On The Road Again...

It has been way too long since I've written on these pages.

Over the last three years, I have graduated from residency (hallelujah!), met a wonderful man and gotten married (woot woot!), had my first child (aww...), and started my first job as an attending physician (eek!). Career-wise, I have had periods of intense job-love and periods of intense burn-out. 
And though I have been away from this blog throughout this time, my life truly has not felt complete without the ability to process each and every one of these experiences on these pages. 

I won't go into the reasons behind my writing hiatus. I will say, however, that I have always cherished this blog. Without my ability to write, reflect, and reminisce over my experiences in residency, I would not have become the doctor I am today (not that I don't have a long way to go!) Furthermore, I could never express enough gratitude to you, my readers (are you still there?), for taking the time to read my thoughts and express your support and encouragement. This blog, and all of you, played a huge part in helping me make it through my intern year in one piece. 

Writing helped me to reflect on the moments that stuck with me, influenced me, inspired me, and humbled me. I wanted to document the experiences that shaped my growth as a physician. I wrote so that I would never forget what it was like to see and do things for the very first time. My hope was that 30 years from now, I would still remember the feeling of awe and wonder in bringing new life into the world, the heartache and compassion in helping people with life lost, and all the profound moments that happen in between. 

Since the last time I wrote, I have had enough ups and downs to realize that writing was more than just a tool to preserve memories for the future. Writing also helped me reflect on and appreciate the present. It helped me see the good in each life moment over the bad. It turned every experience into an opportunity for learning and growth. 

These days, I could use a little more of that. 

You see, I always imagined that life after residency would be more simple. On the contrary, I have found it to be more complicated. Instead of a single balancing act of life and medicine, I know find myself juggling a career in academic medicine, motherhood, marriage, and my own personal sanity. Trying to be the best doctor/mother/wife I can be is no easy task and in taking up blogging again, I hope to both cherish it a little bit more and forever remember these moments. 

And so, here we go... back on the writing road again! 

Seriously, What Do I Know?

Obstetrics is humbling. Just when I think I know enough about OB/GYN that I can predict a patient’s course in labor, I have a patient whose uterus, cervix, or baby does something completely unexpected. It’s as if God himself is reminding me of my limits.

Take patient A. About a week into my stint as new OB 2nd year/labor floor queen, a 28 year old multip (a woman who has delivered more than 1 baby before) was admitted in active labor. When she first arrived in Triage, her cervix was 5cm dilated. This lovely Latina woman was tough as nails, but every contraction shook her to her core with pain. She asked for an epidural as soon as she arrived on the labor floor. The nurses paged the anesthesiologist and began the tasks they do with every new labor admission. Ten minutes later, they called out for me. “The patient is complaining of pressure. Can you check her before anesthesia sets her up for the epidural?” I pulled on a glove onto my right hand and sat on the side of her bed. The patient was writhing in pain. Between contractions, I quickly checked her cervix. I felt the hard surface of the baby’s head. I felt the ¼ centimeter thickness of soft cervix partially covering his head. She was a good 7 centimeters dilated (out of 10). I looked up at the nurse and said, “She’s 7. We’ve got a enough time to place that epidural.” As these words left my mouth, before I had my glove off, the patient started to bear down. That’s right. She was pushing. “Ma’am” I explained in Spanish, “you can’t push yet. You’re not fully dilated.” The pain was unbearable and my words bounced right off her. She was squeezing her legs together and pushing. “Listen, you cannot push yet!” I repeated, “Let’s get you your medicine, and by then, it will be time to push.” At that moment, a guttural moan emanated from deep inside her and her knees parted. I looked down. A baby head was sliding out of her vagina. As I saw this, I threw a glove onto my left hand at lightning speed. I barely had enough time to lay my hands on the baby before it came sliding out onto the bed. I wanted to laugh out loud. This woman had gone from 7cm to baby in literally less than a minute.

Surprise! You know nothing after all!

Now take patient B. She was a 21 year old woman who was pregnant with her first child. She had ruptured her membranes (AKA broken her water) the night before, approximately 24 hours before she came into Triage to be evaluated. Given that these membranes are an important barrier for both mom and baby from the outside world, the risk of infection becomes higher and higher the longer she’s ruptured. Given that she was full term, this patient needed to be delivered. She came to the labor floor with a cervix that was 4cm dilated. We started Pitocin, a drug that works by causing or strengthening uterine contractions. How much Pitocin we give depends on how quickly her cervix responds to the medication. We started at 2 (it is not unusual to get up to 20). As soon as we started the Pitocin, the fetal heart tracing started showing late decelerations (a drop in heart rate - a bad sign the baby is not getting what it needs from the placenta). When we turned down the Pitocin, they went away…along with her contractions. We played this game all morning. Pitocin, then late decels, then no pitocin, then no contractions. We were stuck between a rock and a hard place. We wanted her to deliver vaginally, but if we couldn’t use the pitocin, we weren’t going to get her in labor. And if we used too much, we could prevent adequate blood flow to the baby. The risk of infection was too high to leave her ruptured until she did it on her own.

We finally settled at 1 unit of Pitocin. It was just enough to give her 1 contraction every 5 minutes (contractions are usually every 2 – 3 minutes in active labor). Even at 1 unit of Pit, the baby was having late decels. Everything else about the tracing was reassuring so we decided to hold course. After about five hours of this, her cervix slowly made it to 5cm (we usually expect 1-1.2 cm of change per hour in active labor). I remained doubtful. By this time, she was ruptured almost 30 hours, was still only 5cm dilated, and was not contracting enough by normal standards to have a baby. I was certain this baby was going to end up coming out the abdomen. Our team decided to give her 2 more hours. If she was still 5cm, we’d call it. We’d head to the OR for a cesarean section. If she changed her cervix, we’d keep going. So, for the next 120 minutes, I watched the tracing, and those late decels, on the edge of my seat. What if in one of those decels that heart rate didn't come back up? What if it stayed down and we had to emergently take her to the OR? I am certain I grew three new gray hairs that day.

Finally 2 hours pass. I return for a cervical exam. Based on how infrequent her contractions were, I was doubtful I’d find any change at all and was confident a c-section was in her future. I glove up and start my exam. I immediately feel baby’s head. I feel around for cervix. I can’t find it. I feel around even more. And then it hits me. This primip (or woman having her first baby) had gone from 5cm to fully dilated in two hours with contractions not closer than 5 minutes apart. Another moment of shock in OB land. Literally, 20 minutes later, a beautifully healthy baby boy was born. I swore I saw a mischievous sparkle in his eye when I caught him, saying "decels, what decels?"

Oh, obstetrics, you will forever keep me on my toes...

Delivery by Zen

I got the page for another labor admission. “K.L. 20 y.o. G1 @ 40’0 wks in labor. 8/100/0. GBS negative. Declines epidural”. (Read: 20 year old, first pregnancy, at term, 8cm dilated.)

Now it’s not terribly uncommon for our patients to deliver without an epidural. But the ensuing delivery often entails lots of screaming, crying, and the occasional out-of-control, climbing-up-the-bed-with-a-baby-head-sticking-out episode. I knew from the moment I met this patient, she would be different.

When I walked into her labor room, I found a lovely young Southeast Asian woman, sitting on the hospital bed, eyes closed, calmly breathing through contractions. She was the quintessential picture of Zen. If she wasn’t dressed in a hospital johnny, I could’ve easily mistaken her for practicing prenatal yoga. She was almost fully dilated by the time she came up from Triage. By the looks of her, I would have thought she was 2.

As she progressed in her labor, her contractions became stronger, more difficult to breathe through. She changed positions, moaned, writhed, shook – but through it all, it was clear that she had 100% control of her labor.

In most deliveries, where the patient is numb from epidural anesthesia, a lot of labor coaching is required. The patient often can’t feel much and a good deal of time is spent teaching a woman how to push. This type of birthing is an interactive process, a team effort.

The birthing experience of this young woman, however, was completely different. Because she had no inhibition of pain or feeling, she was completely in tune with her body. She could feel when it was time to push, she could feel how and where to push, and absolutely no coaching was required. In fact, she was so much "in the zone” that anytime I spoke, I felt like I was interrupting her focus. Her process of birthing was beautiful to watch. It wasn’t that she was quiet (she was definitely making noise). It wasn’t that she was still (she was moving around a lot). It was that she was focused and in complete control with what was happening to her body. It was an empowering experience to watch.

A beautiful 5+ lb baby boy was born approximately 20 minutes into pushing. The patient did 99% of the work on her own. The one and only contribution we had was to catch the baby.

What made this patient different from the other non-anesthetized patients I’ve delivered? What was her secret? Was it her expectations? That she knew it was going to be painful and developed great coping strategies for it? Was it a personality thing? A high pain threshold?

Regardless of what her secret was, I left that delivery room inspired. Empowered. And very, very proud of my patient.

You Know You're an OB/GYN When... (PART 1)

* you get splashed with amniotic fluid and think to yourself, “Do I really need to change my scrubs?”

* you can say you’ve caught a baby with only one glove on.

* respiratory mucus grosses you out more than cervical mucus. 
 
* you think ferning under the microscope is beautiful.

* you can’t remember what the sex of the baby you just delivered was… two minutes ago.

* you can say that your clogs have come in contact with every single body fluid produced by the female body.

* you think placentas are pretty.

* you’ve been baptized by baby pee. And poop.

* you say things like “whiff of pit” or “shrom”.

* seeing a new dad cry makes your eyes well up with tears.

* you refer to your patients as “primips” or “multips”.

* you understand that this means: “This is a 19yo G3P2012 who is PPD#2 s/p SVD c/b PPH after IOL for severe PEC “.

* you can diagnose bacterial vaginosis before you’ve placed the speculum.

* you think Trichomonas under the microscope is really fun (not for the patient of course!)

* you think Mirena IUDs are by far and away the best birth control method. Ever.

See One, Do One...Teach One?

One of the things I love about residency is that the learning curve is just so darn steep. Just when you’ve got one thing down pat, it’s time to learn about something else. The process of self-improvement just doesn’t end.

Example 1: The first half of my intern year was dedicated to learning how to get through the basic steps of a vaginal delivery or cesarean section. I was happy just to get through a delivery without fumbling the baby. If I finished a delivery and the baby wound up in a nice football hold, if I could cut and clamp the cord without dropping the instruments, I was glowing. Same goes for a c-section. If I could hide my intern tremor for the duration of the surgery, I was happy. If I could sew up the uterus and the attending didn’t need to throw in a ton of extra sutures afterwards, I considered it a job well done.

Example 2: The second half of my intern year was dedicated to finesse. It was about maintaining order in a labor room, creating a positive birth experience for my patients, catching a baby with grace, and knowing when and how to intervene if a baby dropped its heart rate or if mom had more bleeding than usual. It was about developing my own style and routine of baby catching. In the operating room, my focus was on doing the c-section start to finish, calling for instruments, delivering the baby without struggling, re-loading my needle driver without touching my needle. It was about a beautiful subcuticular stitch to close the skin. It was about dictating from memory before I walked out of the OR.

Now, a year later, the start of my second year is dedicated to a new learning objecting: teaching. I’m no longer standing at the perineum and coaching a soon-to-be mom with her pushing. I am not catching the baby and handing it off to its waiting mother. I am walking our new interns through it. I am helping with their delivery maneuvers, their laceration repairs, and everything in between. The good is that it’s been extremely rewarding. There is a certain pride you feel when your intern does a beautiful delivery or repair. And with every delivery, they get better and better. As if that weren’t reward enough, their excitement and enthusiasm for these new experiences is incredibly contagious.

The challenge for me in all of this is making the personal transition from the “do-er” to the “teacher”. Struggling with something, be it getting the baby into a good football hold or delivering the placenta, is an important part of the learning process.I know this. Watching it without jumping in, however, is harder. It’s like being the kid in class who actually knows the answer to the teacher’s question but not being able to answer it. It’s like waving your hand in the air saying “Pick me! Pick me!” knowing full well that it’s not your turn to talk. A couple days ago, I hip-checked my intern out of the way when we had a tight cord around the baby’s neck. Afterward, I realized that I had missed a great opportunity to teach my intern how to deal with this situation. What makes me feel even worse about the whole thing is that I remember being in this intern’s shoes. Just a year ago, I remember being so eager to do a delivery, by myself, start to finish. I remember being hip-checked myself and thinking, “Just give me a chance! I can do this!!!”

Reflecting on this experience, I realize that I had panicked in this week’s delivery because, as the next senior person in the room, I felt ultimately responsible for the outcomes of this mom and baby (which is true). Looking back, however, there was plenty of time to walk her through a nice somersault maneuver and still have a happy baby.

Intern year, for me, was about stepping into my role as a doctor. It was about stepping up to the plate and getting my hands dirty. As a second year on the labor floor, I’m learning that my job is to take a step back and teach. It’s to trust my intern with a straightforward delivery. It’s to trust myself that I know when to step in. Like I said earlier, there’s always something to work on in residency.

Babies Having Babies

She was 15 years old. She looked like any other youthful teeny bopper, with her silly band bracelets and hot pink nail polish. She should have been at home, in bed, dreaming about the Jonas Brothers, her high school crush, or what she was going to wear to school in the morning. Instead it was 3:00am and she was in our Triage, alone, and 30 weeks pregnant. She sat tearfully on the hospital gurney as the contractions came and went every 3 minutes. Like clockwork.

Concerned she may have broken her water, I did a speculum exam. Through a dilated cervix and amniotic membrane, I saw a head of hair. It was then that I knew my patient was going to deliver early. By the morning, this baby was going to be a mother.

Explaining the implications of delivering an infant 2 ½ months early to a 15 year old girl was not easy. I’m not sure if it was the fact that she was alone, in pain, or still a baby herself, but nothing I said seemed to sink in.

I explained, in the simplest way I could, that we were going to give her steroids in an effort to mature the baby’s lungs prior to delivery. I talked about the role of tocolytics and its purpose in slowing down the labor long enough to give steroids. I discussed the role of magnesium in protecting the baby from the perils of cerebral palsy. After all was said and done, she looked up at me blankly. Her only response was, “Can I take this off now?” referring to the fetal monitoring system attached to her belly. The next question that followed, “Can I just get a c-section now?”

Her lack of insight was profound. I pulled out my doctoring skills, asked her to tell me what she understood about what was happening. She recited back to me the facts of the situation at hand. Her explanation, brief and without detail, was notably void of any emotion or understanding about the gravity of delivering a 30 week infant.

“Do you have any family with you?” I asked. “Can you call anyone to be with you right now?” Apparently her mother had dropped her off at the Emergency Room and left. Despite several phone calls by both the patient and the resident team, she failed to show up. Our young friend delivered a 2 ½ lb baby girl, alone, at 9:00am the next morning.

Anyone who argues against comprehensive sex education, condom distribution in schools, or unlimited access to family planning for minors needs to meet patients like these. These are young girls with little to no family support or financial resources. Their neurologic development will not be complete until their early 20s. Most of them lack the maturity or understanding it takes to raise a child. Their bodies, underdeveloped for childbearing, put them at risk for severe pregnancy complications like preeclampsia, obstructed labor, and having low birth weight babies. Having a child drastically decreases their likelihood of completing high school and increases their likelihood of relying on public assistance in the long term.

There is also a gender issue here – it takes both a man and a woman to achieve pregnancy. Yet time and time again, it is the young girls who suffer the consequences of pregnancy. It’s their lives that are forever changed, their dreams that are forever shattered. Unfortunately, it is just too easy for boys/men to walk away from their responsibility. When my patient delivered, it was her alone in that delivery room.

The most conservative of parents should know that none of the aforementioned interventions (sex ed, condom distribution, access to family planning) have been shown to promote earlier sexual activity in teens. These teens will start becoming sexually active at the same time as their peers. The difference? They are more likely to use birth control or condoms when they do it.

Of course, we all want our youth to postpone sexual onset. But the fact is, they make mistakes. Are we so dogmatic that we don’t want to give our children room for error? Are we really that strict that we will force our kids to suffer life-altering consequences of unprotected sex? I hope not. For every young girl like this one.

For more info, check out: www.advocatesforyouth.org

“Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness, that frightens us most. We ask ourselves, 'Who am I to be brilliant, gorgeous, talented, and famous?' Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There is nothing enlightened about shrinking so that people won't feel insecure around you. We were born to make manifest the glory of God that is within us. It's not just in some of us; it's in all of us. And when we let our own light shine, we unconsciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others."
- Marianne Williamson