100. The Iron Lady

At 48, Vanessa continues satisfied with her decision to remain childless, but seeing friends unable to conceive, she wonders if she could be of help.  She reasons that a surrogate pregnancy with an implanted embryo, using either donated or anonymous sperm and ovum, would not only help friends, but would also provide her with a family of sorts.  Now caring for an aging mother, she is worried about becoming older without a family.

I told her that an IVF clinic would give her a better answer, but cautioned that she probably would not be accepted as a surrogate mother even with donated embryos.  There's too much at stake to risk the uncertainty of a 48-yr old uterus.

The film "Iron Lady" suggested to me that children or not, successful career or not, aging and loneliness are inextricably intertwined.

99. Hot Flashes

There's a connection between changing hormone levels and the body's heat regulation system.  So when there is a sharp decrease in estrogen level, the body's thermostat thinks that body is overheating, triggering perspiration and dilatation of superficial blood vessels.  The latter shunts blood to the skin, allowing heat to escape.  A perception of increased body temperature follows (though the core temperature has remained normal)--the classic menopausal hot flash (or a hot "flush," recognizing the skin's redness due extra blood near the surface).

48-year old Leeann tells me that she only experiences hot flashes when she's near her husband.  Apparently, there can be more to a hot flash than a malfunctioning thermostat.

98. Turf Wars

Medical turf wars usually involve stent-placing cardiologists up against bypass cardiac surgeons.  Or family practice docs performing colonoscopies that gastroenterologists want to keep as their own.  Or optometrists v ophthalmologists.  But here at StJ's we also fight over call rooms.  Call rooms are for hospital docs who don't need to be up all night but still want to be in the hospital for urgent calls.  Usually we think obstetricians and midwives, but others are involved, too.

StJ has 8 or so call rooms, with advance sign up sheets taped to each door.  Apparently someone has been  playing around with these sheets, to the ire of one doc who found his reservation crossed out.

So he posted this sign, naming the alleged offenders (before taking this pic, I blocked out the names) and this message: "Don't be DICKS and move out people who signed up for call rooms.  Our sleep is just as important as yours." Surprisingly this sign has stayed up for a couple of weeks.


It's a jungle out there.

97. My Husband Won't Let Me

Sandy is 25 with chronic pelvic pain and four kids.  Repeat evaluation over the years has not revealed any cause.  Last week she came in and asked for a hysterectomy; I hesitated because without diagnosed uterine pathology, the pain will likely continue after the surgery.

"Healthy Life Style"  That's what we propose for patients with chronic pain.  Sleep, nutrition, exercise.  Just a daily 20-30 walk outside can combine exercise and a meditation-like mind clearing.

"Do you have time for yourself?" I asked, hoping this would trigger a useful conversation.  Finding time (alone! --an exercise DVD won't work with a house full of kids) is the deal-breaker for many would-be home athletes.

Her reply:  "My husband won't let me."

With some prompting, she explained that he doesn't literally stand in the doorway keeping her homebound, but he refuses to take care of the kids. With no money for babysitters, he has effectively prevented her attempts to gain control of her health.  And I suspect that when someone has to be up at night with the kids, she's the one who loses sleep. Or she stays up late with laundry and other chores.

There's abuse and then there's abuse.

96. La Familia

Though childless at 51, Inez is not without family.  She came to the hospital with heavy bleeding, abdominal pain and just plain feeling terrible.  I've seen her several times--she's never been without family. There were six in the tiny ER exam room.  Two women sleep in her room.  This evening, I counted at least eight, of all ages.  You read a lot about the extended Hispanic family. It's one thing to read about it, another to see it in action.

95. Fate

At 90 Mildred is alert and independent.  She's in the hospital for complications of congestive heart failure: the heart doesn't pump as well as it should, blood and fluid back up in the circulatory system, leading to swelling in limbs and fluid in the lungs.  She needs meds (e.g., digitalis) to strengthen the heart, which should clear up her lungs, allowing for a discharge in a few days.

An abdominal CT scan (not too sure why that was obtained, but it's almost routine), incidentally showed an abnormal uterus, suspicious for cancer.  I recommended a uterine biopsy, to be done in the office after her discharge.  If it showed cancer, surgery might be recommended, or for a precancerous condition called hyperplasia, easy to take suppressive hormones (progesterone) could be recommended.  She said no thanks.

Her son was present and clearly wanted her to accept the biopsy.  A common theme. The kids want everything done for their parents, who often are satisfied to "let nature takes its course."  I argued for a middle ground:  do the biopsy (uncomfortable for a few minutes but no risk to health), then rethink.  She said she would consider but was inclined not to.

94. "Partner" part 2

Beth, 24, came in a few days before New Years' with a couple of issues, including refill of her birth control pills.  She mentioned that she would be leaving for California on Sunday but would be back in the spring. "Going back to school?" I asked.  "No, but my boyfriend is in divinity school there."

93. "Partner" part one

I'm rounding on a recently delivered 34 year I had not yet met.  The father asks if I will write a note excusing him from work for another week since she had an unanticipated cesarean delivery.  Sure, I said, and returned to the nursing station to write a note (most companies don't mind a hand-written note for this purpose; as long as there is some paper trail).

Then I realized I forgot his name--no problem, I'll just check the admission record; his name should be on it.  But no, for emergency contact, just her mother was listed.  Too bad because I had already started a note: "Please excuse [blank] from work until Jan 9th because his wife underwent an unexpected operative delivery."  When I wrote "wife" I had a fleeting thought--"maybe I should write 'partner.'" But that didn't seem right in this setting.  During that brief encounter, they seemed... well, like a married couple.

A recent analysis of census data shows that 51% of all adult Americans are married, an all-time low.   In my state about half of all deliveries are to unmarried women.  My own records over the past 15 years show that 70% of the woman whose deliveries I have attended are married.  That number will probably decline.

Anyway, I left the note as written, asking for and adding his name when I returned to give it to him.  I doubt that he or anyone reading it will give a second thought to my outdated social prejudices.