Let's talk about sex, baby

Lately, there has been a lot of talk about sex. From the lecture I had today on contraceptive counseling to the recent public debate over federal funding for Planned Parenthood to the omnipresent national abortion conversation. For some reason, I thought that people had at least some basic knowledge about sex and contraception from either their parents or their junior high health classes or, hey, the internet. Apparently this is not the case, so let's clear a few things up.

1. “The fact is that 95 percent of the contraceptives on the market kill the baby in the womb,” said Jim Sedlak of the American Life League.

INCORRECT. The American College of Obstetricians and Gynecologists defines pregnancy as beginning with the fertilized egg’s implantation. Even if you believe that life begins prior to that - at the joining of sperm and egg - the majority of contraceptive measures intervene BEFORE the sperm and the egg meet. Let's review:

a. Hormones (aka the pill) - birth control pills prevent a woman from ovulating. If there is no egg, there is nothing for the sperm to fertilize and thus no baby is formed. The pill also has the happy side effects of decreasing the risk of ovarian cancer, reducing acne, and decreasing period-related pain. There are plenty of reasons women take the pill that have nothing to do with sex; it is a first line treatment for dysmenorrhea, endometriosis, ovarian cysts and fibroids.

b. Intra-uterine device (aka IUD) - One form of IUD, the Mirena, contains hormones and thus partially acts via the same mechanism as the pill. All IUDs also cause alterations in cervical mucus, which prevent sperm from being able to fuse with an egg. There are enzymes in cervical mucus that aide the sperm in 1) getting to the egg and 2) penetrating it. Without these cervical enzymes, fertilization does not occur.

c. Condoms - okay, I should hope this is self-explanatory. If the sperm is in a wrapper and not in the vagina, it's not going to make contact with an egg and create a baby.

2. If I have anal or oral sex then I won't get STDs.

INCORRECT. In fact, if you are having anal sex you should be getting regular anal pap smears. A cotton q-tip is swabbed in the anus and the cells analysed the same way they are for a cervical pap smear. HPV will do the same thing to the cells in the anus as it does to the cervix: cause cancer. Recall that some strains of HPV do not cause symptoms so you're not safe just because you don't have warts. Famous case: Farrah Fawcett died of anal cancer. HPV has also caused a rise in mouth and throat cancers, however we do not routinely swab for oral HPV at this time.

3. Guardasil (the HPV vaccine) is only for girls.

INCORRECT. It has been FDA approved for men as well. Men can transmit HPV to their sexual partners and, when infected, HPV causes an increased risk for penile cancer (still rare though). HPV will cause anal and oral cancers just as effectively in men as women.

4. “Fertility and babies are not diseases,” said Jeanne Monahan of the Family Research Council’s Center for Human Dignity

SORT OF. Many physicians consider pregnancy a natural and healthy state; however it does have a diagnosis code (an ICD-9) and it does dramatically and sometimes permanently alter the physiology of the mother. If it were totally benign we wouldn't require so many pre-natal visits, lab tests, ultrasounds and testing. There are diseases a woman can have that make pregnancy a clear and present danger to her health, even potentially fatal. There is also the issue of implantation in an abnormal part of the body (ectopic) which is also extremely dangerous to mom.

Public debate is healthy and I don't expect everyone to hold the same opinions as me; however I think is important that we are at least factual and informed about the topic. Let's not pass laws in ignorance.

On scrubbing

I have recently spent several weeks on surgical services within ob/gyn. It's been much more interesting and fun than I expected, however there were a few surgeries where the fellow or the attending told me *not* to scrub in. I was still in the OR, observing the surgery, being asked questions and being taught, but somehow, it's not the same. When you're scrubbed in two things happen: you have a much higher chance of participating in some way and you feel like part of the team.

The first point - participating - is exciting. Throwing stitches, retracting, using electrocautery and various scopes are skills that are difficult to learn well without practice. Truthfully, it makes the surgery a little less boring as well and keeps your attention on what is going on and not on what the anesthetist is doing, what time the clock reads, or the conversations of the circulating nurses. More importantly, it is usually impossible to get a good view of what is being done below the incision if you're not part of the sterile field. This means your ability to learn anatomy and technique are compromised when you're not scrubbed.

The second point - feeling like part of the team - is important in encouraging the morale of the medical student, something surgical fields traditionally struggle with. In general, as a medical student I aim to be useful or, at minimum, not be a drag on my team. Getting told not to scrub is like being put on time-out. Either you've done something wrong or there is no possible way in which you can contribute - not even to hold the skin open. Talk about feeling small and unwanted.

It takes very little to make a medical student feel good and we spend most of our time feeling tired, understudied and unhelpful. It takes time to teach us and we're aware of that. Residents and attendings frequently go home later when they spend time including and teaching us and we're grateful when they do. But it takes no extra time to let us scrub and observe from within the sterile field, so c'mon, throw us a friggin bone here.

subcuticular stitches

When closing the skin after abdominal surgery, one has two options: staples or subcuticular stitches. Staples are quicker, but subcuticular stitches leave a prettier scar. Subcuticular stitches are also one of the few things a medical student may be allowed to do in the OR causing an interesting phenomenon: the surgeons are artists within the body. They do an amazing job and while you may feel better, you will likely not be able to see their work. On the other hand, the medical student's skin stitches will be on display for you and others for the rest of your life. The least experienced person in the room is doing the most aesthetically relevant portion of the procedure (under supervision, of course).

I was recently allowed to do the subcuticular stitches on a women after her abdominal sacrocolpopexy and right-salpinooopherectomy. I am slow at them, but I do a decent enough job. The following morning when I went to pre-round on the patient, she told me she married her husband while he was in medical school. She looked straight at me and asked, "did they let you close?" I nodded. She replied "let's get this dressing off and see if you're any good." I convinced her to wait until the resident joined us for work rounds and he took the dressing off. As he peeled it off, she peered at her abdomen. "I approve." The resident looked puzzled and I was beaming. Excellent start to the day.

It's a little frosty in hell

I can't believe I'm about to say this, but after two days of orientation I am actually excited to begin Ob/Gyn. It seems like a really fun mix of procedure, continuity and okay, some clinic. We did some training on the laparoscopy instruments today and it was very cool. Holy crap. After two years of swearing up and down this is the last thing in the world I would ever do...

On the other hand, I still don't think I would be a psychiatrist, so they aren't ice skating in hell just yet.

X vs Y

According to my pathology review book, if you have an extra copy of the Y chromosome (male) you are more likely to have severe acne and be a violent criminal. If you have an extra copy of the X chromosome you are likely to have menstrual abnormalities.

If you have two extra copies of the female chromosome you will have mental deficiencies, but if you have two extra copies of the Y chromosome you will be dead.

Happy thoughts...

Dr. V on maternal mortality:

" That's about 6 jumbo jets per day that crash full of pregnant women and they all die."

Yesterday afternoon's class consisted of watching a video of a cesarean section and a second video of a vaginal birth (all the funnier because it was filmed in the '70s). You may be surprised to learn that I would still prefer a cesarean. Neither looks like fun so maybe .... no kids. But, accidents happen and in that case... I'll take the surgery.