In my line of work there is sometimes a fine line between cruelty and kindness. Sometimes the line can seem to blur. Hang around me long enough and you will probably be shocked at some stage.
The guy had apparently fallen asleep next to his fire. When he rolled over into it his alcohol levels ensured that he only woke up once his legs were well done. Someone found him and brought him in late that night.
When I walked into casualties I could smell him. You can almost always smell the burn patients. I took a look. The one leg actually wasn’t too bad. It had an area of third degree wounds but they weren’t circumferential. I could deal with that later. The other leg, however, had the appearance of old parchment from about mid thigh to ankle right the way around. This could not wait for later.
In third degree circumferential burns, the damaged skin becomes very tight. Constricting is actually a better description because unless it is released the taught skin will so constrict the leg’s bloodflow that if left untreated the patient’s leg will die. It is like a compartment syndrome only the entire leg is the compartment. Interestingly enough in third degree wounds all the nerves have been destroyed so in these areas the patient has no feeling whatsoever. That means when we do the release (an escharotomy which is cutting the dead skin along the length of the leg in order to release the pressure and thereby return the bloodflow) no anaesthetic is needed. You just cut the skin and as soon as you hit an area that the patient feels you’ve gone too far. If you do it right they will feel nothing. The longer you wait the higher the chance that he will lose his leg. I knew what I needed to do. I also knew my students might never get to see this again before they might have to do it themselves in some outback hospital in their community service year.
I asked for a blade and gathered my students around me. I sunk the knife through the dead skin and ran it down the length of the leg. The wound burst open as the pressure was released. The patient didn’t flinch. Quite a number of the students did. One excused herself and ran out. I think she might have been crying. Despite me telling them that it wasn’t painful and it was in the best interests of the patient to actually see it was more than most normal people could take.
When I wrote my last post and expressed a form of traumatic stress I found the contrast within myself compared to this incident quite interesting. everything seems to be relative and during the job there will be things that leave scars and many things that traumatise/desensitise us. I was ok doing what that one student obviously thought was gruesome and bizarre because I was convinced it was in the best interests of the patient. When I did this procedure which, on the face of it, is so much more brutal than taking someone to shower, I was ok, but the shower incident was terrible for me. I ended up hoping the student didn’t see me as quite that monsterous. I also hoped she would get over the trauma I had inadvertently caused her.
Transgender issues have been in the news with the recent announcement that Cher’s daughter, Chaz Bono, is transitioning from female to male. This subject has been plagued by misunderstanding and fear of the unknown. Transgender children are often shamed, bullied, and made to feel totally alone. As adolescents and adults, they face denial of adequate medical coverage and other forms of discrimination – and worse. Just two months ago, a Colorado man was found guilty of murdering an 18 year old transgender woman in what was judged to be a hate crime.
Chaz’s decision to go public with his private struggle is extremely brave. His publicist said,
“It is Chaz’s hope that his choice to transition will open the hearts and minds of the public regarding this issue …”
Step one in reaching the public is defining terms. The terminology surrounding gender issues can be confusing. “Transgender man,”, “transmale,” and “affirmed male” have all been used to refer to a biological female who transitions to a male. I found a glossary of transgender terminology offered by the NCTE to be extremely helpful.
What exactly does transitioning mean? It’s the period during which somebody starts to live as his/her new gender. It can include changing a name or legal documents, taking hormones, and getting surgery. One misconception is that transitioning requires surgery. It doesn’t. As Mara Keisling, the Executive Director for the National Center for Transgender Equality (NCTE) told me, “Most transsexuals don’t get surgery. This is about gender identity, not about genitals.”
There’s a lot of controversy and confusion but experts agree on two crucial concepts:
1) Being transgender is not a choice.
2) Biological sex and gender identity are two different things.
There are people whose external appearance is female but who have felt they were male since they were toddlers – and vice-versa. Norman P. Spack, M.D., an endocrinologist at Children’s Hospital in Boston, Dept. of Pediatrics, Harvard Medical School, has been treating transgender patients since 1985 and significant numbers of teenagers since 1998. Most of his patients have told him “as far back as they can really remember that they were in the wrong body.” Dr. Spack said, “there’s a heavy skew to under 6 years.”
Dr. Spack points out that because transgender has been labeled as a psychiatric illness (“Gender Identity Disorder”) by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), patients are not adequately covered by health insurance. He says that the insurance industry will cover psychiatric costs but denies hormonal and surgical therapy, claiming they are non-covered cosmetic treatments. A step forward came in 2008 when the American Medical Association House of Delegates passed a resolution supporting “public and private health insurance coverage for treatment of gender identity disorder in adolescents and adults” and opposing “categorical exclusions of coverage for treatment of gender identity disorder in adolescents and adults when prescribed by a physician.” But for now, many transgender patients continue to receive inadequate medical coverage and therefore inadequate medical care.
Nobody knows how many transgender people exist. The very definition of transgender can differ from study to study. Some only count people undergoing hormonal/surgical treatment; others rely on self-identification. In the Netherlands and Belgium, estimates based on patients receiving surgery and/or hormones were about 1 in 12-13,000 for transfemales and 1 in 30-34,000 for transmales.
But Mara Keisling told me those estimates are way too low. “Our best estimate is that one quarter to three quarters of one percent of Americans are transsexuals.” That’s 2.5 to 7.5 in a thousand. Dr. Spack’s estimate is about one in a thousand.
We are not close to understanding all the variables that go into determining why someone feels trapped in the body of the wrong sex. Parents often feel guilty but the wide consensus is that parenting does not cause a child to be become transgender. Research in animals suggests that there are critical periods of development during fetal or neonatal life during which exposure to testosterone influences the sexual differentiation of the brain But we’re far from putting together any sort of unified theory of gender identity that weaves together genes, cell biology, hormones, brain wiring, and nurturing.
Experts stress that transgender is part of a wide continuum of gender identity. As Stephanie Brill and Rachel Pepper say in The Transgender Child: A Handbook for Families and Professionals, “Today, gender can no longer really be considered a two-option category.” They emphasize the importance of patients and families understanding that they are not alone and that there are competent professionals who can help. They say they wrote the book, which I found to be very helpful, to “provide caring families with helpful tools they can use to raise their gender-nonconforming children so they may feel more comfortable both in their bodies and in the world.” The authors quote Dr. Spack who, referring approvingly to the Dutch treatment of adolescents by delaying puberty and giving them hormones, said: “Suicide attempts, so frequent elsewhere, are almost unknown because parents and children know that they will be taken care of and will ultimately join a society known for its tolerance.” Referring to his own patients, Dr. Spack told me “They may be anxious, they may be depressed, but many, many no longer have psychiatric diagnoses after they are treated properly.”
In today’s video segment of CBS Doc Dot Com, I speak to Dr. Ward Carpenter of the Callen-Lorde Community Health Center in NYC, a facility that provides care to patients across the spectrum of gender identity and sexuality. In the segment that follows, Dr. Carpenter explains what surgery and hormones can entail. A warning: it’s a graphic description. Its purpose is not to shock but to educate. Hopefully, better education will lead to less misunderstanding, less fear, and wider acceptance for people like Chaz Bono.
Other Resources:
NCTE: Understanding Transgender Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline
True Selves: Understanding Transsexualism by Mildred L. Brown and Chloe Ann Rounsley
Directly imaging dynamic biomolecular processes can reveal secrets which scientists have been trying to uncover in indirect ways. The interaction between various virus species and the immune system is one of those topics that would benefit from novel visualization techniques. Now researchers from the Howard Hughes Medical Institute have imaged, with considerable detail, a rotavirus as it is grabbed by an immune system molecule. The technique may allow the development of better vaccines against not only rotavirus, but open a large range of research possibilities in the life sciences.
In the new experiments, Howard Hughes Medical Institute (HHMI) researchers have mapped the structure of an antiviral antibody clamped onto a protein called VP7 that stipples the surface of rotavirus. The structural map reveals intimate new details about how the antibody interferes with VP7, a protein that helps the virus infect cells. The information may be useful in designing a new generation of rotavirus vaccines that could be easier to store and administer than current vaccines, said the researchers.
Rotaviruses replicate mainly in the gut, where they infect cells in the small intestine. The virus has a triple-layered protein coat, which allows it to resist being chewed up by digestive enzymes or the gut’s acidic environment. Rotavirus does not have an envelope covering its protein shell. A virus’ envelope helps it enter host cells, and viruses without envelopes face significant hurdles in penetrating the membrane of the cells they infect. “Since they have no membrane of their own, they must therefore perforate a cellular membrane to gain access to the cytoplasm (the interior of the cell),” [HHMI investigator Stephen C. Harrison] said.
The new research shows that as rotavirus matures inside an infected cell, it assembles a kind of “armor” coating made principally of VP7 and a “spike” protein called VP4. When the mature virus particle exits one cell to infect a new cell, it perforates the endosomal membrane of the target cell by thrusting in its VP4 spike like a grappling hook.
The virus’ ability to infect cells depends on a critical structural change that quickly removes the coat from the interconnected VP7 proteins — an event that unleashes the spike protein. Although researchers still do not know precisely what triggers the uncoating of VP7, they do know that it appears to happen when the virus senses a lowered concentration of calcium in its environment.
“VP7 sort of closes over VP4 locking it in place like the metal grills that surround a tree planted on a city sidewalk,” explained Harrison. “And it is the loss of VP7 in the uncoating step that triggers VP4 to carry out its task.”
To get a closer look at how antibodies latch onto VP7 and neutralize the virus, Harrison and his colleagues used x-ray crystallography to examine the molecular architecture of VP7 in the grasp of a fragment of the antibody. X-ray crystallography is a powerful tool for “seeing” the orientation of atoms and the distances separating them within the molecules.
Before Harrison’s team could use x-ray crystallography, however, they first had to crystallize VP7 in complex with the antibody fragment. Only after that step was completed, could they move on to bombarding those crystallized proteins with x-rays. Computers helped capture the diffraction patterns that emerged as the x-rays scattered from the crystal lattice. By rotating the crystallized protein complexes through multiple exposures, the researchers could record enough data to calculate three-dimensional models, which exposed the underlying architecture of VP7 and the antibody fragment.
The resulting detailed structural map of the VP7-antibody protein complex revealed that the antibody neutralizes the virus by preventing the VP7 proteins from dissociating, said Harrison. “Normally, calcium creates a bridge between VP7 molecules that holds them in place until uncoating,” he said. “Our structure revealed that the antibody makes an additional bridge, cementing the subunits together, making the virus resistant to the uncoating trigger and preventing it from infecting cells.”
Current rotavirus vaccines consist of weakened live virus that triggers the immune system to produce neutralizing antibodies. However, the new structural findings suggest how researchers might engineer a different type of rotavirus vaccine consisting only of immune-triggering protein, said Harrison. This protein-only vaccine could be made of a chemically linked complex of VP7 molecules that would stimulate the immune system more vigorously to produce anti-rotavirus antibodies.
While live-virus-based vaccines have been effective, said Harrison, they have drawbacks that a protein-based vaccine might overcome. The virus-based vaccines are perishable and require refrigeration, but vaccines based on proteins are more stable and can be stored at room temperature. Another benefit, said Harrison, is that protein-based vaccines could be combined with other protein vaccines in a “cocktail” that would cut down on the number of clinic visits since blending cannot be done so readily with virus-based vaccines. These advantages could make protein vaccines especially useful in developing countries that lack an extensive public health infrastructure and where the vast majority of childhood deaths from rotavirus occur, Harrison said.
Abortion and the intense debate about it in an otherwise enlightened (?) country was the topic of two of my earliest posts in this blog (this post and this one). I posted again when it looked like the debate was going to start in India. Thankfully, it died a natural death.
Those of you who follow me on twitter know that abortion has been on my mind following the sickening murder of Dr. Tiller. For the record, I didn’t even know that there existed such a doctor as he till I chanced upon news of his death. I refrained from writing anything here as I figured I had stated my views already.
The abortion “issue” is such a hot topic that I have never written about it on this blog until today. I hope I won’t regret that decision but I felt it was appropriate to respond to this medical student’s essay – and the ~560+ comments that follow it – as a physician who has witnessed (but never performed) about 100 abortions. Let me explain.
Also read the medical student Rozalyn Farmer Love’s post, My Choice, in the Washington Post.
I’m a third-year medical student at the University of Alabama at Birmingham. I plan to become an obstetrician-gynecologist. I dream of delivering healthy babies, working with families and supporting midwifery. But as part of my practice, I also envision providing abortions to women who need them. …
I agree that ending an unwanted pregnancy is a tragedy. When I advocate for reproductive rights, for choice, I don’t claim that abortion is morally acceptable. I think that it’s a very private, intensely personal decision. But I was stunned when one of my professors, a pathologist and a Planned Parenthood supporter, told me that decades ago, entire wings of the university’s hospital were filled with women dying from infections caused by botched abortions. It’s clear that women who don’t want to be pregnant won’t be deterred by limited access to providers or to clinics. And I believe that it’s immoral to let them die rather than provide them with safe, competent care.
The lines that affected me the most were…
I plan to choose a residency program that provides further training — a place where I won’t worry that asking to be taught to perform an abortion could somehow limit my future options. At the start of medical school, I was very careful about how I presented my pro-choice views to the faculty for fear that I could jeopardize my grades or hurt my chances for recommendations or of being accepted into a program run by any of the professors. This experience of treading lightly is unique to medical students in more conservative parts of the country, where opposition to abortion is widespread…
I was equally moved by these lines from Val’s post…
I initiated rapid sequence intubation with the assistance of the anesthesiologist, and then moved to get the ultrasound machine to visualize the uterus and its contents. Much to my discomfort the fetus was fairly large – and was moving around normally, even sucking its thumb at one point. I asked the Ob/Gyn resident why the fetus was being aborted since it didn’t appear to have any structural abnormalities. She responded that the mother simply didn’t want to have the baby, and had wrestled with the idea of abortion for a long time before she made her final decision. The rest of the procedure is a bit of a blur – with details too graphic to describe here. But suffice it to say that the resident performing the dilatation and curettage had a fairly difficult time removing the fetus through the cervix, and had to resort to eliminating it in smaller parts, rather than a whole. It was very sad and it took a long time to make sure that the uterus was fully evacuated. I decided that I couldn’t watch another one of these procedures.
All I can say to Val is: Do not visit any ObGyn procedure room or OT if/when you visit India.
I did not set out to write this to hand out that gratuitous bit of advice to Val. I wanted to highlight something else that she had written that caught my attention and raised some doubts.
In my opinion women should have the right to choose to have an abortion, but I’d hope that they also consider their right to choose to give their baby up for adoption as well. Some believe that an abortion is “easier” than giving up a baby for adoption – but I’m not so sure that’s the case from an emotional perspective.
I want Val and all those who share similar views re. adoption as an alternative to abortion to read this moving essay by Judy Brown in which she says When Abortion Was a Crime, I Would Have Sought One. Read the entire essay and pay particular attention to the two paragraphs at the end…
There are approximately 500,000 children in the foster care at any time in the United State — many of those children are adoptable, but will not be adopted — why don’t “pro-life” advocates step forward to adopt them now? Do they want the forced return to warehouse orphanages for still more unwanted children? Do they want women sent to prison for seeking an abortion, and doctors also jailed, when we already have a shortage of doctors in this country? And nurses jailed, when we have a shortage of nurses in this country? How much damage and destruction of life will they support to force the rest of us to subscribe to their “religous” views? I’ve never heard a so-called “pro-life” advocate answer those questions honestly. Making abortion illegal will not stop abortions, it will just stop safe abortions, as is the reality in the few civilized countries in which abortion isn’t legal, but their abortion wards are full to bursting with maimed women, and whose morgues overflow with dead women.
I agree with Val’s concluding paragraph that Rozalyn, the third year medical student may change her mind after witnessing or performing a few procedures.
Even in a country where abortion is a non-issue, I believe there are many medical professionals who are troubled by late trimester abortions and abortions-on-demand. I am one such. But the sad reality is that we are the minority here. I feel particularly sad because occasionally in my professional role as a diagnostic radiologist I am the cause of some of these wrenching cases of late trimester abortions. Some of them I can agree with, though they could have been avoided by earlier diagnosis and decision-making, like an anencephaly being diagnosed at 35 weeks gestation. But most are not that morally or ethically clear cut.
Cell phones are their feature are an ever growing topic in today’s families. It used to be that the hot button issue was whether to get the phone. Now, we have to deal with all the features: texting, Internet, camera…to name the tip of the iceberg!
Clearly we’re becoming a more mobile society with our cell phones taking over features previously reserved for our computers. A recent Nielsen Wire report confirms this observation showing that in Q1 of 2009 21% of cell phone owners used their phones to search the Internet, up from 16% in Q4 of 2008.
At the moment, digital plans are pricey so it’s easy to lock our kids out of their cell phone Internet access. However, not too long ago we said the same exact thing about texting and now we have affordable unlimited texting plans.
Given the impulsivity of tweens and teens and how difficult it is for us to help kids with appropriate Internet use on computers, do we want to open the door to having them have access to the Internet on cell phones? Once data plans become more affordable, should we let them have cell phone internet access?
Perhaps it would be easier to answer if asked slightly differently. How are our teens and tweens doing with the digital cell phone freedom they have right now? Given the rise of extreme texting and sexting, I’d say not so great. Before we open the door to new issues and digital freedoms they are not ready for, we have to help them more with the freedoms they already have – and are clearly struggling with. Plus, as parents, we are still sorting out the issues with the digital uses of technology our kids are currently using. Let’s sort those out first before we give the green light to other mobile freedoms that will certainly be more complex and harder to control.
If all goes well, data plans will remain unaffordable for a while longer so we won’t have to cross another digital bridge none of us are ready for.
*This blog post was originally published at Dr. Gwenn Is In*
It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…
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In my line of work there is sometimes a fine line between cruelty and kindness. Sometimes the line can seem to blur. Hang around me long enough and you will probably be shocked at some stage.
Directly imaging dynamic biomolecular processes can reveal secrets which scientists have been trying to uncover in indirect ways. The interaction between various virus species and the immune system is one of those topics that would benefit from novel visualization techniques. Now researchers from the Howard Hughes Medical Institute have imaged, with considerable detail, a rotavirus as it is grabbed by an immune system molecule. The technique may allow the development of better vaccines against not only rotavirus, but open a large range of research possibilities in the life sciences.
