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


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 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


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…

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.