Tuesday, August 15, 2017

Quaeritur: Care of Transgender Patients (Part 2 of 2)

This post is a continuation of a conversation about Catholic teaching applied to transition for transgender patients. A medical student asked whether gender dysphoria could licitly be relieved with medical and surgical therapies. Following my reply, the student wrote back. I'm going to interject my responses outside of the block-quoted text from the student.
My initial reaction is that I completely agree with your succinct assessment: “The Popes have said that we are born male or female, and that is our gender. Any distress we feel about our gender is a disorder.” My thought is that for the vast majority of us, this is a clear cut statement. For persons with intersex conditions (and I would add transgender as well), they suffer from a disorder.

I’m going to take intersex cases an example before approaching transgender persons: Some of them are born with ambiguous genitalia and chromosomes. Determining their correct gender is a difficult clinical task involving input from the physicians, parents, and children. I’m sure that Pope Benedict would probably agree that due to the brokenness of the human condition, persons are sometimes born with mixed features from both genders. The existence of intersex persons doesn’t disprove or say anything about Catholic teaching regarding sex and gender, it just confirms for us that we live in a fallen world. Another analogy would be that persons are born with down syndrome, schizophrenia, and many other illnesses that impair intellectual capacity. The existence of these persons obviously does not disprove the existence of the “intellect” or the “will” that human beings, as rational animals, possess. These cases are just more examples of the brokenness of the human condition in our fallen world.

I think (hope?) that the above paragraph isn’t particularly controversial. I’m sure that most Catholic theologians would probably agree with my statements.
"Intersex" is a colloquial term, not a medical one. In medicine we refer to people with ambiguous genitalia, and I think that's more helpful in this discussion, because it's only a physical (and pretty external) defect. "Intersex" is a more emotive term that tends to lead the hearer to believe in a spectrum. Since I know that sex is binary, I find it an unhelpful term, much like "gender-fluid" or "bisexual." These terms refer to things that exist (e.g. a woman who has periods in life or even periods during the day in which she feels more like a man, or a man who finds himself attracted to men and women), but the words themselves tend to make us think of reality wrong. Words should help reveal the way things are; doubtless, many people today believe that "intersex" and "bisexual" reveal the way things are, but since we believe that humans are male or female, I would disagree. I don't mean to be picky, but I do want to draw your attention to the use of a term that is non-medical and possibly unhelpful. I agree, however, that persons with ambiguous genitalia do not prove that sex is non-binary.
I’m going to (try) to apply the same principles to some (maybe not all) persons that identify as transgender. My understanding is that the current scientific theory about gender dysphoria is called the “brain sex” theory. Essentially, it confirms what we Catholics have been saying for a while: Sex and gender are deeply ingrained properties of the human experience. They are the result of many neurological and hormonal puzzle pieces that have to fall into place during development. For most people, all the puzzle pieces align and our biological sex and neurological sex are congruent. Most males feel as though they are male, and most females feel as though they are female. However, like most of human development, there are many other environmental factors that come into play. I am sure, as you have pointed out, that for transgender patients, the experiences of "broken early relationships or abuse, self-hatred, misunderstanding of femininity or masculinity) as well as the co-morbid conditions (domestic violence, high risk sexual behaviors, mood disorders, substance abuse, etc)” are all contributing factors into why they experience gender dysphoria. So, my conclusion is that for these people, they really do have a physiological justification for why their body does not feel right for them. They have a mismatch between their neurological sex and their biological sex.
I think this is likely correct, although the lines between neurological and psychological are difficult to pin down.
Now, this doesn’t necessarily justify any of the treatments or therapies I will describe below for this disorder, but I think that it makes an argument for why these persons may have a biological/neurological basis for their gender dysphoria. I have heard some relatively influential Catholic commentators use the term “gnostic” to describe these persons, and I really do think that this could be a mischaracterization of the conditions these persons face.
I don't understand why people use the term "gnostic."

So, moving on to therapies for gender dysphoria. I completely agree with you that these patients probably do need therapy to help them with: "broken early relationships or abuse, self-hatred, misunderstanding of femininity or masculinity) as well as the co-morbid conditions (domestic violence, high risk sexual behaviors, mood disorders, substance abuse, etc)”. However, and I certainly do not consider myself an expert in this vast and complex field, but my understanding is that there is little evidence that these reparative therapies for gender dysphoria actually work. From my understanding, the APA and American Academy of Pediatrics appear to be against using reparative therapies. Now, certainly, there is a political agenda with these groups and they are fallible organizations, but they are the experts in these fields and I haven’t found any convincing studies that would tell me why I should ignore their advice on these matters (if you know any, please shoot them my way!).
Finally, with regards to some of the more “dramatic” and irreversible therapies such as sex reassignment surgery and/or hormone therapy, my initial thought is that they would be similar to a preventative mastectomy/hysterectomy. The intent would be to relieve the patient of their severe mental suffering, and the sterilization would be the secondary effect in this case. I know that my thinking here is not as clear, but I don’t know if I necessarily agree with the comparison to elective abortion. Elective abortion is a grave evil precisely because it destroys a human life, which has infinite human dignity. There has been crystal clear teaching on this issue throughout Church history, beginning with the Didache. However, with regards to persons suffering from gender dysphoria, I sort of see this an attempt to help relieve them in some way of a neurological/biological mismatch that they are experiencing between their physical appearance and inward state. I sort of see it as a last ditch effort which does have proven clinical efficacy. I don’t like the fact that these patients have to mutilate themselves and recreate their bodies according to their “neurological sex", but I haven’t seen any therapies that are more effective.
Now some clarification: I am not a proponent of reparative therapy, which I understand to be largely in reference to people with SSA. SSA is just a desire and is not a sin, and reparative therapy is not the answer that the Catholic church extends. Unfortunately, many other Christian denominations with less philosophical patrimony, don't understand this yet. My hope is that they can, and the strange well-meaning punishment of people with SSA can stop.

If you're extending the concept of reparative therapy to those with gender dysphoria, you might be referring to therapists who don't help them through "transition" to the other sex. These therapists might try to redirect the person to their biologic sex or (dishonestly) promise transition therapies initially and put up walls, never intending to fulfill their promise. Before I go further, is this what you are referring to? I ask because I've never heard anyone refer to refusal-to-transition as reparative therapy.
I guess to put my point bluntly, I am wondering if (some, maybe not all) persons who identify as transgender could be allowed to undergo the sex-reassignment surgery and/or hormone therapy to relieve them of their distress? It seems to be clinically efficacious. I guess all the long emails before that were trying to justify why I reached this point. I know that this is definitely risky, uncharted territory in terms of Church ethics, which is why I was trying to use analogies to persons with ambiguous genitalia and down syndrome. If I am wrong, could you explain to me why? I am not trying to go against the Church’s teaching, and I also want to help these people and do what is best for them.
I and many theologians would bluntly reply that no persons who identify as transgender should be allowed to undergo sex-reassingment surgery or hormone therapy. Very bluntly: these patients' comorbidities should be managed and they should undergo significant psychotherapy for their dysphoria. Like other patients who are deeply uncomfortable with aspects of themselves (DID patients, body dysmorphic disorders), they should be helped to understand who they were created to be.

Here is my explanation for why. Our gender/sex is sacred and is inseparable from our soul. It's part of the way God makes us to be saints. Men and women are irretrievably different in ways we can only clumsily understand. Philosophers have tried and failed many times to identify what category of quality "gender" is. Poets and thinkers have tried to articulate what "masculinity" and "femininity" are but only come up with generalizations and analogies. This is a hard thing to understand! It's no surprise that people think that gender is something we decide on.

The same thing happened with sex and procreation in the 1960s, when Pope Pius VI commissioned faithful Catholics like yourself to research the idea of birth control. The so-called "birth control commission" concluded that our fertility is something we should manage rationally, like we do every other aspect of our lives. There were parts of the physical universe (chemicals/hormones) that we could use as sons of Adam to change our lives. Shouldn't we do this?

It is hard to see the truth: gender, sex, and fertility are sacred ground because they more than anything in the physical universe are signs of who God is and are avenues to make saints. Luckily Pope Pius saw the truth about contraception in 1968. I think you and I are called to see the truth about gender now. It can seem like a big "no," but just like contraception/NFP, it's a strange and important "yes."

Sunday, July 30, 2017

Quaeritur: Care of Transgender Patients (Part 1 of 2)

Recently a medical student emailed me a long and well-considered question.
I have a question regarding the care of transgender patients. Before I begin, I just want to say that I consider myself an orthodox, pro-life Catholic who is trying to follow Church teaching on this issue. I am not attempting to undermine Church teaching, and I do not want to be spreading heresy. Also, when I speak about transgender persons, I want to differentiate them from intersex persons (who actually do have ambiguous genitalia).

From what I have been reading about Church statements and Church teaching (from Pope Benedict and Pope Francis), there is a consistent condemnation of “gender theory”. This is something that I completely agree with. There is no such thing as “multiple genders” and those who claim there are are incorrect. During many of my LGBT lectures, they have included slides on how there are many different genders that someone can “define themselves” as. I think that for many people in the Church, this is what the transgender movement represents, and this is why there is such a strong backlash against many of its beliefs and ideas.

However, there are people suffering from gender dysphoria who are caught in the middle of this fight. Reading a lot of the stories of persons who really suffer from gender dysphoria breaks my heart. Many of these persons have co-morbid psychiatric illnesses, and many attempt and/or successfully commit suicide. They face a lot of abuse from family, friends, and sometimes Catholics/Christians. I didn’t provide the links with this email, but my understanding is that the current medical techniques to help some of these transgender patients are very effective for the majority of patients. Most transgender patients who undergo the hormone therapy and/or sex reassignment surgery really do experience psychological relief. I included a link here from a blog of a transgender Catholic who discusses Church teachings on this issue....

**Also, I want to clarify. My understanding is that most children who experience gender dysphoria grow out of it later in life, so if the Church were to approve of certain medical procedures, they would only apply to later in life.**

With all this being said, what do you think our role is as Catholics and healthcare providers for future transgender patients? Do you think it is ethical to help some, maybe not all, patients undergo hormone therapy? What about sex-reassignment surgery? Also, my understanding is that different transgender people cope in different ways. Some of them do not even want any medical interventions and prefer to cross-dress or just identify as the opposite gender, while some do have these interventions and then regret them in the future. The Catholic Church, from what I understand, does not have a clear teaching on this, but we are going to be in the front lines helping patients struggle with gender dysphoria.
This is a very important question. First, I am grateful that you are striving to be faithful to the truth and follow Church teaching. I understand that your questions is about persons who suffer from gender dysphoria (e.g. genetically XX individuals who feel male, or genetically XY individuals who feel female), not people who have physically ambiguous genitalia or people with SSA.

Let's clarify what Pope Benedict meant by "gender theory." In your email you define "gender theory" as the idea that there are multiple genders. (I'll stick with Benedict because he is a philosopher by training and was first among popes to articulate arguments about gender etc.) In his 2012 Christmas address, he used the word "theory" to describe the idea that our gender is not an innate property. The "theory" is that maleness and femaleness are not congenital, but societally or personally determined. I pasted the relevant paragraph from the address below my signature line for you. This means that what the Pope condemned is not only that male and female is binary (he states that this is a "duality" in the Christmas address); he also condemned that maleness and femaleness is something an individual can interpret or assign themselves. It's part of their nature and their nature does not lie. To make it very clear: the popes have said that we are born male or female, and that is our gender. Any distress we feel about our gender is a disorder.

I am not saying (and neither are the popes) that people suffering from gender dysphoria aren't suffering. They are, as you point out, in distress and sometimes constant revulsion, fear, or self-hatred. They do, as you point out, often suffer rejection and abuse from others. And they can experience psychological relief with transgender medical and surgical treatment.

Tell me what you think of this: the fact that someone is suffering and experiences relief after a certain therapy may not mean that the disorder causing the suffering should be treated that way. An easy example is elective abortion: it relieves the enormous distress of the threat to self and lifestyle that a mother-to-be faces, but it is not the right approach to that distress. If not all treatments that result in relief are the right treatments, then trans medicine and surgery may not be right for people with gender dysphoria. Indeed, many believe (as I do) that the right treatment for gender dysphoria is to dig to the root of the dysphoria and treat the cause (broken early relationships or abuse, self-hatred, misunderstanding of femininity or masculinity) as well as the co-morbid conditions (domestic violence, high risk sexual behaviors, mood disorders, substance abuse, etc).

The medical student sent me a response back, which is to follow in the next post.

Saturday, July 15, 2017

Third party reproduction

This post conforms to the blog rules.About a year ago, a gestational carrier of twins was admitted to our antepartum wing. Her condition required a long-term stay and she was not in her home state. To make matters more complicated, the presenting twin was not vertex. There was heated disagreement between the intended parents and the gestational carrier about mode of delivery because my attendings recommended a cesarean section for the twins. The carrier did not want a C-section. The physicians' hands were tied: we couldn't do a C-section on a non-consenting woman without committing assault and battery. But the agreement signed (while not designed for this state) did specify that the gestational carrier was to comply with physician recommendations on mode of delivery.

To translate into colloquial terms: about a year ago, a surrogate carrying twins for a gay couple came to our hospital while out of her home state. Because the first twin was not head-down and for a few other reasons, my attendings recommended a C-section for delivery. There was a painful, days-long disagreement between the surrogate and the couple, because the surrogate didn't want to have a surgery. We couldn't do a C-section without the surrogate's consent, but the contract signed by the surrogate and the couple said we should have been able to. ("Surrogate" is not a term preferred by the ASRM or third party reproduction lawyers.)

The ethics committee was, as I recall, rather unhelpful. No member of the healthcare team ever saw the agreement signed between the intended mothers and the gestational carrier. All residents whose names were not already in the chart were encouraged not to open the chart or see the patient out of concern for legal repercussions. The intended mothers of the children became rather forceful, asking that the healthcare team discuss matters with them before discussing them with the patient and lurking around the floor to catch any healthcare providers who might be discussing the case of their children. When it once appeared that the twins might suffer some adverse neurologic outcomes because of the disagreement, one of the mothers stated she did not want the child if there was brain damage.

All of this was a rather unpleasant ethical case that ended as well as it could, since the gestational carrier agreed to a C-section eventually and both babies were born. I have many dissatisfied feelings about the way all five people's lives changed during this pregnancy episode. I began to wonder whether the true nature of things (a contract about goods belonging to the adults) came out in the unpleasantness.

Recently my program has been adding more IVF experience for us. A few months ago I drove out to the IVF clinic of the new professor we'll be working with. As luck would have it, there wasn't much on the schedule and I didn't have to explain much. Although I've written about being "inside IVF" before, this one afternoon included actual experience of ARTs (two IUIs and an embryo transfer). Since I know how these procedures are done, in a way it wasn't earth shattering. But in another way, it was painful. By the end of the morning I felt nauseous and had to talk aloud with the Lord in the car about the experience.

Unfortunately, this isn't the end of this topic. I haven't covered it much on my blog, as I've mostly focused on contraception and sterilization. But now that I'm becoming a third year resident, who will spend two consecutive months on the REI service, it will become a topic of much more discussion.

Friday, June 30, 2017

Residency pre-Fellowship is Different (A Rant)

You know I work an average of 70 hours per week, and you can guess that making time to study is hard. You might not know how much there is to study. And did you also know that I'm expected to go to one conference per year and publish 1.5 peer-reviewed publications per year?

Let's start with the stuff that ACOG puts out. There are 79 Practice Bulletins and 236 Committee Opinions. Those are usually three- to fifteen-page documents, including references and tables. That sounds almost manageable, but then the Guidelines for Women's Health Care is 907 pages long and the Guidelines for Perinatal Care is 599 pages long. There are also seven Task Force documents, only one of which I've even opened (the Hypertension in Pregnancy report, which is a hundred pages long). Te Linde's is 1300 pages, Gabbe's is 1200, as is Creasy's. And then there are landmark papers that we are supposed to know.

Our program recently started giving us "homework" because our CREOG scores went down. I do not think this is the right answer for me. The answer is no more wasted lecture time, let me privately study and read. Don't give me extra materials, let me work through what I'm responsible for first.

And I'm also supposed to study obstetrics and gynecology while researching and furthering the field. This seems stupid in several ways, and I suppose the old way of doing it was that attendings did research and used medical students and residents as peons so that they could learn how to do it. I can't memorize study designs and statistical tests while also trying to memorize pelvic anatomy! In fellowship you have to do your own statistics and are usually responsible for higher-level study types (e.g. randomized controlled trials, bench science, etc), but you get a year without clinical responsibilities to do it. This week I clocked 70 hours and I presented a poster and submitted a manuscript.

Time spent researching is time not spent studying. Time spent reading a practice bulletin is time not spent reading a textbook (viewed by my program as better). Time spent reading a textbook is time not spent praying. This truth goes on and on for cleaning the house, sleeping, cooking, exercising, and recreating.

Recently I had a mentor meeting and we talked about the juggling act. "Residency is a different animal for you, compared to your peers who don't want to do fellowship," she said. "It's a fundamentally different thing." In my opinion it's fundamentally crazy. </rant>

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.

Src: www.catholicmedkc.org
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.