Self Sufficient September 16, 2009

One of the things that I love about Ob/Gyn is that we do it all: Obstetrics, gynecology, medicine and surgery!! This last month I have been wearing so many different hats. We have had some interesting admissions: pulmonary embolism, sickle cell crisis, Liddle’s syndrome (hypokalemia), factor VIII deficiency, etc. It’s great because I really do get to put to use my medical school education, while building upon it.

Beyond the field being fairly self-sufficient, I’ve been becoming more self-sufficient as an intern. I had the busiest night ever last week!! I’m so happy it was after 5 weeks of being on this rotation, not my first week. In a matter of a 13 hour shift we had 17 patients come through triage and 6 deliveries! I saw, worked up, admitted (or discharged), and delivered all of the patients that needed it that night. I still don’t know how I survived. It was non-stop running from one room to do a history and physical (and of course writing a note on the spot), then to a delivery, then another H&P, then another delivery non stop for 13 hours. Literally I didn’t even have a chance to go to the bathroom or eat! At the end of the shift I was so pooped… However, looking back it was great. I didn’t make any bad management decisions and every baby was delivered by me, not on their own in a triage bed!

Only a few more nights left and I’m back to normal hours… can’t wait!

Halfway Done August 29, 2009

It’s already been 3 weeks doing my night float rotation, which means I’m halfway done!  I must say that this has been an enjoyable rotation thus far.  I’ve delivered about 30 babies, worked 80 hours a week, and still managed to go to a wedding and help my little brother move into his college dorm.  I’m pretty damn proud of all that I’ve done in the past 3 weeks.  The hardest part was switching from clinic to inpatient, on top of the fact that I’m working an extra 30 hours per week and it’s all at night!  I’ve seen some very interesting things though: large volume postpartum hemorrhage, 2 shoulder dystocias, classic placental abruption (actively bleeding at presentation), PPROM, severe preeclampsia, and I’m sure there is more that I’m leaving out.  I feel much more comfortable with laceration repairs after delivery.  One of the other great things about OB is the interface between medicine and Peds.  I’ve had to work up and/or manage an asthma exacerbation, diabetic ketoacidosis, deep vein thrombosis – one with Factor V Leiden another with Protein S deficiency, and a preop pt with mitral valve prolapse.  As for Peds, I’ve delivered quite a few premies, with the smallest being 3lb 4oz, and a few with congenital anomalies.  Also delivered a kid with polydactyly (extra digit) on each hand.

Each day that I go to work, I definitely feel like I made the right career choice.  I can’t wait to see what the rest of this rotation brings. Hopefully plenty more deliveries for me!

Pimping August 25, 2009

No it doesn’t end after med school… I find every morning during sign out rounds is the chance for the interns to get pimped.  It can be a little nerve racking at times.  Usually all of the cases are presented to the incoming day team and attending by the upper level.  The upper level will definitely get quite a few questions about management and as the intern I don’t get asked much about that.  However, occasionally since I’m sitting right next to my upper level I’m the prime target for random questions.

One attending in particular will ask a question and then stare right at me and say, “Interns?”  In that situation, I don’t have a name, but I’m expected to respond.  A few questions for example, “What are MVUs, and what number is considered adequate?” or “What specifically are you worried about when preeclampsia patients have RUQ (liver) pain?”  I definitely realize the importance of reading!  I’ve been lucky to have been recently reading about the topics I’ve been getting pimped on lately.  I know some of the questions were things that I didn’t know as a med student.  It’s a little intimidating to answer when there are 30 people in a room all staring at you for the answer!  In med school pimping was usually in the OR with maybe 4 people, or maybe on walk rounds with 10 people… but this definitely takes the cake.  Anyhow, back to work soon with my books in hand.

Postpartum Hemorrhage August 19, 2009

What a night I had.  It started off great!  Triage was just a smooth steady flow of patients, nothing too complicated: evaluation of labor, rule out preeclampsia, etc.  I did three deliveries, all of which had no lacerations and minimal blood loss.  Well about 4 hours after that 2nd delivery I get called to the bedside.  A patient stood up and expressed several blood clots from the vagina and felt dizzy.  Her blood pressure was low normal (90s/60s), but returned to baseline once she sat down.  I felt her uterine fundus and it was firm (as it should be), however it was still about 2-3 cm above the umbilicus and tilted to the left.  I did some fundal massage and the bleeding wasn’t too significant so I left.

Just a few minutes later, I get a frantic, “Is Dr. Obsession there?  You’re needed in the room now!”  So I run to the room and blood is just pouring out of her vagina.  I put gloves on eventually and start bimanual massage from the inside and outside.  She feels firm, but inside the blood and clots are pouring out.  The nurses are all asking different questions: “Do you want a speculum to look for a laceration,” “Do you want methergine,” “Do you want cytotec?” etc, etc.  So I decide for them to bring the cytotec and meanwhile look up and her BP is 64/47!  Anesthesia makes it to the bedside.  We had her LR wide open.  He adds some phenylephrine to her line to bring her BP up.  Meanwhile, I sent the med student to page my upper level who was pushing with a laboring patient in the other ward.  My upper level arrives and does way more aggresive massage.  I definitely wasn’t as effective as they were.  The patient ends up having about 2 liters of blood and clot through the towels and chucks!  The cytotec finally arrives and I place 1000mcg in her rectum.  The upper level orders for 0.2mg methergine IM.  Then… my upper level gets called back to the laboring patient because she’s about to deliver.

Once again, I felt alone in a room full of people.  Anesthesia gets a 16 gauge IV in and we give her Hextend, which will stay intravascular better.  My chief resident arrives and also decides that we can give Hemabate and some pitocin in the fluids to the patient.  The the cheif resident leaves and I’m alone again.  The nurse comes back in with the Hemabate and wants to know the dose.  I have no idea what the dose is and I verbalize it!  I was asked 4 times what the dose was.  Finally a nurse left and looked it up and it was just 1 ampule (250mcg).  By now the patient’s blood pressure is 120s/70s without the need for pressors.  We continued to cycle her blood pressure and give her the fluids with pitocin.  Typed and screened for 2 units of packed red blood cells.

In the aftermath, I went back to triage and I was shaking.  I was trying to write down the dosages of the medications and couldn’t even write straight.  I know that the patient was okay, but I just felt so overwhelmed because I didn’t now the exact order to give medications and definitely didn’t expect that she would bleed down to the point of 64/47 blood pressure.  I know that my upper levels have my back, but I guess my game face was too good.  I remained calm at the patients bedside, but they had no idea that I was freaking out on the inside.  After it was all said and done I ended up talking to my upper level and expressing that I felt a bit alone and overwhelmed due to the sheer volume of blood loss, the blood pressure, and all of the people in the room asking different questions all at once.  They reassured that I did the right steps and once again reiterated that I need to be more aggressive with getting those clots out.   I ended up learning so much from the situation and will definitely be more prepared for the next one!

PS I delivered a 9lb 1oz baby too… so the post below is already null and void for my record high baby weight!

8lb 10oz August 17, 2009

I was on call last night and got to do a few deliveries!  The deliveries are definitely the highlight of my night.  I know that I will get my numbers up, but now I still get a rush from delivering babies.  Yesterday’s call was interesting because I delivered both the biggest and the smallest baby so far.  Granted… I’m only 1 wk into my night rotation and just came off clinic, so I’ve only delivered about 20 babies!

Nonetheless, the lady last night was a G2P1 (2 pregnancies, 1 delivery beyond viability age).  Her first baby was only a 4 pounder since it was born 6 weeks early.  This time around by my estimation the baby was going to be about 8lb minimum.  I was hoping that she would be able to get that baby through that pelvis.  She’s pushing and the head is out, 1 cord around the neck, then it was time to get the anterior shoulder out.  I had her keep pushing got the shoulder out and then the rest of the baby followed! It was amazing because that baby weighed 8-lb 10-oz and she had no tears .  I was proud of her… and myself for protecting the perineum so well.

In contrast, I also delivered the smallest baby ever: 5lb 4oz!  That was great because they can just slip out being so small, but she had no tears and didn’t land on floor…

6/60%/-1 August 11, 2009

That’s right… cervical checks galore!  Now that I’ve started on night float, I’m in charge of seeing all the women that come through triage.  The overwhelming majority are for Evaluation of Labor or Preterm Labor thus far.  That requires me to get very comfortable checking the cervix.  I’ve had the nurses or senior resident check behind me initially since I’m still getting the hang of it.  One of the nurses that’s been there for like 20 years complemented me yesterday saying that I was good with my checks!  That was great to hear.

We had 2 multiparous (several prior deliveries) ladies yesterday that were only about 6cm when they came into triage and progressed to complete (10 cm) within 30 min and the other in 1 hour.  They both had 2 prior children so once that cervix was open the baby popped out!  The first one basically delivered in her bed as she was being wheeled from triage to her LDR (labor delivery recovery) room.  That was definitely my lesson of the night.  Labor goes quick for multips!  Next time I’m going to personally escort them from triage . Alright, got to stop typing so I can get ready for my next shift on night float.

Realities of Domestic Violence July 29, 2009

Since starting my Ob/Gyn internship, I have interviewed several women as they set up care during their “New Ob” visit. One of the questions that we always ask is, “Do you feel safe at home?”  We then further elaborate trying to find out whether verbal, physical, or sexual abuse exists.  In the instance that there is abuse at home, we help her determine if she would like help, and if so align her with social work to get access to the appropriate resources. 

I was actually shocked to see quite how many women stated that there was some type of abuse at home.  That prompted me to look up some stats on DV.  According to the American Institute on Domestic Violence: [Visit their site for more statistics: AIDV.]

• The health-related costs of rape, physical assault, stalking and homicide by intimate partners exceed $5.8 billion each year.
• Of this total nearly $4.1 billion is for victims requiring direct medical and mental health care services
• 85-95% of all domestic violence victims are female
• 5.3 million women are abused each year
• Over 500,000 women are stalked by an intimate partner each year
• 1,232 women are killed each year by an intimate partner 

Despite these staggering statistics, many women still choose not to report instances of domestic violence.  Interestingly, I was emailed by a reader asking to do a guest posting on my site.  I have never had any posts not written by myself, but I figure after 2+ years of doing this, it’s time for a change.  I asked her to write a post discussing why domestic violence often goes unreported:

Domestic violence, unlike widespread perception, is not something that happens only to people who don’t have money and who live in bad neighborhoods. It happens in almost every household, sometimes in subtle ways. But we hardly hear of these incidents because more often than not, they go unreported. They may end up hurting women and children, sometimes badly, but they are still kept hidden from the rest of the world. And if we look at the reasons behind this obsessive need for secrecy, we find that domestic crimes go unreported because of:

• The fear of repercussion: Some women keep quiet because of threats from their spouse or partner to harm their children or other members of the family if they report the violence. The fear of others being attacked keeps them from opening their mouth – they would rather bear the torture than have others exposed to it as well.
• The fear of ostracism: Some women are worried about what society will say and how the neighbors will perceive them. They distress over the whispers that will take place behind their backs, and the malicious gossip that will spread faster than wildfire if they call in the police to resolve a domestic conflict that went too far.
• The fear of loss: Others are just plain scared that they will end up losing the only family they have or know, and so they bear the agony in silence. They have no means of fending for themselves and are at the mercy of the man, and this gives him an unlimited sense of power over her.
• A sense of inadequacy: Women who are constantly put down by men and kept submissive tend to develop a sense of inadequacy over a period of time. They lack the courage and conviction to report the violence and seek help for themselves.
• Adaptation to the situation: And some women have just become so used to it happening because it takes place on a regular basis. They just cry and get on with their lives because it is something that they have accepted even though they don’t like it.

If you are a victim of domestic violence, you must speak up to prevent it from happening again and again. When you do find the courage to report it, other women may be encouraged by your example to do the same. And the more the number of women who speak out, the less the incidence of this crime.

This guest article was written by Adrienne Carlson, who regularly writes on the topic of radiography technician schools . Adrienne welcomes your comments and questions at her email address: adrienne.carlson1@gmail.com. 

For resources about Domestic violence please visit the sites of the National Domestic Violence Hotline, and An Abuse, Rape, Domestic Violence Aid and Resource Collection, which is full of resourses for women that are being abused.  Please feel free to share any additional resources that may be useful for women suffering from DV.

Bloody First C-Section July 27, 2009

I was on call again over the weekend… notice it’s been 2 weeks since you’ve heard about me being on call… I love having a night float system!!  Anyhow, I was on call and a C-section was called.  I’ve assisted on 2 C-sections thus far as an intern, but maily retracted during the opening and was allowed to close.  Well on the 2nd case of the day, the attending decided he would let me open (cut the belly) for the case! 

If you didn’t catch it from the title… this was the first time I ever opened for a C-section.  So he hands me the scalpel and I successfully cut through the skin.  I use the bovie to get through the subQ.  Use the scissors to get through the fascia, and bluntly dissect the muscles off of the fascia.  Then it’s time to enter the peritoneum, and create a bladder flap.  After all of that, I was feeling pretty good.  The attending was giving me positive feedback and I was feeling great.  Finally it’s time to cut open the uterus and get the baby out.  I make an incision and the attending says good job, and for me to go over my incision one more time to actually get through the full thickness of the uterine wall.  So as I get to the edge of the second incision blood starts pouring out… profusely.  There was no amount of suction or blotting with the lap pad that would even allow us to visualize what was bleeding. So after what seemed like an eternity of trying to visualize the source, the attending decided we just needed to get the baby out.  You can imagine that the incision wasn’t that large since I hadn’t fully extended it.  He manages to get the baby’s head out, but had to manually extend the incision for us to get the whole body out.  The baby crys immediately and is fine. 

Time to tend to the bleeding!  The attending decides to just start closing up the uterine incision.  Finally after a 3 layer closure, the bleeding stopped!  I was  so happy that it stopped… What made the scenario even better was just how calm he was.  He never once yelled at me or made me feel bad for what happened.  In fact, he apologized to me for closing the uterus up on his own.  After the acuity of the situation calmed down we thought about what happened.  We decided that this lady must’ve had a vessel (likely venous since it was more of a spilling than a pulsating stream), that curved to the front of the lower part of the uterus. 

Whatever the case may be, I will remember one thing: you can’t cut where you can’t see.  Despite having only a small incision, he was able to get the baby out by making enough room only by touch.  I hope to develop that skill… and even moreso, I hope that my next C-section goes more smoothly!

Paging Dr. Obsession July 11, 2009

Last night I took my first call as an intern!  After a full day in clinic, I headed over to one of our affiliated community hospitals for call.  The chief resident showed me around L&D, the Gyn floor, the ER and most importantly the cafeteria.  He was in the middle of working up a patient for preeclampsia, so I tagged along for that.  Then around 8pm he went home to be with his family.  Yep! That meant I was alone in-house… Of course, there was an attending in house as well, but it was up to me to evaluate the patients, call/pg my chief after I’d done the work-up, and then present to the attending.

The night started slow with a few pages: Ambien here, Zofran there, etc.  I did a post-op check on a patient and was quite surprised how the night was going.  Then a lady came in with possible preterm rupture of membranes (breaking her water too early).  I went and saw her, sent off basic tests (urinalysis, fetal fibronectin, nitrazine) did an exam, and also looked under the microscope for evidence of rupture, and also evidence of infection.  Via phone, my chief agreed with my plan and I presented her to the attending.  After everything came back negative I sent her home!  I was so happy to make it through the first one.

After that, I went to my call rooom, worked on my notes for the next morning, and laid down to sleep.  Just as I was getting into a nice dream, the phone rings!  Yet another rule out labor patient… this one was full term.  I did the appropriate workup with her, called my cheif, presented to the attending, and she was out the door too.  I was really happy to be able to handle the patients on my own (for the most part) without having to physically call my chief back in house.  I think the attending was a little annoyed to go over the strips with me (even tho my chief viewed them at home), but overall it worked out well.  The attending even complimented that I was doing very well, and she wouldn’t have guessed it was my first call!

By now, it’s 3:30am and a C/S is called by the another private attending on call.  Since I was in house, not my chief, she asked me to be her assistant.  It was great.  I helped push the baby out successfully and she pinked up nicely once we got the cord from around her neck!  After that, I got to suture the bladder flap that we created back to the uterine serosa.  I also got to close the fascia.  My experience on my Gyn Sub-I definitely had me ready!!  She complemented that I was doing a great job with my suturing skills.  She was patient with my knot tying, but hey I’d rather it be slow and a square knot than fast and a slip knot.  Since it was the middle of the night by this point, she did the dictation for me and said on my next call she would let me do more!

I can’t wait until tomorrow… yep, I typed correctly.  I’m already on call again tomorrow.  I should probably get to bed so I can function.

Multi-Tasking Galore June 29, 2009

Today was definitely really my first day as a doctor!  I arrived at the hospital at 5:30 am in order to meet the team and get ready for postpartum rounds.  I did a pretty good job: saw all of my patients, used an interpreter phone for the first time, and managed to only be 2 min late to rounds.  Considering the other intern was about 15 min late to rounds, that 2 didn’t feel quite so scary.  I only got interrupted for more details on one of my patient presentations, and the rest went smoothly!  It was so cute, the new cheif clapped for me after my first presentation as a Doctor .

So after rounds, I met one of the patients in labor.  I got started on all of my notes… the goal in the first few days is to have all notes done before rounds.  I finally managed to get all of my notes, daily orders, discharge papers, discharge prescriptions done.  In the interim, I was paged about patient’s diet, taking a shower, starting benadryl, new triage patients and more.  The rest of the day I was in triage seeing patients. I’m so thankful for the midwife because she really held triage together as I was pulled away for postpartum issues, and of course: deliveries!

I had the smoothest deliveries today.  Both of the women weren’t on their first baby, so those tend to go pretty quickly.  What made it exciting is that these were the first 2 deliveries that I ever performed as a doctor!  Amazingly enough, neither of them had lacerations.  Of course, like I said before neither were on their first born, but still, I was impressed.  The great thing about the L&D at my hospital is that we have midwives.  So far they know what they are doing and these moms are having smooth deliveries.

I wish I could say that I would be having more of this, but I will be starting in the clinic tomorrow!  It’ll be some time before I’m actually on the L&D service.  Overall, I had an amazing day.  I pulled a 13-hour shift and really didn’t feel tired until I got in the car and thought about it some.  Can’t wait for what the rest of the week holds.