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 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.