wading pool was an option. My pleasure turned into hurt.

My dad took the chance to teach me something I have thought about several times since then. "There will always be people who get eleven cents with lots of work and people who get dollars without doing much," he said. Later in life, he would add, "We're called to be faithful, not successful." So I'll try to apply this attitude to work. I will do what I can to pursue my calling faithfully.

Saturday, April 15, 2017

Stories from Vacation: Bedbugs

This post conforms to the blog rules.I have encountered bedbugs before. But I have never encountered bedbugs in my next door neighbor's apartment. My next door neighbor is a retired policeman my grandfather's age. When I first moved in he gave me a new microwave oven, a re-gift he didn't need. I picked it up and as I was leaving with it, I noticed a semi-automatic rifle mounted on the back of the front door. "That's in case some guy I sent to prison comes knocking," he said.

"Ah," I replied, not sure what else to say. Was my neighbor paranoid?

"No, I mean it," my neighbor said. "There one particular guy who sent me letters and called me telling me he's coming for me now that he's out of prison."

"Sir, do you tell all your neighbors these things?"

"Well, I guess not," he mumbled. "Well anyway, I'm pretty sure it's not gonna happen but it'd be a good story if it did."

Img credit: houstondwiPhotos mp
My neighbor was full of stories. "My step-son," he'd grumble, "was a disaster as a kid. He'd get drunk and get into fights and do drugs. I was always afraid that me and my wife were gonna get the call that he was dead. One time--" he started to laugh, "one time he called me, you know, once there were cell phones. He called me from the bathroom of a bar and said, 'Dad, come get me. I'm in this stall and the whole rest of the bar is out there ready to kill me.' I was in favor of him getting in trouble. His mom wanted me to go get him. She said 'He'll be arrested, and then he'll have a record.' And that gave me an idea. So I said, 'All right, son.' I got on my uniform and got my gun and a pair of handcuffs and went to the bar. Sure enough, there was a riled-up crowd shouting for him to come out and trying to bang in the door. Poor bouncers. I moved through them and banged a little myself. I shouted, 'You're under arrest!' And I put handcuffs on him, the works. We left and I took 'em off in the car and we went home. I hung up my uniform and he went to bed. Everyone was happy."

I thought my neighbor was hilarious. I would bake bread for him occasionally and I took him to Mass once or twice. He gave me a tablecloth and an end table, and he made mechanic recommendations. We'd see each other as I went to and from work and make small talk. I knew that he helped the others, too.

Then I learned he'd been diagnosed with cancer, but couldn't be debulked because of his coronary artery disease. He had a combined triple CABG and cancer surgery. He came home in a wheelchair with an incision as long as my arm. Home health visited three times a day. I went to see him and found out that he had bedbugs. First, he told me the fact. "Thanks for comin' over," he said. "Don't mind the exterminator who'll be here in a bit."

"You're brave," commented his step-son, who dropped in to bring groceries in the middle of my visit. "When I visit him, I sit on a wood chair."

I soon learned why. I flicked away no fewer than five bugs of at least two different species (or different life cycle stages?) while I was sitting on his living room couch. It was tricky to be cordial and let him decide when the visit was over! He was clearly bored and wanted some company, and my visit lasted three hours. As I walked to my door when I finished, I vowed that I was going to wash every thread I wore with steaming water and dry it on super hot. As I was taking off my hoodie, I saw and crushed a blood-filled bug.

Img credit hiroo yamagata
Luckily, after that there were no signs of bedbugs in my apartment. Then a few days later, I noticed that the hand sanitizer at our secondary hospital really bothered my hands. I was itching like crazy. As I was driving home, I realized it wasn't the hand sanitizer. I had several discrete red bumps on my hands. "Oh good, it's just bug bites," I thought, "I can still use the sanitiz--OH NO. I HAVE BEDBUGS." I immediately called my apartment manager and he sent a home debugging bottle, complete with personal spray wand for the tough-to-reach spots.

I don't think I ever had bedbugs, though.  I got those bites just sitting with my neighbor. Happily, he's now bedbug free, too. Please pray for him as he recovers. Pray especially for his return to Christ and his conversion.

Thursday, March 30, 2017

Baptizing Daughters (Hope for Heather)

This post conforms to the blog rules.I waited a long time to tell this story because I didn't want to change many details. What follows is an accurate but anonymized version of my two encounters with "Heather."

The other day I was in clinic and a young teenager (think junior high or early high school) came in for her new OB visit. She was there with her "mother," but the mother was probably fifty years older than the patient, and she was of a different race. I don't know why that was--perhaps this was a grandmother or a foster-mother--but I didn't ask. This is how I met "Heather" and her mom.

Heather was in her late first trimester and pregnant with twins. When I saw her in our MFM clinic, she had just had been told from an ultrasound that she had two daughters and that they were monochorionic/diamniotic, meaning that they were at risk for twin-to-twin transfusion syndrome. They were at risk for a lot else, but TTTS is what most of our initial conversation was about. Heather had not planned this pregnancy and she had thought about abortion, but her mom talked her out of it. Heather herself really wanted the babies now. Her boyfriend was not in the picture. Heather told me in the presence of her mom that she had experimented with cocaine. But she was obviously tough. She had accepted the fact that she would be pregnant at school and finish a year late. She was clear on her new policy about drugs and sex: "One giant nope." This made me hopeful for her.

Heather's mom was suffering, but it was almost imperceptible. She was clearly not the type that engaged in drugs or sex at such a young age. Her hair was grey, she was plump, she wore grandma shoes and pastel pants, and she had perfect grammar. (In fact, she was eerily like one of my apartment neighbors, who is a nun.) I could tell that Heather's mom was working hard to accept Heather and her choices, but that those choices were very far from what she wanted for her daughter. She was never openly disappointed with Heather during our visit, and asked many helpful questions to support her daughter during the beginning of pregnancy. This made me even more hopeful for Heather.

I tried to cover basic obstetrics and adjusted it for an adolescent, mentioning by requirement that Heather was legally the one to make the decisions about her pregnancy, any birth control, and her daughters' care. I closed my visit with Heather cordially, planning ahead for six months of careful TTTS screening in addition to routine prenatal care. Our MFM clinic is not a continuity clinic (super bummer), so I did not expect to see her again.

A few weeks later, I was working labor and delivery and the upper level resident was in a C-section with the L&D intern. I was sitting at the L&D desk in her stead. The details of this next part of the story are fuzzy because there were about eight phone calls/conversations about how Heather should come to L&D and how she was asking for me by name.

The charge nurse called me over and simultaneously, my zone phone rang. On the phone was the triage intern. "The ER is sending up are seventeen-week twins, apparently super uncomfortable." The charge nurse, meanwhile, wanted to ask me whether the seventeen-week twins in the ER should come right to L&D. I said to start them in triage. Then the triage RN called the charge nurse and asked that I come to triage. The charge nurse was in the middle of asking me to go over, explaining that they knew me by name, when the intern called me again. "I'm sending this seventeen-weeker over, she's five centimeters. She's also...asking for you?"

Readers probably know that a woman in labor near term has to dilate to 10 centimeters. You might not know that tinier babies don't need 10 centimeters of dilation. Seventeen week twins would certainly and easily fall out of a five centimeter cervix.

Heather was given the room next to the statue of Mary. Mary is at the end of the L&D hall and those rooms are the quietest and frequently used for women losing children.

Heather was having a very difficult time due to pain. She also didn't know what labor at seventeen weeks meant! She had texted friends to come visit her because she was having her babies. They were all excited. She asked to get some pain medicine before they arrived.

When I heard this, I started her pain control and then explained to her that her daughters would die today after they were born, unless they had already died in her womb. She was in shock and this did not appear to faze her, but she at least registered it. Now she was on emotional overload, with confusion, mixed sadness and relief (now she would be able to finish high school without maternity leave).

I prayed that her daughters could be born alive for baptism. I delivered her first daughter alive. I asked her if she would like the baby to be baptized before she died. "I don't know," she said, "I've been thinking about that. But my mom's Catholic, and she wanted it."

I knew this little daughter had very little time on earth, but I also knew about the validity of sacramental baptism. "Heather, this is your daughter. You must ask for baptism."

After a small pause, Heather said, "all right then. Can we baptize her?"

The nurse had called the chaplain, but sometimes they take forever to come. They don't realize the urgency of the matter and come after reviewing the mother's chart. Often, I think they don't see the difference between baptism and blessing the baby's body. Frequently, they see their job as more of a crisis emotional counselor. So I called for sterile water (and yes, I did say the word "stat").

I asked Heather what the little girl's name was. She had already picked out first and middle names for both daughters. The nurse handed me a bottle of sterile water. I poured a little water into the bottle cap, mentally making sure I knew the words to say for a conditional baptism, in the case that the baby showed no signs of life by the time I turned around. I touched the baby and noticed that she recoiled, so I baptized her with the formula for living people. Shortly thereafter, the second daughter was born, and I baptized her as well. (Between baptisms, Heather's high school friends came to visit and I sent them packing to the waiting room.)

The chaplain arrived after everything was over. I pronounced Heather's daughters dead that day and filled out two birth certificates and two death certificates. But I know there were two saints praying for their young mother. I prayed to them immediately after their deaths, and I still pray to them every once in a while. I have not seen or heard from Heather since I discharged her postpartum day two. But in a tiny way, these are my spiritual daughters, so I talk with them to keep in touch with their other mother.

There are two saints praying for Heather. Strangely, I am very hopeful for her now.

Wednesday, March 15, 2017

I post these when something gets through peer review. This is primarily to celebrate that I'm happy and secondarily to explain to readers why there might have been a dearth of recent quality posts. :)

Tuesday, February 28, 2017

Most emotional delivery of my life

This post conforms to the blog rules.I was recently in a delivery with an attending and the baby was extremely stressed out and had failed an operative delivery. We went back for a C-section. We ended up doing a "red" (emergent) C-section even though heart tones weren't down in the OR, because the mother started to have a seizure. Between her tonic-clonic activity and the baby's profound asynclitism, molding, and caput, it was the hardest C-section I've ever done. I couldn't get the baby's head out, so my attending tried. She couldn't, so I tried. I couldn't, so she tried again. Everyone was screaming. And meanwhile, because it was a red section, the room was in chaos. My chief was pushing from below and another attending was called. The original attending couldn't get it out, and I tried one more desperate time (all the while screaming for a Murless) and got it out.

It looked dead, but it had a good one-minute Apgar. It's doing fine now, and so is mom. I spent the rest of the C-section crying, though, because I thought the baby was dead. Five minutes feels like so much longer when your brain is screaming, "the kid's heart rate is slow, the kid is dying!" And that baby was more limp than any other baby I've seen.

Except, perhaps, for the vaginal breech I did the other month. That was awesome.

All's well that ends well, but that C-section was the worst delivery I've ever been in. Please pray for me. The 19-day streak that I mentioned at the end of the last post turned into a 26-day streak followed by one weekend and another 24-day streak. I am so tired!

Wednesday, February 15, 2017

Seven Quick Takes

This post conforms to the blog rules.It's been quite some time since I did seven quick takes, a blogging/sharing technique created by Jen Fulwiler in the peak of her blogging days. (It's a cheap way to write a quick post when you're studying for CREOGs.)

I have begun to realize that unity among pro-lifers is harder than I thought. I went to a huge benefit dinner for a (very successful) evangelical pro-life group, and I had to will myself to keep smiling. There was so much talk about how God would save America and how America was going to become great. There was so much talk about proselytism. As a Catholic, I know that God promised His Church would survive, not that my decadent country would survive. And I'm around to evangelize by example, not by discussing acceptance of the Lord with women in crisis. 

But I don't have to love everyone's tactics. Pro-life needs unity.

Speaking of unity, Christian unity would be great for the culture, too. I've mentioned before that a lecturer I had in med school defended the LGBTQ community (awkwardly, and not to the enjoyment of the LGBTQ in the audience) by pointing to Christian disunity. He was attempting to explain how LGBTQ Christians should be comfortable with Leviticus, and expansively pointed to the number of denominations there are. The bible means whatever you want! 

At this point I'd settle for SSPX or the Orthodox Church coming into whatever communion with the Roman Catholics as is possible.

Here's something to help Christian unity: pray for an increase in your desire for Christian unity. Pray that the disunity will start to be painful to you, rather than just a bummer fact. Schedule this prayer for every time you pass a church of another denomination. Simply pray as you drive: "Lord, unite us."

Are there any college students or PhD candidates reading? I would like a Catholic PhD so that I can fund bench research in mitochondrial replacement, methotrexate mechanism of action investigation, naprotechnology basics, and ectopic rescue. This is a big call--tell friends and relatives I'm looking.

I have several friends who are rapidly becoming more and more accusatory of the Pope. We don't owe him affection, guys! We owe him filial obedience in matters of faith and morals. In the middle ages and renaissance the papacy was super messed up, but Catholics like St. Hildegard, St. Catherine and St. Joan continued to respect it supremely. They respected it because they worshipped Christ and trusted in His decision to establish the office. Let's do the same.

Speaking of Pope Francis, there was a break-out session at the CMA conference about his theology. According to the presenter, his work is a type of Christian personalism, a theology of encounter. Authentic encounter leads to renewal of life and joy, in the pope's view, and a God-given mission follows on this renewal. The Christian mission is always one of mercy, the pope has said, and everyone is called to this mission of mercy. 

Moreover, the pope emphasizes frequently that the privileged starting place for our evangelical mission is with the poor. This is because the mission is modeled on Jesus, the "man for others," and thus will entail suffering as we accompany others into the Father's arms. This break-out session was largely drawn from Evangelii Gaudium, but much of Pope Francis' other work echoes these themes.

I started cantoring at my parish a few months ago. I haven't cantored since middle school, and have been saddened by the weakness and loss of range in my voice since residency. My parish desperately needed cantors, so I volunteered.

I was shocked at how much stage fright I've developed! I can do a crash C-section fearlessly but I'm shaking while singing the Ave Maria that I sung at age ten in front of a packed church? It shows me a well of timidity (a form of pride) that I didn't know I had. I've been trying to care less and less about "human testimony" (Jn 5:34), and this is another chance to do that. Plus, it definitely confirms that I am an alto. I tried so hard to be a soprano as a kid, and now there's no doubt left.

I had a wonderful, consoling, productive vacation. This makes me want to be a better doctor, but it also makes me want a calmer schedule. In particular, it makes me dread my upcoming 19-day run without a golden weekend. Say a prayer!

Monday, January 30, 2017

Uterine Rupture

This post conforms to the blog rules.
The other day I was scrubbed to do an orange repeat C-section (urgent, not scheduled but not a life-or-death emergency). The patient had a history of two C-sections and was in spontaneous labor. Women aren't supposed to go into labor with two cesarean scars: their risk of uterine rupture (breaking open their cesarean scar while they contract) is too high to be generally accepted.

I stood next to the patient on the OR table as the sterile prep solution dried on her abdomen, before I covered her with a sterile drape and began the surgery. Opposite me was my chief resident and the MFM fellow, also both scrubbed. The attending was standing next to the door, not scrubbed, on the phone. I have no idea where the sub-intern was, but she wasn't ready yet.

Suddenly the fellow pointed to the patient's abdomen as a very dramatic fetal movement changed the contour of her pregnant belly. Her water suddenly broke all over the table. "Well," said the attending, "now we have to move faster."

"I'm worried she ruptured her uterus," the fellow said under his breath, as he walked up to the table.

I draped the patient and the fellow and I put our hands on the uterus. "I can feel baby with a lot of definition," I said. I could feel little elbows way too well, as if there weren't enough layers between me and the baby.

"Go stat," the attending said. The C-section priority changed from orange to red, and in a moment I had my hand in the patient, fishing for a fetal head without having to cut any uterus. It was clear: she had ruptured her uterus. I felt the head in her pelvis and started to lift it up. The moment I did, the baby swam away and then all I felt was buttocks. I extracted the baby breech, and then I got a chance to look at the uterus. She had broken open her old scars.

I've never seen a uterine rupture, I've never seen it happen right in front of my face, and I've never had a baby who had room (and cheek!) to swim away from me during a delivery. Wow! Baby and mom were fine.

Sunday, January 15, 2017

Suffering and Joy in Catholic Medicine (CMA Conference)

I went to the CMA conference last October and spent most of the time with my poster and networking with people. I was late to almost every talk! There was lots to take away, but there were also things missing.

From Ashley Fernades' talk before the first panel began, I took away that not all hard days are bad days. The idea that suffering and joy are not mutually exclusive is still hard for me to integrate with my life. When I am exhausted, I have no energy to be happy. My reason accepts that happiness and joy are not the same, but when there is no reason for satisfaction besides God it is rather hard for me, a sinner, to be joyful. Dr. Fernandes made it a point to say, on day one of the conference, that joy is a choice made each day.

Bishop Conley drilled this further. Joy seems like hard work, he said, but it is possible with Christ. He can work a total transformation in us. Our entire lives must be missionary joy, it's an unshirkable responsibility. This doesn't have to be overwhelming, the Bishop said. This is cor ad cor missionary work--one heart to one heart at a time.

Michael Aquilina spoke on the emergence of the hospital, which paralleled the rise of Christianity. Mr. Aquilina observed that there were resources for hospitals in the ancient world, but the hospital only came about once a religion that valued solidarity, charity, human dignity, and the redemptive value of suffering became legal. He asked a rather chilling question: will the hospital survive in a post-Christian world? I think it's already gone in most ways. The hospital now is a cog in healthcare and research systems, embedded with lots of bureaucracy for the purpose of payment and prestige. Of course, as long as there is illness and as long as there are charitable caregivers, there will be that spirit of merciful care of the sick. But the hospitals of St. Basil, St. Pio, and even St. Theresa of Calcutta are not the ones that western doctors work in now.

Then came the practical advice of John Travaline, a physician and deacon who spoke about practicing like a real Catholic. He stressed the importance of seeing opportunities to restore human dignity to those with diminished personhood, to look for chances to be present to others (e.g. don't double book, imagine the workplace as a holy place, make your office accessible). He stressed that wounds are a sign of God's presence, chances to participate in Christ's restoration of man.

Finally, Dr. Greg Burke reviewed a sample examination of conscience for physicians. Several things were relevant to this theme of missionary suffering and joy. Am I ashamed of my Catholic identity? Am I plagued by guilt without sin (blamed or self-blaming for a case when you acted according to your conscience)? He reminded his audience that it is humanly impossible to know everything. "Don't beat yourself up for being human," Dr. Burke said. Strive to become more and more a saint instead, consult appropriately, avoid scurrilous conversation, and don't worry about the messiness of how it plays out.

All these men encouraged attendees: find in medicine a chance to become Christlike. It was a great message.

This post wouldn't be complete if it ended without my personal reflections on going to the conference. Perhaps this is because I'm used to the breakneck pace of residency, but I found the conference a little slow and a little repetitive. For the first time I was frustrated with the CMA for ignoring a few elephants in the room. Why wasn't anyone talking about NPT and evidence-based gynecology? Why wasn't anyone talking about virtue-based pediatrics? The conference was refreshing because it was more anecdotal and had a looser schedule (very effective for burnout prevention), but I was still hungry for more at the end. Going through the talks again was helpful, but I wish there was more original research and open discussion at these conferences.