Health Law and RU-486

Despite the fact that I roll my eyes any time I hear anyone discuss law, I am going to attempt to blog about law.

This semester, my MPH cohort and I have been arguing every Tuesday in an amazing Health Law course. Our professor literally wrote the book on Health Law, and we have learned a lot of terrifying things about what we should and shouldn't do as doctors. Like give out free health advice. So, present friends - all of my present and future advice means NOTHING. I am NOT your doctor, and you should go see your real doctor if you are less than perfectly healthy. So throughout the course, all that my class of future doctors can do is groan in anguish that yet another case seems to say that even when the doctor tries to do the right thing, they are liable for their human mistakes and tough cookies, but they are going to pay the price.

Enough on law class. Now, a case. I recently researched this case for a meeting I helped host for pro-choice grad students in Boston (if you want to come to these meetings, let me know!!). The following is what I was able to decipher from the legal jargon, along with a heaping dose of my opinion, and a pinch of medical fact.

A woman from Idaho found an online physician to prescribe and send her an FDA approved pharmaceutical called RU-486, which she used to end her pregnancy (medical abortion). In the case (McCormick v. Heidman), the 9th circuit court decided that she could not be prosecuted because of limited access to abortion and her right to life and liberty (14th ammendment) up until fetal viability (24 weeks).

When patients are counseled and followed by health professionals, medical abortions are very safe. Women take mifepristone (RU-486) which blocks progesterone, causing the lining of the uterus to break down and the cervix to soften. Misoprostol completes the procedure, by causing the uterus to contract and empty. Women undergoing medical abortions experience some pain, cramping, and heavy bleeding. About 98% of the time, medical abortions successfully end the pregnancy with no complications. Few women may need a procedure to empty their uterus, very few women may need a blood transfusion, and of a whopping 1.1 million cases, only 7 have been fatal. Biggests risks: blood loss and infection.

If you know me at all, you know that I am pro-choice (and pro-life according to this great article). My issue is - if this woman got RU-486 online, how did the doctor know how far along she was, or if she was eligible for this type of abortion. This doctor is not available to help in the rare case of complication. The patient can't follow up to make sure the medication worked. There are definite ethical implications of this court decision. I am not sure if proper care can be given over the internet. Then again, if the government didn't limit women's reproductive choices and more physicians became abortion providers, these types of problems wouldn't be encountered. I am glad that the 9th circuit decided that McCormick could not be penalized for making a decision about what was best for herself and her family. I just wish that McCormick had more options.

On that note, you can find a pro-choice voter guide here --> CLICK ME!
(And Floridians - vote no on amendment 6!)

Broken Heart Syndrome

Today marks the halfway point in the cardiovascular block of second year.

I spent a lot of time figuring out how to read EKGs for different heart problems, and then got to diagnose someone in clinic the next day! My clinic partner and I correctly identified ST elevation, T wave inversion, and Q waves that suggest recent myocardial infarction (heart attack!). Not good news for my patient, but glad we caught it so that he could get a complete heart check-up to make sure he is okay. This is the progression of EKG changes in ST-Elevation Myocardial Infarction (STEMI):

Learning about heart disease is scary because it is soooo common and soooo serious. Not to mention that almost every risk factor for heart disease runs in my family. I better stay on my workout schedule!

Broken Heart Syndrome

Yesterday, appropriately enough, I saw a heart disease on twitter that we didn't learn about in class: Takotsubo cardiomyopathy. Because this heart disease is most commonly caused by emotional stress, such as the death of a loved one or a break-up, the condition is also known as broken heart syndrome. It is most common in post-menopausal women, and can also be caused by a physical stress to the body.

A = left ventrical apex weakening, B = octopus catching pot

The stress of heart break increases levels of catecholamines, which can cause sudden temporary weakening of the myocardium (heart muscle) at the apex of the left ventricle. The base of the left ventricle works fine, but the apex balloons out and is unable to pump well (akinetic), causing symptoms that mimic a heart attack (including chest pain and EKG changes shown above). The heart ends up looking like a Japanese octopus trap, a tako tsubo, hence the name of the disease. Luckily, these patients are unlikely to die of this disease if it is treated acutely, and the broken hearts heal in a few months.
The main difference between a broken heart and a heart attack is that these broken-hearted patients have little or no coronary artery disease. The stress causes their heart to dysfunction.

I'd say that broken heart syndrome calls for a prescription of ice cream, tissues, and support from friends, but these patients may also want some beta blockers and aspirin.

And for fun, a print of the heart that I made in an undergrad art class. Hearts are fascinating (and complicated) structures. My print may not be anatomically correct, but I dig it.