Bam!

Well, can I describe my frustration to you? Of course I can; that's why I have a blog! I am beginning to understand the frustration of the emergency medicine physician: triage but no admitting privileges. Pain, pain, pain.

Basically, it works like this. Because we're in training, the MFM fellows cannot bill for labor floor inpatient care. We can, however, bill for outpatient care, so we manage triage on our calls. But this is progressively making me crazier as I have more an dmore problems with insubordination.
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 I was staffing triage last week. It was not crazy busy, but it was steady. A very sweet 24 year old primip* came in - a walk-in patient, naturally - at 39 and 5/7 weeks with contractions every 8 minutes. I'm in the room with her, and both she and her boyfriend are smiling and chatting, and I know she's not in labor before I even examine her. But then, I ask my usual four questions**, and hey: she's been leaking fluid for four days. Hmm.

I explain to patients all the time that we have three, or possibly four, tests to diagnose ruptured membranes. We look in the vagina to see pooling; we test the fluid from the vagina for its pH and see whether it turns nitrazine paper blue. And we look under the microscope at a dried slide of the fluid - amniotic fluid crystallizes in these beautiful ferns (they look kind of like snowflakes on glass; it's quite pretty.) If those are negative, then I usually do a quick look with the ultrasound to confirm that the amniotic fluid around the baby in utero is normal.

So I examine her, and there's a pool. It's water. It's nitrazine blue. But it does not fern. While waiting for the ferning, I scan her, and her amniotic fluid is normal. Hmm.

Regardless, there's that pool, It's clearly coming from the cervix, it's clearly water.  I tell her that all the tests don't match up but I am pretty sure she's ruptured her membranes, and although I do not like to induce primiparous women, I am uncomfortable sending her home. There are risks to an induction as well, especially because it's her first baby, but given that I think she ruptured her membranes a while ago, I really recommend induction.

We talk, we discuss, questions are answered. She would like to stay for induction. I ask the nurses to admit her to L&D. Done.

Except. Well. The attending on the floor calls me. Why are you admitting her, she asks. Well, I say, I think she's ruptured and been ruptured for a few days. But, she says, why is the fluid around the baby normal? Why is there no ferning? Bodies are weird, I say. I agree that it doesn't totally make sense. I talked this over with the patient, I say. Regardless of the mixed data, I think she's ruptured.

What I didn't say was: This is my judgement. This is why I am here.  This is the diagnosis I have made. If you are uncomfortable with that, feel free to come examine the patient on your own. I am not discharging this patient to home.  If you are going to treat me like someone who is not trustworthy, then I would prefer to go home and put Smoosh to bed, and not stay up all night, thank you very much.

What I did say was: I am uncomfortable discharging this patient. If you would like, I will happily repeat the speculum exam and see if I can get ferning.

Twenty minutes later, the nurse tells me that the patient is grossly ruptured, with fluid all over the bed. Because I know that I will be asked, I swab some fluid, and finally see ferns. The patient is admitted, and I want to scream.

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To clarify: I am an attending. I have been for many years. Before fellowship, I was on my own for 2 years, and did just fine.  I am fully capable of handling this - and many, many other things - by myself, without supervision. But the side effect of this triage job, and of returning to training in general is that I get "supervised" for many things that I already know, not just Maternal-Fetal Medicine subspecialty things. There's an element of protection in this: I am supposed to be learning, after all! But also an incredible element of condescension, leading to insanity and snarkiness on my part.


*Having her first baby
**Contractions? Leaking of fluid? Bleeding from the vagina? Baby moving? You want 3 nos and a yes, and if so, have effectively ruled out most obstetrical pathology.