49. Three Stories

Juanita is 17, pregnant with a second child, struggling as a single mother, working and trying to finish high school. I see her for an ultrasound to precisely date the pregnancy, important if she terminates.

Jane is 34; an 18 ultrasound showed a "Chiari II" syndrome, which means injury to the primitive brain due to a malformation of the skull (20% of these babies die in the first year because of respiratory failure; it's the primitve brain the controls breathing. There is also an injury to the spinal cord in the lower back; this child will never walk. She is hopeful that surgery within a few days after birth will release pressure on the brain.

Jasmine is 22, a life-long diabetic who experienced an epidode of diabetic keto-acidosis when she was a few weeks pregnant. Diabetes means that blood glucose can't enter cells; instead it stays in the blood, hence the high sugar levels of diabetes. The brain needs glucose but is the one organ that can't store it, so fats are broken down with ketones as a by-product. High levels of ketones are life-threatening. The risk of birth defects is high when DKA occurs in the first trimester.

Three women with extraordinarily difficult decision. Why should some old white guy from Ohio make this decision for them?

48. DV

From a chart note:

"Case worker called me back to say that [Anita] was admitted to [St Elsewhere] after a severe beating from her boyfriend. She was only recently discharged and case worker says she still is black and blue. FOB is currently in jail but she still has contact with him. She declines to initiate restraining orders. She told case worker that she occ uses cocaine."

Soap operas and learned commentaries both lament the difficulty that abused women have separating themselves from their abusive partner. It's counterintuitive and you wonder if it's an exaggeration of reality, useful for a plot twist or to create interest in a written report.

No, it's not.

47. Belly Dancer

L. is 42, divorced without children. She presented with abdominal pain. There was no associated gastrointestinal symptoms, no urologic issues, but her current menses, tho light, had been ongoing for 3 weeks. At our first visit, the exam and her membership in a belly-dancing troupe suggested a "soft-tissue" injury, that is, a problem associated with trauma to muscles, tendons or ligaments.

Over the next three weeks, we proceeded through a number of blood and radiology testing, the final an abdominal CT scan; all normal. At our last visit, I decided to start over with a history and exam.

When asked about stress factors, she describe multiple sources:
1. Work difficulties: called to task for being slow when from her perspective, she is just doing her job ("courtesy bagger" at Safeway). She worries that she is being set up to be fired so that she can be replaced by a lower wage (less senior) new employee.
2. Estrangement from family; her father died last year and her sisters didn't even tell her about it.
3. Financial difficulties.
She finally acknowedged that her current pain may be associated with one day when she had push a large number of grocery carts from the parking lot to the front of the store, a sudden stop jamming the cart handles against her abdomen. She has not returned, and has not answered by follow-up calls.

46. Intelligent Design

This morning around 3:30 while I was watching 9lb 6oz Gary trying to figure out an exit strategy with the help of a determined mother and a patient midwife, I decided that anyone who believes in "intelligent design" must never have witnessed a human childbirth, or if she/he has, it's been totally erased from conscious memory. I can understand how the pressures of natural selection could lead to such a strange means of reproduction, but as a thought-out, planned-in-advance design by a superior being? Nope.

45: Resistance Is Futile

From an office email I received last week (I'm not the one being addressed, I just happen to be on the mailing list):

"... good to run into you last night. You discussed with me that you were experiencing some resistance to standard deployment of the tools of [new program X] into your department as well as some concerns from some of your colleagues that movement upstream to primary care may cause problems…

As we discussed our job is to understand that resistance and work with our teams to move through it adjusting our strategy and work as appropriate based on their good thinking."

When I find myself in a room with these people, I don't know what to say, it's like I'm listening to a foreign language I learned in college. Sure, I recognize a lot of words, but I have no idea what is being said.

44:OK, I Believe You

T. presents with pelvic pain. The abdominal exam with its initial gentle palpation that tries to localize the pain and estimate its strength, was, frankly, unimpressive. T. must have sensed this; without warning she grabs my hand, pulling it deep into her abdomen. After a long 30 seconds, she lets go and assumes a semi-fetal position, tears streaming from pain. She explained that she just wanted to demonstrate the pain.

43: Thanks

received an email today:

"Thanks so much Dr. H. Enjoy your Easter Weekend."

Illness can make it hard to see a caregiver as a person, especially when we don't have much to offer (which happens more often than I want to admit), so when someone breaks through and says thanks, well... what can I say but thanks in return.

42. The C Word

from an email received March 23th:

"I have an appt. for the 15th of April - but I have to say - I think it's crazy you have to wait so long for an appt. when its something potentially as serious as this is. I'm having a hard time concentrating on anything else. My father was recently diagnosed with cancer so this is making me crazy. I think three weeks can make a huge difference in whether or not someone beats a disease... or not!"

Two possible replies:

1. Explain that an abnormal Pap smear usually diagnoses "precancer," (dysplasia) not cancer, and that the progression from dysplasia to cancer takes years, so a three week delay really is acceptible. Three months would be okay. Three years not okay.

2. Offer an appointment tomorrow, my call day so it may mean some extra shuffling back and forth from the hospital to the clinic, but usually doable.

Number two of course. The time to talk about the difference between dysplasia and cancer or about the natural progression of the disease is BEFORE not after the results are known. But I'm not the one who obtained the Pap smear.

p.s., biopsy obtained during the appointment; she has moderate dysplasia (maybe 10% chance of become cancer over a few years). She accepted a procedure that will remove a button-size segment of the cervix, almost always including all of the dysplasia)

41. Diversity

Apparently bored by my discussion about antepartum risk screening (the result being reviewed estimated that the risk of Downs Syndrome was 1:35 so not a trivial discussion), a father-to-be said, "Doctor, can I ask you a question?"
"Sure," I answered.
"Are you a mulatto?"
"Must be; my hair's from Bathsheba, eyes from Thor and my deviated septum from Genghis Khan. It's my genetic diversity that promises a long, healthy life."

[the question was real, the answer sadly, was really something along the line of, "Must be, if you go back far enough..."]

40. Macrosomia

Macrosomia, literally "big body;" in my world, babies over 9 lb at birth (greater than 90th %ile). B. delivered a "macrosomic" baby two years ago, 9 lb 15 oz. Uncomplicated vaginal birth. Concerned that a second child might be larger, an ultrasound was obtained yesterday, two weeks before her due date. Estimated fetal weight: 5000 grams, or about 11 lb. For most babies, the head is larger than the shoulders so once the head delivers, the baby slides out. But macrosomic babies may have larger shoulders that get stuck, an obstetrician's nightmare: injured nerves, fractured clavicle, paralyzed arms, stillbirth; I've seen them all.

So one of my partners, who herself underwent two uncomplicated Cesarean births, gave her the option of skipping labor, going straight that same day to the operating room for a Cesarean delivery. She said yes. I was on call and delivered a 10lb 5oz baby boy. Would this baby have safely made it through the birth canal? Probably. Would I have counseled her differently? Probably. Would she still have chosen an elective Cesarean? ... Probably.

39. In My Country, part V

The ultrasound demonstrated not one but several "echodense" (i.e., sound waves don't pass through so white area on ultrasound) areas, consistent with collections of silicone. Not something one wants to surgically remove (the cure possible worse than the disease) unless symptoms increase. So, we like to call, "watchful waiting."

38. In My Country, Part IV

I asked S to return, to discuss results of antepartum screening. Four pregnancy "hormones" are measured and in a complex equation compared with the results of other women whose outcome is known. The results: for every 71 women the same age and weight as S, with the exact same results, 70 had normal babies and one had a baby with Downs syndrome. So her risk of having a baby with Downs Syndrome estimated at one out of 71. Using age alone as the predictor, one would estimate her risk for Downs at about one out of 200. I offer her an amniocentesis--withdrawing fluid from the amniotic sac, containing cells sloughed off from the fetus, which can be nurtured, after a couple of weeks yielding enough DNA to give a definitive answer. Problem is that the procedure has a 1/400 risk of miscarriage. It's always a tough call. S immediately declines the amniocentesis, a decision entirely consistent with her earlier request for an elective cesarean delivery. Baby comes first.

37. In My Country, Part III

After our discussion about the Prenatal Risk Screen, S asked me to evaluate the recent onset of leg pain. It seems that several years ago in Peru she received an injection of silicone into her buttocks for cosmetic reasons. S has a normal weight and body shape; I'm not sure and didn't ask the exact location and rationale behind the injection. Anyway, she reports past episodes of this leg pain which her doctors attributed to the spread of the silicone into her thigh, with relief obtained by injections of steroids and/or antibiotics.

Today she has a 4 by 6cm firm, mildly tender swelling on the lateral right thigh, with just a blush of erythema (redness). There are no breaks in the surrounding skin that would suggest an infectious process. I have no idea what this is, but will obtain an ultrasound. Either that or tell her to take a couple of tylenol and see me next week.

36: Pheromes, part II

While we're on the subject, a recent study from Florida recruited young men to opinionate on t-shirts worn by women while sleeping on three consecutive nights. There were three groups of t-shirts, one set from around the time of ovulation (when there would be an evolutionary advantage to attract sexual partners), a second set from a time distant from ovulation, and a control set.

The men rated the ovulation t-shirts as most appealing. Testosterone levels were higher when the ovulation t-shirts were being evaluated.

An earlier study showed that exotic dancers received more tips around the time of ovulation. Many factors here, visual, auditory as well as olfactory, the t-shirt study being just olfactory, but the conclusion is the same: we can't entirely escape our evolutionary destiny, too much of it is unconscious.

35. "In My Country"

"In my country women of my age [36] always have Cesarean deliveries. They say it's safer for the baby." I told S that in our experience, women over 35 can delivery vaginally without putting the baby at risk. Then she explained that she is very anxious about labor and "just couldn't handle it."

It is not uncommon to receive and accept requests for scheduled Cesarean deliveries based on physical health issues other than a previous Cesarean, even though I often wonder if an underlying fear of labor may be the unspoken but stronger motivation. It's all out in the open with S: she acknowledges that it is all about anxiety and fear.

So is fear a valid reason for an elective Cesarean? Most of the health risks of Cesarean deliveries are for those performed after a long labor. There is not much evidence that a vaginal birth is safer than a scheduled Cesarean delivery. Easier recovery, yes; less expensive, yes; safer? perhaps not.

34. Pheromones

Women who live together may find that their menstural cycles synchronize, presumably due to pheromones (olfactory signals). This menstrual synchrony is generally accepted as real, though with many factors influencing menstrual timing, it may not be apparent for all groups of women living in proximity.

Now consider Mrs. H. who experienced a year without menses, which is the definition of menopause and totally expected for this 56-yr old. Then her daughter and family moved in with Mrs. H. and her husband. After a few months, Mrs. H's menses resumed, the timing synchronous with that of her daughter's menses. The daughter recently found a house to rent and may be moving out in a month or so. I'll be curious to see then what happens to Mrs. H's menses.

33. Grouchy

"Menopause makes me grouchy," she said.

Half-tongue in cheek I countered, "What makes your husband grouchy?"

"He's a guy, it comes naturally."

Actually the hormonal shifts of menopause do not increase depression or the irritability that is often the harbinger of depression.
Health issues that arise in the 50's (the knees, the back), kids leaving (or not leaving) home, careers of husband and wife at a plateau, and the earthly departure of friends and relatives--these are the triggers of acute depression. Along with existential angst as one considers, "is this as good as it gets?"

32. Breech

Near the end of the day I met K. for the first time. She is 38, about a month before her due date. Three years ago she adopted a Nepalese infant who suffered some brain trauma at birth (not sure whether or not K knew this at the time of adoption, I think yes, but not the extent). K thinks it may have been a vaginal breech delivery, a not uncommon source of birth injuries.

So of course she is worried whether this baby might be breech. My impression from an abdominal exam was that the baby was head first and I confirmed that with an ultrasound.

She was visibly relieved: "You've made my day."

"I wish it were always this easy," I noted. And we both laughed.

31: Pay Now or Pay Later

Eight states require insurance plans to cover in-vitro fertilization (IVF). Costly decision? Well, maybe not. Couples who pay per cycle (about $10,000) demand implantation of multiple embryos with each cycle, in order to lower total costs. While this may lesson the number of cycles necessary for a successful pregnancy, it also means more twins, triplets, etc., And that means millions more spent in neonatal intensive care units. The average cost of triplets is $300,000. These eight states have significantly fewer IVF multiple births.

30. Have You Thought About...

...going to Haiti? Yes, but my assumption has been that the need is for providers who have experience dealing with acute trauma, and that there have been more volunteers than the infrastructure can handle. To wit, the following comes from an email sent by a rehabilitation psychologist:

"Hi everyone. Just back from Haiti and I wanted to put forth a few thoughts to those of you who would like to volunteer… It is absolutely key and essential that ONLY people who have had large-scale and severe disaster experience go over at this point. Many of you know that I have been to Sichuan--have had many experiences with large hurricanes, Katrina, etc., but I cannot tell you how horrendous and very different this situation is right now… We were doing surgeries almost 24 hours a day....mostly amputations. Unfortunately many of the people who have had amputations have already become infected within a day or two of the surgery (remember essentially no aftercare)... The docs I flew back with came to the consensus that if 30% of the people they operated on survive, they will be lucky... Even the tsunami was in a country where you could find some infrastructure...somewhere. Here--there is nothing. For the first time in my life I truly had to consider [my own] survival …"

Other sources estimate tens of thousands of amputees, which will burden Haiti's health care for decades.

29. Foreign Bodies

T., a 29-yr old exotic dancer, doesn't want to have any more kids. She has three and thinks that's enough.

She tried an IUD, a T-shaped piece of plastic about an inch long that is placed inside the uterus. But then had it removed after several months because "it bugged me having something foreign like that inside of me." I restrain from making the observation that her breast implants aren't exactly natural.


So we decided on a tubal ligation, a day surgery.

"How long," she asks, "do I have to stay off of pot before the surgery?"
"Don't really know," I say, "how does 48 hours sound?."
"Good, that's what my boss says too"

Smart lady, getting lots of opinions before making a decision

28: Pulmonary Embolism

After several years of menopausal quiescence, Mrs. J's 60 yr old uterus erupted a few days before Christmas. What was the stimulant--stress hormones? More likely estrogen produced by adipose cells, of which Mrs. J has in excess. Whatever the source, too much stimulus can cause cancer, necessitating a biopsy, obtained last week.

Tonight I called her to explain the results: hyperplasia with atypia, just one stop short of cancer. I needed to tell her about my referral to a local gyn oncologist who will certainly recommend major surgery. Her husband answered, and I asked for Mrs. J. He paused and then slowly and quietly explained that she had gone to the ER last night, short of breath. And then died there. In the ER.

27. Zero-Sum Game

Ironic that tonight, while a sizable segment of America is salivating at the thought of defeat of health care reform, I'm on call for the ER. Two patients without insurance. One will have a shorter life because of delayed diagnosis of cancer. She couldn't afford a doctor despite telltale symptoms for several months. The other bleeds half of every month, receiving periodic transfusions in the ER, just enough to get her on her feet and out the door. Why does America think that health care is a zero-sum game: every benefit given to one means less benefit for another?

26: Ah, Now I Understand

Yes, I was annoyed when Dr. A called me on Sunday, asking me to come in to see a patient Monday morning (with the unspoken understanding that I would assume care for her). T. delivered six weeks ago (by Dr M), with a rare complication that required two subsequent minor procedures, one by Dr. M, the other by Dr L. She was later re-admitted by Dr J, and followed by Drs W., M, and A in the hospital. So why call me? Well, it seems that the patient made that request, having met me during antepartum visits. Well, of course--my unimpeachable bedside manner. But doesn't Dr A (or any of the others) have the communication skills to establish a relationship with patients in whatever setting? To make plans and carry them out? Whatever.

So we go to surgery, this time more of a final approach, gratefully not as difficult as predicted, and her uterus remains intact. Meeting her mother in the waiting room afterwards, I noticed a book peeking out of her handbag. Glenn Beck. Dr. A is black. It's not my bedside manner, it's the color of my skin.

25: the Token

Received an email last week advising me that I would shortly be receiving "The Token," and that I should carefully read the attached instructions.

Wow, am I being inducted into a secret society? Will it help me find the Holy Grail, or open the back door to Hogwarts?



No, it's just a security upgrade. My "remote access" allows me to review all of my organizations medical records, for its 500,000 current members plus several hundred thousand former members. So yeh, I understand the need for security. So when I log on, I'll need not only my personal password (which I have to change every 60 days or so) but also the token's 6-digit number, which I assume changes much more frequently.

24: Che

Dr. Jesus Bonifaz Q. was kind enough to provide his office for our use. The office wall contains scriptural quotations (the name of the clinic is “Christian Jerusalem Clinic”), flow charts for diagnosis/ treatment of H1N1 flu, pregnancy stages, and... a poster of Che Guevara.

At the bottom of the poster is an ad for a multinational drug company. Che se da la vuelta na tumba!

P.S, I asked our Ecuadoran translator what people think of Che: “He’s a hero.” A hero to some, Castro's executioner to others.

23: Donde le duele?

Riobamba turned out to be mostly outpatient, a little disappointing, maybe, but okay. Here's a summary from one day:

12 patients, including two men. All 12 spoke only Spanish (I could begin the conversation and understand much of what was said, with an excellent interpreter filling in the gaps).

Abdominal pain: 3
Symptomatic varicosities: 2 (I had brought with me compression stockings for surgical patients, ended up using almost all of them for outpatients)
Enlarged uterus: 1
Bladder prolapse: 1
HPV: 2
Worried well: 2
Persistent yeast infection: 1 (also sees Ecuadoran doctor; I reinforced his recommendations)

The three abdominal pains included:
1. prior abdominal surgery that lasted "15 horas", using an incision from sternum to pubis to remove what I assume was a benign tumor, which has apparently returned and appears to be wrapped around and may slowly osbtructing the bowel; I could only recommend returning in February when MMI returns with a general surgeon.
2. a "7 hora" vaginal surgery that left has left the patient with chronic abdominal pain and some difficult bladder issues.
3. pain associated with an enlarged uterus, heavy bleeding, and stress urinary incontinence which adds up to a sound indication for surgery--pt initially accepted surgery but then returned, and cancelled; it appeared that her husband didn't want her off work for several weeks.

22. Blogging at 9,000 feet

In Ecuador for my 7th overseas medical trip, some words about the previous six (nb, dates are approximate):
#1 Montalvo, Ecuador 2004. Blankets hung over ropes for exam rooms, major gyn surgery in an OR previously used only for cesarean deliveries, real questions about risks and limits of overseas surgery. An evangelical group (mmint.org) with three goals: medical care, support for the local church, and a spiritual experience for the participants, many of whom came with no medical skills or background. These goals were at times in conflict, but don’t be mislead by my habitual second-guessing; a tremendous experience.
#2 Accra, Ghana 2005. The organizer could not deliver on his promises so no real medical work, but whoa, what an amazing place. We stayed with a local family, met with government and church health system administrators. African art came alive.
#3 Chengdu China 2006. A first hand view of modern Chinese medicine (at least as practiced in large cities) . Should Western medicine feel complimented as China hurtles towards a Western health care system? Yes and no.
#4 Vietnam 2007: A medical exchange; I lectured with a bust of Uncle Ho looking over my shoulder; tried to assist with a hysterectomy, only to have language prove to be an unsurmountable barrier; listened to medical students explain why thy chose medicine, a mixture of filial duty and personal, usually negative, experiences with the medical system.
#5 Mozambique 2007: Sounded like a perfect setting: a rural Methodist-funded hospital with two ORs a couple of anesthesiologist, and no local gynecologist. Ii even knew some Portughuese! Though hindered by the absense of any prior screening, I helped with some deliveries and confronted the most difficult hystectomy I have ever done. And an unanticipated bottleneck: the small autoclave (sterilizer) couldn’t keep up, so some cases cancelled simply because there were no sterile drapes/gowns. But also an opportunity to appreciate the perspective of local chronically overworked operating room staff: I came wanting to do lots of surgery; but for them, I just represented extra and uncompensated work.
#6 Guayaquil Ecuador 2008: A group from Phoenix with a local connection to provide access to military hospitals and almost completely self-sufficient (no want of sterile drapes/gowns). In 8 days I saw 50 outpatients and performed 12 major surgeries and a couple of minors. My fingers were literally sore from tying so much suture. Finally.

21. Flu Stories

The distribution of theH1N1 flu vaccine has been unpredictable in terms of both timing and quantity; when our clinic received its first small batch, an email went out advising staff that they were high priority and should go to the injection room to get their vaccine. A few minutes later, a second email arrived: "Make sure if you come up to the fourth floor injection room check in, that you are quiet as to why you are here. Patients are told we do not have any flu vaccine in our clinic. Thank you."

Two public servants in Alberta were fired for having provided the flu vaccine to members of a professional hockey team, disregarding established priorities. The team doctor who ordered the vaccines, and the team manager who concocted the scheme suffered no repercussions.

Somehow our clinic in Federal Way received more vaccine than it needed. Tacoma was short. No problem, we said, just put some in a box and bring it to Tacoma. Nope... it seems that vaccines can’t cross county lines.

20. Priorities

A 28-year old in her 26th week of pregnancy is in the ICU, near death. The pandemic flu. A story repeated across the nation.

Meanwhile in the clinic patients are dithering about whether to accept the vaccine, especially the preservative-free vaccine, which was available first.

19. Whatever Works

I complemented A. on her well-behaved daughter, quietly sitting in a chair during her mother's antepartum exam.

"Oh, I just told her she was getting a shot."

18. Twilight

J. delivered on Halloween, naming her baby girl Bella. I don't know whether the Twilight series will have much staying power, but if it does, then in about 15 years her daughter will either think that her mother was awfully clever or had a misdirected sense of humor.

J., though, is clueless: "Twilight what?" she says.

17. And the Answer Is

Link from Zelda

16. Multiple Choice

One of those everything-went-according-to-plan deliveries yesterday, a girl to be named Adelaide. Their first child is Link.
I asked the origin of that name. What do you think?
A. One of the leads in Mod Squad
B. As in link to a website
C. protagonist in Legend of Zelda
D. Short for Lincoln.

15. DV

Domestic Violence yesterday
1. R. raped by some one she knows; won't tell his name because she's afraid of reprisal.
2. S. is pregnant; her estranged husband threatens to come to the hospital with a loaded gun to take the baby.
3. J. was kidnapped by her husband, driven around while deciding how to kill her (so he said). She quietly dialed 911. A dutiful dispatcher kept the line open and with GPS technology the police rescued her.

Why this local epidemic of DV? Must be the threatening storm of gay marriage

14. Calling Dr. Ruth

Dr Ruth (still going strong at 81) told us to call it like it is: vagina, penis, cliterus, scrotum and so on. An honesty is the best policy approach. My patients are seldom so forward, though when they talk about "having sex," or being "intimate," the message gets through. But today S. would only allude to, "when my husband and I do adult things." You mean like drinking, or voting maybe?

13. Someone Famous

There are 9 of us in the department, and when a new patient makes an appointment, she has the option of first looking at our photos and a "bio."

T. said she picked me because I looked like someone famous, in this case Dr Zorba from Ben Casey. She is not the first patient to have made this connection. Other patients have mentioned Billy Crystal or Dr House. I like to think that I have the authority of Dr Zorba, the bedside manner of Billy Crystal and the medical knowledge of Dr House. Though I wouldn't mind if I just brought Ben Casey or George Clooney or even Matthew Fox to mind.

12. Who's Paying the Bill?

The Mirena IUD embeds a hormone inside a plastic T. Inside the uterus the hormone both suppresses the uterine lining and thickens mucous in the cervical canal, while the "T" triggers an inflammatory response. A three-act contraceptive, good for five years. At about $500, that's $8 a month for very effective birth control. So L. has a Mirena inserted, paying just a $15 copay for the office visit. Three months later she and her husband decide to try for another child and has the IUD removed. The IUD of course is discarded. How will health care reform fix this?

11. It's Not About the Money

After the delivery, I returned to the ER: J. is 34 and childless, with two weeks of pain and fever and a large pelvic cyst which is probably a tubo-ovarian abscess. With antibiotics and the cyst drained, she'll be okay. She just can't pay a hospital bill that may reach $10,000, which the hospital will just pass on to its insured patients, leaving J. with a bad credit rating. So? It's not like she's in the market to buy a house. But let's say that health care reform would give her access to outpatient health care. Would she have gone in earlier? Would earlier invention have protected her fertility, which I expect is now non-existent? Health care reform is not about money, it's about health.

10. I Think So

Down in the ER admitting a patient (more to follow), and a young woman is brought in on a stretcher, obviously in labor. Not my patient, but hey, I'm there, so I check her--complete dilated and ready to push. Just like on TV: straightaway we wheel her towards the elevator, grabbing a "precip" pack on the way (the basic instruments for a "precipitous" delivery). We manage to avoid an elevator delivery, but just by a few minutes. Afterwards, someone asks a pretty obvious question (I think they were working up to something more): "Were you in labor at home?" Her reply: "I think so." Well, yuh.

9. Bizarre

Remember the 50-something who came in with what she thought was a labial wart (and knew that genital warts are STDs)? It looked looked like a wart but sounded like herpes (itching, tender); biopsy showed herpes; so I tested her herpes immunity which suggested exposure in the distant past. I explained (trying to be as discrete as possible) that this could have been the result of a peck on the cheek from a cousin with a cold sore, that found its way down south. Granted this is unlikely, but the appearance of a herpes lesion is no reason to reevaluate a marriage. Dirty socks on the floor, yes; recurrent herpes, no. Her reply? "Bizarre"

8. Will the Real Father Please Stand Up

A. is a 20-something Asia-born dealer at a casino. And pregnant. Soon after breaking up with a white boyfriend, she started going with a Cambodian and is not sure who is the father. She's okay with not knowing: "they're both good guys."

M. is a 30-something former exotic dancer who supported a deadbeat husband and three kids for years until she decided that she couldn't keep on dancing for much longer. She decided to become a security guard, which requires some course or certificate which she duly earned. In the process of this mid-course correction she also kicked out her spouse--but not before having sex with him one last time. A week later she was in bed with his brother. Now she's pregnant. I'm not sure if current DNA testing can tell who's the father. But that's the least of her problems. She's pregnant and looking for a job as a security guard, wondering how she's going to support her family.

7. Thinking Clearly

At 46, M. has a problem list that one would expect at 86: heart failure, liver failure, diabetes, morbid obesity. So she takes seriously the living will that every hospital admit is encouraged to discuss. "If there is a problem with the surgery," she says, referring to a relatively simple excision of an ovarian cyst, "and I don't wake up, then just turn everything off. I don't want to be on all those machines if I'd wake up and not be able to think clearly. But if I'll still be able to think clearly then do everything you can." I like M. Dr. House wouldn't, but I do.

p.s., she did wake up, the cyst was benign, and her thinking is quite clear.

6. ER

24 year old, mother of two and now 16 weeks with a third. Bipolar. Her doctor told her to stop taking her antidepressants (the kind of doctor who would tell her she'd go to hell for drinking a glass of wine during pregnancy). She complied (most of us like to think of ourselves as not needing to take any medications). Depressed moms don't make good moms. Now suicidal and infanticidal, she was seen hitting herself on her abdomen as hard as she could. Tackled by police as she tried to leave the ER. I was consulted regarding the need to hospitalize her against her will to monitor for possible placental abruption. No bleeding, no cramping, normal ultrasound; I said no.

5: HSV or HPV

Remember the 54 yr old matron who was concerned about the appearance of a genital wart and her concern that it was an STD? Well, I biopsied it, and it turns out it was not HPV but HSV: herpes! I've yet to reach her but can offer her some immunity testing that will tell us whether this is a newly acquired herpes or a reactivation. Will she accept or leave well enough alone?

4. The Clock Is Ticking

A's mother died a few months ago after a brief, unexpected illness. Current boyfriend "is the best yet," but they have been arguing lately. So no surprise that her cycles have been off-kilter lately. Helpful friends tell her she may be entering menopause which is frightening because she still wants to have a child--just not now. I reassured her that at age 37, menopause is unlikely but acknowledged that the clock is ticking and she shouldn't wait too long

3. Deadlines

Really needed to leave clinic by 5pm (usually I leave at 5:40 to catch the 5:50 bus). Down to the wire: at 3:30 I'm waiting for an Implanon insertion (subdermal contraceptive), having caught up on everything else. There's a 4:00 new referral and a finally a 4:30 checkback. The 3:30 showed up at 4:00 so I asked that she be rescheduled, something I do about once every 5 years. At 4:15 she's in the waiting room crying, so I said, okay I'll see her, but she has to wait for the others. The 4:00 was late and complicated, 54 yr old with vulvar wart wondering if it is an STD. My reply evasive. I started with the 4:30 at 4:55. She had lots of questions; finally finishing around 5:30. So I finally meet Ms Implanon. She looked like she just came out of a Vermeer painting. How could I have been so mean to her? We talked and decided to go for an IUD instead, which was done by 6:20; one last but important phone call; made the 6:40 bus.

2. Miscarriage

An email from a patient who recently experienced a miscarriage:

"But for now to get over what a failure I am I will have to bury myself in my school work and work as at least these are two things that I am not a failure and do have some type of control over."

1. The Living Fields

Heng is a community call patient, meaning either no insurance or no established relationship with a local specialist. Her employer offers insurance but she didn't understand how to sign up. She is Cambodian and though speaks good English I can understand how such issues would be difficult. But her daughter will help and in a few months she may be able to have her enlarged uterus removed, a uterus responsible for bleeding that has left her with just half the blood volume she's supposed to have, prompting the ER visit an my interview.

 The same daughter who was born in a Cambodian field as Heng and her father fled Vietnamese bombs. As she told the story I could see her reliving the fear of that day. "Run faster," her father pleaded, neither of them understanding that she was in labor. Finally she had to stop, and attended by her father with only a pocket knife, gave birth.