Friday, December 11, 2009

Fighting the Cynic Inside

I have always envisioned myself as becoming a doctor who would empathize with her patients. Regardless of they were, where they came from, or what they presented with, I always wanted to approach my patients with patience and compassion. Now, three weeks into my Night Float rotation, I am finding this vision much more challenging than I anticipated.

One of the wonderful aspects of my residency program is that our hospital runs its own Emergency Department for women of all ages, pregnant or non-pregnant, with any sort of acute OB or GYN issue. It is a high paced environment in which patients are rolling in with anything from labor, miscarriages, cancer complications, surgical complications, sepsis (aka widespread infection)… the list goes on and on. It makes for fantastic resident training.

On nights, when I am not in the delivery room or the OR, I am often found tending to these high acuity patients. After all, one would think that a person would have to be really sick to come into the ED at 1:00am, right? Ha. This is where the issue of my dwindling patience comes in. Let me introduce you to the 24yo non-pregnant female who came to see us last night. Her chief complaint? Vaginal SPOTTING between periods. In the setting of a history of irregular menses. I’m serious, this was a regular problem for her and she decided that one day of spotting was an emergency. She had gone through HALF of ONE pantyliner. Clearly not hemorrhaging. There are also the dozens of women each week who come into the Emergency Room after getting a positive home pregnancy test. I mean, really? You need to come in to the ED at 2:30am for a positive HPT?!? Oh, and the woman who “lost a tampon” in her vagina?

The icing on the cake was a patient I had the other night. She was a 20yo female who was pregnant with her THIRD child in the last THREE years. She had had ONE prenatal care visit during this pregnancy and not for lack of insurance or health care provider. She didn’t know her last period and as a result, we had no idea how far along she really was. Her chief complaint? She had come to the ED because she decided that she wanted a C-section that night. SHE decided. I was shocked.

I’ve seen many a bitter physician throughout my training - the sort that blame their patients for everything. I don’t ever want to become that person. Fighting cynicism, however, is an ongoing battle. Especially when you feel like there are so many patients who take advantage of our services.

Now I am educated enough to understand that our shabby health care system, with its limited access to primary care, is largely to blame. Our G-rated version of sex education has also left women so unfamiliar with their bodies that they run to a physician for the most minor issues. I also understand that WE were the ones who failed S.M. when we let her have two babies at our hospital and never set her up with reliable birth control. But remembering this is a struggle. I am resolved to doing it, to be the kind of doctor that I would want to go to. But it takes a conscious decision I make each and every day.

Tuesday, December 8, 2009

She Growns Up

I don’t know how it happened. But it finally has. I am starting to feel like a bona fide doctor.

As you can read in my previous posts, the first couple of months of intern year were racked with insecurity. For instance:

The first week of my intern year, my 2nd year resident and I got called to a postpartum hemorrhage on the floor. One of our recently-delivered patients was found to have active vaginal bleeding a couple hours after the birth of her child. We rushed to the bedside. There was blood all over the bed, her hospital gown, and her legs. She was crying. Before I knew it, my 2nd year bolted into action. She was calling for vital signs, IV access, Pitocin, Misoprostol. She shouted out an order for Morphine to make the patient comfortable. She gowned up into sterile gear and started a vaginal exam at the bedside. Before I knew it, she was using her hand to clear out the uterus. Out came handfuls and handfuls of clot. In less than 5 minutes, the uterus had been evacuated and the bleeding had stopped. I will always remember that moment in my intern year. It was one of awe – awe regarding my resident’s ability to keep her cool and bring order to a frantic clinical scenario. It was also one of terror – terror regarding the idea that in 1 year, I would be expected to handle that situation with the same level of calm and skill. It seemed a daunting task.

Fast forward to my first shift on OB nights. It was 2am. The high pitched squeal of my pager shot me out of my near slumber. “Postpartum hemorrhage, pt J.K. in room 5015.” I jumped from my seat and headed towards the elevator. On the ride up, I recalled the steps in the management of post-partum hemorrhage in my head. Before I knew it, I was running it. I was calling for vitals, calling for IV access, for Pitocin, Misoprostol. I was clearing out her uterus. I was calling for a stat hemoglobin. Before I knew it, the patient was stable and her bleeding had stopped.

It didn’t hit me until later, when I was recalling the experience in my head, that I had missed something. That feeling that had haunted me for months – the panic, the insecurity, the tachycardia – was not there. In its place was an excitement, a sense of pride, and a rush that shouted “yes! I did it!” Yes, folks, I am growing my doctor wings.