ramen and pickles

science, technology, and medicine served up with some tasty noodles

My experience with abortions

On my OB Gyn rotation, an optional component is being able to observe during terminations of pregnancies.  Because this is such a controversial topic, I thought others might be interested in reading about my experiences.  I wrote these thoughts down several years ago, and I recently found them again:

First, to give some background, one thing that I learned is that most abortions in the US are to women who already have kids.  That was my experience in the outpatient OB Gyn clinic as well, when women came in after just finding out they were pregnant, the only ones who asked about termination were older women who already had children.  In some cases, women were older and with some health problems of their own and taking medication when they got pregnant.  The first trimester is often the most sensitive time to toxic exposures, and women often do not know they are pregnant early on in the pregnancy, particularly if they have irregular menses at baseline.  Lots of medications, such as some of the common medications used to treat hypertension (e.g. lisinopril) increase the chance of fetal defects; advanced maternal age also increases the risks for lots of pregnancy complications and fetal abnormalities on it’s own, and I think a lot of the concern these woman had was both about not being healthy to take care of a baby, particularly one with potential health issues of its own. The statistic might also arise from unmarried women who are already taking care of a child, and are already struggling.  In any event, you can read about the demographics here:

https://www.guttmacher.org/media/presskits/abortion-US/statsandfacts.html

From what I understand, abortions are also an optional part of OB Gyn residency; some residents learn how to do abortions, some do not; it is their individual choice.  The same is true of other medical staff, they can choose to not participate.  In the hospital where I was observing, that meant that there were sometimes issues with staffing the procedures, independent of the doctors.  Termination of pregnancy is usually done in the outpatient (clinic) setting, but for some more complicated cases (such as in a pregnant woman with serious health issues), it is done in the OR.  Many of the scrub techs, circulating nurses, etc. did not want to participate, and there seemed to be a little bit of tension about this.  I’m not sure if it is also a problem when the patients go to post-op recovery, but from what I observed, everyone was taking care of the patients once their procedure was done.  The medical students just stand in the background watching.

One thing I also learned during my rotation as a whole is that abortions are sort of on a spectrum.  There are various kinds of pregnancy which are definitely non-viable, such as an ectopic pregnancy, molar pregnancy, an “inevitable abortion” (kind of miscarriage), etc.  In many cases, there is some sort of fetal-like material that needs to be removed using a dilation and curettage or other procedure.   Some women actually have very strong feelings about not having treatment to end their ectopic pregnancies or molar pregnancies, which actually can be quite dangerous to the woman’s health, as they are more like a quick growing cancer than a “pregnancy”.   However, it is also sometimes not so straightforward what is healthy and viable, and there is sometimes no bright line.

If you have strong anti-abortion feelings, and someone tells you they want to give you a drug to end your ectopic pregnancy (sometimes called a tubal pregnancy), you might react strongly to this.  We actually had a woman with an ectopic pregnancy identified in the emergency department leave for a little while, but she eventually came back.

As mentioned, many terminations of pregnancy can be done in the outpatient clinic, and I saw this being done once as well.  However, I also observed some done in the hospital OR.  These were done in the OR because the patient had particular health concerns or the fetus was of advanced gestational age.  In that way, my experience was probably biased, but most of the patients I saw had serious health problems, which is why they needed to have the procedure done in the controlled setting of the OR.  These same health concerns in many cases actually made being pregnant risky itself:

 

For example, for a woman with pulmonary hypertension trying to bring a baby to full term, maternal mortality statistics range from 30-50%.  Medical science is improving all the time, and hopefully these numbers will go down steadily, but trying to counsel a pregnant patient about these risks and options is a very hard thing to do, certainly emotionally, but also intellectually because these numbers are very “soft” without great studies behind them.

It is also worth spending a moment to mention the attending physician I was observing in the OR.  He was a man, and he was absolutely amazing when it comes to patient interaction.  Many of his patients were, perhaps unsurprisingly, quite nervous and stressed out.  He had an incredibly calm and empathic demeanor.  He also put a lot of effort into describing the procedure and what was going to happen to the medical students.  Talking to him a little bit at the end of the day, he gave some of his personal background.  As a young man, he was doing some medical work in Kenya as a volunteer, and he saw many women who had botched “back alley” type abortions, and it so horrified him that it became a very important part of his life’s work to help women get access to medical abortions.  It is also worth mentioning that in terms of demeanor and warmth to patients (and medical students) he was probably the best doctor I’ve observed in all of my clinical rotations (certainly one of the best); he himself noted that he actively cultivated gentleness in both his physical procedures and interactions because he thought the standards on a man in his profession were much higher.  To one patient in the post op area, he said, with the utmost sincerity: “Thank you for the privilege of your trust”,  I had never heard a surgeon come out of the OR and say something like that to a patient, and certainly not with that much earnestness.  I hope to cultivate such an attitude and warmth toward all my patient interactions.

The early gestational age terminations were very straightforward, a sort of suction like device removes some gloppy red, indistinct material (called the POC, products of conception), and then it’s over.  Very quick, gentle, and smooth.   For some of the patients, the issues were around things like how they were tolerating anesthesia with their other health problems, and the termination of pregnancy seemed like an incidental part of the process.

However, I also saw the termination of a 20 week pregnancy, and that was a completely different story.  This was in a very young teenage (nearly a tween) girl, and there was a fairly complicated and dark back story of how she ended up pregnant and why she was getting the termination done so late in gestation; I didn’t learn the details, and I was not going to quiz her or her family about it.

The medical students had been told a few times in advance that many people find these terminations from later in gestation unsettling, and that was definitely the case for me.  It was a “Dilate and Evacuation”, which is a more involved procedure:

 

In this case, the fetus is quite recognizable and basically has to be taken apart before it is removed in pieces.  Seeing it happen, it made me feel a bit sick to my stomach, and a sort of generalized feeling of melancholy swept over me.  This was the last procedure of the day, which was good because I didn’t feel like being there any more.

So that was my medical school experience with abortions.   I am grateful to the patients who let me observe.  I think it was definitely important to learn about, as I now have specific knowledge about what is involved if a patient asks me.

Overall, it has really inspired me to make sure I am able to give my patients good quality advice on contraception; although the women seemed grateful to have access to the abortions, clearly they didn’t want to be in that situation.  As there is usually a computer in clinic, now I try to show my patients this helpful infographic from the NY Times when they ask about contraception.  It shows different anticipated pregnancy rates with different forms of birth control:

 

Vaccination Thoughts on Labor and Delivery

I wrote this down a long time ago when I was doing an obstetrics rotation in medical school.  For this rotation, I had to do overnights in the Labor & Delivery unit, hanging around waiting for babies to be born to then run over and try to help deliver the baby, so I had some time to reflect and write down some thoughts while I was there:
One of the difficult things about rotating in Labor & Delivery is that I am surprised by how many parents are anti-vaccine.  There is currently a measles outbreak ongoing in California, and there is plenty of high quality vaccination information available online.  However, many parents still don’t want vaccination for their kids.
McSweeney’s has a satirical birth plan which is sort of summarized by:
While we do not have a traditional “philosophy” of “childbirth,” we have been heavily influenced by orthodox Wholefoodism and the “(d)well baby/good design” movement.
And it goes on to include the line:
We will not be vaccinating our baby. Please vaccinate all other babies on this floor.
That seems to be a lot of that sentiment going around, but it’s not just the very entitled alternative-medicine-seeking-people implied in the satirical birth plan who don’t want to vaccinate their kids, it’s just all sorts of parents.
Some people have even proposed suing the parents of unvaccinated children who spread disease to other children.   However, the people who publicly advocate against vaccination would seem to me to be the more guilty here, as I think the parents are victims of mis-information.  For example, Anderson Cooper recently interviewed former Congressman Dan Burton, who has long been a anti-vaccination advocate.   He still seems to be strongly telling parents not to vaccinate their children over mercury fears, despite all the evidence that Anderson Cooper presents.  If someone creates a website full of misleading information, is that person liable for that misinformation?  What about giving a public talk on the subject?  When is that person practicing medicine without a license?
It makes me sad, that I help deliver a baby, and it’s beautiful and healthy, and yet it’s not going to get protected from serious illness like measles.  The mother went through all that work, and there is a reason it’s called “labor”, and not getting the child vaccinated is like being unwilling to buy insurance.  Admittedly, vaccines are not entirely without some risks.  You’re injecting something, their could be an allergic reaction. Crossing the street and taking a shower also have risks of getting hurt in the process. However, something like acute disseminated encephalomyelitis is even more scary.

Battle of the Kimchi; Hipster vs Korean Grocery

Kimchi is a living things, so it can vary quite a bit over time, even from a careful maker.  However, I thought I would compare the kimchi made by artisanal foodie hipsters (Farmhouse Culture) vs standard kimchi sold in the Korean grocery store.

Now, is it fair to call the Farmhouse Culture team artisanal foodie hipsters, well, I don’t personally know the people who make it.  However, they make it in Santa Cruz, and sell it out of wooden barrels at high end farmers markets in the San Francisco Bay Area. Even if the people at Farmhouse Culture are not hipsters, they are certainly making it for and selling it to, hipsters.

Anyway, I digress.

The two different kimchis are quite different; you can see right away that the color and overall look is quite different.  The Farmhouse Culture version is much greener with visible carrot.  The Cham Kimchi is much redder, with visible red pepper flakes.  This difference is recapitulated in taste, with the Farmhouse kimchi having a much more green vegetable flavor, perhaps because of the leeks.  The Farmhouse also had strong ginger notes.  They were roughly equally spicy, but the Cham Kimchi tasted of more red pepper flavor.  You can buy giant bags of red pepper flakes at a Korean grocery, and in addition to the piquancy of the capsaicin, there is a very distinct pepper flavor.  It’s a lot less sweet than some of the other popular pepper types (e.g. jalapeño) and more astringent.  The Farmhouse also had more of the effervescence of a fermented food (but that might have more to do with timing of eating relative to packaging).  The Cham Kimchi had more fresh and rigid, chewy texture of the cabbage.

In terms of production, the Farmhouse seems to be entirely vegan, while the Cham Kimchi does use some shrimp flavoring.

I think if I were cooking with kimchi, I’d prefer the Cham, as it is more structurally robust and will add spiciness to the dish.  For just eating and snacking on kimchi, the Farmhouse has more complex and sweet flavors, adding to something else you are preparing (e.g. a fried rice) might add unexpected flavors and remain a less distinct element of the dish.

It’s worth noting at the Farmhouse Culture also makes a smoked jalapeño sauerkraut which is a little spicier than their kimchi.  It has a lovely, rich smoky favor that would be a complement to many other dishes, although it’s a bit too spicy (for me at least) to eat on its own.  I could see it as a great way to combine with something fairly bland (like a bowl of rice) to make a really tasty meal.

Happy probiotic snacking!

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Some tasty fusion treats in Honolulu

I particularly enjoy in Hawaii as I really like the fusion of Japanese techniques and Polynesian ingredients, and there are many other fusion influences (Portuguese, American, Filipino, etc.), so I thought I’d go through some of the unique and very delicious things you can get there.

First, Chef Morimoto is a celebrity chef known for starring on both the Japanese Iron Chef, but also the American version as well.  He has a string of restaurants around the world, but his branch in Honolulu, in addition to being a wonderfully elegant restaurant with lots of delicious things on the menu has something special.  It is pineapple tempura with jamon iberico on top and a wasabi tzatziki sauce.  This four way fusion (Japanese, Hawaiian, Spanish and Greek) dish is just fantastic.  The salty ham gets you first with the crunchy tempura, and then the wonderfully sweet and tart pineapple juice fills your mouth.  So good.  As a side note, pineapple is technically originates from Brazil, but now it is strongly associated with Hawaii.  Apparently the lack of pollinators are also what makes pineapples from Hawaii so delicious (they don’t get seeds) and why hummingbirds (which can pollinate pineapple) are barred from the Hawaiian islands.

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Photo from Paige S on yelp.

Second, another piece of deliciousness from Honolulu is the kalua pork Cubano from Waikiki Brewing Company.  Kalua pork is a very traditional slow cooked pork dish, the mainstay of luaus.  The Floridian style sandwich has the kalua pork, ham, homemade dill pickles, and Dijon mustard and then is cooked in a sandwich press.  Served up with one of the delicious brew pub beers (for example the amber ale), it’s pure deliciousness.

Third, if you’re looking for something a little (although not too much) lighter, then you may want to try some musubi‘s from one of the many Iyasume locations around Honolulu.  They have some main cafes and some express locations.  The Japanese o-nigiri rice ball might be most easily compared with the peanut butter and jelly sandwich (or maybe sandwich more generally) in the US; it’s a basic and simple snack that can be taken anywhere.  Miyamoto Musashi took them as snacks when he adventured around, at least in the novelization of his life, so they have a storied history.  It’s basically rice wrapped in dried seaweed to keep it packaged and contained.  Lots of fillings can be added, although I tend to prefer ume plums, pickled mustard greens (takana), cooked salmon, and beef and ginger.  In Hawaii they specialize in spam musubi, the spam can be marinated in a teriyaki like sauce and then browned slightly before putting it on the rice ball.  I like a variant which includes a little bit of shiso leaf and Takuan pickle.  Takuan is named after Takuan Soho the legendary Zen monk and tea ceremony master who serves at the mentor and spiritual guide for Miyamoto Musashi in the aforementioned text.  So when you are eating your musubi, it’s appropriate to have a moment of Zen.

Happy eating!

 







 

Ippudo Ramen, Westside, NYC

I finally got to try the Westside branch of Ippudo in NYC.   Ippudo, a branch of a chain from Japan, has had a location down in the East Village for years, and it was one of my most favorite ramen places.  It has been a bit of a “scene,” with an active bar area with lots of fashionable young people on dates or in groups.  Within the past few years, they openened another branch over on 51st street.

I was in a big hurry this visit, and I think that impacted my enjoyment of the meal a bit.  Luckily I was seated within 10 minutes (often Ippudo can have a long wait).

The crowd was attractive fashionable young people hanging out at the bar area having drinks, much like the I remember from the other location.  I was seated at the bar area next to a couple on a first/blind date; he was a young guy from Long Island with a fancy watch who went to college upstate and is now starting out in finance, and she was a premed at one of the NYC colleges. He actually knew a lot about ramen and Japanese food and spent a lot of time teaching her about it.   It was close enough seating that I basically couldn’t help but hear their whole date conversation, and I think that is probably reflective of the ambience of the place overall.

As a starter, I got a fusion maki full of vegetables (notice the orchid on the plate).  It’s nice to be able to get something light, as many ramen places just have side dishes like fried chicken and fried rice.

I got the torishio ramen, with a side of pickled mustard greens.  Overall the soup was excellent.  The broth was a delicious, light shio style.  The noodles were a little bit too Hakata style for my taste (I like a little more curly/springy and yellow), but good.  The add-ins were delicious.  The egg was very good.

Overall, like the one in the Village, this Ippudo has excellent food.  It’s one of the most fashionable and up-market ramen joints I’ve ever been in, and you may have a long wait if you go during a busy time.

I don’t know if Ippudo is still one of my favorite places in the world for ramen, but it’s still quite good, and worth a visit if you go to NYC.

As a side note, apparently the chain in Japan itself isn’t really something super special; it is just the NYC locations that have become so hip and fashionable.  I guess it’s a bit like McDonald’s in places like Russia and Brazil; in the US obviously nothing special or particularly a destination, but when the first McDonald’s opened in these places, it was definitely a destination for the hip and well off youth.

 

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Ajisen Ramen, Westfield Mall, SF

Down in the food court in the lower level of the Westfield mall in San Francisco, facing the south side of Market, there is Ajisen Ramen.

It’s an underground food court, but the ramen place has it’s own seating area (not the communal food court seating), so I guess everyone in your party has to eat ramen (or katsu don or whatever else strikes your fancy on their menu).

The staff was incredibly friendly.  The menus were colorful with pictures of everything you can order.  I ordered the Ajisen ramen.  It was a white broth with cabbage, black mushroom, a marinated egg, and chashu.

Overall the broth wast decently rich and tasty.  The noodles were good.  The chashu was okay.  For some reason I really liked the consistency and mouthfeel of the cabbage and the mushroom.  The egg was really disappointing.  You can tell from the picture it has a smooshed sort of appearance and that tells you something about it’s hard mealy consistency.

Overall, Ajisen was an okay place for a mall food court chain.  It was good to get warm bowl of soup on a cold San Francisco evening, but I wouldn’t head to it as a destination.

 

 




 

Noraneko Ramen, Portland, OR

Norneko Ramen is a somewhat hard to find, but tasty place in Portland.  It’s by the people who started Biwa, and has some of the really delicious chicken karaage on the menu.  The fried chicken is a definite recommend here.  It has a lot of the Portland-hipster feel with nice wood, but something about the building makes you feel a bit like community college cafeteria.  The people that worked there were super nice and friendly (lots of people who came in asked tons of questions), and that is true of some of the customers.  However, some of the other customers we encountered on a fairly busy weekday at lunch were really obnoxious entitled acting hipster jerks, who were loud and rude about things like not wanting to wait, issues with getting the seats they wanted, etc.  It was very different from a Japanese ramen-ya experience in that way.

The shio ramen you can see was very good, with delicious melt in your mouth chashu, great soft boiled egg and other add-ins.  They also had a umeboshi soda (basically umeboshi with club soda and I assume some extra sugar), very delicious and highly recommended.

Overall, a definite recommend, but it is a seemingly odd part of town, and I don’t know what you’d be in the neighborhood to do other than going here, but it’s good enough to make it your destination reason for being there.

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Umami Burger, Pickle Plate – again

I mentioned the Umami Burger pickle plate  in a previous post.

I visited the location in San Francisco this time and tried the pickle plate.  The carrots and cucumbers were good.  I was less enthusiastic about the other pickles.  I don’t even remember what they were now.  However,  I thought I would share the photo for completeness.

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Ramen Bar, Philadelphia

Ramen Bar in Philadelphia is a tasty destination when you’re in town.

I got a traditional shoyu ramen with chashu.  It was solid, very traditional.  It’s been a while since I’ve gotten a slice of naruto fishcake, so that was a welcome addition.   It was tasty, and it was nice to find a really solid bowl of ramen in that part of the East Coast.

 

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Cosmopolitan, Las Vegas

This was a bit of a surprise, but the Cosmopolitan Hotel/Casino has pork ramen on their room service menu.  The hotel is supposed to get a David Chang’s Momofuku branch soon, so maybe this is part of that planning.  It would be awesome to get Momofuku as room service.

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The ramen was actually surprisingly good.  There wasn’t enough broth, as you can see from the picture (I haven’t had any yet), although maybe they underfill the bowl, as they put cling wrap on it and have to transport it up to the room.  However, the broth was good.  The egg was deliciously soft-boiled.  There were good onions.  The chashu was some of the most bacon like pork in ramen I’ve ever had.  It was a bit like cross grain thick cut bacon; however it was very smoky and tasty.  The noodles were the more thin and wheaty hakata style that is not my favorite (I like thin noodles, that are more crunchy and yellow, but that is just a taste thing).

Overall, the fact that you can get it delivered (still hot) and enjoy it from a view means I definitely have to give this ramen a strong recommendation.

 

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