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:


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.