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.

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.

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?

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.

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.

When Crabs Attack

Have you ever been so tired that you wanted to throw yourself on the floor and have a temper tantrum? Have you ever been so sleepy that you doze off mid-sentence? Have you ever been so zapped of energy that your 80 year old stroke patient can get out of a chair faster than you can? Welcome to Suckiest Call Night 2010.

I have been told before that I am one of those people with a “happy gene”. I am a glass half-full kind of girl and generally opt to see the positive side of everything. MICU call last night, however, was too much for even this eternal optimist to handle.

It’s one thing to pull an all-nighter doing what you love. OB call? Not a problem! I am running to deliveries, c-sections, seeing patients in Triage. The variety keeps me awake, stimulated, and always on my toes. MICU call (read: glorified secretarial work) is another story. Last night consisted of sitting in front of a computer admitting one patient after another. I sat up all night writing H&Ps, entering admission orders, following up on labs, studies, and vital signs. These are not the kind of activities that keep me awake after 24 hours.

At 4:00am this morning, while admitting our fourth patient of the night, I was struggling. Sitting at my computer with a hospital chart laid out before me, I fought with every ounce of reserve I had to create an assessment and plan of care for my patient. It was a losing battle. The sentences on his note trailed off li..ke.. th….is….. It took me triple time to enter his orders. From the time I read his home medication on his chart to the time I looked up to my computer to re-order it on our computer, I had already fallen asleep. A quick second later, I’d wake up and forget what I was just about to order. I tried everything to stay awake. I tried stretching. I tried brushing my teeth. I tried eating. I even gave in and had some coffee. Somehow I pulled through the Suckiest Call without killing anyone. But I couldn’t help wondering what the impact of my resident fatigue was on the patients I was treating.

Around 5:30am this morning, I got my second wind. Great for getting me through the last 7 hours of work, right? The caveat, however, was that last night’s sleep deprivation had turned this usually cheerful, happy-go-lucky resident into cantankerous little bitch. I didn’t even recognize myself. I heard myself snap at the pharmacist on the phone. I grumbled under my breath about our half-hearted medical student. I felt my blood rising as my senior resident butted into a conversation I was having about a patient. I struggled not to roll my eyes when my attending embarked on his usual 20 minute long “teaching point” during rounds. I was tired, cranky, and in no mood for either inefficiency or intellectual masturbation. At this point, I was even annoying myself with my bad attitude.

By the time I leave the hospital, I had been up for approximately 30 hours straight. My eyeballs felt coated in sandpaper. My head was heavy and my facial muscles lacked the strength to smile. The only thing I could think of is my warm cozy bed. I was asleep before my head hit the pillow.

P.S. Just to end on a positive note, there was one great thing about last night. I discovered TEDS! These sexy little stockings (insert sarcasm), most commonly used in bedridden patients to prevent blood clots, are a dream come true to every on-call resident. They feel like a 24 hour long calf massage. Ahhh...

It's Oh So Quiet...Shhh...Shhh...

In preparation for the season's biggest snowstorm, schools have been closed, work schedules have been rearranged, grocery aisles have been cleared, and snow plows are rearing to go. Now, as the evening turns into night, guess how many inches are on the ground? A big fat zero! For a California girl who still sees each snow day through the awestruck eyes of a four-year old, this plain sucks! There goes my dreams of post-call snowball fights, sledding, and snowmen. Boo.

Instead, I wait for another night to pass in the MICU. It is suspicously quiet. My senior resident is sleeping in the call room (slacker!). The nurses are huddled in their social circles basking in their daily gossip (did I hear my name?). Patients are tucked away in their narcotized slumbers (can I have some?). And yours truly, the intern with nothing to do, has spent the last two hours engaged in some highly productive activities: eating and reading internet gossip. What could be more exciting at 9:30pm than Apple Jacks and Kendra's post-baby body secrets? (Uh, photoshop? Duh!) Or John Mayer spilling his guts about Jessica Simpson bedroom ways? (Remind to never hook up with that D-bag, by the way). Of course, now the sugar in my bloodstream has me antsy, antsy, antsy.

If there was snow out I could go run around in it until I tuckered out. Instead, looks like I'm hitting up perezhilton.com again.