Sunday, August 1, 2010

Seriously, What Do I Know?

Obstetrics is humbling. Just when I think I know enough about OB/GYN that I can predict a patient’s course in labor, I have a patient whose uterus, cervix, or baby does something completely unexpected. It’s as if God himself is reminding me of my limits.

Take patient A. About a week into my stint as new OB 2nd year/labor floor queen, a 28 year old multip (a woman who has delivered more than 1 baby before) was admitted in active labor. When she first arrived in Triage, her cervix was 5cm dilated. This lovely Latina woman was tough as nails, but every contraction shook her to her core with pain. She asked for an epidural as soon as she arrived on the labor floor. The nurses paged the anesthesiologist and began the tasks they do with every new labor admission. Ten minutes later, they called out for me. “The patient is complaining of pressure. Can you check her before anesthesia sets her up for the epidural?” I pulled on a glove onto my right hand and sat on the side of her bed. The patient was writhing in pain. Between contractions, I quickly checked her cervix. I felt the hard surface of the baby’s head. I felt the ¼ centimeter thickness of soft cervix partially covering his head. She was a good 7 centimeters dilated (out of 10). I looked up at the nurse and said, “She’s 7. We’ve got a enough time to place that epidural.” As these words left my mouth, before I had my glove off, the patient started to bear down. That’s right. She was pushing. “Ma’am” I explained in Spanish, “you can’t push yet. You’re not fully dilated.” The pain was unbearable and my words bounced right off her. She was squeezing her legs together and pushing. “Listen, you cannot push yet!” I repeated, “Let’s get you your medicine, and by then, it will be time to push.” At that moment, a guttural moan emanated from deep inside her and her knees parted. I looked down. A baby head was sliding out of her vagina. As I saw this, I threw a glove onto my left hand at lightning speed. I barely had enough time to lay my hands on the baby before it came sliding out onto the bed. I wanted to laugh out loud. This woman had gone from 7cm to baby in literally less than a minute.
Surprise! You know nothing after all!

Now take patient B. She was a 21 year old woman who was pregnant with her first child. She had ruptured her membranes (AKA broken her water) the night before, approximately 24 hours before she came into Triage to be evaluated. Given that these membranes are an important barrier for both mom and baby from the outside world, the risk of infection becomes higher and higher the longer she’s ruptured. Given that she was full term, this patient needed to be delivered. She came to the labor floor with a cervix that was 4cm dilated. We started Pitocin, a drug that works by causing or strengthening uterine contractions. How much Pitocin we give depends on how quickly her cervix responds to the medication. We started at 2 (it is not unusual to get up to 20). As soon as we started the Pitocin, the fetal heart tracing started showing late decelerations (a drop in heart rate - a bad sign the baby is not getting what it needs from the placenta). When we turned down the Pitocin, they went away…along with her contractions. We played this game all morning. Pitocin, then late decels, then no pitocin, then no contractions. We were stuck between a rock and a hard place. We wanted her to deliver vaginally, but if we couldn’t use the pitocin, we weren’t going to get her in labor. And if we used too much, we could prevent adequate blood flow to the baby. The risk of infection was too high to leave her ruptured until she did it on her own.

We finally settled at 1 unit of Pitocin. It was just enough to give her 1 contraction every 5 minutes (contractions are usually every 2 – 3 minutes in active labor). Even at 1 unit of Pit, the baby was having late decels. Everything else about the tracing was reassuring so we decided to hold course. After about five hours of this, her cervix slowly made it to 5cm (we usually expect 1-1.2 cm of change per hour in active labor). I remained doubtful. By this time, she was ruptured almost 30 hours, was still only 5cm dilated, and was not contracting enough by normal standards to have a baby. I was certain this baby was going to end up coming out the abdomen. Our team decided to give her 2 more hours. If she was still 5cm, we’d call it. We’d head to the OR for a cesarean section. If she changed her cervix, we’d keep going. So, for the next 120 minutes, I watched the tracing, and those late decels, on the edge of my seat. What if in one of those decels that heart rate didn't come back up? What if it stayed down and we had to emergently take her to the OR? I am certain I grew three new gray hairs that day.

Finally 2 hours pass. I return for a cervical exam. Based on how infrequent her contractions were, I was doubtful I’d find any change at all and was confident a c-section was in her future. I glove up and start my exam. I immediately feel baby’s head. I feel around for cervix. I can’t find it. I feel around even more. And then it hits me. This primip (or woman having her first baby) had gone from 5cm to fully dilated in two hours with contractions not closer than 5 minutes apart. Another moment of shock in OB land. Literally, 20 minutes later, a beautifully healthy baby boy was born. I swore I saw a mischievous sparkle in his eye when I caught him, saying "decels, what decels?"

Oh, obstetrics, you will forever keep me on my toes...

Wednesday, July 21, 2010

Delivery by Zen

I got the page for another labor admission. “K.L. 20 y.o. G1 @ 40’0 wks in labor. 8/100/0. GBS negative. Declines epidural”. (Read: 20 year old, first pregnancy, at term, 8cm dilated.)

Now it’s not terribly uncommon for our patients to deliver without an epidural. But the ensuing delivery often entails lots of screaming, crying, and the occasional out-of-control, climbing-up-the-bed-with-a-baby-head-sticking-out episode. I knew from the moment I met this patient, she would be different.

When I walked into her labor room, I found a lovely young Southeast Asian woman, sitting on the hospital bed, eyes closed, calmly breathing through contractions. She was the quintessential picture of Zen. If she wasn’t dressed in a hospital johnny, I could’ve easily mistaken her for practicing prenatal yoga. She was almost fully dilated by the time she came up from Triage. By the looks of her, I would have thought she was 2.

As she progressed in her labor, her contractions became stronger, more difficult to breathe through. She changed positions, moaned, writhed, shook – but through it all, it was clear that she had 100% control of her labor.

In most deliveries, where the patient is numb from epidural anesthesia, a lot of labor coaching is required. The patient often can’t feel much and a good deal of time is spent teaching a woman how to push. This type of birthing is an interactive process, a team effort.

The birthing experience of this young woman, however, was completely different. Because she had no inhibition of pain or feeling, she was completely in tune with her body. She could feel when it was time to push, she could feel how and where to push, and absolutely no coaching was required. In fact, she was so much "in the zone” that anytime I spoke, I felt like I was interrupting her focus. Her process of birthing was beautiful to watch. It wasn’t that she was quiet (she was definitely making noise). It wasn’t that she was still (she was moving around a lot). It was that she was focused and in complete control with what was happening to her body. It was an empowering experience to watch.

A beautiful 5+ lb baby boy was born approximately 20 minutes into pushing. The patient did 99% of the work on her own. The one and only contribution we had was to catch the baby.

What made this patient different from the other non-anesthetized patients I’ve delivered? What was her secret? Was it her expectations? That she knew it was going to be painful and developed great coping strategies for it? Was it a personality thing? A high pain threshold?

Regardless of what her secret was, I left that delivery room inspired. Empowered. And very, very proud of my patient.

Monday, July 19, 2010

You Know You're an OB/GYN When... (PART 1)

* you get splashed with amniotic fluid and think to yourself, “Do I really need to change my scrubs?”

* you can say you’ve caught a baby with only one glove on.

* respiratory mucus grosses you out more than cervical mucus. 
 
* you think ferning under the microscope is beautiful.

* you can’t remember what the sex of the baby you just delivered was… two minutes ago.

* you can say that your clogs have come in contact with every single body fluid produced by the female body.

* you think placentas are pretty.

* you’ve been baptized by baby pee. And poop.

* you say things like “whiff of pit” or “shrom”.

* seeing a new dad cry makes your eyes well up with tears.

* you refer to your patients as “primips” or “multips”.

* you understand that this means: “This is a 19yo G3P2012 who is PPD#2 s/p SVD c/b PPH after IOL for severe PEC “.

* you can diagnose bacterial vaginosis before you’ve placed the speculum.

* you think Trichomonas under the microscope is really fun (not for the patient of course!)

* you think Mirena IUDs are by far and away the best birth control method. Ever.

Thursday, July 15, 2010

See One, Do One...Teach One?

One of the things I love about residency is that the learning curve is just so darn steep. Just when you’ve got one thing down pat, it’s time to learn about something else. The process of self-improvement just doesn’t end.

Example 1: The first half of my intern year was dedicated to learning how to get through the basic steps of a vaginal delivery or cesarean section. I was happy just to get through a delivery without fumbling the baby. If I finished a delivery and the baby wound up in a nice football hold, if I could cut and clamp the cord without dropping the instruments, I was glowing. Same goes for a c-section. If I could hide my intern tremor for the duration of the surgery, I was happy. If I could sew up the uterus and the attending didn’t need to throw in a ton of extra sutures afterwards, I considered it a job well done.

Example 2: The second half of my intern year was dedicated to finesse. It was about maintaining order in a labor room, creating a positive birth experience for my patients, catching a baby with grace, and knowing when and how to intervene if a baby dropped its heart rate or if mom had more bleeding than usual. It was about developing my own style and routine of baby catching. In the operating room, my focus was on doing the c-section start to finish, calling for instruments, delivering the baby without struggling, re-loading my needle driver without touching my needle. It was about a beautiful subcuticular stitch to close the skin. It was about dictating from memory before I walked out of the OR.

Now, a year later, the start of my second year is dedicated to a new learning objecting: teaching. I’m no longer standing at the perineum and coaching a soon-to-be mom with her pushing. I am not catching the baby and handing it off to its waiting mother. I am walking our new interns through it. I am helping with their delivery maneuvers, their laceration repairs, and everything in between. The good is that it’s been extremely rewarding. There is a certain pride you feel when your intern does a beautiful delivery or repair. And with every delivery, they get better and better. As if that weren’t reward enough, their excitement and enthusiasm for these new experiences is incredibly contagious.

The challenge for me in all of this is making the personal transition from the “do-er” to the “teacher”. Struggling with something, be it getting the baby into a good football hold or delivering the placenta, is an important part of the learning process.I know this. Watching it without jumping in, however, is harder. It’s like being the kid in class who actually knows the answer to the teacher’s question but not being able to answer it. It’s like waving your hand in the air saying “Pick me! Pick me!” knowing full well that it’s not your turn to talk. A couple days ago, I hip-checked my intern out of the way when we had a tight cord around the baby’s neck. Afterward, I realized that I had missed a great opportunity to teach my intern how to deal with this situation. What makes me feel even worse about the whole thing is that I remember being in this intern’s shoes. Just a year ago, I remember being so eager to do a delivery, by myself, start to finish. I remember being hip-checked myself and thinking, “Just give me a chance! I can do this!!!”

Reflecting on this experience, I realize that I had panicked in this week’s delivery because, as the next senior person in the room, I felt ultimately responsible for the outcomes of this mom and baby (which is true). Looking back, however, there was plenty of time to walk her through a nice somersault maneuver and still have a happy baby.

Intern year, for me, was about stepping into my role as a doctor. It was about stepping up to the plate and getting my hands dirty. As a second year on the labor floor, I’m learning that my job is to take a step back and teach. It’s to trust my intern with a straightforward delivery. It’s to trust myself that I know when to step in. Like I said earlier, there’s always something to work on in residency.

Wednesday, July 7, 2010

Babies Having Babies

She was 15 years old. She looked like any other youthful teeny bopper, with her silly band bracelets and hot pink nail polish. She should have been at home, in bed, dreaming about the Jonas Brothers, her high school crush, or what she was going to wear to school in the morning. Instead it was 3:00am and she was in our Triage, alone, and 30 weeks pregnant. She sat tearfully on the hospital gurney as the contractions came and went every 3 minutes. Like clockwork.

Concerned she may have broken her water, I did a speculum exam. Through a dilated cervix and amniotic membrane, I saw a head of hair. It was then that I knew my patient was going to deliver early. By the morning, this baby was going to be a mother.

Explaining the implications of delivering an infant 2 ½ months early to a 15 year old girl was not easy. I’m not sure if it was the fact that she was alone, in pain, or still a baby herself, but nothing I said seemed to sink in.

I explained, in the simplest way I could, that we were going to give her steroids in an effort to mature the baby’s lungs prior to delivery. I talked about the role of tocolytics and its purpose in slowing down the labor long enough to give steroids. I discussed the role of magnesium in protecting the baby from the perils of cerebral palsy. After all was said and done, she looked up at me blankly. Her only response was, “Can I take this off now?” referring to the fetal monitoring system attached to her belly. The next question that followed, “Can I just get a c-section now?”

Her lack of insight was profound. I pulled out my doctoring skills, asked her to tell me what she understood about what was happening. She recited back to me the facts of the situation at hand. Her explanation, brief and without detail, was notably void of any emotion or understanding about the gravity of delivering a 30 week infant.

“Do you have any family with you?”
I asked. “Can you call anyone to be with you right now?” Apparently her mother had dropped her off at the Emergency Room and left. Despite several phone calls by both the patient and the resident team, she failed to show up. Our young friend delivered a 2 ½ lb baby girl, alone, at 9:00am the next morning.

Anyone who argues against comprehensive sex education, condom distribution in schools, or unlimited access to family planning for minors needs to meet patients like these. These are young girls with little to no family support or financial resources. Their neurologic development will not be complete until their early 20s. Most of them lack the maturity or understanding it takes to raise a child. Their bodies, underdeveloped for childbearing, put them at risk for severe pregnancy complications like preeclampsia, obstructed labor, and having low birth weight babies. Having a child drastically decreases their likelihood of completing high school and increases their likelihood of relying on public assistance in the long term.

There is also a gender issue here – it takes both a man and a woman to achieve pregnancy. Yet time and time again, it is the young girls who suffer the consequences of pregnancy. It’s their lives that are forever changed, their dreams that are forever shattered. Unfortunately, it is just too easy for boys/men to walk away from their responsibility. When my patient delivered, it was her alone in that delivery room.

The most conservative of parents should know that none of the aforementioned interventions (sex ed, condom distribution, access to family planning) have been shown to promote earlier sexual activity in teens. These teens will start becoming sexually active at the same time as their peers. The difference? They are more likely to use birth control or condoms when they do it.

Of course, we all want our youth to postpone sexual onset. But the fact is, they make mistakes. Are we so dogmatic that we don’t want to give our children room for error? Are we really that strict that we will force our kids to suffer life-altering consequences of unprotected sex? I hope not. For every young girl like this one.

For more info, check out: www.advocatesforyouth.org

Monday, July 5, 2010

“Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness, that frightens us most. We ask ourselves, 'Who am I to be brilliant, gorgeous, talented, and famous?' Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There is nothing enlightened about shrinking so that people won't feel insecure around you. We were born to make manifest the glory of God that is within us. It's not just in some of us; it's in all of us. And when we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others."
- Marianne Williamson

Tuesday, June 29, 2010

Big People in Pregnancy

Let me first say that I believe healthy women come in all shapes and sizes. I don’t believe that one body type fits all. I also strongly believe that too many women feel shame, rather than pride for having a body that is less than the super model standard. In other words, our body image as a nation has a long way to go.

On the opposite end of the spectrum, however, is the epidemic that is eating our nation up alive – the obesity epidemic.

What people don’t understand about their obesity is how difficult it makes it for us to provide them with good medical care. On pelvic exam, I can’t accurately assess uterine size or feel for adnexal masses. Fetal monitoring can be near impossible in morbidly obese patients simply due to the amount of tissue between mom’s abdomen and the baby inside. These patients are at much higher risk for both pregnancy complications, like pre-eclampsia and gestational diabetes, and birth complications like shoulder dystocia (when baby gets stuck in the birth canal). Perhaps the most dreaded place to treat a morbidly obese patient is the operating room.

It was my first day as a second year resident on my nights rotation. Instead of the quick and easy primary (or first time) cesarean sections, I was being graduated to repeat and crash cesarean sections. I was excited. It was about 2:00am when I got my first page from the OR in this new position. The patient was a morbidly obese woman with a history of 3 prior c-sections who presented in labor.

From the moment we started prepping and positioning the patient, we knew it would be a challenge. Her belly was too large to see her lower abdomen so it had to be pulled up and held in place with tape. After I made my first incision, I had more than 7 cm of subcutaneous fat to get through before I got to the fascia and muscles underneath. Her fascia, the usually thin layer of tissue covering her muscles, was thickened with scar tissue from her multiple prior c-sections. Instead of cutting easily through a Ziploc bag-like material, it was like cutting through leather. The muscle underneath was no better. In a primary section, you can separate the abdominal muscles in the middle easily and make your way into the abdominal cavity. In this patient, however, her muscle was attached to her uterus was attached to her bladder. She had so much scarring in her belly from her prior c-sections, even my attending and chief resident were having trouble identifying what was what. As if this scarring weren’t a challenge enough, we struggled to keep that thick layer of skin and fat from obstructing our visual field. We tried retractor after retractor and finally settled on using not one but three large retractors. Our poor medical student got a serious arm workout that day. Finally, after almost half an hour of careful dissection, we made our way inside her abdomen.

At this point, we had finally exposed the uterine surface. I made my incision and reached for the baby’s head inside. I grabbed it easily enough but trying to deliver the baby out of the uterus presented a new challenge. Normally, one surgeon applies pressure at the top of the uterus to create the force needed to push the baby out while the hand of the second surgeon is lifting the infant’s head to the uterine incision to guide its way out. In this case, her body mass so much that it was difficult for my chief to apply enough pressure in the right place to push the baby out. She was leaning most of her body weight on the patient’s abdomen to deliver this baby. Knowing this wasn’t going to be easy, we called for a vacuum. This suction cup was applied to the baby’s head and slowly, we were able to pull her out. Delivering this child took probably about 3-4 times as long as normal.

Finally it was time to close up the uterus. Normally, we pull the uterus out of the abdomen, stitch it up under good visualization, then return it to the abdomen. In this patient, with her thick abdominal wall in combination with the scar tissue that made everything stick together, we were forced to stitch her uterus up while it was still inside her belly. Again, the thick layer of fat continued to get in our way and obstruct our field of view. And again, it took us twice the amount of time as usual to close up the uterus. Take note, that a patient continues to bleed until that uterus is closed. By the end of the case, her estimated blood loss was 300-400cc higher than we usually expect. Almost an hour and a half had elapsed since we started to c-section (compare this to the usual 30-40 minutes).

The danger for this patient isn’t over now that the surgery is completed and her baby is delivered. She has got a high risk of poor wound healing and infection. Her belly hangs right over the incision, and as you can imagine, sweat and moisture are not conducive to healing wounds well.

My intention with this post is not to poke fun at morbidly obese patients in any way. I acknowledge that obesity is a struggle and getting/staying thin is not easy. I write this more to point out when one is morbidly obese, pregnancy should not be taken lightly. It benefits both mom and baby to get healthy before pregnancy happens. This particular patient was having her fourth c-section in the setting of morbid obesity. Let me just say I am thankful she wanted her tubes tied that day.

For more on the issue, check out this great New York Times article on the subject: http://www.nytimes.com/2010/06/06/health/06obese.html

Wednesday, June 23, 2010

Passing the Torch

As we welcome in the new interns this week, I pass on my position as the new kid on the block. What better way to make that transition than to hand down the valuable lessons I’ve learned throughout the year? As such, here is my survival guide to life as an OB/GYN intern:

1. Don’t take anything personally. In our field, people have many reasons for being grumpy: lack of sleep, hunger, stress. As an intern in any residency, you will inevitably be the one who gets lashed out on. Sometimes it will be justified. Most of the time it won’t. The key to getting through your newfound role as Lowest-Person-On-The-Totem-Pole is not taking it personally. When you feel the sting, remember. It’s not you, it’s them.
2. Residency is four years – for a reason. You WILL make mistakes. You WON’T always know the answer. You may not be able to find that cervix. You may not be able to deliver that head in a c-section. You may not be the one to resolve that shoulder dystocia. It is OKAY. Beating yourself up will not change this. Take a deep breath and use it as a learning moment instead.
3. If you don’t know, ask. Dovetailing off the previous point, don’t be afraid to ask questions. Your senior residents and attendings have tons of experience – and pointers. How do they usually handle a tight nuchal cord? What’s their trick to getting the baby’s head out of the uterus?
4. Read like the wind. Okay, so this is a tough one. Who has time as an intern to read? As daunting as this goal might be, the payoff is twofold. First, the benefit of learning is obvious. Second, the act of learning something new is just as much a boost to your confidence as it is to your knowledge base – and when you spend the majority of the day feeling like you just don’t know enough, your confidence will need all the boosting it can get.
5. Anticipate, anticipate, anticipate. Part of being a good physician is being prepared for badness. With every patient, you want to think about the worst case scenario possible and prepare for it. That patient with the Estimated Fetal Weight of 9lbs? As you walk to her delivery, you should be thinking about every step of management in a shoulder dystocia. A patient who is a grand multip who has delivered 6 babies before? You want to be prepared for a postpartum hemorrhage and have the doses of all the drugs you would use memorized. Not only does being prepared help you keep your cool in an emergency, but it also wards off bad juju. Murphy’s law, you know? Badness happens when you’re least prepared for it.


Take the torch. No, really, take it!!! 
 
6. Play nice with others. This especially includes the hospital auxiliary staff. Nurses, scrub techs, nurse assistants, cafeteria workers, housekeeping - they can make your life heaven or hell. If they like you, they can make you look really good in the OR or labor room. They can make things happen for your patients quickly. They can be the shoulder you cry on when you’re having a bad day. These folks have a wealth of experience and knowledge that you don’t in this stage of the game. So be nice. Value them. Make the effort to learn their names. And be humble. Having an MD behind your name does not make you entitled to anything.
7. Be a team player. If you have any gunner-ish tendencies, pack them far, far away now. Intern year is not an independent endeavor. You need your co-residents to get through it – both literally, figuratively, physically, and emotionally. If you see a resident struggling, help out. There will invariably be a time when the roles are reversed and you need some sort of help. Karma definitely exists in the world of medicine. The next time you are swamped in clinic or need a call switch made, you’ll be glad you have people to call on.
8. Remember, everyone has a story. Just like out in the real world, you have people that only ask for help when they really need it AND you have people who whine like the sky is falling. It is hard to be compassionate with the non-pregnant vaginal discharge patient who rolls into Triage at 4am. But if you take that moment to sit down with her, open your mind, and listen, you’ll hear that she just found out her partner has been unfaithful and is paralyzed with anxiety with the thought of having a sexually transmitted infection. All of a sudden, instead of passing out diflucan like candy, you can use this as a good teaching moment about safer sex practices. The chief complaint is usually just the tip of the iceberg. Being an effective physician means taking the time to learn the bigger story.
9. Exercise: Residency is busy. You don’t eat regularly and when you do, it’s easy to eat crap. “I haven’t eaten in 8 hours, of course I deserve these fried chicken strips!” You don’t sleep regularly. You don’t always release stress in appropriate ways and it often builds up, builds up, and builds up inside you. Exercise can be a life saver in dealing with every single one of these issues. It has been my lifeboat in the world of insanity. I honestly attribute 50% of my positive work attitude to the couple of hours I take per week to pound the pavement in my running shoes. Besides, how can we preach healthy living to our patients if we can’t do it ourselves?
10. Remember to be you. Think about the person who filled out those residency applications. That person who prides herself on her cooking skills, who has traveled the world, who played tennis in college, who was a kick-ass salsa dancer. These things make you you. And as easy as it is to let these hobbies fall by the wayside when you work 80 hours per week, you’ve got to do everything in your power to keep this from happening. You will become a very sad, sad person in residency otherwise. Think about it. Your self esteem, no matter how healthy it is now, will take a serious bruising intern year. To keep yourself balanced, you’ve got to have a couple of areas of your life where you feel like a success. Trust me, it’s worth the sacrifice in sleep. You are a doctor now, yes, but don’t forget the dozens of other things you are as well.

Finally, for extra credit, HAVE FUN! What we do day in and day out is such a privilege! Enjoy it!

* Readers, any tips you'd like to add? Add them in the comment box!

Wednesday, June 16, 2010

Resident Prankster

It is a lovely thing to be at a happy residency program with people you can call friends. There is always someone to turn to and a shoulder to cry on when things get tough. You can ask any and all questions without feeling like a numbnutz. There is always someone around to laugh with. In some sick and twisted way, work can sometimes feel like social time. I wouldn’t trade this culture in for anything.

Once in awhile, however, we can get a little too close for comfort...

Consider my very first day as a second year. I was in the operating room doing my first repeat c-section and it was NOT looking pretty (thankfully not because of me, but because the patient was a terrible operative candidate). In the background, I heard my pager (a.k.a. my hospital ball-and-chain) go off. Wanting to make sure no one urgently needed a resident, I ask Pauline, the circulating nurse to check the new message. A minute later she tells me “It was just the pharmacy.” Relieved, I continued operating.

About a half hour later, we finished with the case. I finished the patient’s post-op orders and paperwork. By the time I was done dictating the operative note, everyone was gone. I remembered to check my pager. It read:

DR. C, YOUR CHLAMYDIA PILLS ARE READY FOR PICK UP IN THE MAIN PHARMACY.

Um, what?!?!?

Now let me be clear – this was a JOKE. I do not, nor have I ever had an STD. And if I did, I surely wouldn’t go to the pharmacy at my hospital where people know me…

As I read this text I literally gasped. I felt my face get hot. I thought of Paula, who read the text. I wanted to explain, but she was nowhere in sight. What was she gonna think of me now? And in the peri-op crew, gossip travels like wildfire. Crap! Craaaaaap!!! I immediately thought of about four people who might’ve had the gall to pull a prank like this. “I swear I'm gonna kill them…” I said to myself.

Well, if I had the slightest bit of worry that the peri-op team might think the information on that text page was real, it was dispelled soon thereafter. I became The Butt Of All Jokes that night. Every single time I saw a scrub tech, a circulating nurse, or an anesthesiologist that night, I was greeted with, “Hey Doctor, we have your piiiiilllls….” followed by bursts of laughter. Even my ATTENDING joined in on the fun. Dr. S, one of my most prim and proper, hair-and-makeup-always-done attendings, snickered at me with barely a straight face and said “So I heard about your little problem…” It's two days later now and I still don't think I am ever going to live this down.

Like I said earlier, I wouldn’t trade my 80 hours a week of work with friends for anything. But seriously guys, just remember. Revenge is a dish best served cold…

Sunday, June 13, 2010

We're Movin' On Up!

Today marks a huge milestone for me in my medical career. I’ve completed by intern year, my first 365 days as a physician. Tonight I start my life as a second year. I am officially a “resident”.

I greet this day with mixed feelings.

First there is the pride and awe at looking back on the year and realizing how much I’ve learned. I’ve delivered about 200 babies, both vaginally and surgically. I’ve taken out uteruses (uteri?), ovaries, fallopian tubes, and cysts. I’ve become comfortable looking inside the uterus with a hysteroscope and cleaning it out with a curet. I’ve placed IUDs, implanons, and tied tubes - my contribution in the fight against unplanned pregnancy. In addition to skills and procedures, my knowledge base about obstetrics and gynecology has shot through the roof (I think…).

Next there is excitement and anticipation. Now it will be my regular job to do repeat and crash cesarean sections. I will learn to run the labor floor and become the primary health care provider in the delivery room. I will learn to manage bad fetal heart tracings. I will experience the subspecialties of OB/GYN, like urogynecology, family planning, and infertility. I will start my research and come one step closer to the academic job I hope to have in the future.

Finally, heading into my second year, there is a very real sense of anxiety and nervousness. As an intern, you know two things: 1) no one really expects you to know anything and 2) you’re not really responsible for anything or anyone. There is a sense of security in this. Intern year is all about deferring what’s difficult to the residents above you. Now, however, as I move up the totem pole, I become one of those residents!!! When those new little interns, lost and insecure, start this week, I will be the one they turn to for guidance! God help us...

In all seriousness, I do want to be a good resident to the incoming interns. Being the Type A personality and incessant planner I am, I am already thinking about how to do this. I think about the senior residents I have now, specifically the ones I look up to, whose styles I’d like to emulate. I want to be patient. I want to be approachable. I want to be knowledgeable (hear that Green Journal? We’re gonna get real close this year). Finally, I want to be supportive. Intern year is hard, and without my go-to people at work I would’ve given up a long time ago. (Thank you, work wifeys!)


Starting second year feels like I am on a 10m diving platform. I’m hesitant to jump in, but know I’ll feel proud of myself if I do – even if I belly flop it. One. Two. Three. Here goes nothing...

Tuesday, June 8, 2010

My She-roes

“Because women's work is never done and is underpaid or unpaid or boring or repetitious and we're the first to get fired and what we look like is more important than what we do and if we get raped it's our fault and if we get beaten we must have provoked it and if we raise our voices we're nagging bitches and if we enjoy sex we're nymphos and if we don't we're frigid and if we love women it's because we can't get a "real" man and if we ask our doctor too many questions we're neurotic and/or pushy and if we expect childcare we're selfish and if we stand up for our rights we're aggressive and "unfeminine" and if we don't we're typical weak females and if we want to get married we're out to trap a man and if we don't we're unnatural and because we still can't get an adequate safe contraceptive but men can walk on the moon and if we can't cope or don't want a pregnancy we're made to feel guilty about abortion and...for lots of other reasons we are part of the women's liberation movement.”
~Author unknown, quoted in The Torch, 14 September 1987

There are so many things I love about Obstetrics and Gynecology. I love catching babies and bringing new life into the world. I love the operating room and being able to see the human body in a way that most people never do. I love the relationship building between me and my patients. I love the potential to make great change in the lives of women.

But, above all, I love being surrounded day in and day out with so many women that just plain kick ass.

I’ve always known this at some level, but this realization hit me head on at a leadership conference for my hospital last week. The audience was filled with women who are committed to promoting women's health in various capacities. We had research experts, nationally renowned OB/GYN specialists, academic generalists, hospital administrators, midwives, pharmacists, and primary care champions. The list goes on and on.

As I sat in this ballroom, I noticed an amazing energy in the room. I was surrounded by women who I know to be brilliant, successful, and highly skilled. They speak their minds. They don't take no for an answer, they stand up for what they believe in, and they are not to be trifled with. They relish in their determination, not in their docility. They are women of all different races, ethnicities, and sexual orientations. Some are fresh out of residency or fellowship, some have been practicing longer than I’ve been alive. Yet, every one of them is excited, eager to learn, and passionate about the work that they do. I looked around and thought with pride – we are women caring for women.

I know in the grand scheme of things, we have a long way to go in the world of gender equality. This is particularly so in the field of Medicine. Throughout my four years as a medical student, the vast majority of department chairs and tenured faculty were men. In fact, only 3 women pop into my head as leaders within their departments.

You can imagine my excitement then, to be part of this residency microcosm now, in which women can do absolutely anything a man can do (maybe better!). Looking around me, I can’t help but feel that there is nothing that I cannot do. We are a group of powerful and unstoppable women who are working everyday to make other women powerful and unstoppable too.

Saturday, May 29, 2010

Sleeping With the Fishes

Dating is hard. Dating as an intern riding on a year’s worth of insufficient sleep and little-to-no free time and it is a near impossible task.

Exhibit A: Over the last week, I’ve been emailing with this charming guy from Boston. He is smart, witty, loves music, and is passionate about the work he does. Perfect, right? He asks to set up a phone date. “Sure,” I write back, smiling to myself about how well this is going. We set up a phone date for Wednesday night at nine pm. Wednesday rolls around and by the end of the day I am exhausted. I had just transitioned from working nights to days again and my sleep schedule is just whacked. By the time 8:15pm rolls around, it is all I can do to keep my eyes open. I debate whether or not I should reschedule. Ultimately, I figure that my first impression will probably be less than stellar if I’m tired so we reschedule for the next day, same time. Thursday rolls around. I get home from work at the reasonable hour of 6pm. I sit on the couch to do some reading about Thyroid Disease in pregnancy. Fascinating, I know. Where do I find myself next? Face down in a puddle of drool on the sofa. I sit up with the start. It’s 10pm! Shit! I call him back and get voicemail. Damn. Damn. Damn. Thank goodness he’s been forgiving. We’re re-rescheduled for Sunday now. Third time better be the charm.

You mean, this bitch found her Prince Charming whilst she slept?
Lies, I tell you, lies!

Exhibit B: Date #2 with a lovely gentleman who works in the field of biotech. He lives in Cambridge and drives the 45 minutes to have dinner with me. Upon seeing me, he pulls out a small pink rose he cut from his yard. He is tall and handsome and goofy-awkward in the most adorable way. We sit down to dinner. He is clearly nervous. As he scans the menu, he fidgets in his seat and keeps looking around for the waiter. I try to lighten the mood and start talking. I crack a joke about the Italian restaurant we are at being straight out of the movie Goodfellas, gangster accents and all. “You want some wine? I’ll getchoo some wine. Tell me whatchoo want ‘n I’ll get it for ya!” I get a couple of chuckles out of him. A glass of wine later and we are both much more relaxed. Conversation flows easily. We laugh. We eat. We drink more wine. He becomes much more chatty.

Now, a bit of wine is great to take the edge off. However there is a fine tipping point between social and comatose in a person who has the baseline somnolence of a bear in the dead of winter. Unfortunately, halfway into my second glass of wine, I found myself the latter.

The more he spoke, the heavier my eyelids became. I began fidgeting in my seat, hoping the stretching would keep me awake. I had a couple of subtle hypnic jerks (the jumping phenomenon that happens as you fall asleep). There is such a thing as falling asleep with your eyes open (any overworked resident will tell you) and I felt my eyes going crossed every time I started to drift off. He HAD to have noticed. But if he did, he was damn good at hiding it. Did I mention that I accidentally dropped and stepped on the rose he gave me as I hugged him goodbye? I’ll be surprised if there is a date #3.

Thursday, May 27, 2010

CRASH!

OMG! I‘ve officially done my first Crash section! Wow. Wow. Wow. Talk about an adrenaline rush.

It all started with a 30-something year old woman who was 37 weeks into her pregnancy. She walked into Triage with a blood pressure of 200/120 (normal blood pressure is 120/80). The first thought on everyone’s mind was Severe Preeclampsia. Preeclampsia is no joke. It is a hypertensive disease of pregnancy that can have serious consequences for both mom (seizures, liver failure, renal failure, pulmonary edema) and baby (fetal demise, intrauterine growth restriction, placental dysfunction). Given that the “badness” of this disease often happens suddenly, we take it very seriously. We rushed our patient into a room, started an IV, drew her blood for labs, and started blood pressure and anti-seizure medication.

Her physical exam was just as scary as her blood pressure. While she denied any symptoms, her reflexes were abnormally brisk and she had marked clonus (meaning after I flexed her foot, it continued to involuntarily tap) – both signs that the Preeclampsia was affecting her nervous system. The only cure for this disease is delivery. We knew that this woman needed to have her baby ASAP. Orders for induction of labor were written.

While all this was taking place, her baby started to tank on the fetal heart monitor. It began to show prolonged episodes of dropping its heart rate. The variability, or ability of the baby to respond to its environment by increasing and decreasing its heart rate on a beat to beat basis, was minimal. These were all signs that the baby was not getting enough oxygen. We repositioned mom on her side. We put her on an oxygen mask. We increased her IV fluids. The tracing just got worse. At this point, the decision was made: We were not going to have time to induce this woman. We needed to get this baby out NOW.

In less than 3 minutes, the patient is in the operating room. The OR staff worked like a well-oiled machine to get the patient ready for surgery. In the next 3 minutes, my attending and I were gowned and gloved and ready to start. The goal on everyone’s mind, including my own, was to GET THIS BABY OUT. My usual OR anxiety was gone, and I was focused solely on our mission. I made the first incision. In two swipes of my scalpel, we were through the skin and onto the fascia (the last layer of the abdominal wall). A couple of cuts with our scissors and we were on the uterus. I made the uterine incision. The baby’s head was easily delivery, followed by her shoulders and body. She was floppy, did not instantaneously cry, and was not at all the vigorous infant we like to deliver. Once she was out, we clamped and cut her umbilical cord and handed her to the NICU team waiting beside us.

Next we delivered her placenta. A large hand-sized clot came out behind it. Our patient had had a placental abruption. (Her blood pressure had gotten so high that the placenta had started to tear away from the uterine wall, compromising the amount of oxygenated blood that went to the fetus.) We had found our reason for the baby’s poor tracing.

The room breathed a sigh of relief. The baby was out. The rest of the case was like your average c-section. The tension and anticipation in the room dissipated, the anesthesiologist put on his music. We sutured mom back together. And with a little TLC, mom and baby did remarkably well.

By the end of the case, I was on Cloud Nine. I was riding high with the feeling that for the first time, I had just helped to save someone’s life. The rush was indescribable.

Saturday, May 22, 2010

A Slice of Humble Pie

Since well before medical school, I’ve had visions of myself being a special kind of doctor. I wanted to work in indigent communities providing high quality care to those who need it most but rarely get it. I wanted to exude compassion, patience, and understanding. At the risk of sounding cliché, I wanted to make a difference.

Now, eleven months into my intern year, I am learning the hard truth of how difficult this is. It often feels like an uphill battle. My patients consist of poor, young women with little by way of education and opportunity and a lot by way of substance abuse, depression, poverty, and social chaos. They hold on desperately to men who bounce from woman to woman. Unplanned pregnancies and sexually transmitted infections are rampant and my patients have little to no negotiating power with the men they “love” to prevent this. As a medical provider, it’s hard to stay hopeful and easy to feel powerless. Sometimes it’s all I can do to stop myself from grabbing them by the shoulders and shouting, “Open your eyes! Don’t you want a better life than this?”

It’s one thing to feel overwhelmed by it all. But combine this with lack of sleep, 80 hour work weeks, and the social isolation of being on Night Float, and it becomes something dangerous. This sense of frustration becomes bitterness. After four weeks on Nights, this is what I’m struggling with. And I don’t like the kind of doctor it’s turning me into.

Last Thursday, in the wee hours of the morning, I sign up to see a patient with vaginal spotting in the setting of early pregnancy. I go through her chart and review the notes from her prior visits. She is 17. This is her fourth pregnancy. This will be her second baby. Her first is only 8 months old. I read some old notes from social work about her failure to fill her birth control prescriptions.

On a day with adequate sleep, exercise, and food, I like to think I would have seen this visit as an opportunity to reach out to this patient. On this particular night, however, I had had none of these things. I was tired, crabby, and could think of nothing but how irresponsible she was.

I walk into the room and find a baby-faced teen sitting on the hospital bed. Her boyfriend, who looked like he had left adolescence behind years ago, looked bored as he sat in the corner of the room. After the initial history taking, I ask her.
  
    “Your baby is only 8 months old – how did this happen?”
    “Well, I had the IUD, but it fell out.”
    “And you couldn’t use a condom?”
    “Well, he doesn’t like them.” as she gestured to her boyfriend.
    I looked at him. “Condoms are no fun, but this is going to keep happening.”
    He looked back at me. “Well that’s her problem,” he said casually.
    I glared at him. “This is both of your problems. It takes two to get pregnant.”

As I left the room, I was seething. I walked across the hall into our workroom to vent to a co-resident. “You’ll never believe this…” I started.

Five minutes later, I walk back into the room with my nurse for the exam. As I walk in, my patient looks at me. As she starts to talk, she looks down at her hands. “I don’t mean to be rude, but could you not tell everyone about me?” she says quietly. “It makes me feel bad. I mean, I know I’m young and everything, but it’s just hard to hear people talk about me, okay?”

I feel like a brick drops in my stomach. I realize in that split second how unbecoming my behavior had been. “I am so sorry. You’re right. I didn’t mean to disrespect you.” I say, knowing that I can’t undo the damage I just did.

“It’s just that I am trying really hard,” she continues. “I am meeting with child services, I’m meeting with my counselor every week, and I am trying really hard to get things straight.” I learn about all the things she is doing to get her life together. I learn about her life in foster care. I realize that she is dealing with more as a 17 year old than I ever had to deal with in my teen years combined. First and foremost, I had judged her without knowing her.

I am not proud of this moment in my medical career. I thought long and hard about whether I should write about it at all. After all, it would have been easy for me to post only the fun and exciting stuff about residency. Ultimately, I remembered that that is not why I started this blog. I wanted to write honestly about my life in residency. In addition, if I’m going to become the kind of doctor I described in the beginning of this post, I need to start holding myself accountable now.

Friday, May 14, 2010

Downward Facing Delivery!

Last weekend’s call started out normal enough. I rounded on the postpartum patients. We met in the resident lounge at 7:00am for sign out. I learned there was a patient in LDR 17 who was fully (dilated) and pushing. She was a multip (had had babies before) with a history of bipolar disorder, had been pushing for some time now, and had not been able to get an epidural. After 8 failed attempts, she was placed on IV pain medications instead. My senior resident asked me if I would go check on her and deliver her if she was close. “Of course!” I replied, with my I’m-almost-a-second-year-resident confidence.

As I approach the room, I hear the screaming. A couple steps later and I find the patient in a most unorthodox birthing position. She is on the bed, on her elbows and knees, face planted in the bed, bum in the air – a modified version of child’s pose for you yoga buffs out there. Upon seeing the confusion on my face, the labor nurse explains. “We’ve been pushing for over an hour, this is the only position she has made any progress in.” I take a quick second to assess the room and figure out what my next step is. The patient is writhing in pain, screaming for us to pull this baby out. The nurses look exhausted, both from trying to coach a very belligerent patient and from trying dozens of birthing positions. I make the decision to proceed as is.

As I don my sterile baby catching suit, a dozen thoughts run through my head, namely, HOW THE HELL AM I GOING TO DO THIS??? The woman is upside down compared to the usual lithotomy position (face up, legs in the air). She keeps dropping her bum to the bed - how is this baby going to have room to come out? Is she going to have a tear beyond all tears from this? And how do I figure this out without letting the room know that I have NEVER delivered a baby in this position? Another huge question is on my mind: what in the world am I going to do if I have a shoulder dystocia*? Remembering that my panic will cause the room to panic, I take a deep breath and remain calm. On the outside, that is.

At this moment, my (favorite) senior resident walks in. I explain the situation. She says to me, “Okay, you can do this. It’s the same maneuvers, just upside down.” She says this so confidently that it makes me believe that I really can do this. Then, as if she is reading my mind, she announces to the room, “Everyone, if we have a shoulder, we will quickly flip the patient on her back, okay?” There, she said it. I breathe a sigh of relief.

I don’t know if I could post a blog long enough to describe the insanity that came next. It really was like delivering a baby upside down. The patient was in pain, not following directions very well. One minute her bum would be in the air and I would have plenty of room to catch the kid. The next minute, her bottom was down on the bed. It was like trying to deliver a baby through a drawbridge that kept opening and closing. My coaching tone changed from my usual soothing voice to my loud command voice.

Finally, after an entire team effort, she delivered the baby. There was no shoulder dystocia. Baby was a little floppy from all the IV drugs, but otherwise fine. Mom was fine. The whole room breathed a sigh of relief. Me, most of all. This was just another moment in residency when I walked away after doing something I didn’t know I could do. I left smiling inside.

* A shoulder dystocia is when the infant’s head delivers, but the shoulder is stuck. It is a dangerous situation and can lead to asphyxiation or nerve plexus injuries of the baby. We have a toolbox of maneuvers to deal with this, but they all revolve around mom being on her BACK!

Monday, May 10, 2010

Under Pressure

In general, I find myself to be a pretty darn cheerful person. I try to acknowledge the good in life more than the bad. I try to count my blessings. I try to smile. A lot.

That being said, I am not immune to the periodic funk.

Now let me be clear. I love what I do. I am thankful for the job I have each and every day. And I would never think of doing anything else. But folks, residency is hard. The hours are long, the expectations are high, and the workload is never ending. It’s easy to get run down. Most of the time, I can handle the challenge just fine. But being on night float has zapped away my reserve. It’s like my own Neverending Story, and I am Atreyu’s horse Artax, getting sucked into the Swamp of Sadness!

"Artax, please, you're letting the sadness of the swamps get to you....you have to try!"

Like most people who gravitate towards Medicine, I have a Type A personality. I need to be good at what I do. In my student days, this wasn’t very hard to achieve. I worked hard, studied, did well. The formula was simple. Now, as a resident, the ability to perform the way I want to is a whole lot harder.

It’s no longer just about book knowledge.

It’s a juggling act of skills.

I’ve got to run a delivery room. I’ve got to coach mom during her labor while interpreting her progress while listening to the fetal heart pattern while keeping the labor nurses in the room on the same page. I’ve got to become a surgeon. I’ve got to operate quickly and gracefully and be able to get the baby out no matter where or how that baby is sitting inside the uterus and throw perfect sutures and tie perfect knots every time. I’ve got to become an effective ER physician. Out of the dozen not-really-sick patients I see every night in Triage, I’ve got to identify the one or two truly sick ones.

There is simply no room for error. And as a learner who has not quite gotten everything under my belt, this has been the most difficult part of residency. Of course, the person who is the most hard on me is me. Take last night. This was my 8th day of work in a row. I worked a 24 hour call this weekend. I’m on night float for going on three weeks. So my reserve is already low. Now objectively, I had a pretty good night. I did two vaginal deliveries (one in a most unconventional position - more on that later), I did a c-section for breech, and I saw a crap-ton of patients in Triage. Despite this evening of productivity and fun, I walked away feeling blue. I ended the night with a perineal repair that I was just not happy with. As I drove home this morning, all I could think about was this woman having an ugly looking vagina for the rest of her life – and it being all my fault.

Sigh. Here's hoping for a more cheerful post tomorrow.

Monday, May 3, 2010

13.1

I love running. It is my life line, my stress relief, my instant Prozac. The odd thing is that I was never more than a fair-weather runner until I started residency. I suppose the need for stress relief has never been so great. And it helps that the springtime scenery is infinitely more life-giving than the concrete jungle of my home town. There are only so many times you can run past a strip mall and inhale 72% car exhaust before you want to turn around and go home. But I digress…

10...more....steps...to...the...finish...line....

I am happy to announce I ran my first half marathon! That’s right, 13.1 miles, baby! At the present moment, I feel like someone just finished kick boxing my thighs and my joints resemble those of an 80 year old. I’ve got the zombie walk down pat. And, I am popping Ibuprofen like it’s going out of style. But my spirit is still riding high on endorphins. And given the post-vacation funk I was in last week, I needed this serotonin boost. It’s one thing to come back to work after vacation. It’s another ballgame to come back to start night float. There is something über-depressing about working while most of the world is asleep. And sleeping while most of the world is awake. That being said, the race couldn’t have come at a more opportune time.

I’ve been training for this race for about 3 months. Let me be clear that I’ve never been one for speed. I had one goal alone: to finish. Never mind the middle-aged mom types that power-walked right past me. Or the elderly runners who cruised on by as I was huffing and puffing through the last two miles. I didn’t even mind the full marathoners that finished at the same time as me. The fact was that I had run longer than I have ever run before… and I lived to tell about it! High five to me.

Next race? October 2010. I think I'm hooked.

Friday, April 23, 2010

Half Eaten By Wild Dogs

All right. I finally did it. Faced with the realities of being a single woman working 80 hours a week on the hospital wards, I joined the online dating scene.


said reality

However, I don’t know how realistic it is to expect to find love via the internet. I mean, it’s a great place to buy shoes, order books, browse clothing – but can the wonders of modern technology really bring you a head-over-heels, butterflies-in-the-stomach experience? Friends tell me yes, but I have my doubts.

I started trolling over some of these sites this morning. Whether any of this will translate into actual dates remains to be seen. Maybe it’s because, as with everything else in my life, I am too damn picky. (Wait! Strike that! I have some friends who might beg to differ based on my dating history…) Anyway, my morning peruse went something like this:

Profiles that don’t say very much = either you’re really boring OR you just don’t care who the cat drags in.

Profiles that say too much = wow, you really think highly of yourself. A little too highly? Will you wake me when the monologue is over?

Profiles without a picture = This tells me you’re hiding something… or from someone…

Profiles with pictures of scenery = I mean, really. Really? You think your appreciation for a sunset is going to make me date you?

Profiles with potential suitor who is shirtless, flexing, or in any other way showing off their muscles = just, ew.

And with that my new adventure begins! If nothing else, this latest endeavor will serve as my own little sociological experiment. And hey, maybe I’ll get a couple of free dinners out of it.

P.S. To my two loyal readers (a.k.a. Mom and Dad), don’t worry. I promise to stay away from all the weirdoes, serial killers, and unemployed men out there.

Monday, April 19, 2010

A Bad Kind of Itch

For better or worse, I get very attached to my clinic patients.

Maybe it is because patient continuity is so hard to come by as a resident. Every five weeks, you are shuttled off to a different rotation. Unless you happen to be on the labor floor when your clinic patient shows up in labor, the chances are that someone else will deliver them.

Y.S. is one of my dearest clinic patients to date. She is a lovely young woman from Guatemala expecting her first baby. It’s a boy. She’s going to name him Jack after her equally lovely husband. Y.S. was an unusual clinic patient. First off, her pregnancy was actually planned. She was healthy. She had a supportive family. She had no substance abuse or psychiatric issues. (Gives you an idea of what our resident clinic is usually like, no?)

One day, Y.S. came to me for her usual prenatal visit. Her only complaint was some relentless itching that had developed around her 34th week of pregnancy. She had no rash. The itching was worse at night. For my non-OB readers, this presentation is concerning for a disease known as Cholestasis of Pregnancy. It’s a rare disease which, for reasons that are not clearly understood, can result in an IUFD, or fetal demise. It is so rare that I doubted my patient had this. But being a responsible resident means ruling out “badness”, so I sent her to the lab to have her bile acids (a liver product) checked.

Normal bile acids are less than 40. Hers came back at 82. Dammit. We sent her to Gastroenterology and started her on a medication called Ursodiol. Despite our best efforts, by her 36th week, her bile acids were >180 (read: beyond what our lab could calculate).

My last day at work before vacation, Y.S. was brought in for an amniocentesis, a test for fetal lung maturity. The plan was to confirm that her baby’s lungs were developed and start an early induction of labor. We wanted to bring this baby into the world before Cholestasis had a chance to take him out of it. Unfortunately, things rarely go as planned. Little Jack’s lungs were NOT yet developed. Now what were we to do? Deliver a baby with the risk of breathing problems due to immature lungs? Or let him cook a little longer and risk his life to do it?

* UPDATE: As I returned to the hospital today, I made a beeline straight for Y.S.'s room. I found her - glowing, smiling, as happy a new mother as they come. Little Jack is fantastic. He is a healthy, bouncing, 6lbs 7oz bundle of joy. After a 2 day induction of labor, Jack was welcomed into the world around noon yesterday. Successful vaginal delivery - check. Healthy mom - check. Healthy baby - check. Now this folks, is a happy ending.

Throwing Out the Alarm Clock

Ahhh… I am officially on vacation! Phew… This is not my first vacation this year, but it has been by far my most-needed one to date. Over the last three months , I have rotated through the Surgical ICU, Medical ICU, OB Days, and now Gyn Surgery – with tons of call in between. Boy, have I been beat.

I hopped on a plane home last night right after coming off a 24 hour shift (gotta make each non-work hour count!). I slept on the plane, landed, and went out for some dinner and dancing to celebrate the birthday of a dear friend. By the time I got home, I was so sleep deprived that I fell face first into my childhood bed and into REM sleep. It was a lovely 10 straight hours of snoozing. Once I mustered myself out of my bed and onto the couch, I snuggled up to another dear friend: My parents’ big screen HD TV.

Yes, I am one of those self-righteous liberals who brags about not having television. “It helps me to be more productive!” I often gloat. The secret is that we are the ones who salivate over TV the most. Hotels, friends’ houses, my parents’ home – what do these things have in common? Cable TV! And boy did I get my fill today. I learned all about Extreme Cake Decorating, The Fabulous Lives of Heiresses, Mystery Diagnoses, and being 16 and Pregnant (though I think my work teaches me more about this last one than MTV could).

my aspiration for this vacation is simple!

Of course, now that I am recharged, the Type A personality in me is already thinking of ways to make my vacation week productive… I should kick up my running schedule, hit up my old yoga studio, hit up the beach, learn some of my mom’s recipes for home cooking, do some non-medical reading, see my college friends, see my med school friends...

…sigh…

Or maybe I can just lie on this couch here for the next seven days.

Sunday, April 11, 2010

Who, Me?

Ten months into my intern year and I have gotten used to a lot of things: the labor room, the operating room, the wards, the intensive care unit. I’ve gotten to know both birth and death. I’ve been covered in probably every bodily fluid imaginable. To top it off, I’ve become BFFs with the vagina.  

What I still haven’t quite gotten used to is being called “Doctor”.

The issue doesn't come up with my patients. In fact, looking as young as I do, I’ve had to get over that one pretty darn fast. I couldn’t tell you the number of times I’ve heard, “Aren’t you kind of young to be a doctor?” Then there are those split seconds after I introduce myself as Doctor when patients quickly glance down at my ID badge to make sure it really does say MD. I often feel like shouting "No, I didn't buy this white coat at the costume store! It has my name on it and everything!"

It is with hospital staff that being addressed as “Doctor” makes me feel like I'm playing dress-up. Sure I went to medical school. Sure I learned about the pathophysiology of the human body and the pharmacokinetics of drugs we use. But textbook learning doesn’t hold a candle to the years of experience in patient care that the nurses and OR staff have. In fact, I’ve learned just as much about operating from the scrub techs as I have from my attendings. I’ve learned just as much about patient care from the nurses as I have from my senior residents and fellows. The first issue I have is that the title implies that I know more than them. And frankly, I still rely on them way too much to believe that I do. The second issue is the age difference. Many of these people, from the housekeeping staff to pharmacists, are my parent's and grandparent's age. Maybe it's the Asian persuasion in me, but I feel like if any one is going to be addressed with a title of respect, it should be them.

Who you calling Doctor?
 
A Scenario: The OR. A scrub tech who has 20 years of experience regularly gives me advice on how to improve my surgical skills. She knows the steps of each surgery down to a T. She hands me the instruments I need before I even ask for them, saving me the embarrassment of revealing I can’t remember the name of the instrument that comes next. Is it Metzenbaum scissors? Or curved Mayos?  I call her by her first name. She calls me Doctor. Trying to buck the system, I tell her “You know you can call me by my first name”. “I can’t do that,” she replies. “I’m old school”. I sigh. Back to square one.

Tuesday, April 6, 2010

Woman vs. Wild

Gynecology is filled with fun and satisfying procedures. Of course, there are those cases that are technically difficult, (i.e. tumor debulkings, vaginal hysterectomies) that make you embrace the title of surgeon. But gynecology is also a land mine of small procedures that are fun in the same way as zit popping. Quick and satisfying.

Today was an OR day of hysteroscopy. This is a procedure in which a patient is put to sleep and a special camera is placed inside her uterus to look for any abnormalities. Simple enough. My second case of the day, however, was no simple hysteroscopy. The patient was a 54 year old female with a history of postmenopausal bleeding. There are many causes for this: atrophic endometrium (aka thin and fragile lining of the uterus), endometrial polyps, pre-cancer and cancer of the uterus. As I placed the hysteroscope into her uterine cavity, I saw it, projected on the OR television screen: the polyp of all polyps, spanning from the top of her uterus to the top of her cervix. It was an endometrial polyp on steroids.

Polypectomies are fun. You see one, you grab it, you pull it, and you’re done. And you have a neat product to show off afterwards. I told you, it’s like zit popping.

This
polypectomy, however, was not your average procedure. I placed my little graspers through the hysteroscope and lined it up with the big, fat stalk of this polyp. I bit into it. I twisted. I pulled. When I looked again, I saw only the tiniest bite out of the polyp stalk. The polyp held its ground. This happened over and over again, for about 5 full minutes. Meanwhile, my attending and chief in the background are cheering me on. “Come on grab it! You got it! Twist! Pull! Pull! ...(silence)... Did you get it? Ohhh…(sigh)” The polyp remained there proudly, laughing at us.

I took out the hysteroscope. I needed a bigger instrument. I was determined to show this polyp who was boss. I inserted a polyp grasper through the cervix into the uterine cavity. Blindly, I felt around with my tool and tried to grab on to something. The little mofo kept escaping my grasp. My chief resident stepped into try. Finally something. She pulled out a nice 1cm polyp! That was it! We got it!

We replaced the hysteroscope to take a final look. Once inside, lo and behold, what do we see? The mother effing polyp was still there, it all its glory (minus a tiny bit from its end), taunting us. I pulled the hysteroscope out again. I went in again with the graspers even more determined this time. I felt something. I tugged. And tugged. Finally, another 1cm piece came out. “Yay!” we shoutedd! We must have gotten it this time! For good measure, I curettaged the endometrium (I inserted a sharp instrument to scrape out the lining of the uterus). I did this to make sure we got every last bit of polyp. When I finished, I reintroduced the hysteroscope. You can guess what happened. Polly the Persistent Polyp was still waving back and forth at us! “How’s it going suckas???” it seemed to say. I was fuming – and laughing at the same time. We all were. At this point, the entire OR staff (my attending, my chief resident, the scrub tech, the circulating nurse, and the anesthesiologist) was cheering me on to take this pesky polyp down.

Again I remove the hysteroscope. I picked up the granddaddy of graspers – the myoma graspers (meant for fibroids). It barely fit through the cervix. When I fully inserted the instrument, I felt it bite. I twisted. I turned. As I pulled the remainder of the polyp out, I swear I heard it curse at me. “I’ll be baaaaack….”

Whatever. Round 5 and I’m the winner.

Monday, April 5, 2010

Love in the Dirty Thirties

The business of love was much easier in my younger days. The goal was simple - find someone you like and spend time with them. When things stop being fun, you end it. There was no stressing about long-term compatibility, matching family values, or similar parenting philosophies. I didn't have anxiety about religious or cultural differences. I didn’t freak out at conversational lulls, the lack of/or presence of chivalry, or the way we split the check on a date. Dating was simply more lighthearted back then.

I always envisioned my 30s as a time when I would know exactly who I was and exactly what qualities I wanted in a life partner. In many respects, that is true. However, what I haven’t learned yet are which qualities (and how many) are okay to compromise on. I am not so idealistic to think that one day I will meet a Mr. Perfect. I’ve never believed that exists. But I would like to believe there is a mind-blowing Mr. Almost Perfect out there. And I hope that I am still lighthearted enough to be swept off my feet by him. These days I’m not so sure.

So let me break it down.

The Good: I’m smart, pretty cute, and got a rock-solid future ahead of me. I think of myself as a darn good catch (pats self on back).
The Bad: I work at a hospital, 60 to 80 hours per week, where every man I encounter is either old, taken, or gay. Slim pickins’ I say. I’m in my early, early 30s (yes, that’s TWO earlies!) and while my biological clock isn’t quite ticking yet, my eggs are not as fresh as they were 10 years ago.
The Ugly?: I’ve met some lovely men in the last 6 months of my newfound singlehood. There’s one quite special one, in fact, that shall be known as New York. He is HOT and smart and thoughtful and funny and ambitious. Did I mention he’s HOT? In my lighthearted days of youth, this is someone that would’ve “had me at hello”. These days, however, I’ve got major security detail working round the clock to protect my heart. My brain is on overdrive calculating the likelihood of relationship success given our very different backgrounds. I’m exhausted from overthinking it. In the end, I think it all boils down to one thing – after a bruising heartbreak, I’m just not ready for another go at this.

When did falling in love become so much gosh-darn work? Where are those intoxicating endorphins when you need them? Have I grown out of that exhilarating kind of falling in love? Is it all rational and thought-out and controlled from here? And if that’s how it’s going to be, should I revert back to my college dreams of being eternally single with a rotating schedule of lovers throughout the world?

Monday, March 29, 2010

Maybe I DO Know a Thing or Two!

Last week in Triage, I signed up for a patient whose chief complaint was listed as “vaginal discharge”. As I walk to her room, I think of the common stuff: yeast infections, bacterial vaginosis, spotting. When I pulled back the curtain, I found myself faced with a lovely and adorable elderly woman who was radiating worry. “What brings you in today, Ms. B?” I ask. Long story short, over the past couple days, she’s had more than your run of the mill vaginal discharge. My elderly friend had (*STOP* reading here if you are grossed out easily…) stool-like material coming from her vagina. You read it right; my sweet little patient had poopy vajayjay. Let me tell you – this was not my most pleasant pelvic exam…

Anyway, I’m sure you’re wondering “How on earth does that happen?” It’s called a fistula. A track from the vagina is formed to the rectum or colon where stool is passing by. And again, you ask “How on earth does that happen?” Well, anytime you have an area of long-standing inflammation between these two areas, a connection can form. This inflammation can come from diverticulosis (bulging pockets in the colon that form with constipation), surgery, infection, radiation injury or cancer.

Upon delving further into her medical records, I find that she has a distant history of endometrial cancer. She had her uterus taken out 15 years ago for this reason. After her surgery, she was told the cancer had been entirely removed. No need for chemo or radiation. Upon hearing this, my team was convinced. “It’s her cancer. She’s had a recurrence. And now she has a fistula because of it.” I protested. Maybe it was because she was so cute and I wanted her to have anything BUT cancer. Maybe it was because I tired of delivering bad news. But I was stubborn. “I don’t think she has cancer. She is old and constipated and I think she just has diverticulosis.” Being an intern and the lowest on the totem pole, my theory was not taken seriously. I’m a newbie, that’s fine. I get it.

Ms. B was admitted to the hospital that night. She was admitted to the GYN Oncology service and a CT scan was ordered to look for suspicious masses.

The next day I stroll into work per my usual routine. Ms. B had been on my mind. I logged into the computer system and pull up her file. The CT results were in. I open up the final reports and scroll down to look at the impression. Final diagnosis? Rectovaginal fistula secondary to DIVERTICULOSIS! “Yes!” I shout, as I fist pump the air. I literally do a victory dance in the middle of triage.

There are not many times when you are right as an intern. So when that rare occasion comes, you’ve gotta own it. And I owned it that day. Oh yes I did.

Wednesday, March 17, 2010

Nine Months

Today was one of those days when everything comes full circle.

I was in Triage this morning scanning the board for a patient to sign up for. A patient whose chief complaint was “labor” was checked in and I signed up to see her. I walked in the room and began to introduce myself. She was a big and beautiful African American woman with her hair tied back in a brightly colored scarf. She looked awfully familiar. “I know I’ve taken care of you before. What did I see you for?” Her partner smiles. “You were the one who told us we were pregnant back in August!” I was blown away. Here she was, 8 months later, full term and in labor. Had that much time really passed since the start of my intern year? Was I really nine months into my career as an Obstetrician?

After the shock wore off, I ran to clinic expecting a long afternoon of prenatal care, annual exams, and gynecology follow-ups. Fortunately, it was one of those rare clinic days where everyone who comes in is straightforward, on time, and in and out. I was done with clinic by 4pm. On my way back to Triage, I stopped by the labor floor to check out the action. I am nearing the end of my second OB Days block and have been working closely with our midwives to get “signed off” on deliveries. Most OB residencies require an intern to do a minimum number of deliveries before they can run the labor room independently. Our program is a little different. Our midwife faculty members evaluate our ability to control the delivery room, monitor fetal well-being, and carry out the delivery prior to letting us loose. Needless to say, I was scoping out the labor floor to see if I was going to be lucky enough to have The Official Sign-Off Delivery.

As I meet up with the labor floor midwife and my 2nd year resident, a nurse comes out of a delivery room. “The patient in here feels rectal pressure. Can you check her?” And of all patients, who could it be? Yes, it was my Triage patient. The one I first saw as a wee, insecure, and intimidated little intern just six weeks into my residency. Now, just a little bit older and wiser, I sat on the edge of the bed to check her cervix. Immediately I feel baby head. And no cervix. She was fully dilated and ready to start pushing.

It was one of those flawless deliveries. The baby’s heart rate remained perfect throughout pushing. He was delivered after maybe 5 minutes of maternal effort, and that’s being generous. The baby was strong and vigorous as he slid into my arms. I placed him immediately onto his mother’s belly for his first dose of maternal affection. The placenta delivered quickly and beautifully. To top it all off, she had no tears to speak of. Like I said. A perfect delivery. One to remind me exactly how far I have come as an OB intern. From the days when the delivery room made me tremble with anxiety, when the cervix felt like mush I couldn't describe...to this. A bit of pride swelled in my chest and I walked out of the delivery room beaming.

By the way, yours truly, is now officially signed off on vaginal deliveries.

Sunday, March 7, 2010

Surgery Voodoo

There is some kind of cosmic force in the OR between myself and our various attending physicians. With some attendings, I operate confidently and (somewhat) gracefully. I am happy with my suturing and knot tying, I am able to deliver the baby’s head from the uterus, and can keep up with the pace set forth by the attending. With others, I operate like it’s my first c-section ever. I am clumsy, can’t seem to throw the suture in the right place, and work at a snail’s pace. I’ve noticed that this pattern is set forth by the success or failure of my first OR experience with an attending. If it’s a good case, then I am forever blessed with decent OR skills with that particular surgeon. If it’s not, I am doomed to a lifetime of surgical ineptitude in future cases with that attending.

Yesterday, I scrubbed in with Dr. B for the very first time. She is young, smart, and lovely to work with. Unfortunately, the case was a postpartum tubal ligation (a.k.a. PPTL, a.k.a. The Most Annoying Surgery Ever). Let me remind you that I have not done a PPTL since my first round of OB back in August. That’s right, it had been 6 months. Needless to say, I had forgotten the steps, which instruments to ask for, where to tie, where to cut. The scrub nurse, taking pity on me, periodically whispered hints in my ear. The more flustered I got, the worse my technique got. The worse my technique got, the more critiques I got. The more critiques I got, the more flustered I got. See the cycle? Wash, rinse, repeat.

Today, I scrubbed in with Dr. B again for a primary C-section. I thought to myself, “Great! A surgery I know well! It’s my chance to redeem myself!” You see, in that brief moment, I had forgotten about my OR voodoo. The relationship had already been set! Because of the disastrous PPTL the day before, I was doomed for the case today. First, I didn’t cut my incision big enough. Then, I bovied (used an electrosurgical tool) right through a blood vessel. Moving right along, we arrive at the uterus and I made my incision. I see little baby face staring back at me. I thought to myself “I got this!” I reach inside, wrap my hand around the baby’s head and lift. But the head doesn’t budge. I try reaching around, orienting myself, flexing the her head – all to no avail. I can’t deliver this baby’s gosh-darn head. Then I hear the words every intern dreads hearing. “Why don’t you let me do this part.” Read: you are failing at the task at hand and I am taking over. I sigh. Now, baby’s out and we move onto repairing the uterus. Now I am flustered. As I suture, I am reunited with my old friend: Intern Tremor! My hand shakes as I throw each stitch and suddenly I am taken back in time to my first couple of OR experiences. Oh intern tremor, I thought I had left you behind long ago… Finally the god awful task of repairing the uterus with med-student hands is done. I tie off my suture. I think the worst is over but then as I throw down my third tie, I notice it. The dreaded Air Knot (a.k.a. a knot that is too loose to stop bleeding or hold your tissue tightly together.) I had sewn all across the length of the uterus only to finish the job with a knot that made my suture obsolete. Ouch. The rest of the case was a blur. As we finished, we shook hands across the patient in usual end-of-the-surgery fashion. She smiled. “Thanks for your help! That was…uh…good…”

About 12 hours later, I still sit here cringing at that OR performance. I swear one of these days, I’ll break this curse. Right?

Monday, March 1, 2010

Gone, Baby, Gone

Let me apologize in advance for another sad blog post. I’d much rather be ranting about my labor room mishaps or triage craziness, but such is medicine.

I had my first IUFD today. For my non-medicine readers, an IUFD is an intrauterine fetal demise, the death of a fetus inside the womb.

The couple was a lovely young Indian couple. She was 34, healthy, and had had a ridiculously uncomplicated pregnancy. She came in to Triage because she hadn’t felt the baby move all day. She wasn’t too worried. In fact, she was relaxed and calm when I met her, convinced that everything would be fine. As I scanned her belly, I noted the curious absence of fetal heart activity. I thought it was me and my novice ultrasound skills. I searched and repositioned the probe what felt like a hundred times. This had to be a mistake. Finally, I handed the probe to the Triage midwife for a second look. Unfortunately, her findings were no different than mine. The baby was gone.

The patient was understandably devastated. Her husband, awkward in his grief, tried desperately to quiet her down, to console her. I wondered how this poor man was going to cope with his own feelings of loss given how hard he was trying to be strong.

Later in the afternoon, we took her to the operating room for C-section. (She had several contraindications to delivering vaginally.) Before we started the case, my attending took me aside. She held my hands and looked in my eyes. “Okay. This is going to be a difficult case. But we are NOT going to cry. We can breakdown and cry our eyeballs out once we leave this room, but while we are operating we need to be strong for the patient. We need to focus on the case.” I quietly nodded in agreement as the tears threatened to make their way out onto my cheeks.

Delivering an IUFD is a painfully awkward and emotional experience. The OR is silent aside from the repetitive beeping of anesthesia’s monitors. The room lacks the aura of excitement and energy that usually accompanies the delivery of a live baby. Voices are hushed. The usually operating room chatter is absent. There is no iPod blasting music into the room. There are no celebratory cheers when the baby comes out. The fetus is whisked out of the room without fanfare.

A friend who understands well my recent bout of sad medicine asked me later how this experience compares to my difficult conversations with family members in the ICU (see last post). I thought about it. In the ICU, it was certainly heartbreaking to share a patient’s poor prognosis with their loved ones. But with all of these experiences, I was able to explain how and why the patient got so sick. What reason do I have to give this healthy young woman for the death of her baby? She wants only two things: she wants me to bring him back, and if I can’t do that, she wants me to tell her why he passed. Sadly, I can do neither.

The rest of the day, I wallow in my limitations as a physician.

Tuesday, February 23, 2010

To Cry or Not To Cry

“One of the most common experiences in the practice of medicine is the experience of loss and disappointment…from the small nudge of a lab test revealing a medication is not effective, to the blow of a patient dying. It is a great deal for any caring person to handle. Yet most of this loss remains unacknowledged and ungrieved…The expectation that we can be immersed in suffering and loss daily and not be touched by it is as realistic as expecting to be able to walk through water without getting wet. The way we deal with loss shapes our capacity to be present to life more than anything else. The way we protect ourselves from loss may be the way in which we distance ourselves from life. Protecting ourselves from loss rather than grieving and healing our losses is one of the major causes of burnout.”
- Rachel Naomi Remen, M.D. "Kitchen Table Wisdom"

My second to last call night on MICU was an emotional one. I learned a very important lesson that night. For the first time in my medical career, I gave myself permission to grieve, to acknowledge the pain of losing a patient. The situation involved a family discussion with a dedicated wife and her adult children. Her husband/their father had walked into the hospital 1 week ago with fatigue. On his 2nd day, he seized, breathed his stomach contents into his lungs, and developed a dreadful case of aspiration pneumonia. He had gotten so sick that his heart stopped. The code to bring him back lasted over an hour. The lack of blood flow to his brain during this time left him with irreparable brain damage. On this call day, we broke the news to his family. Mr. R would never be coming back. In fact, he was in the slow process of dying. His family was devastated. The room was filled with tears. His wife was inconsolable. “How can this be? He walked into this hospital last week!” she sobbed, tearing apart a used piece of tissue in her hand. After several minutes, she looked up, her eyes filled with tears and memories of love. “He was so healthy. You know we purposely did not get the paper delivered to our house each day? It was how we got our exercise. Every day, we would walk to get the paper. It didn’t matter if it was raining or not. Then we would come home and read it together.” It was this moment, the description of a small, every day event that got me. It reminded me that this patient was more than a body in a hospital gown. When I walked out of that emotionally-charged room, time stopped for an instant. As I walked out, I literally saw two paths in front of me. I could shrug this off and rejoin my co-residents, finish my work, and move on to dealing with other patients. Or I could choose to stop and allow myself to feel the gravity of this moment. For the first time in my career, I chose the latter. I walked into the bathroom. I burst into tears. As I sobbed, I couldn’t figure out why I was so upset. This wasn’t my family. It wasn’t my loss. In retrospect, I guess it was the picture of a man who was once very much alive and the very real love he shared with his wife. It was about the injustice of loss. It was about the feeling failure when, as a practitioner of healing, you have nothing else to offer a patient. Allowing myself to feel that sadness, albeit in the midst of a hospital bathroom, reminded me that I was human too. That I am not a robot in a white coat. That I myself am very much alive.