Two Dimensional

It was a busy clinic day: patients scheduled every 15 minutes, serveral in-office procedures, and one of the medical assistants out for the day. I was shadowing, and wishing that (in all the hustle and bustle) I could be more like other shadows: two-dimensional.

I slid into the exam room for one of the procedures and plastered myself against the wall behind the doctor and the medical assistant, who was needed to prepare sterile instrument trays and specimen cups. The patient was from the local prison--not only was she wearing the typical uniform, but there was also a female prison officer in the room, facing the wall.

Almost as soon as the physician looked at the lesion she decided she needed an additional piece of equipment, so she and the medical assistant left the room, in order to find the suitable piece. I was left alone with the patient and her escort.

Patients from the prison are generally indistinguishable from others except by their uniforms, escorts, and a vague atmosphere of army-like obedience and frankness. This patient's face was weathered, her affect strangely smoothed as if by constant tumble with roughness. I couldn't tell what she really like, the prison-aura was so pervasive.

But she was slighly nervous about the procedure, so it was important that (in the awkward time during which the doctor fetched the right biopsy punch, or whatever) I make her feel at ease. I struck up a conversation. (This is much easier to do with a patient than with other people, for some reason.)

First Year of War (or, The Old Testament Makes Sense)

As of last Thursday, I have officially lived in one place for twelve consecutive months (a feat I have not accomplished since high school).

More importantly, it has been twelve months since I began to pray the Liturgy of the Hours. I have been amazed by how relevant each day's prayers can be; by how well-suited the Ordinary is to the way my mind works; by how poetic the psalms and the Old Testament are; by how good God is.

I have a friend who tells me that the Old Testament "doesn't make jack for sense." Maybe he is thinking of passages like Psalm 149, which sounds lovely:

Sing a new song to the Lord,
his praise in the assembly of the faithful...
For the Lord takes delight in his people.
He crowns the poor with salvation....

until it turns violent:

Let the praise of God be on their lips,
and a two-edged sword in their hand,
to deal out vengeance to the nations
and punishment on all the peoples;
to bind their kinds in chains
and their nobles in fetters of iron;
to carry out the sentence pre-ordained;
this honor is for all his faithful.

"Ugh," you might think. "God sounds disgusting; he unleashes his randomly-chosen favorites on everyone else, calls it an honor, and prizes it as if it's worship."

Lines and Highlights for the Icon

This is one of several posts on the process of painting an icon.
1 2 3.

When I set aside the icon of my guardian angel at the beginning of the summer, it looked very incomplete. In fact, the green undercoat to the face and hands looked strange, to say the least. It might look a little better now, that I've redrawn the lines and applied the first of three "highlights," applications of lighter-colored paint to add depth and color to the figure.


I read more of the Summa as I did. I was worried about repainting the lines: every time I have to re-do the face, I worry that it will look stupid and that I will have to look at a stupid face every time I look at the icon.

I continue to discover that the process of painting an icon exposes parts of my character or interior life, like my tendency to worry and my frugality to excess (hurry or the paint will dry and we don't need to waste any paint because it was expensive!!). It's tricky to try to focus on the person of my guardian angel, and not on the distracting stuff that constantly comes up.

</TMI> My plan for the icon's final colors is embarrassingly incomplete. When I began, I thought, "oh, I want the robe to be white in the end," but when I read more about the first highlight, which should be full-strength and very bright, I thought "uh...how's this going to work?" I have a long way to go in terms of technique.

The redrawing of lines is meant to represent order over chaos, as God separated and ordered parts of creation in the early days of the stories as a foundation for future creatures.

The highlight adds light to darkness, and stands for the lights we have by nature, like the powers of the soul (chiefly, the intellect).

And a final note: shadow is added not by application of dark paint, but by absence of light, just as sin enters creation not by action or existence, but by absence of good will and grace. (This is not to imply that my guardian angel or any holy person has sin, but the process of painting mirrors creation and part of the world that will appear on the last day, St. Augustine notes, are the shadows of sin.)

IUDs are Painful

IUD insertions are probably super common procedures for med students. But I guess I'm unique, because I'm in two particularly painful positions.

Position One

For the first three weeks I shadowed here, Dr. D didn't insert a single IUD. However, I knew she prescribed them because during the first few days she recommended one and we discussed it. Dr. D is pro-life; however, she read some research long ago that showed her IUDs don't carry a higher miscarriage rate than normal, healthy young women. Thus, she believes they are not abortafacient.

I searched for the article and I think I found it, but I can't be sure, since Dr. D only remembers that it was published about twenty years ago. I contacted the second author on a similar paper. This author wrote back:

Bottom Line: IUDs work by inhibiting sperm transport but all these methods have back up mechanisms, just like hormonal contraception - - interfering with implantation should ovulation / fertilization occur.

And am I the one to call this to Dr. D's attention? "Dr. D, you know you've been inserting abortafacients all these years, right?" Boy, would it strain a so-far pleasant mentor-mentee relationship. Is it my place? Is it my duty? I get a headache and a heartache just thinking about it. 

Position Two

I'm a Catholic and morally opposed to contraceptives whether or not they are abortafacient. Thus, I'm wearied watching all of my mentors prescribe, recommend, endorse, encourage, and expect contraception and perform sterilization.

This is not usually a problem when the contraceptives are pills, rings, patches, condoms, caps, implants, shots, etc because I am not capable of being involved. (The story was a little different when I used to work at a pharmacy and had to decline ringing people up for birth control.) However, as a medical student learning in small steps to participate in procedures, I am definitely vulnerable to participating in an IUD insertion.

Thus, if there hadn't been any IUD insertions during my externship, I could've avoided asserting my right to conscience. Alas! 'Twas not to be...

The Story

Just Stay until the Uterus is Out

The other day I scrubbed in three times. I put in three Foley catheters. I used eight pairs of sterile gloves. I sewed up three incisions. I watched an intubation. And I took out three uteruses.

Okay, so I didn't actually perform any hysterectomies; my preceptor is the only one licensed to do that. However, I was operating the uterine manipulator at the bedside while my preceptor worked at the da Vinci robot. And the person operating the uterine manipulator is the person who slides the uterus out once the hysterectomy is complete.

That it is pretty amazing for me. I have slowly moved into incrementally larger roles in the operating room: may I put in the Foley catheter in? I'll take that Vcare! Could you show me how to use the Rumi? And before I knew it, I was "delivering" a large uterus.

Admittedly, all these roles and jobs are very, very menial in the long run. It does not take a Ph.D. to obediently rotate a handle attached to a balloon in a uterus. However, it is cool to help, especially when the helping is as demonstrative as removing the organ in question. Let me tell you more about it.

Scrubbed in for the first time!

I'm shadowing Dr. D, a gynecologist, as part of the IBPCA preceptorship. I've worked with her for three days so far and I'm really enjoying her company. One of those days was her "surgery day" and I watched a BSO, a myomectomy, and part of an adhesiolysis. She did all three with the da Vinci robot. (That machine is pure 'wow.')

As a pre-medical student and a first-year medical student, I wore a cap and mask (you are not allowed into ORs without these). But I had to stand at least three feet away from everything blue when I watched surgeries.

If you've every seen an operating room, you know that most of the interesting stuff either is or is near something blue. So, I watched the screens and waited for the day when I could "scrub in." Scrubbing in is something third-year students learn to do at my school. I had heard there were prescribed methods of (literally) scrubbing each finger. Scrubbing in was apparently a ritual cleansing that would rival Deuteronomy. The caste of the scrubbed in wears gowns and gloves and are free to touch everything sterile (and nothing else).

Last week I was allowed to scrub in. The scrub sinks are deep, stainless-steel things that have foot pedals or other hooks and knobs so that personnel don't have to contaminate their hands by turning off the water or dispensing the soap.

Brush with nail pick.

Above the sinks are shelves of masks, face shields, beard covers (...), and individually-packaged scrub brushes. Mimicking everything Dr. D did, I tore one open and covered it liberally with soap that I dispensed with my foot. I turned on the water with my leg and dutifully scrubbed each finger and fingernail, and my arms up to the elbows. A rinse and *poof,* I was sterile. I backed my way through the OR door and a scrub tech tossed me a sterile towel. Then, she helped me gown and glove. The first thing I did with my hands was touch something blue. (I touched my own gown, because that's actually what you're supposed to do to help yourself avoid contamination.)

During the first procedure, I watched and "mmhm'd" a lot. Dr. D. quizzed me about the origins of the ovarian vessels. My anatomy professor would be agonized to hear that I forgot that the left ovarian vein (not the right, just the left) empties into the left renal vein. DARN IT!

Philly.com.

During the second procedure, however, I got to hold the camera! It was a difficult myomectomy and Dr. D needed two assistants, not just the one who was scheduled. As a result, I got promoted from "observer" to "menial task assistant" and held the camera, moving it as best I could to follow the tips of everyone's instruments and keeping the operative area in view. It was surprisingly hard, especially because the da Vinci camera, unlike other laparoscopy cameras, is a chunky piece of equipment. (The picture at right cuts off the top few inches of it.)

The experience was a mixture of cool and weird, like many first-things in my budding medical career. It was cool to be helping in a surgery; cool to be advancing; and cool to be "driving" the image on the laparoscopy screens. It was weird to be pivoting a camera on a stick in someone's abdominal wall.

However, since that action isn't morally wrong, I have no problem with getting over the weirdness and dwelling on the coolness of taking another step toward being a surgeon.

The Stuff I've been Knee-Deep in

So, you probably already know this, but there is a small explosion going on in the world of contraception. I am talking about 1flesh.org, the brainchild of BadCatholic's Marc Barnes plus (an apparently large) number of young adults. They've taken Janet Smith and added all the flippancy of the meme age. PP and Jezebel aren't happy. Excellent.

EDIT! I am also super excited about IuseNFP.com. I was thinking 1Flesh was getting a little negative and needed some positive "this is what NFP is" action, and the next day they linked IuseNFP.com. How perfect!


In other news, I am working on abstracts for the poster session of the CMA. One is about tubal surgery to open/heal fallopian tubes in women with tubal factor infertility. This is an ethical alternative to IVF and growing in popularity in mainstream gynecology because it can allow a pregnancy rate very close to IVF's. I'm super excited about this, because I'm discovering I love surgery and tuboplasty has long been a part of surgical naprotechnology.

I deferred my application to the Pope Paul VI institute's Medical Consultant program because of lots of commitments during this school year. However, I asked them to hold my application for two years, since I hear fourth-years have tons of time.

In the meantime, WYA is launching Fertility Education + Medical Management (FEMM), and with a weekend in New York this September, I might be able to become a FEMM teacher.

I've finished the opening work on my local Med Students for Life and CMA-SS websites (no, I won't be linking those) and I've put out emails so that people can review and offer to add content. Hope that works....

I made really tasty Jambalaya...I soaked and cooked red beans in water with onion powder and chicken bouillon, and there was just enough water from the beans to cook all the rice and shrimp. Admittedly, I used a mix, but I still felt like a chef.

School starts in three weeks. I have that familiar back-to-school feeling: May seems long ago, but at the same time it feels like yesterday.

Getting to Mass means Getting over my Appetites

On clinic days (which begin at 0900) I can go to the 0700 Mass; on surgery days (which begin at 0730), I go to the 1730 Mass.

It's so hard to leave each time! Dr. D normally has three cases each surgery day, and I always miss the second half of the third one because I leave for Mass. I especially loathe to miss the extra incisions I could close! Each surgery day, as 1700 ticks closer, my conscience and my appetites fight. "But daily Communion isn't required!" the appetites whine.

"We've been over this a thousand times," my conscience sighs, not exaggerating. "It is not required, but heroic. It is an act of love. It is the One you love and long to spend the rest of your life and the rest of eternity with."

"It would be rude to leave," my appetite said, trying again.

"We've spoken with Dr. D and explained that we have a previous committment. She has been fine with this and quite cordial. You are not a pivotal part of the surgical team."

"But what about suturing?" my appetites remind me. "It's so much fun, it's such good practice, and you're really good at it."

"Surely you don't think suturing is more important than God Incarnate deigning to descend unto us." my conscience says drily.

"Don't brush it off! It's gold stars for your Dean's Letter and the letter of recommendation that you're certainly getting out of this preceptorship. Plus it feels cool. You're all hatted and gloved and the assistant hands you a needle-driver and forceps and sponges like you're a surgeon! This is good. You're advancing."

"You're right; all of that is true. But we don't always do everything that is good, remember? Remember how we don't eat all the pudding we want?"

"Pwned" does not translate into Latin.

"Yeah...," admit the appetites. They still miss that pudding. "But," they grumble, "we don't get anything out of Communion...."

And now they've lost, because my conscience has intellectual guns that make all the appetities' swordplay useless. "Wrong!," my conscience booms, with the magnitude of St. Thomas. "The Sacrament of the Body of the Lord puts demons to flight, defends us against the incentives to vice, cleanses the soul from sin, quiets the anger of God, enlightens the understanding to know God, inflames the will and the affections with love of God, fills the memory with spiritual sweetness, confirms the entire person in good, frees us from eternal death, multiplies the merits of a good life, leads us to our everlasting home, and reanimates the body to eternal life!"

"Oh," my appetites say from the floor. "I guess we'll go, then."

"That's right."

Affordable Care

Obamacare was passed and deemed constitutional as a tax. I do not feel like political commentary today, however, and I just want to talk about healthcare and patients. This post is a lot of lists.

We have a problem in the first world. The problem is: healthcare has gotten very expensive. What would make care affordable? I posit that this is impossible without a change in mindset. The first world must re-learn a few things (I placed negative principles next to the positive counterparts and bolded what I though were the two:

1. Death and suffering are not the greatest evils (not even close).
   Rather, holiness is the greatest good.
2. Simplicity is a great means to the greatest good via the second greatest commandment.
   This means acquisition of wealth is not the greatest good, or the greatest means.

This is, simply stated, justice and righteousness. I'm asking for a lot, and it's not going to happen in every soul in the next twenty years. However, the more we realize these truths, the better off we will be. Just to give some examples of the potential effects:

1. Physicians' (and other providers') motives shift from moneymaking to taking care of patients.
2. Legal professionals' motives make the same shift (albeit to protection of justice) and medical malpractice insurance goes down, lowering fees for service.
3. Patients are less afraid of death and place an appropriately higher value on conservative (cheaper) treatment.
4. Anyone affected protects the sanctity of life (abortion is chosen as an alternative to a kind of death, or suffering).
5. Perspective reigns and people across borders are truly equalized: the phrase "first-world problem" is an embarassing testament to our lack of perspective. Although some medical problems are objectively distressing, some that are currently treated ($) could be tolerated if a mindset change occured.

Practical suggestions are almost futile without this large-scale change of heart, but here are a few:

1. Payment in kind to healthcare providers
2. Increase in charitable involvment in healthcare
3. Subsidiarity in healthcare insurance
4. Movement toward the master-apprentice model of medical education to decrease physician loans

The first steps to affect the change of heart in the medical professionals are probably:

1. Improve ethics training in medical education (improves physician's choices of medical procedures)
2. Improve bedside manner (improves patients' self-value and ability to make good choices for their health)
3. Protect the traditional family (health outcomes are vastly better when families are intact) including elder care as the population ages

I feel like God's calling me to a crusade....

Seeing the Invisible

Dr. D, my preceptor for the IBPCA program, is setting a good example in many ways. One example is her generosity in the groups of patients she sees. There is much brouhaha currently about physicians in private practice seeing Medicare and Medicaid patients. But I have never heard any discussion (from physicians, politicians, or mediamen) about two groups that Dr. D sees: prisoners and institutionalized, mentally retarded adults.

In two days Dr. D saw seven female inmates in between her everyday patients. She also saw two mentally handicapped adults coming from an institution with their caregivers. These patients require more paperwork, take up more waiting room space (for guards and caregivers), and are more medically complex. Moreover, she told me the prison has defrauded her of some thirty-odd thousand dollars, which she is successfully appealing for, bit by bit. Nevertheless, she serves these patients as carefully and attentively as she does her successful, healthy, PPO-insured patients.

I was edified, excited, and inspired by this. I want to do the same! I will add one more invisible group, not usually mentioned: consecrated people, e.g. priests and religious sisters. (I have wanted to be "the nun's doctor" for a long time.) Going forward, I will add inmates and the institutionalized to the convents--I want to be the doctor to the invisible.

Hands, Mantles, and Vocations

St. Teresa of Avila wrote,

Christ has no body but yours,
No hands, no feet on earth but yours,
Yours are the eyes with which He looks
Compassion on this world,
Yours are the feet with which He walks to do good,
Yours are the hands, with which He blesses all the world.
Yours are the hands, yours are the feet,
Yours are the eyes, you are his body.
Christ has no body now but yours,
No hands, no feet on earth but yours,
Yours are the eyes with which He looks
Compassion on this world,
Christ has no body now on earth but yours.

As I've moved along the journey to being a physician, I've often looked at my hands and marveled at what they have and will do. I am (almost) used to the strange permission persons grant to me with their bodies. As a hospital volunteer, I was allowed to change the diapers of total strangers; as a phlebotomist, people I'd never laid eyes on allowed me to insert needles into their arms; as a medical assistant, patients would tell me about their medical histories; as a premedical student, people allowed me to watch their encounters with their doctors; as a medical student, people allow me to examine them so that I can learn to discover fibrocystic changes in breast tissue and nodules in thyroid glands.

A doctor's knowledge and capability is bestowed on him in a series of thin mantles of study and experience. These mantles are invisible: they impress and are incorporated into our souls. And it is these mantles that I marvel at occasionally when I look at my hands. How God has clothed them with incredible graces, and how much more will come of what He has given already!

I received a remarkable mantle last semester as I learned to perform a physical exam in Clinical Skills class. However, my school teaches the male and female genital exams at the beginning of second year (about three months after the rest of the body). I was disappointed when I learned this, because I expected it would retard my experience in the preceptorship between first and second year. I thought, as a future OB/GYN, that it would be good to receive this mantle as quickly as possible.

God has His own timing. He put the learning off for a few months. However, last week, I received this mantle: I was permitted to perform a pelvic exam for the first time.

This layering of mantles isn't unique to medicine; all of life is like this, as we receive graces and our souls are shaped into the saints God has in mind. However, the changes in a student doctor are particularly demonstrable, and as I receive each permission (like [scrubbing] and [suturing]) I take notice and thank God.

All this language of receiving mantles reminds me of religious habits! My career closely resembles a religious vocation: a religious sister is visibly clothed because of her special relationship with God, I am invisibly clothed becaus of mine to patients; her habit changes as her vocation matures, as does mine; she restores God's image in souls as I do in bodies; she sets aside everything but Jesus by vows, while I set aside everything but patients by profession. Of course, I should probably say that my career is even more analogous to a married woman's: she doesn't always wear her wedding gown (as I don't always wear scrubs or a white coat), but she is invisibly changed by the intangible desires, vows, and actions that called her to marriage and keep her in it.

Medicine, marriage, and consecrated life...becoming a saint and doing God's will is so beautiful!

Tough Case 1

I met "Lisa" right before her surgery. She is not much older than I am. She was surrounded by her parents, her sister, and her young husband.

Her physician had seen something suspicious on an ultrasound, and so the procedure she was scheduled for was a "ovarian cystectomy, possible myomectomy, possible RSO." In other words, she could be in for a 45-minute removal of a cyst, a several-hour removal of a fibroid, or the loss of an ovary at a very young age.

In pre-op, the surgeon promised her that "in somebody so young" the ovary would only be taken out if it was absolutely necessary.

Once Lisa was moved to the OR, anesthetized, and prepped, the surgeon asked me to feel her mysterious mass. To my surprise, I could feel it (medical students usually aren't good at that). I didn't feel how large it was, but it was as hard as an uncooked potato.

The procedure began, and once the camera was placed in its trocar, the assistant raised Lisa's uterus and, with it, the mass. It was a fibroid, almost as big as the uterus itself, and attached at the uterotubal junction. The surgeon began making shallow cuts into it, and called for methyline blue, a dye.

A fibroid at the uterotubal junction is very bad news for a young woman. Fibroids are bad enough: they're painful and recur throughout life. But Lisa's fibroid was growing where her fallopian tube met her uterus, so it was possible that that tube was blocked, and very likely that this would be difficult surgery. I pictured her young husband and wondered whether they were planning a family. The surgeon was calling for dye to inject it into Lisa's uterus and see whether the affected tube was patent.

The surgeon kept cutting, and I mentally cried out, "Stop! Wait until the dye arrives."

I didn't speak because of the difference in status and personality between me and the surgeon. By the time the dye arrived, there was a decent-sized cauterized area. The dye entered Lisa's uterus and turned it a bright blue. But dye dribbled out of the cauterized area, indicating that the surgeon had cut into the uterotubal cavity while waiting for the dye. Beyond the fibroid, the affected tube was pink, indicating that it was not receiving any dye (either because it was blocked, or because dye was flowing out of the cauterized area before it reached the ampulla of the tube).

Worse, the opposite tube was likewise pink, indicating that it was also blocked.

Lisa was infertile, unless the diseased tube was still patent at some point along its length and was reattached to the uterus at the open uterotubal junction. This would be a time-consuming and technically demanding procedure. I expected (correctly) that this procedure would not be performed.

Thus, Lisa was infertile. The suddenness of the discovery shocked me. Infertility is something that people usually have time to become aware of. Here, in an instantaneous and unceremonious way (a glance at a picture, an absence of color) Lisa's condition was announced to a roomful of relative strangers. She would probably be the last to know. My heart broke for her and her husband. And I wondered: would the dye result have been different if the surgeon had waited? Did this surgeon just cost Lisa her fertility?

If the tube had never been patent, then there was only the tragic discovery of infertility for this young woman. There was nothing lost by the surgeon's too-early cauterization. Perhaps because of this, the surgeon began to voice aloud what I knew was impossible as she continued to dissect the fibroid away from the uterus. "Strangest anatomy I've ever seen...the tube connected to the fibroid and not to the uterus." Lisa, said the surgeon, was probably born like that. (That is highly unlikely, according to what I know about embryology and fibroids.)

This denial made me more certain, in an irrational way, that this surgeon just lost the patient her only patent tube. Admittedly, there was no clear evidence of destruction of a tube which was patent along its entire length; there was only evidence that the surgeon diminished the validity of the dye study by opening the uterine cavity and making it possible for a patent tube to remain pink even when dye was injected into the uterus.

The fibroid and tube, assumed to be useless, were removed. The ovary (which was to be protected "in a woman so young") stayed behind; nevertheless, it lost its most exalted purpose.

To the surgeon's credit: later in the surgery we spoke more about the patient's anatomy and (after some mention of embryological orgins) the surgeon said that the tube must have emerged from the uterotubal junction and the tube was originally connected. The surgeon told the Lisa's family that the fibroid "dissected the tube away from the uterus" as it grew, an explanation that I think is likely.

If I had been operating, things might have been different. I would have waited to cut so that the dye study could show for certain whether both tubes were blocked. And regardless of the result of the dye studies, I would have attempted to save Lisa's fallopian tube, since tubes can be reopened. Perhaps this surgeon assumed that the tube was blocked and ordered the dye as an insurance policy for the removal of the tube. Or, perhaps the surgeon was not bothered by an inconclusive dye study. Or, perhaps the surgeon didn't see any reason to save a tube for recanalization when the patient would probably just get IVF.

But what if the patient (or her husband) were Catholic? What if they were too poor for IVF?

I left the OR feeling sad for Lisa and her family, and sad for this surgeon.