Why amniocentesis is hard

Ok, let's start with a pregnant belly, sideways on a bed: 

For an amniocentesis, you are trying to get fluid (grey); for a chorionic villus sampling (CVS), you are trying to get placenta (green). Here's part of why this is hard to do. 

This is not an unusual skill set. Moving your hands and eyes separately, and knowing where you are in space regardless of what your eyes (or inner ear) tell  you is what laparoscopic surgery is about as well, and that's a skill-set that I felt pretty comfortable with by the time I graduated residency. But even with that background, it's hard; after a day of procedures, I am completely wiped out by the laser focus of concentration it requires of me, again and again. But I am getting pretty damn good at it, and that's very satisfying. 

*Meaning, I am really bad at this and it takes me forever. Not an objectification issue, I promise. 

How to be a total jerk in seven easy steps

1. Start seeing patients in HIV perinatal clinic

2. Ask third patient of the afternoon if she has everything ready for the baby, who will be born in less than a month.

3. She says: "Actually, I need to know what kind of formula to buy, because I'd like to stock up."

4. Launch immediately and automatically into your pro-breastfeeding, you-can-do-it, rah-rah-rah lecture.

5. Two sentences in, notice that patient is giving you what can only be called A Look.

6. Remember that HIV positivity is (one of the only truly legitimate*) contraindications to breastfeeding.

7. Turn red, stammer, apologize.


*Confers increased risk of infecting the baby. Just so you know, I totally knew that, and I continue to know it, and I just...brain fart? Tired? Spend too much of my own time on milk production? I don't know. I was only seeing HIV positive patients that day, so I don't really have an excuse. Anyway, she was super nice about it.

You folks are always interesting. Have I told you lately how much I love comments? I love comments.

That last post wasn't meant to be about the inconsiderateness of the woman who wanted to avoid doctor-me. In fact, if anything, I felt inconsiderate at the time: her mom had cancer, so what the hell am I whining about? It was more about the lack of safe space as a doctor. It turns out that most people in the world are patients, and so their response to physician sentiments of insecurity? imperfection? negativity? from physicians are closer to mistrust than charity. We just weren't the company each other needed right then. But I also had to learn where the safe places to express my doctor-angst. This has become one of them.

But thanks for the comments. It's always fascinating to see what I end up saying, and how it differs from what I thought I was saying.
------------------------------------------

Hey, what does it say about my priorities that I'm lusting over a $300 ultrasound book and a $600 stroller, but all my clothes are from Target and at least 2 years old? Am I :
a) Totally on track
b) Not taking very good care of myself
c) An angst-ridden mix of (a) + (b)
d) In desperate need of both a stylist and a cash influx

----------------------------------------------

We are having a fellows-vs.-attending debate next week.  We are discussing emergent (physical-exam) indicated cerclage*, so I gotta go work on that. Instead, I have been toying with various fonts in which to announce what I have titled: "Cerclage Smackdown 2012". Also adding refreshments to the event. Would costumes be too much? Honestly, the lengths I will go to to avoid having to do a literature review are getting more and more impressive.

*stitch around the cervix for the treatment of cervical insufficiency

From the archives

Of my brain, that is. I wrote this today.

---------------------
Some of my absence can be attributed to discovering the Kindle app for my phone, and simultaneously the ebook section of my public library. I can read, with one hand, while nursing. This is revolutionary, and I have been consuming narrative fiction at a rate unknown since my early teens. I think the constant input is making me need a forum for output a bit less. Or my kids have all been febrile and I'm just too tired to write. One of those.

Anyway, I love fiction. I prefer fiction that is interesting and not totally stupid, but light. And by light, I mean that nothing bad happens, at all. If bad things have to happen, I prefer them to either a) have happened by the time I am introduced to the story or b) happen in an alternate world. That's why you'll see a relatively significant scifi/fantasy component - it dulls the blow.

Here's what I've read so far:

• The Magician King. Lev Grossman. I am disappointed, only because I *loved* The Magicians, and I feel like he dropped the ball with this one. Perhaps he was rushed? I also want more. More, Mr. Grossman!
• Juliet, Naked. Nick Hornby. Love me some Nick Hornby. A little fluffy, but in a great and completely enjoyable way. 
• Anna Karenina. Leo Tolstoy.  Free from Google books. More readable than I would have thought. Yes, sad, but also happy and with a lot more philosophy (which I tend to skip over). 
• The Historians. Elizabeth Kostova (I think). Recommended by Professor D. I really liked it, but pretty scary and sad for a wimp like me.
• Swamplandia. Karen Russell. Did not like, both because I thought it was overwritten and disjointed, and for other reasons that I cannot share without giving away huge portions of plot. Had trouble finishing this. 
• I Shall Wear Midnight. Terry Pratchett. I've read a lot of Terry Pratchett lately. Always good for non-dumb, but relatively light reading. But if I read more than 2 or 3 in a row, I need a break. 
• American Gods. Neil Gaiman. I was a little not loving this? Even though I think I should have? I'm not sure why this disappointed me, or what I was looking for. 
• The Robber Bride. Margaret Atwood. So good. SO SO SO good. 
• Cat's Eye. Margaret Atwood. See, I think I just can't read the same author so close in succession. It's like I know their tricks, and I find them stale, or tired. Anyway, didn't love it as much, also for reasons dealing with plot spoilers. 
• In the Woods. Tana French. Well-written, excellent murder mystery, but guess what the thing is about murder mysteries? TERRIBLE THINGS HAPPEN. I don't know if I can read this kind of book. 
• Cutting for Stone. Abraham Verghese. I am in the middle of this now. I am not quite ready to forgive everyone who recommended it for the extended obstetric trauma that comprises the first 10% of the book. Excellent writing, whatever. YOU PEOPLE SHOULD KNOW I CAN'T HANDLE THIS. I'm still reading it, though. 
• Then there were some others. I have some Jane Smiley on my phone right now, and am on the wait list for a lot of other stuff. 

So: any light-but-not-too-light suggestions for me? 

-------------------------------------------------------------------------------------

I had been an intern for less than three months. I had been an intern on the gynecologic oncology service for less than three days. I had a desperately needed day off, and I was invited to dinner at a friend's house. I couldn't stop talking; about how tired I was, about how scared I was, about the patient who started bleeding during rounds, about the dressings I had to change, about how I didn't know how much narcotics I could safely give a post-operative cancer patient, a patient to whom I had given more morphine than I ever had before but who was still screaming in pain. What to do, what to do? I was scared to kill her with narcotics; I was  scared to undertreat her pain. I gave little bits and little bits more, and maybe it wasn't enough, and I just can't learn to be better at this any faster, but it's not fast enough. I talked, and tried to explain, and I talked some more, because there was just so much to say, there had been so much that I had done,  and it was so nice to say it to people who didn't work with me, or yell at me, or tell me I was doing it wrong.

Until later, when an elegantly attired 40-something-year-old woman, a friend of my friends, sat at the end of the table, spoke up. She had been quiet, until dessert. Then, genteely drinking her tea, she asked me, in all seriousness: "How do I make sure someone like you isn't taking care of my mother?"

I put my head on my forearms next to my dessert. I stayed there for a little while.

Barriers to care

1. You are a 33 year old woman at 26 weeks pregnant with a life-threatening cardiac condition. You sign yourself out of the Cardiac ICU because you

a) Have nobody to take care of the three kids at home and are scared that they will end up in foster care
b) Are worried that your boyfriend will cheat on you while you're gone
c) Signed out AMA from a different hospital and are concerned that you will get in trouble
d) All of the above

-------------------------------------------------

2. You are a 19 year old woman at 39 weeks pregnancy with contractions. You take an ambulance to the hospital when they start to hurt because
a) You live 2 different bus lines away from the hospital and it takes over an hour
b) It's snowing today and a weekend, so that's more like 2 hours
c) Your boyfriend refuses to drive you because you yelled at him earlier today
d) All of the above

-------------------------------------------------

3. You are a 32 year old woman at 36 weeks with your second pregnancy and a history of a stroke. You are not taking your blood-thinner injections appropriately because
a) You were told that the clot is gone, so why bother?
b) You hate needles.
c) You were very scared by your prior cesarean and very much want to labor and thus are very preoccupied with the fact that this baby might be breech and want to discuss a version instead.
d) All of the above.

Answers: 1. (d) 2. (d) 3. (d)

Happy birth day

I followed this patient from her last pregnancy, when she came in at 20 weeks and delivered.

That was her second loss of a pregnancy after 12 weeks.

She also has had a stillbirth at 33 weeks.

This pregnancy, I made sure she got a cerclage placed. I watched her carefully. I gave her medications that might help and not hurt. I watched her carefully some more.

Around 35 weeks, we both started to get antsy. We've won this game, so let's get this baby out before we lose.

I debated for a long time, asked for a lot of help: when should I deliver her? 36?39? I don't want to give her a premature baby for no reason. I also don't want to increase the risk the bad outcomes she's had before.

I took her cerclage out at 36 and half weeks. "Maybe you'll just go into labor." I said. "Then I can stop thinking so hard." We laughed.

She didn't.

I booked her, in the end, for an induction at  38 weeks.

Her last visit with me was at 37 and 5/7 weeks, 2 days before her induction. Her baby looked great. She said she wasn't anxious. "If you're anxious.", I said, "That's a reason to move up the induction. We can think about that, that counts. Do you want to consider that?"

I was anxious. I felt like I wouldn't breathe until she made her way onto L&D.

"No", she said. "We're fine, this time."
--------------------------------------------------------

She was right.

I couldn't figure out a way to be there for her induction, but I checked in, by computer and by phone.

Last night, at 5:06 pm, she had a vaginal delivery of a baby boy. Weight: 2950 grams. APGARs 9 and 9.

Happy birthday to you, baby boy. And to her. And (a little bit) to me.







*Stitch around the cervix

We are experiencing....

(And really, not all of these happened on the same night. Poetic license, and all that.)

----------------------------------------------------

The good ultrasound machine is not working

The bad ultrasound machine is working (well, as much as it ever does) but the trackball is wonky, so you can't do measurements. Thus, basically, it's useless: you can look at the pretty fetus but not measure anything about it.

The handset on the triage phone at the doctor desk is broken; they can hear you but you can't hear them.

The lamp used for speculum exams is missing.

The outlet that the good ultrasound machine is plugged into is not working

The glucometer is missing! How can I check my diabetic patient's sugars?

The good ultrasound machine is plugged into a working outlet and still not working.

The lamp used for speculum exams is found, but it won't turn on. Different outlet? Tried it, no dice.

I sent a serum glucose to the lab on my first diabetic patient, and then we found that the glucometer had been taken (accidentally) to a different floor. Victory.

The intern wisely switched out the handset from the doctor desk phone with one of the triage room phones. Still not working, but noble effort. 

The EKG machine is working but there is no paper to print.

The second-year resident shows me how she downloaded an app on her phone that makes it into a flashlight*, and that's what she's been using for speculum exams.

If you really lean on the trackball and outsmart it by going the opposite way of what you wanted, sometimes you can get the bad ultrasound machine to do measurements. It helps if you curse under your breath.

The NICU machine has paper; they allow us to borrow the machine.

We don't have enough EKG stickers, so we cut them in half. They work - EKG performed successfully! Send intern on EKG sticker and paper hunt.

The intern switched out the whole phone from the doctor desk with one of the triage room phones. Works! But you don't have access to two of the lines, so you can only pick up 50% of the calls. Still an improvement!

I find an online care manual for the ancient bad ultrasound machine, and unwisely try to open the trackball casing to clean it as per recommendations. Unwise and unsuccessful implements included: a key, a dime, the tip of an 18 gauge needle (this was very stupid and short-lived effort, but while wearing protective eye-gear), more swearing.

Stole (with permission) from another floor some EKG stickies and paper to load into our machine. At this point, cannot figure out how to make it fit. Likely different model? Unclear.

Engineering called as they open at 8 am with 5 exceedingly polite yet urgent service requests.

Go home. Car works, that's good. Unlock door. Key works, that's good.

Kiss babies. Kiss Bearded Economist.  Turn on hot shower. Get in. Cold water. Turn hot water up. Still cold water.

More swearing.

*Really truly. I am simultaneously appalled that this is what we had to do and really proud of her ingenuity.