Escaping the Inevitable

Any OB/GYN will tell you it’s inevitable. Sometime, no, multiple times during your career, you will perforate the uterus. They all have a story in which an instrument they so gently insert into the uterine cavity goes a little too far… and into the abdomen. But it could never happen to me, right?

It was the last case of the week and I scrubbed in to do a D&C Hysteroscopy with an attending I had never worked with. I sit down to do the procedure while Dr. M supervises. I examine the patient and note the position of her uterus. I place the speculum and visualize the cervix. I place the tenaculum, a grasping instrument which allows the surgeon to manipulate cervix. I sound, or measure, the length of the uterus and then dilate the cervix. I look inside the uterine cavity with the hysteroscope (an intrauterine camera). Everything is going super smoothly and I am proud of my independence in the case. Then it came time for the curettage. I introduce the curett, a long instrument with a sharp metal loop at the end used to shave off the endometrial lining. It is entirely done by feel. Once I feel as though I am done, we re-introduce the hysteroscope to make sure the uterine cavity looks clean and intact.

This time, I am having a difficult time getting oriented in the uterus. I move the camera past what I believe is the cervix, but the uterine cavity just looks more lumpy than usual. I rotate the camera to try and get my bearings when I see something that makes my heart drop. My camera focuses in on two round bulging structures that look frighteningly familiar. “Dr. M, do you want to take a look and tell me what this is?” She takes control of the hysteroscope and is quiet as she examines these structures. Finally, I say it. “Is it BOWEL???” Everyone in the OR, the circulating nurse, the scrub tech, the anesthesiologist, rush over to the camera screen. To get bowel, aka intestine, into the uterus would not only require a perforation of the uterus, it would require a huge tear. How clumsy could I have been to do that without feeling it?

Then again, it really does look like bowel. Dr. M and the surgical staff don’t know what to say. They have never seen anything like this. We remove the hysteroscope and two other GYN surgeons are called in for a second opinion. The wait for them to appear was painful - you could taste the tension in the room. Meanwhile, thoughts race back and forth in my head. Will we have to cut her abdomen open? What if I perforated her bowel too? Will we have to do a bowel resection? How are we going to explain this to her and her family? I thought about my own fate as well. What will the program say? What if I get sued? No attending is ever going to want to work with me again. Maybe I picked the wrong field after all. I am just going to quit before I hurt anyone else. I even start seeking help from a higher power. Please God, please don’t let me have perfed the uterus. Please…

Finally the other surgeons show up. They replace the hysteroscope. Although it’s a bit bloody and messy inside the uterus, we can’t seem to find those structures again. The consult surgeons suggest using a resectoscope, which is bigger and can dilate the uterus much more to increase our visibility. What we find is shocking. We see a perfectly normal and intact uterus. Dr. M and I can’t believe it. We examine every wall of the uterus 5 times. One ostia, another ostia, anterior wall, posterior wall. All smooth. All intact. No perforation, no bowel. Nothing but normal uterus.

The consult surgeons laugh. “See! We told you everything would be fine! There’s nothing!” The rest of the OR and Dr. M. breathe a huge sigh of relief. As for me, it takes me a good ten minutes before I trust that everything is going to be okay. What. A. Scare.

We never did find out what it was that we originally laid our eyes on. On theory was that we saw clots. My theory is that it was a miracle. God really must not have wanted me to quit my residency program.

Breathless

It has been awhile since I have written.

In one's life, there often comes a time when they are let down by the person they rely on most. For me, I have been more than let down. I have been crushed and devastated. My plans for a future with my presumed best friend and soulmate - getting married, becoming a wife, a mother - have ended. And I don't know if they can ever be mended with him.

This last month has been felt like I have been cut off from the air I breathe. I can only now begin to type these words.

I won't say much more. I will simply continue my professional journey into the world of medicine. Because right now, it feels like it is all I've got.

Drug Seekers

When I found J.M., he was wincing in pain on the ER stretcher. Attempting to get moderately comfortable, he shifted his position from side to side to no avail. I introduced myself. He was my age, clean cut and pleasant, resembling someone I might have been friends with under different circumstances. He explained his story. One year ago, he had fallen off a room and injured his lower back. With the help of his Orthopedic Surgeon, he was back to himself after a couple of months. Unfortunately, he recently re-injured his back and the pain was intolerable. I could see the discomfort on his face and tears welled up in his eyes as he told his story. “I can’t walk. I have to call the neighbor to help me to the bathroom. Do you know how embarrassing that is?” My heart broke for him. He was on an impressive regimen of Percocet and Oxycodone at home and it just wasn’t managing his pain. As I set out to examine him, no doubt a painful endeavor, I recalled something an ER Attending had said to me. “ER docs are notoriously bad at managing patient’s pain. So make sure you don’t forget to make a patient comfortable.” So, before I went any further, I said to J.M. “I’ll be right back with some pain medication for you and then we’ll finish the exam.” He looked at me with gratitude. “Thanks.” he said.

Four milligrams of Morphine later, I returned to his room. He was still writhing in pain. “Doctor, the medicine didn’t touch me. When I was in the hospital last time for this, they gave me Toradol and Dilaudid.” I gave him both. After examining him, I called the Orthopedic resident to come down to see him. Clearly this patient’s pain control issues and lack of mobility warranted his admission to the hospital. The Orthopedic resident did not agree. Our conversation went like this:
Ortho: “I know this guy. He’s had back problems forever. He just wants a prescription for pain killers and he will go home”.
Me: “You don’t understand. His pain medications are NOT working. He CANNOT WALK by himself.”
Ortho: “How did he get to the ER then?”
Me: “He told me his Dad carried him in!”
Ortho: “Allright fine. Get some X-Rays and I’ll come and see him”.

Long story short: Ortho came down. Saw that his X-Rays had not changed at all - meaning his back issues had not gotten, that we could see, any worse. Ortho found out he ran out of his Oxycodone last night. Offered to write him a prescription for new pain medications and send him home. The patient agreed. Ortho got him to demonstrate his ability to walk. Ortho also found out that he had been to 4 ERs in the span of 2 weeks asking for pain control. Needless to say, his story got fishier and fishier. And I got more and more embarrassed.

How could I have not seen this? Was it because he looked like someone I could relate to? Was it because he didn’t have a history of drug abuse, like so many of our other patients? As a physician, how do you balance being compassionate and being taken advantage of? How do you avoid enabling prescription drug abuse? Let me know if you have any ideas...

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The Learning Curve

I’m finally finished with my first OB rotation! The moment is bittersweet. I love obstetrics. It is exciting, emotional, and empowering. It is also one of the most difficult rotations of intern year. I struggle to stay under the 80 hours of work each week. Each day, I am pulled between the operating room, the labor floor, Triage, and the postpartum floors. Our Triage is unique in that we see all pregnant women regardless of gestational age as well as non-pregnant patients with GYN issues. We essentially function as a women’s emergency room. It is great for my training and experience, but it also means there is never any downtime. When I am not in a delivery or on the floor, I am in Triage seeing several patients at a time. Aside from the hours, the technical skill set we are expected to acquire is huge. In addition to fundamental knowledge about pregnancy and women’s health, we have to master the technical aspects of the trade. Learning how to read a fetal monitor. Learning how to work the ultrasound machine. Learning how to check a woman’s cervix as she progresses towards labor. Learning to deliver a baby. Learning to break her water or insert a device to measure her contractions. Learning to do a C-Section – how to get into the pelvic cavity, pulling the baby out, clearing out the uterus, suturing, knot tying… the list goes on and on.

As a medical student, I got a taste for some of these skills and learning them was always fun and stress-free because there was always someone who walked me through it. Now as an intern, I’m much more on my own. Clinical decisions are made based on my exams or assessments. Avoiding a tear or birth complications are based on me delivering her baby as smoothly as possible. Avoiding post-operative pain and bleeding after a C-section depends on me controlling the bleeding by suturing and tying knots well. There is so much more pressure riding on my skill set than ever before. It’s a scary place to be because I truly want the best for my patients. But I also can’t second-guess everything I do simply because I am new at this. Part of my learning to be a good physician is taking ownership of my clinical judgment.

So, now, I leave Obstetrics a little more skilled and a little wiser. Above all, I leave with determination to do things even better, and with more confidence, the next time around.

The Honor

It is the stage in which new life enters the world. Where women overcome the seemingly insurmountable challenge of giving birth. As a new intern, the delivery room is a thrilling place. However, I often wondered – will this ever get old? Routine? You hear time and time again about the OB/GYN who no longer does OB because of the “lifestyle”. Will that ever be me?

It was 4:00am and I was nearing the end of my 24 hour call. I had delivered 6 babies throughout the day and night and the shift was finally winding down. I was at the computer reviewing patient labs and vitals, trying to stay awake for an early morning of postpartum rounding. My pager goes off. It reads: “DELIVERY IN LDR 19”. I jump out of my sleepy stupor and rush upstairs. I gown up for the delivery elated at the opportunity to catch one more baby before the end of my shift. After all, I could use the extra practice with hand skills and suturing technique. I approach the patient and explain what will happen next. She is visibly tired from pushing. Her mother and husband whisper words of encouragement and take turns stroking her hair. This is her first baby. She is both scared and exhausted. We push for about 10 minutes and make little progress. The baby is crowning but at this point, we can only see the top of her head. This continues for another 10 minutes. Our patient starts to lose patience. She starts wailing in pain and threatening to give up. She doesn’t want to do this anymore. “Please, I just want to stop,” she wails “I can’t do this anymore!” Her husband encourages her to keep pushing and opens himself up to her wrath. “Shut up! Just shut up! Don’t touch me!” she screams. The tension in the air is palpable.

I call her name loudly to get her attention. I remind her that she can do this, she will do this. We remind her to breathe… and focus… After several minutes, she calms down and breathes deeply. I feel around the baby’s head and note that there is plenty of room. The nurse pours on some Astroglide to help the baby slide out easier. I hold pressure with my fingers at the base of her vagina. “Push where you feel my fingers,” I tell her, “Push my fingers out.” She closes her eyes to focus on the task at hand. She pushes with all her might. The crown of the infant’s head slowly advances out. Then her forehead. Then her face. With two more pushes the infant is out. For a split second, the room is silent.

I hand the child to her mother and she whispers in the softest of voices, “Oh, my baby.” The patient’s mother and husband burst into audible tears of joy and the three of them embrace around the newborn child. I feel a lump in my throat upon seeing this display of love. My eyes well up. I look to my resident and my attending standing next to me and their eyes are teary as well. We look at each other and without speaking a word, I know we are all thinking the same thing. This is what we signed up for.

I realized then that this experience could never get old or routine. The delivery wasn’t about practice or refining my skills. It was about the immense honor when a woman trusts you with her body during the most intimate of all experiences. It was about the privilege of being the first person in the world to lay hands on a newborn child. This is something I could never, ever take for granted.

Slippery Babies

Babies, and their entrance into the world, are always unpredictable. At this point in my short residency career, I have delivered about 12. By the middle of my weekend on call, I felt pretty darn comfortable with the process. The head is delivered with a little downward pressure, followed by one shoulder, then the next. The rest of the body is delivered quickly after. Then, with a swift move of the hands, you flip the squirrely little neonate into a secure football hold while you suction out his nose and mouth and clamp the umbilical cord. Seems pretty straightforward right?

Ha. Today’s call day reminded me that I am a mere intern with a lot to learn.

Working in triage today, I hear the team call out, “She’s complete (read: fully dilated)! We’re taking her straight to L&D!” Being the team member assigned to vaginal deliveries, I hop out of my seat and follow the patient up to the labor floor. We rush into the room and everyone takes their places. Patient is moved to the bed, nurses pace around frantically setting up for the delivery, and my attending physician, Dr. T, and I gown up in what one patient called our “storm trooper outfits”. It’s true. Baby deliveries are messy! You have virtually every body fluid being thrown your way at any given time. You’ve got to protect yourself! So, we don our face shields, surgical boots, surgical gowns, and sterile gloves. Now the process of pushing to delivery can vary anywhere from a couple of minutes to a couple of hours. As the baby catcher, you generally have a bit of time to get mentally prepared for the upcoming events. Alas, that was not the case today.

One push and the baby’s head slides out easily. Too easily. My hands on either side of the head alternate between applying upward and downward pressure to ease out the baby’s shoulders. All of a sudden, the rest of the baby catapults out. I try clumsily to secure the baby in my football hold but can’t get a grip on her legs – she just comes out way too fast. Before I know it, in painful slow motion, I am fumbling to keep this baby in my grasp. And everyone is watching. After a split second in real time (but eons in my brain) I regain my grip. Like a magician pulling a rabbit out of a hat, a jump up with the baby in my arms. Ta da!!! “Here is your beautiful baby girl!” I quickly clamp and cut the umbilical cord and place the baby in her mother’s waiting arms. A decent recovery but my face still burns with embarrassment. Shaken and struggling to remember what to do next, I undo the clamp on the placental sided umbilical cord to collect a routine cord blood sample. I replace the clamp and hand the specimen off to the nurse. When I look back there is umbilical cord blood spraying all over the place. It’s hosed the floor, the nurses, my boots. Apparently, in my self-conscious stupor, I replaced the clamp but did not secure it shut. Don’t worry, everything that came out was from the placenta, not the patient, so no one was hurt by my debacle. Just my increasingly fragile intern ego. And my happy place with those labor floor nurses.

Bad News

M.K. was 5’4” weighing it at only 100lbs, but she was feisty. You could tell she was a knockout before the cancer came. She had big blue eyes and blond pixie haircut reminiscent of Meg Ryan in her Sleepless in Seattle days. She had come to our care after noticing blood in her urine. Didn’t think much of it – she had been battling cervical cancer for five years and figured this was just another bump in the road in her fight against cancer. Thus far, she had been through surgery, radiation, and several rounds of chemotherapy. And despite the orange-sized mass protruding out of her left backside, she anticipated being out the door almost as soon as she came in. Unfortunately, the bleeding persisted. And then, her platelets dropped. A week later, the bowel obstruction came. Her tumor had grown into her intestine and she was no longer able to pass stool through a portion of her large intestine. The nausea and vomiting became so bad, she couldn’t eat or drink. A CT scan revealed that the tumor was now 4mm away from invading her spinal cord. A week and a half after she came into the hospital, the oncology team knew she would never leave alive. But M.K. didn’t.

Being human presents a big obstacle in providing good medical care. It is simply not in our nature to be the bearer of bad news. We want to impart hope, to heal, to cure. Unfortunately, there are many times in medicine when the only thing a patient needs is the truth. The cold hard truth.

Thus far in my short career in medicine, I have seen too many times what happens when doctors are afraid to tell patients and their families the truth. At best, a patient lives the last months of her life with the false belief that she will eventually get better. And she is subjected to the pain and discomfort of tests, procedures, and medical interventions that do nothing to prolong her life and everything to prolong false hope. At worst, it means a patient dies in a cold hospital room surrounded by white coated strangers, with tubes coming in and out of every orifice and ribs cracking under the force of CPR.

I have also seen the alternative. A great oncologist at my hospital always tells his patients the same thing when they first meet. “You are well now, and we will do everything we can to keep you well. But there will come a time when I will have nothing left to offer you. And when that time comes, I will say to you, we are done.” We had that talk this week with another patient, K.A. Because she had had time to think about it before, she was able to say, “Okay, I am done fighting. I just want to be comfortable. I want to live my last months at home with my horses and dogs and die surrounded by my family.”

The same went for M.K. and her family. Before we had The Conversation, her family wanted everything done. It didn’t matter if how futile or physically painful it was, they felt this obligation to do everything to prolong the life of their daughter. And the dutiful daughter M.K. was, she felt obliged to go along with it. Each time we walked into the room, the anxiety was palpable.

Then The Conversation came. M.K. and her family learned that with the way things were going, she would never make it to treatment. She didn’t have much time left and now we were asking M.K. how she wanted to spend the remainder of her life. The room swelled with sadness and tears that afternoon. But curiously enough, it also swelled with relief. The patient and her family had finally been given permission to let go. It was if they had needed to hear that it was okay to stop fighting.

The useless medical treatment was replaced by comfort care. The IV was taken away. The daily injections were stopped. The anxiety in the room disappeared. Shortly after, M.K. started to lose consciousness. It won’t be long before she’s gone, but when she is, her life will end in the most peaceful of ways. Without pain, surrounded by friends and family in a room filled with love.