gravity circus

2012-02-15T14:55:00.000-05:00

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

2012-02-09T20:38:00.001-05:00

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

2012-01-17T22:06:00.000-05:00

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

2012-01-07T21:53:00.000-05:00

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....

2011-12-26T20:51:00.004-05:00

(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.

It's not rocket science

2011-12-13T14:20:00.000-05:00

What the consult note from neurosurgery said:

Thank you for the chance to see our joint patient, Ms. XX. Her history of a cerebral vasculopathy puts her at high risk for both a hemorrhagic and ischemic stroke. Because changes in intracranial pressure can provoke such issues especially during labor, delivery, and postpartum, I recommend a cesarean delivery for her current pregnancy.

Thank you,

Dr. ZZ

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

What I think the consult note from neurosurgery should have said:

Thank you for the chance to see our joint patient, Ms. XX. Her history of a cerebral vasculopathy puts her at high risk for both a hemorrhagic and ischemic stroke. Because changes in intracranial pressure can provoke such issues, those changes should be avoided, especially during labor, delivery and postpartum. I defer to your obstetric opinion as to how that can be best achieved. You may want to offer her a cesarean section, but although occasionally more controlled, that mode of delivery usually involves an increased blood loss which can have hemodynamic consequences. (I wouldn't know, since my surgeries are very different.) Your suggestion of an early epidural, to help control blood pressure changes associated with pain as well as advantageous blood pressure effects, along with an assisted second stage of labor, to minimize the amount of pushing Ms. XX would do, sounds eminently reasonable. But you're the obstetrician! You probably know best about that stuff.

Thank you,

Dr. ZZ

Justice for all

2011-12-01T12:17:00.000-05:00

Sitting in jury duty, and musing on the similarities and differences between courts and hospitals. They're both people machines; people enter, something happens, people exit. Many people who come here never wanted to be here, thought they'd never have to go here, and now they're here and it's so damn important and scary. And maybe it will be ok, but sometmes it's not.

Oher people work here, and every day is just not a big deal; your life-changing day is just their Tuesday afternoon. And the elevators don't work, unless you know the trick, and the good food is at the store around the corner, not the one across the street, but someone has to clue you in, and a thousand other secrets to surviving.

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

By the way? Pumping at court is a bit of a disaster. Way harder than at the hospital. Cloud, thanks for the shoutout, but you know, there are ways in which pumping at work is easier for me than for anyone else. For example, we actually have pumps and parts on postpartum; I've never had to do this but I theoretically *could* run over there if I forgot something. And I have a private call room, which I usually lock (we do have male fellows, you know).

It's here, in the land of civilized time and scheduled lunch breaks that I'm having to work a bit hard to work it out. Several nice people have given me some not-quite-legal space to pump in, but I've had to negotiate it every session, which is exhausting. I can't imagine that I'm the first one with this problem, here in Large Urban Area. I wrote an email to their department, in which I pointed out that despite my status as a lactating woman, my judgement is still quite good. #OccupyJuryDuty continues.

Things I said on call

2011-11-24T21:11:00.001-05:00

I'm here.

I'm going over there

Can I run down to get some food? I'll be back in less than ten minutes... you know what? Forget it.

Because you've had chlamydia twice this pregnancy, let's check again.

Labor is a bodily process, and bodily processes are not always predictable.

I don't mind delivering her in triage, but I need some gloves. A cord clamp would be gravy.

OK, B, but now you're a resident. What do *you* think her workup should be?

Don't judge me for eating chocolate for dinner.

Smoosh, were you a good boy at dinner? I'm so glad. You helped get the babies in pajamas? Thank you, my big boy.

Ms. X, your cervix is open and you are 25 weeks pregnant. I'm admitting you to the labor floor right now to hopefully stop your labor.

Sure, Dr. Z, I can cover room 5. I'm just going to run upstairs to pump...you know what? Forget it.

Labor is like a roller-coaster. You're still in early labor, which is that slow, unpredictable part up the hill.

I'm here. You paged me to room 2? Don't you mean room 5?

Let's calm down our breathing, and push. Ma'am? Look at me. Let's focus. Let's push, one last time. And: it's a boy!

I'm here, did you guys page?

Hey, Nurse Q. Thanks for asking about my kids. Want to see pictures? How are your kids?

Breech. Dammit, breech. Someone call anesthesia, the nurse manager, and the OR.

I'm running upstairs to pump. Page me if you need me.

Hi sweetie. So they're all asleep? What did you give them for dinner? Sorry, that's an alarm bell -- gotta go.

I'm here. Is peds here? Ok, I'm going back to room 2.

Room 9 is fully dilated? With a big baby? And diabetes? And Dr. Y is in a section? OK. That's fine. I mean, it will probably be fine. Let's get a step stool in the room.

Congratulations! It's a girl!

Labor is a bodily function, and you know what? Sometimes bodily functions are weird.

Did you see this cute picture of my babies? I know, so big already. Yeah, still breastfeeding.

Contractions every 30 minutes usually do not cause significant cervical opening.

At this point your best option for paternity testing is to wait until the baby is born.

Well, the great news is that your back pain looks like it's just part of the normal discomfort of pregnancy.

You're doing a great job with your labor. We'll try to get you a room and pain relief as soon as we can.

Guys, is there any way you can find a room for this lady a bit faster? I know you're swamped, but she's moving pretty fast.

Labor is like a roller-coaster, and roller-coasters are weird.

Wake me if you need me.

I'm awake. I'm here.

When is the last time you saw a doctor?

Hey, Dr. Y? I'm admitting a 16 year-old P2 in labor to you. You know, that's a really sad sentence.

Did you already hear my speech about the labor roller-coaster? Sometimes it's weird.

I'm running upstairs to pump. If you can, page me about 4 minutes before you need me, ok? I need time to get decent.

So you found out about this pregnancy 3 weeks ago?

I guess then let's do this: give room 8 to the multip who's 6 centimeters, room 7 to the primip with high blood pressures, and the 36-weeker with ruptured membranes will hang out with me in triage for an hour or two.

The day team will have to make it work.

Smoosh, did you sleep all night last night? I'm so proud of my big boy. Mama will be home very soon.

-------------------
(Bratschegirl, don't you worry! This didn't happen on Turkey Day.)

And maybe sometimes I'm (d)

2011-11-15T21:03:00.002-05:00

The Bearded Economist has pointed out that parts of this post are very, very angry. I guess I'm sorry about that; I don't think I'm even being clear on why I'm angry (partially because I can't. HIPAA, you know.) I thought about taking it down, but that made me feel angry too. So. You know. Try not to hate me.

-----------------------------------------------
I. Staples, expanded:

1) Some surgeons don't remove staples before post-op day #5 if it's a repeat cesarean or if there are other risk factors for wound separation: diabetes, obesity, steroid use, etc. I was not trained this way, and I don't think there's a definitive right answer in the literature. But it isn't an unusual or unreasonable thing to do.

However, when you have an incision through pretty firm tissue, or one that is under tension because you excised all the firm scar tissue, then steri-strips might not hold it together sufficiently. I do sometimes swap staples out for steris + benzoine (sticky stuff) on post-op day #4 if I'm sending someone home but I don't think their incision is ready to roam free. As it were.

2) We do have visiting nurses who come to houses. Presumably that could have been set up; maybe it even was. This patient, who, as all of my stories, is fictional/a composite/mythological character, may have given a false address, or may not have had a stable address. Or may not have insurance that covers home visits. Or we may have dramatically fucked up. I don't know.

3) I do actually believe in a single-payer system, but please realize: there's no easy solution here. I heard once, and it makes sense to me (although you public health types can chime in) that one of the reasons that the U.S. has such (relatively) abysmal health outcomes despite enormous health expenditures is because we treat a population of unparalleled ethnic, economic, and social diversity, especially among developed nations. Economic diversity may just be a euphemism for financial inequality, but regardless, it seems a true part of the explanation to me.

------------------------
II. Rant:

Is there a nice way for me to say that I wish people would stop saying:"Your crappy outcome/shitty care/terrible scenario would never have occurred if she had a midwife"? I mean, you can say whatever you want, and I won't delete it*, because I don't really believe in that. So I guess I mean that I wish people would stop thinking it.

Because maybe it's true that all problems stem from the doctors in this situation, but arguably it's not. Look, I have always worked with midwives (some of whom may be reading this blog right now). I have immense respect for the work they do and the different perspective their training brings to the care we give. I have learned a lot from them on the management of normal pregnancy and labor.

I value these things so much that in the past, I have taken on considerable professional risk by overseeing said midwives (and no, not by performing cesareans on all their patients). I work with midwives now, who manage all the prenatal care for their patients as they see fit, unless they ask for help from one of us. They deal with many of the same challenges I do, and their patients - who do, often, become my patients - have outcomes that reflect that.

So to me that comment sounds like saying: "Your crappy outcome/shitty care/terrible scenario would never have occurred if she had me/my midwife." Yes, possibly. Also it would probably have helped if she lived in your neighborhood, was white, and had any sort of financial security. But, unfortunately, that's not what we're working with here.

So I ask that the respect goes both ways, yes?

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

III. Rant the second:

You know how it takes only one generation for the revolutionary to become boring? In this case, what I'm talking about is a lot of what you guys are talking about: patient communication and respect. For example, I know that some of you went to med school at approximately the same time as I did. Wasn't it drilled into your head that you should call patients "Mr." or "Ms." and never, ever, ever by their first name? I'm sure that I lapse, but it ain't because I wasn't properly taught.

I don't know. I think that fight has been fought on the grounds of medical education, and has been won. You'll reap the benefits, such as they are, in about 20 years. When patients get called by their first name these days, it is probably because their doctor is either a) from a time before this curriculum b) tired c) forgetful or d) a jackass. I am (b) + (c).

--------------------------------------------------------
IV. Explanation of rantage**:

Can you tell that I'm feeling unappreciated? And perhaps embattled? And that this, in turn, is making me grumpy? I have a whole speech about how you don't go to work because you love your patients; you go to work because it is YOUR JOB. You go to work - and you do a good job - because you are a professional. If you love your patients, then you all will have a much much better day. If they love you, even more so.

But love is, by its very nature, not always immediately apparent. And on the days that it's hard to find? You still go to work. You still do a good job.

That, my friends, is maturity. That is ADULTHOOD. That is practicing effing MEDICINE.

So. Right. There it is. But, of course, I can be a grown-up and fight the good fight for just so long without feeling appreciated, and then I get tired. And a nice job at Mega-Pharmaceuticals-R'-Us starts to look pretty appealing: 9-5, no overnights, less overt hostility, less gut-wrenching responsibility. A shame, that would be, if I left the work I love to do.That I usually love to do.

You know, I spend a lot of time thinking about the power differential in the patient-doctor relationship. I think I write about it a fair amount here, and I try to figure out where ths anger comes from, and how we can make it better. There's a lot of work there to do, there is. Clearly, many patients are not happy with the situation as it stands. But: many doctors, too. It's not particularly cushy on this side, at least right now.

*Unless it's really offensive. Like, really really REALLY offensive.
**Do you really want to be the one to tell me that this is not a word? DO YOU?

I got a million like this

2011-11-08T22:21:00.000-05:00

A 32 year old comes into triage. She's a walk-in, with no prior care with us, at least not this pregnancy. She is having her 5th baby; she had 1 vaginal delivery without event, then a c-section, then a successful VBAC, then another c-section. Her youngest child - that second c-sectiond delivery - is only about 16 months old. He was born, coincidentally, at our institution.

The patient now seems to be about 41 weeks pregnant. We're not entirely sure, since she's a bit iffy on her last menstrual period - it was a long, long, long time ago, after all - and she has only had two prenatal care visits this pregnancy, neither of them in this country. She's here now because she is having decreased fetal movements and contractions, and just generally wants out of this pregnancy.

Noted on exam are stable vital signs; a gravid uterus, and at the incision site, a bumpy keloid scar. On further palpation, it becomes clear that the skin is bumpy because it healed over the staples, which are still in situ. She tells me that she never went to her postoperative visit. I ask her why; I ask a couple of times, because I want to know who, exactly, fucked up. Was it us? Was it her?

She's very vague; she doesn't really explain. Yes, I know they're not supposed to be permanent. I don't know, maybe I left here with an appointment for the clinic? I have a lot going on.

I try to push her, but she's not that interested in assigning blame, or talking about this with me.

We dissect out the staples and perform a scar revision during her cesearean section. We can't tie her tubes - even though it's what she tells me she wants - since her papers aren't in order. She gets staples again because the scar revision makes suturing too difficult. There's an appointment for an incision check and staple removal made for postoperative day 10.

2011-10-28T17:26:00.000-04:00

We travelled for a work thing that then got postponed while we were on our little car-packed-to-the-gills way, so we went anyway. Spent a week in our old haunts, seeing lovely old friends, and then came back. Baby B (of the apple cheeks) got a bad cold, and became very wheezy, so I availed myself of the local emergency room, where his wheezing alarmed everyone, but his cheeks and chubby thighs and wicked smile (even at 3:20 a.m.) charmed everyone. Multiple ineffective nebulizers later, we decided this is not asthma, and if he's still smiling, it's probably ok. They wanted to watch us a bit longer, so I curled up with him on the stretcher, and he slept. We went home by the morning, with him still sleepily wheezing against my chest, but things have improved from there. Then we packed up our car to the gills again, and came home.

All of this goes to say: I haven't posted in a while. I'm working on something, a thought about disillusionment and professionalism, but I haven't even had a moment to jot it down. Have a great weekend, and I'll get back to y'all.

It's the cancer, stupid.

2011-10-04T22:32:00.004-04:00

The problem is that when I really have something I want to say, it takes long enough to say it that I never can quite find the time for the cogent thought process it would require. A week after starting this post, I'm just pressing "publish"; you're just getting what's below, because this is a blog, and not a dissertation.

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

For baby blog names, what about "Plum" for our Baby A, and "Apple" for our Baby B? Not in the mode of Gwyneth Paltrow's fruited child. More, actually, because these are what their delicious cheeks remind me of. Nom nom.

I'm thinking on it.

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

Can we talk about this? (It seems to let me link to it without a payment since it's an old article, but if you have trouble, I'll just tell you that it's a New York Times article reporting a $42 million gift to create an institute teaching University of Chicago medical students to become compassionate doctors.)

On the surface, I should love it. I mean, I do my freakin' research on physician communication skills. I mean, compassion - who's against that?

I guess I am, a bit. Sorta. Yeah, I'm surprised, too.

This relates a bit to the post with which I started this blog, almost 2 years ago now.

I object. First of all, I'm not sure that this is what everyone wants. Example: this donor found it lovely that their doctor went by their first name, instead of "Doctor So-and-so". And gosh, that's awful nice, right? But I'll tell you this: many patients want their doctor to say: "I'm Doctor So-and-so." I have this issue with our interns all the time; they start out saying "I'm Dr. Smith, but you can call me Jess". Sure, your patients can call you Jess; but most of the time, they don't want to. They want to call you doctor, because they want you to be a doctor. Not an an arrogant-jackass-doctor, but a-really-smart-person-who-went-to-school-for-a-long-time-and-makes-important-decisions-regularly-and-successfully doctor.

Second of all, I don't think this is a great use of resources. In the article, the very rich philanthropic patient found it touching that her doctor - not a surgeon - showed up, scrubbed, to her cancer surgery, just to be there. And honestly, as loving as it was for this doctor to show up at this surgery, wouldn't his time have been spent better, I don't know, seeing someone who needs his advice about cancer? Even without a shortage of care providers in this country, it seems a bit unreasonable to use a fully trained physician as a support person. I mean, realistically, this does not happen (and as my next point reveals, probably should not happen) for those of us without $42 million dollar shopping lists.

Third of all, I think the expectations are unreasonable. Even if she could, I don't think your oncologist should go to all your cancer surgeries, just like I don't think she should give all her patients her pager and allow them to use it for 24 hour support. We all want the person we want when we need them, but if that person is never protected, and never allowed to pursue other important pursuits - like family, or hell, even sleep* - then that doctor will not survive long in clinical life. I guarantee it.

But finally, here's my real issue with this institute, the concern that I have with the fundamental concept at its center. I think this kind of idea just willfully and persistently misses the point.

Why? Because this effort to be more patient-centered and compassionate is, in fact, less patient-centered. It is doctor-centered. It is saying that the doctor is the important person, the doctor is probably the problem in a bad communication experience, and the doctor can, if communicative/compassionate/beatific enough, be the solution.

But that is, in fact, not true. Yes, we should be nice. But honestly; we actually just shouldn't be that important.

One of my mentors at work pointed this out to me. She said: You know, you can have a really lovely bedside manner when you tell someone they have breast cancer. And you can spend a lot of time with them, and be loving, and use all the right techniques. And about half the time, they will still leave that conversation either hostile, or with an incorrect understanding of what you talked about. And you know why? It's not you. It's the cancer, stupid.

I'm not saying that the good bedside manner and the compassion and the communication techniques are not important. They are, and they should be part of the skill set physicians bring to their practice, as much as drawing blood or writing a decent history. And you can make that conversation worse in a million different ways, by not telling people what they need to know in the way they need to know it, or in a way that they can hear it. That's a skill set that all care providers should all have, the same way that we should all be able to do a decent physical exam, or insert an IV without hurting someone unnecessarily.

But what I am saying is that there's a limit to how much the doctor, even after much saintly communication training, can actually help. I'm saying that the doctor is, at most, the second or third most important person in the room. And I'm saying that the medical information and treatment issues going on in that room are, often, not the most important things being discussed, either.

To me, the educational initiative in the article seem to propagate the myth of the doctor as all-important. And the nice part of attributing all that power centrally is that it gives you the idea that you can fix the interaction by fixing that powerful figure. But the down-side is that it's largely untrue, and subsequently, of limited effectiveness. Because, in the end, sometimes the doctor needs to be smaller, instead of larger. Sometimes the doctor needs to know that it's not them. Most of the time, it's the cancer, stupid.

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

At least, I think that's what I wanted to say. I don't know. It's a blog, people. Help me out.

*This does not imply that family and sleep are compatible pursuits. In fact, I have recent results that shows that they are often mutually exclusive.

Sigh

2011-09-16T14:30:00.000-04:00

Let me clarify: I'm not saying that I wasn't upset at this patient, because of course I was. Not to get into politics, but I'm not angry about the tax dollars; I think money spent on prenatal care, even for non-adherent patients, is still a pretty decent investment. I'm not angry because she's going to sue me, because I don't think she will. I don't think she will partially because she lacks the sophistication and the empowerment and (sadly) the energy to pursue bringing a suit. But also because one of the perks of taking care of the quite-sick is that the expectations of perfection that regular OBs deal with are gone; if this pregnancy continues, this baby is going to have issues, and it cannot reasonably be argued that it is her provider's fault.

The part I regret about our interaction has nothing to do with whether or not it was unprofessional, or angry, or inappropriate, although all of those are possibly true. I regret it because I didn't think it would be effective: she's a kid. I have kids, I know how this works. She's 17, she wants to see her boyfriend in another country; she has worries that I don't know about (but given my experience with 17 year old boyfriends, her insistence on going to visit him may very well stem from worries about him cheating on her.) She actually can't - not just won't, can't - process that much, and I could see it in her face. I should have had her bring her mom in, so that we could work this out together. She needed more help, not less.

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

Anyway, yesterday I got a page from the ultrasound unit. "We wanted to update you on the findings", they said. "The findings for this 17 year old diabetic patient."

"Oh, ok." I said. "But I only saw her for half a visit. I think she usually sees my co-fellow. Maybe you should call him?"

"Well", they said. "When we asked her who her doctor is, she said it was you."

Sad

2011-09-12T22:30:00.001-04:00

She's 17.
Her diabetes has been with her all her life
She got pregnant when her sugars were too high.
At high concentrations, glucose is a teratogen and leads to abnormalities.
Her fetus has a very complicated cardiac problem on ultrasound.

She declined discussion of termination.
She missed the pediatric cardiology appointment to talk about the cardiac problem.
She is supposed to check her glucose levels 4 times a day.
She checked it four times a week.
All the levels she checked were abnormal.

She wants to go to out of the state to see her boyfriend.
She said that the other doctor told her she could, if her sugars were good.
I want her to see the pediatric cardiologist. I want to admit her to the hospital. I want her to pay attention. I want to fix the part of it that we can.

If your sugars were good. I said. But they're not. They're not even here.
I waited.
She didn't explain.
I said: Do you want to be a mother to this pregnancy, or not? Because if you do, it starts now. It actually started months ago. Decide.

I got her an appointment this afternoon with the cardiologist. He was available only right then, so we didn't finish our visit.

Now I think I was too hard on her.
I don't know if she'll come back.

Everything about this was preventable.

I'm sad.

Things that happened

2011-09-01T14:46:00.002-04:00

Welcome to Julie, all the way from Australia, where we have to admit, people are just cooler. Especially Emma in Sydney, who sometimes comments, which is always thrilling.

Bratsche girl, you are right. These babies need blog names. They do. Can you help me with that? I will tell you that I committed the unintentional but cardinal sin of rhyming their real names (We just liked those names. It took us a few days to realize what we had done. Sorry, babies!) I will also tell you that Baby A has a killer smile, and Baby B has a love for eating that is impressive and has led to a 4 pound (that's 25% , people) differential in their weights, and also the most delicious chunky cheeks this side of Smoosh. It also means that people routinely ask me if they are different ages. Yes, I say. The little one is 20 minutes older.

Anyway, does any of this give you any good name ideas?

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

On call last night. Patient with history of diabetes and multiple past pregnancies complicated by early and bad pre-eclampsia comes in with stroke-level hypertension at 20 weeks gestation,with a headache and right upper quadrant pain, symptoms very typical of pre-eclampsia. It's unlikely that this is pre-eclampsia; it's just so early in the pregnancy that it is just barely possible. And she does have a history of migraines, but they're "never this bad", and in the past have always responded to her headache medicine. The nurses have an IV in by the time I get to bedside, and we push some powerful medications to bring down her blood pressure. her sugar is also through the roof; she gets some insulin. Neurologic exam is normal, although the light is hurting her eyes. There's a live, active fetus by bedside ultrasound. Her headache persists. Labs are pending, and I'm reluctant to give tylenol because of her right upper quadrant pain - what if she has HELLP* syndrome? I shouldn't add liver-toxic acetominophen**. But she's in pain. I decide that if we bring the blood pressure down but she still has a headache, I'll give her narcotics and off she'll go to the CT scanner to assess for a stroke. I turn off the light and she, thankfully, falls asleep on the little triage bed. A twenty-minute catnap later, she feels better. I transfer her to the antepartum service for improved blood pressure, glucose control, and a right upper quadrant ultrasound.

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

On call last night. Speak to Smoosh at 7:53pm; he says he loves me and misses me but the last part is unintelligible because he needs to go over to the window to look outside RIGHT NOW on the off chance that there is an interesting truck out there. Bearded Economist says he is ok; the babysitting help is managing the twins until Smoosh bedtime, when hopefully they'll settle down for the rest of the evening. I feel that familiar mix of reassurance - everyone at home is still alive and fed! - and guilt - but not because of me! I also just miss them terribly.

Now it's quiet for a moment; there are three patients in triage, but they all have plans and are waiting on something - labs, or a repeat exam, or more fetal monitoring. I run upstairs to pump some milk, which I hate, not least because I do not have time for another bodily function right now. Sitting down, hydrating, pumping. Get paged, just the triage number. Call back: "20 weeker with blood pressures of 189/115. Intern pushing labetalol." I disattach myself and run downstairs. Two hours later, I get back to the call room. I gather up the detritus of the pumping session, refrigerate the milk, and wash off my supplies. I am too tired to pump again, and I lie down before the next page hits.

*A variant of pre-eclampsia known for its Hemolysis (breakdown of blood cells) Elevated Liver enzymes and Low Platelets. It is a Very Bad Disease
** Generic name for Tylenol

Who wants to know what multidisciplinary fetal diagnosis rounds was about this past Tuesday?

2011-08-25T22:47:00.001-04:00

Thank you all for raising your hands.

1) Quiz #1: A picture of a fetal brain. What was missing from the picture?
Answer: A corpus callosum. Happens in 1% of people. Turns out you don't always need all brain structures, so the agenesis of the corpus callosum can be incidental and not a big deal. However, it can also be part of a larger, uglier syndrome. Our patient had a fetus with a larger, uglier syndrome.

2) Quiz #2: What is this dilated cystic structure in the abdomen of this fetus? Oh, you want to know the sex of the fetus? It's male.
Answer: A ureterocele (a dilation of part of the tube that carries urine from the kidneys to the bladder). Often seen in a duplicated collecting system (i.e. the development of two ureters on one side). Probably not a big deal, although the associated backwards flow of urine can cause kidney damage, so good to know about so we can monitor the newborn and intervene if necessary.

If the fetus is female, can be hard to tell the difference between ureterocele and an ovarian cyst. So, a gold star to you guys for knowing the right follow-up question. I know ovarian cysts in the pre-pre-pre-pubescent sounds crazy but is relatively common, and generally benign.

3) Presentation on acardiac twin pregnancy.

4) Presentation on fetus with holoprosencephaly. This is one of many abnormalities in which large portions of the front of the brain did not develop. The version we saw, alobar holoprosencepahly, is particularly bad. The understanding of the genetics behind this abnormality has exploded, and become quite complex. But one of the main genes is called "sonic hedgehog", which is funny in and of itself, but also means that there are articles with titles like: "Holoprosencephaly: Have We Become Too Hedgehog-Centric?". Yes, really.

5) Discussion of a fetus in heart failure (which is called hydrops), where the signs were so extreme that we were misled into worrying about a genetic abnormality.

I don't even want to tell you how long it takes to prepare this talk. All I can say is that I have had three jobs for a week: I go to ultrasound 9-5, then come home to a frantic second job of caring for 3 children, and then, when they were all in bed, (plus/minus a bath, dependent on various factors) , I would start my third job of researching this talk. At some distant point in the night, I would go to sleep.

The talk was reasonably well received.

And now it's done. Today, I lost my cell phone twice (although found it twice), I sent off an email to six collaborators asking them to fill out a form but didn't attach the form, I forgot to pay back someone for lunch, and I just threw a dirty disposable diaper in the laundry bin and put socks in the diaper pail. Time for sleep.

TRAP

2011-08-13T22:46:00.001-04:00

(in which I talk about strange and disturbing fetal anomalies, so don't read if that kind of thing gives you nightmares.)

There is a disease entity called Twin Reverse Arterial Perfusion, or TRAP. It is, thankfully, rare: 1/35000 pregnancies. The other name (likely, the older, less scientific name) for it is acardiac twin. Basically, the pregnancy consists of a normal twin with heart, and a very abnormal twin that... doesn't have one. The abnormal twin - the acardiac twin - only continues to live (if that's the appropriate term) because the twins have a placenta that connects, and in fact, shares a blood system. So the normal twin - the "pump" twin - has a heart that moves the blood around for both of them.

When I say "very abnormal", it's hard to know how to explain. There can be structures in the acardiac twin that are recognizable - a skull, or a leg - but there might not be, and even if there were, they become unrecognizable because they get swollen and deformed as the pregnancy progresses. The acardiac twin doesn't have a brain, so far as we would recognize one. It is a pregnancy that would have been long lost - would never have developed - but for the fact that it is attached to something else that keeps it going.

The tragedy here is not the acardiac twin, although that is sad. The tragedy is the pump twin, which over time, has a heart that is working too hard to fill two systems, and over time, gets sick, and fails. That fetus then dies.

So what do you do? If you need to, you can do some intra-uterine surgery - use a laser to block the acardiac twins cord, or use radiofrequency ablation to burn it, or somehow, break the connection between the two parts of the pregnancy. There are risks, and it doesn't always work, but it can be a way to get a healthy baby out of this very complicated pregnancy.

I'm not feeling poetic, but if I was, there would be plenty here to work with: heartlessness, deformity, salvage.
I'm not feeling political/theological, but if I was, there would be plenty here to work with about the murkiness of in-utero life.

I'm feeling sad, and mostly wishing we didn't call this a twin pregnancy. I wish we called the acardiac twin a placental growth or something like that.You could argue that that would be inaccurate, and you'd be right. But isn't the word twin, in its own way, completely inaccurate and unfair, and making this much, much harder than it needs to be? All I know is that these words in the counselling of a relatively unsophisticated patient made our plan sound needlessly ruthless. And that changing them would be an act of charity, and arguably, of honesty.

Why I am bad at data entry

2011-08-04T20:43:00.000-04:00

People feel very very strongly about their references, and about their reference software (like endnote, and others). As a publishing rookie, I don't really understand this. Can someone explain why this is? Can anyone properly educate me on the terrors of just, say, writing the paper without these programs? And finally, can you sell me on your particular method so that I don't make giant mistakes and have to start again?

Thank you.

----------------------------------------------------------------------------------
We ended up getting a research intern - a fabulous medical student who was interested in our study - and she did all of our data entry in about three weeks. Let me review this fact: She did about 10 times as much data entry in three weeks as I did in, oh, 6 months.

And here is why. Because let's say it's Tuesday, at 2:30. I am in the middle of Subject #273's de-identified record, and I'm trying to figure out if her baby, who went home with her (as a healthy baby would) ever got readmitted (as a healthy baby wouldn't). And there's a readmission entry in the record; it's for 27 day after delivery, so would just barely make my criteria for a "Baby Readmission Within 28 Days".

So I open that admission, and find out that the baby presented to the emergency room with trauma. I read further and find out that Subject #273 was somewhere with the FOB*, and a fight broke out. Someone either had a gun, or talked about a gun, and Subject #273 picked up her baby and ran. As the emergency room record has it, she fled, and tripped, and fell, still holding the baby to her chest.

The baby was irritable in the ambulance, and in the ED was found to have a broken arm. There was a relatively uneventful orthopedic consult and cast placement, a short hospital stay with social service/foster care investigation, and the baby was eventually discharged home to Subject #273's care, with physical therapy and rehab services in place.

And I could have not read the whole story, but once I started, I needed to know the whole story. I now care deeply about Subject #273 and her baby, and about what happened to them. So I had to keep reading. (I bet you would have too)

So now it's Tuesday at 3:00 pm, and I put a little "Yes" in a little box. Three hundred and twenty-seven subjects to go.

You can see why I needed to bring in some help.

*Father of Baby

We should get out more

2011-07-26T13:26:00.000-04:00

What am I up to? I am knee-deep in data analysis. I've never done this before, soup-to-nuts. It's hard. That's why they have professionals, none of whom I can afford.

This leaves me feeling betrayed by my training. Why is it that I am under the impression that I should be performing research - and in fact, am required to do so - with no resources for biostat or epidemiology support, when my education is wholly inadequate? Yes, I've been taught statistics approximately 17 times during my training, but receptive (reading/understanding)statistics is a different animal than productive (writing/researching) statistics.

So I feel like I'm trying to home-school my way into an MPH, and it's hard. And frustrating. And scary, because I'd really prefer not to do bad science. Mentoring fills in a lot of the gaps - I don't think any of my friends or advisors would let me send off something for publication that is wrong, or misleading. But writing up my research does feel like I'm writing in a foreign language. I don't know the conventions, because although I've been listening for years, I've never had to say anything much before.

On the advantage side: I'm learning a lot. Also, the program I'm using (Stata) is what The Bearded Economist lives in, work-wise, so he's a great support staff for me. He even got me to start using do-files after much resistance (I was kind of morally opposed to planning my analysis. I know now how wrong that is). And I want to be the first to say: do-files are freakin' awesome. He even understood my objections to his algorithm when I couldn't articulate them, and we wrote another loop instead.

If that's not the most romantic thing you've ever heard, well, you're probably right.

Super-duper-against-all-odds win

2011-07-15T15:35:00.001-04:00

I almost never get to see a patient twice in a row in clinic

This is especially true when I've been out of work for 4 months; my first weeks back have been a blur of everyone-else-is-on-vacation-can-you-cover-a-clinic-for-them-please?

But I did manage to see one patient 3 times in my 3 weeks back. She is, arguably, the only patient I could right now call my own.

She has some health issues that sound terrifying, but ended up having little impact on her pregnancy or delivery plans. She was pregnant with her first baby. She is lovely, and responsible, and a pleasure to talk to.

She broke her water three nights ago, slightly preterm.

I was on call.

I admitted her. I watched her. I ultimately started the augmentation of her labor after not much happened. She, very considerately, became fully dilated 1 hour before my shift was over. I snuck in to her room while all the residents were at board sign-out and coached her pushing. Soon after, we had a beautiful delivery. Her baby boy had a little breathing trouble at first, but rallied, and became a wailing pink guy with a huge head of crazy curly hair. I finished the delivery, cleaned up, went upstairs to get my stuff. I stopped by to say goodbye on the way out. She was so happy she couldn't talk; her mother was so happy she couldn't stop.

And that, my friends, is the whole freakin' point.

GOYAKOD

2011-07-05T21:25:00.003-04:00

Hey you guys! I got quoted over here, so that's pretty cool. I love how she filed it - quite reasonably - under "advice for residents", but for OB/GYN, pager trauma is a lifelong kinda deal.

Also, I took my first call in, oh, four months. The Bearded Economist, the Smoosh, and the babies (blog names, anyone? I'm open to ideas) were totally fine. I was ok, too, although I think I'm too old for a full call. Twenty four hours is just a really really long time to be in the hospital. Like, gratuitously long. Like, you keep thinking it's GOT to be over, but nope: 12 more hours to go. And now the cafeteria is closed, so graham crackers and diet ginger ale it is.

------------------------------------------------
I read a detective novel once where the older, jaded police detective was teaching the young, naive police detective about solving crimes. "It's not about being a genius," he said. "It's not even about being smart. It's about how, when you get to a dead end, you GOYAKOD. Get Off Your Ass and Knock On Doors. Talk to people. Eventually someone talks, or you see something, and the whole thing is done."

And GOYAKOD, in fact, is the answer in medicine too. Here's one example. Earlier this month, we had a postpartum patient in the ICU after a really terrible delivery where she had lost - and had replaced - all the blood volume in her body several times over. She was now postoperative day 2, and generally looked pretty good, but had a very swollen abdomen and an elevated heart rate. Among other things I asked for a hematocrit (a measure of her blood count) to make sure she wasn't losing any more blood; it had been a messy surgery, as these are, and it's never possible to be sure that all the bleeding is done.

I asked the ICU at 8 a.m. when I rounded. It hadn't been done by 11 a.m., so I asked the OB resident to ask again.

And then it was 2 p.m. The patient's blood count yesterday had been 29, and then 28 - relatively stable, so people relaxed. But now here she was, many hours later, with her heart beating fast, and her belly getting bigger, so I GOYAKOD. I went down to the ICU in search of my hematocrit. "I don't know what you're talking about. What hematocrit?, " asked her nurse. "This is the first I'm hearing about it. I was on break."

I track down the resident. "Yeah, I was trying to order it, but I couldn't get the computer to work, so I am hunting down those old paper requisitions; the secretary is going to find one for me soon. But I told the nurse."

I track down the secretary. "Here's one, but it's an old kind, so I don't think the lab is going to accept it."

Screw it. I go and get phlebotomy stuff, and get prepared to draw her blood myself. The nurse sees me getting stuff together, and begins to take me seriously; she does the draw. I run the sample down to the lab myself. The lab gives me a requisition form. I'm grumbling all the way; this is what eleven years of medical training has come to? But that same medical training taught me to GOYAKOD and get it done.

The result came back at 22. She got transfused and stabilized.

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

So that's my lesson to my June interns. Perhaps 50% of being a good doctor is content and smarts and knowing what to do. But the other 50% of being a good doctor is just GOYAKODing. Get It Done. Make It Happen.

And you can do that.

And we're back.

2011-06-30T23:10:00.001-04:00

My first patient today was 40+ weeks pregnant with her 4th baby, had a history of a cesearean section followed by multiple successful vaginal deliveries. She also had multiple positive toxicology screens for cocaine during this pregnancy and had not been seen for over 2 months. She was adamant that she wanted to deliver at home, without an attendant ("I have EMS training! I'll be fine!") so that her children could observe. From the social work notes, it seemed that all her children were taken by child welfare services and no longer lived with her.

On exam, her uterus measured really small, making me very concerned that this baby was undergrown. I sent her to triage, with a plan for induction.

Four hours later, as I'm trying to finish up with the last patient, I get a text from the attending on the labor floor: "The patient you sent in pulled out her IVs and left. Sorry."

I finally leave clinic five minutes later. This very same patient passes me by, heading for the hospital exit, smoking a cigarette. "I told you," she said when she saw me. "I gotta go."

Well, yes. I guess she did.

The Amniocentesis Blues

2011-06-18T23:13:00.004-04:00

I'm back!

Work starts on Monday. First call is in 2 weeks. I have nightmares of coming home after 24 hours away and finding The Bearded Economist's inert body on the floor, covered in spit-up, and Smoosh and the babies looking at me from the fire escape.

He says they'll be fine.*

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

OK, so here's a post I can't believe I have not yet written. It would be called: Prenatal Genetic Testing, and How Statistics Done Us Wrong. Or: The Amniocentesis Blues

A friend recently started this blog (I came up with the name!) about how statistics are generally misused and make him yell at the television. And the very first comment on the very first post was about prenatal genetic testing!

Prenatal genetic testing these days is, well, kind of a mess. I mean, we're trying very hard, but I think we're not ending up being so terribly helpful.

So here's how it goes. Down's syndrome (Trisomy 21 = three copies of chromosome 21) is a relatively common chromosomal abnormality. The incidence per pregnancy increases with the age of the mother (and slightly with the age of the father, but not nearly as correlated). The only way to know for certain whether a certain pregnancy is affected is to go and get a sample from that pregnancy. The ways we can do that are chorionic villus sampling (CVS), where a sample of the placenta is taken from an early pregnancy (11-13 weeks-ish); or amniocentesis, where amniotic fluid is taken from a later pregnancy (16-ish weeks on, depending).

Either way: big needles get involved, and either way, there starts to be a risk of miscarriage. Now, quantifying the risk of miscarriage from these procedures is REALLY hard for various reasons **, but we think it's about 1/500. Before the advent of really experienced ultrasound, we used to quote 1/250 risk of loss from an amniocentesis. At age 35, the risk of Down's syndrome is 1/250.

So, that's where the risks crossed, at 1/250, and that's where age 35 began to be called "Advanced Maternal Age". Basically, at that venerable age and above, your risk of having a Down's syndrome pregnancy started to become greater than your risk of loss from a diagnostic procedure, and thus, according to one way of thinking, the procedure seemed like a reasonable option.

But. Wait. Nobody was really happy with this status of events. And thus people have been working FOREVER to get some way of making these diagnosis that doesn't involve risking what is most likely to be a chromosomally normal fetus. And in the last, say, 10 years or so, non-invasive tests have been invented. They are the triple screen, or the quad screen, or the "first trimester screen" or the "early risk assessment" or what have you. (There are really only two tests, but lots of configurations of them.)

But. Wait. These new non-invasive tests are limited. These tests don't give you a yes or a no; only the big-needle tests can do that.So the result you get from these tests is a risk ratio, an odds. It can say: 1 in 1000. Or 1 in 10000. Or 1 in 10. And then, using that number, you - the pregnant patient - is supposed to decide whether you can live with that number, or whether you want to delve more deeply and get a diagnostic test done with a big needle.

Well, that's the way it is supposed to work. But, you know, it doesn't, for various reasons. First of all, it's rather dizzyingly precise to be told that your Down's syndrome risk is 1 in 2247 or 1 in 117. What does that mean, you'd ask? And some places will try to contextualize it. It's the risk you'd have when you were 21, or 43 - are you worried now? And I'm not sure that helps either (all it makes me do is think about what 21-year-old me would have done, and 21-year-old me would have had no business having a child, but it also would have NEVER occurred to her to worry about Down's. Not because she was low risk but because she would be rather clueless about pretty much everything. No offense to 21-year-old readers). And I'm not even going to address people with numeracy issues^, although that's pretty much everybody.

But a friend of mine actually put this the best way when reviewing the stats he and his wife had recently received about their 17 week pregnancy. His point was this: telling someone that their fetus has a 1/100 chance of Down's syndrome is not terribly useful, since you're not going to have this pregnancy 100 times. It either is, or it isn't, is the way most people see it; and they tend to hear what we say as a yes or a no. And they're not wrong - we're trying to get to a yes or a no. Yes, big needle. No, I'm not worried.

And then people get mad. "The doctor told me the kid had Down's and I did the amnio and it was fine!" is something I hear all the time. Or: "The doctor told me the pregnancy was fine, and then I had an ultrasound that showed all these problems and now you're pushing me to get an amnio but I don't need one!" And there's a general perception that the test is wrong, or inaccurate.

But the test does what it's designed to do. It's a messy test, and a screening test, and not quite the test we want, but we can be all clear on that. The place where this goes downhill, actually, I think is the language. Perhaps statistical language - using odds, or comparable ages - is not quite right. It's inadequate and inappropriate language, maybe, since we really are concerned only about this pregnancy, that I'm having, right now, at my age.

I'm not sure what other language we could use. The most honest language would be to say: Your test gave you results, that when plotted against the regression achieved through many studies of this test, were compatible with those women who on average, had a Down's syndrome pregnancy once every 2247 pregnancies. But that is, if anything, less helpful.

People have tried - people try all the time, and a large volume of decision analysis literature is devoted to the expression of risk and how truthfulness can be achieved. So I'm not original, but I'd love to figure out a language that we could use to speak about this. Because although this is the most blatant example of misuse of statistical language to make big clinical decisions, it's an issue rampant throughout medicine these days, tied to our desire to grant patients autonomy and give full information to all comers.

But we're not doing a very good job, I think. How could we fix that?

*Reinforcements are being brought in. Don't worry! We're only a little bit insane.
**Can be a future post if there is interest, let me know.
^Numeracy is to numbers as literacy is to letters or reading. I didn't know that until recently, but it's a cool word, no? So many of us are innumerate, and Nancy Reagan never cared one whit.

Double credit

2011-05-16T17:26:00.005-04:00

Hey y'all. Thanks for hanging around. We're ok! Sleep deprived, but ok.

I haven't had time/attention to write a post, but I had to write something (pre-babies) for some resident teaching that I did. It's a clinical scenario, and you guys liked it last time, so I thought I'd translate it to layman's language and see if it's fun again.

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

Picture of terbutaline (an old-school medication sometimes used to stop contractions) courtesy of Google images.

So, do you want to play?

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

It's midnight, in the dreary middle of what has already been a busy labor floor call. You are called to triage to see a 21 year old P1, now at 30 and 3/7 weeks, here with contractions. She has been contracting for the last 3 hours or so, and was told to come in.

The patient's OB history is concerning for a delivery at 30 weeks with her first pregnancy; with that pregnancy, she arrived at L&D with contractions and was 2 cm dilated. At that time, her contractions were successfully halted with medication, but she subsequently went into labor and delivered a few days later. The patient reports that her daughter is "fine", but is receiving extra services in physical and occupational therapy.

During this pregnancy, the patient has had only two visits, the first at 16 weeks, and the second 1 week ago. The patient has never had a history of domestic violence, but she has recently relocated with her daughter to a shelter after her mother kicked her and her toddler daughter out of the house. The shelter is safe, but far from your institution, and has meant that she has not been able to make it to most of her prenatal visits. She is well acquainted with the social worker at your clinic. She reports that she is now moving to a closer shelter and is planning to come to all her visits here at your hospital; this should be a lot easier now that she's successfully entered a transportation voucher program.

On exam, the patient is mildly uncomfortable with contractions. Her digital exam reveals a closed, non-dilated cervix. Speculum exam is negative for any signs of rupture of membranes or abnormal discharge. Bedside ultrasound reveals a cervical length of 28 millimeters*, with no funneling. The fetus is head down, active, and with normal amniotic fluid.

The fetal heart tracing is completely reassuring. The contraction monitor shows regular contractions, occurring every 4-5 minutes.

You send labs, start an IV and observe the patient. Two-and-a-half hours elapse. The patient's contractions are no worse, but they are also not better. Her cervical exam remains unchanged.

What do you want to do, Doctor?

* = a long cervix. Usually anything longer than 25 mm is considered relatively reassuring and associated with a lower risk of preterm delivery. Long post about this another day when I've slept more.

We did it

2011-04-18T02:25:00.002-04:00

We're all here and so far, all doing well.
Introducing Baby Girl and Baby Boy (blog nicknames and full story will have to wait for another day).
We are so, so, so blessed and lucky

36+4

2011-04-10T21:47:00.000-04:00

I'm sorry.

Append to this post: "Because I am so very lucky, and everything - so far - seems to be going so very well. I am so blessed." Very true.

But. I have nothing to say because I don't DO anything.

I sleep, but I don't sleep well*; I eat, but I don't eat well. I do a tremendous number of fetal kick count checks, but then I forget that I've done them, panic and do them again. I lie in the bed and smoosh the Smoosh, but he gets bored, you know? And goes to do something more fun**.

I shower every day, and I get dressed. That sounds underwhelming, but if you knew what I had to do to get socks on my feet, you would nod understandingly.

Once a week I go to the doctor and to a fetal assessment appointment. That's pretty much why I put on the socks.

Oh, I read some books: The Magicians, by Lev Grossman, sent to me by a lovely benefactor. HIGHLY recommend, really liked it. I re-read The Alienist, by Caleb Carr; it's not really my deal, but diverting. I seem to be better at books than TV/DVDs. They are, despite technology, still more portable, especially because I can't always sit up on the couch.^ So if you have some light-but-not-stupid-fiction to recommend, please do!

I have some emails/comments from y'all that I should respond to, but I can't comfortably sit and type for more than 4 minutes at a time. This does not lead to sustained cognitive efforts on my part.

I was going to say that I'm a giant uterus with a head, but the head is not my most saliently functional feature right now. So: I'm an incubator. I'm doing a pretty good job at it. It's not much to talk about, but I didn't want anyone out there to worry.

*This could be a post, but it would be so whiny and uninteresting that even I cannot muster the effort to care. Briefly, better living through chemistry, but not very much better.
**Mostly garbage trucks. The child is very consistent.
^Great excuse to get an Ipad? Perhaps.

Too-Muchness

2011-03-30T21:00:00.000-04:00

If this post isn't cogent, we'll revisit it in 6 months or so. I am still not sure.

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

Do you want to get mad? I mean, I already have the Walmart lawsuit going on, but if you have some extra feminist vitriol to spare, go visit the guy who wrote this post (who is, by the appearances of this sole post, a total jerkwad. I admittedly have not visited his blog to read anything else.)

There's a sneaky appeal to this logic. If you haven't thought the whole issue through, then women-in-medicine having babies can seem crazy and unfair. In fact, someone as pro-babies as my aunt is STILL annoyed at the women who were selfish or irresponsible enough to get pregnant while in pediatrics residency with my uncle forty years ago. These pregnancies, apparently, made everyone in the program work harder. (Although this was pre-work hour rules, so what was harder? How can you work more than EVERY SINGLE SECOND OF EVERY DAY? But I digress.)

Anyway, you all probably already know that this is false logic. Because of course, we can be angry at these women, but that's giving their medical programs - programs dubiously devoted to their education - a free pass. Young women are allowed to have children. In fact, on a societal level, we think this is a good thing. We even think that young men should go home and (gasp!) co-parent said children (although it's a bit harder to get this to happen to an equal level). So instead of being angry at the women, why not excoriate this residency program of the 1970s, for not providing a reasonable safety net for a reasonable event, to allow everyone to function better? And in fact, this is the root of my aunt's continuing annoyance at these women, who are now 40 years older, and likely had long medical careers, and are likely grandmothers. She was asked to give beyond what she wanted for medical training, and anything more - any tiny little thing - was too much. Because it was already too much, before that.

So let's be mad at the too-muchness, then, please? Because it was already an untenable situation. The making of increased instability gives a focus for the anger, but I don't believe it's deserved.

But the appeal of that guy's logic is there - it's actually in a lot of places, in medicine and out - and it's hard to resist, despite the heavy dose of crazy entitledness. Because after reading his post, I realized that this sexist-anti-parenting-why-should-women-work-if-they-are-just-going-to-breed philosophy had snuck into my own head. It's still a fundamental part of medical culture, and as such, is a large part of what's underlying my whole I-should-be-working-guilt-experience. I should be working, that's my feeling, because my patients and my department and my co-fellows need me, and pregnancy is a choice, after all, right? And it's hard enough to choose between two sacred responsibilities, parenting and doctoring. Except the doctoring was already there, and the parenting (or nascent parenting, in the form of gestating) I chose, and I chose to do exactly right now. (Of course, not really. Nor did I really sign up to be quite so high-risk. But let's subscribe to the guilt-inducing theory of complete control over reproduction that most people presume when making these judgements.)

So: Mr. Man: I reject thee, and your false logic. I heretofore remove you from my head. Now stay out.

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

Anyway, there's nothing new about these thoughts. You have hopefully heard them all before.

I have more to say, about tying them to the garage guys who changed my oil (and gave Smoosh a thrill), but that's for another time.

-------------------------------------------
p.s. 35 weeks. We are...managing. But it's a good place to be.

Serious? Or self-indulgent?

2011-03-22T08:56:00.001-04:00

Let's do both!

First, the serious:

Here is an interesting article, which expresses well what I sometimes think. That is, we spend a lot of time reviewing risk and discussing how to best communicated the quantity or numerics of risk. But perhaps it doesn't matter? It's either something that reasonably could happen, or it's not. Either you are willing to assume it won't happen, or you change your life around the real possibility that it could.

What do you think? Am I just being nihilistic about the years of decision analysis and communication work we've put in? It's quite possible.

And here is an article that I've disseminated widely. It is an excellent piece by Ta-Nehisi Coates of the Atlantic Monthly. I think we should consider adopting it as the MFM national anthem. You may not agree, and it is not apolitical. But I think it is true, and I think it is very clear.

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

Ok, now for the self-indulgent. As of this week, I've been at home for about a month. And this week, I became physically and otherwise sort of miserable. This is all small potatoes; I'm so lucky to be pregnant. I'm lucky to be SO pregnant (10 pounds of total baby at last ultrasound). And I'm so grateful to have this time where no one expects too much of me.

But I'm also a mess. I am uncomfortable, and exhausted and I can't sleep and I can't eat, and I can't even be in one position long enough to type, and who knows if I can even think?

I am non-functional as a physician, a parent, a partner, and a writer. This is hard on me. I am incubating well, and I am told that I should be happy with that. And I am. 33+6 - hurray! I never thought I'd see the week, much less the day.

But I am also terrible at being just a uterus, and the truth is, by the end of the day, I'm more than a bit sad. Also: this week, we have crossed the line from discomfort into pain, and really, it's not my forte. I'm kind of a wimp.

Perhaps I should just lower my expectations even further. Ok, I won't get data entry done, or empty the dishwasher, or anything else. And yay: I showered and put on my yoga pants! But watching TV all day is not good for me. I guess I just need to feel a tiny bit of (non-physical) achievement, and it's not going to happen. Re-calibrate. Repeat until gestation complete.

Anyway, without further ado: my self-portrait. Again, the smallest of tiny potatoes. Please know that I realize that I'm being ridiculous. But self-expression did make me feel better.

Note: I have no actual evidence that Baby B has a ninja star on his/her feet, but what the hell else could he/she be using to dig into my bottom rib? It hurts like a mofo.

Flame icon used to represent sites of maximal pain. Didn't you want to know that?
I didn't even include my obsessive fetal kick counts. I will have to figure out how to express them in a graphical form for your enjoyment.

Still fine! Also: I left the house today

2011-03-15T22:05:00.000-04:00

To clarify: I'm not on bedrest. Bedrest, as Denali noted, is not as frequently recommended today, mostly because it DOES NOT WORK, at least for most things. There are exceptions - bedrest will keep your blood pressure down, and it will often give a fetus on the edge a little bit extra blood supply for growth. The real bedrest comes into play for patients on the edge - those with a dilated cervix at 24 weeks, or with water broken at around the same time. Those patients are in bed, in the hospital, and frankly, we sometimes lean 'em backwards just for a little extra effect (the scientific name for this is Trendelenberg). Because, I say, if hanging you by your toes gets us an extra week, then I'll do it.

Otherwise, it does more harm than good - decreases bone mass, wildly increases the risk of developing life-threatening clots. And that is aside from the possible financial/emotional devastation that can result from losing all contact with the outside world. So we try not to do it much anymore, but mostly because it doesn't work.
---------------------------------------------------
But that's not what I'm doing. I'm on "modified rest", which means: Don't come to work. Go home. You can get up and make yourself a sandwich. But don't go grocery shopping, or do the heavy-duty toddler care. Capiche?

I capiche, mostly.

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

Today, I actually went to work. We had our final Breaking Bad News simulation session in the a.m. (hurray!); it was a little frenzied, but mostly went well. And then I stayed around for some meetings. (Naturally, I napped in the call room in between. This was a big day for me.)

Anyway, it's true that absence makes the heart grow fonder. First of all, I miss the fabulous people that I work with. Although it's silly and makes me feel like a wilting feminine flower of Victorian literature, I do appreciate the concern that meant that whenever I entered a room, at least three people would lunge at me with a chair. Sit! they would say. I complied.

But also, everyone asked how I was doing, and was genuinely happy that my leave has been, so far, uneventful. See, in my warped view, uneventful leave is a waste. Right? If nothing was going to happen, I could have worked! (I know. I'm recalibrating.) But everyone is just so...relieved. And happy for me. So that's lovely.

---------------------------------------
And finally, the truth is that I like what I do. I miss it. Right now, I'm at home, nothing terrible has happened, I'm even using my brain - data entry, research, strategizing about fitting three car seats in the back of a small car. But you know what was fun? Going to conference and trying to make delivery plans for women at 36 weeks pregnancy with intractable cardiac arrhythmias, or uncontrolled HIV, or history of weird stroke events.

I think this made me insufferable at conference today, like that kid in fourth grade who is sitting on her hands so she won't raise them too often*. But it's only because I missed y'all.

One Tired Ema told me that I have a job and a career and a passion. I do? I thought at the time. I did have a job (debatable in my current situation.) I knew I had a career. But a passion? But yep, I TOTALLY do. I'm very, very lucky.

*I was not actually this kid, being too shy at the time

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

I'm fine. PLUS: Who wants to learn about abdominal wall defects?

2011-03-09T13:56:00.001-05:00

Hi.

Sorry about that. Didn't mean to leave anyone hanging. I/we are TOTALLY fine. I mean, a triage visit here for decreased fetal movement (thanks, Baby B, who, of course, put on a tap dance show as soon as I showed up at the hospital). And some "modified" bed rest over there.

So: overall, minorly freaked out. But also: 32 weeks today. Rock and roll.

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

As part of the "modification" of my bed rest, I finagled permission to go to part of a Fetal Medicine symposium on abdominal wall defects. This includes fetal anatomical abnormalities such as omphalocele and gastroschisis, as well as other, rarer conditions. Omphalocele is a condition where the fetal intestines stay pooched out into the umbilical cord, when they should return to the belly. Because we ALL do the pooching - it's a normal part of fetal development for the intestines to come out, revolve, and most of the time, return - so this is a defect of timing or degree more than anything else. Gastroschisis is a true wall defect; there's just a big hole to one side of the umbilical cord for various unclear reasons.

It's always been a bit funny to me that omphalocele is often associated with other abnormalities, including genetic ones -- that is, up to 50% of the time - while gastroschisis is not. This surprise comes for me from the way that I think of these processes - of gastroschisis as a wildly abnormal process, while omphaloceles are just....mis-timed. You know, they missed the train back to the body. We can all relate. But that's not how the body programming thinks of it. And this changes how we think about the whole disease, and the chances that the fetus has for general good outcomes.

In any case, there is a lot of interesting stuff going on in these cases. There's the prenatal side, with diagnosis and even in utero treatment (that's my department). Some fantastically talented people in France are performing very rigorous experimentation with the amniotic fluid. There's some thought that the bowel is damaged by continual exposure to the fluid, so they have been doing repeated amnio-exchanges through some of these pregnancies. An amniocentesis is performed, and amniotic fluid replaced, biweekly, with sterile saline. Results from this trial will be out in a few years.

There's the post-natal side, with surgical management and medical management of the defect itself as well as related issues, such as breathing issues. And there's the far, far, in the future stuff like nutritional outcomes and intestinal function for adolescents, and bowel transplants - rare, but bad.

It was a great conference, because it didn't stop at the labor room door, as most conferences do. We all hung out together, perinatologists and neonatologists and pediatric surgeons, and pediatric gastroenterologists. The final session was a brainstorming one: how could you fix this? What would you try if you had all the money and time and resources in the world?

House arrest

2011-02-24T14:37:00.005-05:00

So, I'm on medical leave, apparently. This news has been greeted with tremendous sighs of relief from everyone, except for me.

What happened? Depending on who you ask, nothing. Or: EVERYTHING.

I went in last week for a very minor issue. In addition, (although we knew this already) Baby A is a tiny teeny peanut (but growing, you know. At her/his own peanut pace. And otherwise looking good.) Anyway, the very minor issue freaked me out, but I got checked out post-haste and everything and everybody looked good, and I was all ready to go home. I would definitely have sent myself home from triage, I tell you that.

I was confident. I had my shoes on, I texted the Bearded Economist to go to work, and then, screeching halt: MFM consult. End result: I stayed overnight.

(Sidenote: I didn't have the following: cellphone charger, laptop, underwear, socks, shampoo. The hospital has some of these things. End result: I watched a lot of TLC and was very grateful to get home to my own clothes the next day.)

(Sidenote 2: I told our fantastic PA: I'm so sorry! I'm such a bullshit admission! She smiled at me, but did not relent.)

Anyway, I went home Friday. I rested, as instructed, and was a good girl throughout the long weekend. I thought that my primary OB and I had agreed that if NOTHING happened, I would go to work on Tuesday. At work, we agreed, I would be less active - my preferred adjective was "decorative".

I went to work on Tuesday. I worked in the morning. At noon conference, I was spotted by my division chair. I was summarily scolded (a lot) and sent home. I was called "compulsive"*. Eventually, I went quietly. I've been here ever since.

----------------------------
Blah blah blah. I was going to make this post a more general one about medical leave in pregnancy, or anxiety in pregnancy. But let's be honest: this one is all about me.

----------------------------
Everyone that I've told this too has expressed tremendous sighs of relief. Thank GOODNESS!, they say. That was a little crazy, that you were working.

I suspect that watching me waddle around made everyone very uncomfortable. So, surprisingly, I am the one who is incredibly resistant to this medical leave. Why?

Here's what I've got so far:

1) I just don't think anything is that wrong with me or my pregnancy. I think some small, clinically not-quite-significant stuff is going on. We are, overall, fine right now. I will maintain vigilance, but I really and truly think we're fine. This is my main issue,

2) I feel like, because of (1), this is like pulling the emergency brake on the train for mild indigestion. I like to save this for when I really, really need it.

3) I don't want to have to finish this rotation when I have three kids.

4) I really REALLY hate that my absence pulls other fellows into my personal quagmire. I've been out of the call pool partially for a month or so, and now fully out. Someone got pulled to cover the service while I was lounging in room 630. Someone else had to cover my very ugly clinic yesterday. I just..hate that, ok? These people all have lives, and had plans, and if I thought I was sick it would be one thing, but see item (1)

5) I am trying to resist free-floating anxiety. That is, the explanation I've been given for my medical leave is this: "Go home and rest. This time is very important. We/you would never forgive ourselves if something happened."

Not: Going home to rest has been shown in scientific studies to improve outcomes. Not: here's your diagnosis, and we think this will help.

And I am opposed to this. Categorically. Because if we're going to deal in "never forgiving ourselves" (which is just euphemism for: "We are worried in a non-specific kind of way"), well, then I have a TON of experience in this area. It is a never-ending land, the land of free-floating anxiety, and the borders are quite expansive. I have often visited there, and I don't really want to live there.

I want a diagnosis: we think you have a small abruption (possible). We think Baby A is growth restricted (technically not true, but point taken). I want data-driven care. I want guided worry, rather than worry-gone-wild.

6) I liked being low-risk. I am, perhaps, overly invested in this view of myself. Back then I was healthy but anxious. Now I'm suddenly extremely frightening and not anxious enough. I prefer my old way.

7) I think I liked being at the hospital all the time. It's not like I work in a law office, right? So work is multi-tasking for me. I'm in the right place if something happens. There are excellent obstetricians right next to me, and pediatricians one floor away. If the babies aren't moving, I can waltz my way to triage and sneak a peek. If I'm cramping, I can amble over to the triage and put myself on the monitor. I haven't done much of these - I usually just sat down and things got better - but I found their close proximity very reassuring.

8) Timing. My fears peaked at 23-26 weeks. I kind of already feel like I've won this game; I'm 30 weeks, hurray! And I felt even more overwhelmed with research and presentations about a month ago. So I guess this feels..misplaced? I really needed it a while ago. Maybe I should have asked for it then. I probably should have. I didn't. But I don't feel like I need it as much now.

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

Ways in which they were right:

1) Man, I am so tired. Left to my own devices, I have been getting 10-14 hours of sleep a day. I just woke up from a nap, and I'm tired AGAIN. I think I just got really run-down. Depleted. So, yes. Rest is good.

2) There is no being decorative on service. That was a blatant lie. That single Tuesday morning had one emergent c-section for a woman sitting on service whose baby all of a sudden looked terrible on the monitor. She needed to come directly from antepartum to the OR, and that required a lot of me running back and forth (and I didn't even do the c-section). There were also about seven other things going on. So, you know. They're right about that.

3) It is perhaps true that I should not use the wife in Pearl Buck's "The Good Earth" as my role model. (Did you ever read this? She works in the fields, goes into labor, nurses the babe, and goes back to work.Maybe instead of thinking: Wow, she's a rock star**, I should be thinking: That's kind of messed up.) I am trying to recalibrate.

4) Timing: It is true that every day that I have two live babies growing is a good day. However, this may mean that my standards are too low. Maybe I should not limit myself to the not-quite-worst-case-scenario. I am trying to recalibrate.

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

Hey, Rebecca: Good thoughts! I like adding the physical obstacle course element. But no, the spray bottles were because we are low rent. So instead of having gel that comes in bottles straight from the factory, like you fancy folks, I had to sneakily liberate some perineal care bottles from post-partum, and fill them with gel from a giant gallon container in triage. Of note, the opening to the gallon container is larger than the opening to the perineal care spray bottles. Messy hijinks ensued. It was really gross, and my white coat does not appear to be salvageable. Ah, well.

*I initially took this as a compliment. I think compulsive doctors are GREAT. Now I'm not so sure.
**She would have made an excellent OB/GYN intern. Sad but true.

Reverse intimidation

2011-02-09T14:27:00.001-05:00

What I should really be doing is working on either my presentation for next week on "Sarcoidosis in Pregnancy" or on my next simulation session. But: boring!
---------------------------------------------------------------------

When we had our simulation a few weeks ago, one of the main topics was "teamwork". Teamwork, meaning, we all need to work together to safely take care of our patients. Teamwork, meaning: it's never right to be rude to someone, because they might have the information you need to not make a mistake. Teamwork, meaning: just because you're the doctor doesn't mean you can make everyone else shut up. Or maybe you can, but you shouldn't.

Anyway, good points all, but this is not how teamwork plays out in my house. Or, honestly, in any of the houses I've worked in.
------------------------------------------

Here's how it works for me, far more often: Patient X arrives in triage. The triage note (entered by very experienced, older nurse) says: "Patient at 37 weeks, reports bleeding. Not wearing pad on presentation. Sounds like spotting." That is, Experienced Older Nurse feels that this is not a big deal - a little third trimester spotting - and is telling me that this patient, in her opinion, should go home.

I go see the patient. The patient, excitable but reasonable, not great with English, tells me that she had a big gush of blood about an hour ago; it soaked through her underwear and her pants. No contractions. The bleeding stopped, and she changed and came in as fast as she could. The baby is moving, she is having rare contractions, she doesn't feel like she broke her water. No recent sex, no recent vaginal exams or ultrasound, no recent trauma, and she denies drug use.

I examine her: there's no ongoing bleeding, but there's a bit of blood clot in the vagina, so something definitely happened. There's no obvious source for the bleeding that I can see, so we have to assume it's from the uterus, above where I can look. Her cervix is 2 cm open, as it was at her last visit, so I can't blame the bleeding on cervical change. The baby looks good on the monitor.

So. She's fine right now, right? But she didn't have spotting, unless she's lying or hysterical; she had a pretty impressive bleed, which luckily stopped, and now she's here. In the absence of another source, we have to assume that this is an abruption* - perhaps stable, perhaps impending, but always concerning.

I go tell Experienced Older Nurse, at the front desk, discharging another patient, that I want labs on this patient. And that I probably want to admit her, at least to watch, but possibly to induce. "You want labs?" she says, incredulously, in front of the other patient. "Oooooh-kay, doctor." Pause. "For the patient with the spotting? You want labs and a bed?"

Pause. Pause. Pause. I think: Am I crazy? I'm not crazy. Am I over-reacting? I don't think so. I'm going to go discuss this with someone else, though.

Yes, I say. I want labs, and a bed, and I'm going to go talk to the doctor covering the floor now.

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

When I go talk to the doctor covering the floor, she says: Sounds reasonable. Do you want to induce this patient?

I say: I want to admit this patient, but hey, I don't think we have to deliver her. Because that would be *crazy* , right? Now *that* would be over-reacting! I do not do that. No way, not me.

The doctor is amenable, and bows to my nascent MFM-ness. We admit and monitor but don't induce. In the a.m., the patient bleeds again, is stabilized, gets induced, has a healthy baby.

-------------------------------------
So, this actually, is what happens to me MUCH more often. I don't think I intimidate my staff; I'm pretty mild, and I never yell, and I try very hard to explain what I'm thinking. But L&D is home to a lot of very assertive nurses - not a bad thing! at all! - but when you're new, and they don't entirely think you're on your game, or (as in this case) they just are overwhelmed and need the patient to go away, they are not always shy about undercutting my opinions. This case was particularly egregious (and effective in causing self-doubt!) because it was in front of another patient.

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

In the end, bad teamwork. And it was very influential: I did get intimidated. I held some of my ground, enough that the patient was in the right place, the hospital, when she needed to be. And it's not universal, non-controversial opinion that she should have been delivered immediately, although I think it would have been the right decision (even before the second bleed.)

But I didn't hold all of my ground. And I found this whole experience exhausting. If this had been a few years ago, I would quite possibly bent backwards and sent the patient home. Spotting, right?

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

What's at work here is very interesting. Why did this happen? There are ever more female doctors in Ob/Gyn, so more women in the traditional upper hierarchy, but so few of them comfortable with commanding authority (again, not a bad thing, necessarily! not at all!), and many of us in a constant search for consensus. There are many older nurses on L&D who, for one reason or another, would perhaps have been doctors had they entered the field 20 years later, and have worked with too many people - male and female - who are less competent than they are.

Regardless: teamwork. Respect. Listening. It works both ways, or it needs to in order to be effective. I brought this up during our simulation (with, I will say, one of the nurses who I find extremely hard to work with on L&D). I'm not sure it will make much of a difference, but perhaps a thought to enter the minds of those planning the curriculum.

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

To clarify for Mamadoc: Yup, I think this was an abruption. Clinically, this is all you get. We will have a discussion of how an abruption is diagnosed (or most often antenatally, suspected) another time.

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

Hey, while I'm editing, another piece of housekeeping: Who is this lovely commenter, from this bit here? The one who knows me well and loves me very much? You are either related to me, or the nicest stalker I've ever had (not a lot of competition there, though). It would be so nice if you emailed me at gravitycircusblog@gmail.com to identify yourself, so I could stop looking behind myself at the supermarket.

*Premature separation of the placenta from the uterine wall

So much simulation

2011-01-31T21:24:00.000-05:00

I'm putting a simulation together for tomorrow. Theater people, I feel your pain. I spent 30 minutes today putting gloppy ultrasound gel into spray bottles in the name of science and medical education. I spent long hours cadging old ultrasound probes from various departments. I have to wake up really early to get to our site and set up the rooms. I still have to edit our A-V component, and then I have to get up early to install it in our simulation rooms. I forgot to buy food for my subjects and/or actors and have to wake up earlier for a Dunkin' Donuts run.

I need a nap.

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

Mamadoc, what did you want to know about our day of simulation? It's an interesting day, with a lot of components, and I think something similar is probably going to become standard - or even mandatory - at a lot of hospitals. We did a simulation of an eclamptic seizure (the patient, of course, gets toxicity from the treatment for eclampsia, which is magnesium. Just when you think you're done. No fair.)

We did a simulation of a vacuum assisted vaginal delivery, and one of postpartum hemorrhage, and those were good for working on teamwork skills, as well as regular, plain old clinical skills.

We had a shoulder dystocia set-up, which is one of our oldest drills, but this time with a new addition: all participants had to write an event note. We then debriefed with the chief lawyer of our hospital to review our notes and see whether they were reasonable documentation. (I tend to write long novelas. You probably already guessed that.) That was...interesting, and hard.

We also did a very interesting exercise about estimated blood loss (EBL). This EBL number is where surgeons and anesthesiologists basically guess how much blood was lost during a case. Everybody is notoriously bad at it. There's a large volume of literature that speaks to the fantastically poor estimates made by OR nurses, anesthesiologists, and especially surgeons.

In any case, during this exercise, we walked around and look at various amounts of (fake) blood spilled out - onto a pad, onto a chux*, soaking OR lap pads.We had to guess how much blood loss each little diorama represented. Then we went through similar scenarios, with the faculty showing us how much blood a similar scenario used - 30 mL to soak an edge of a lap pad, 200 mL to fill an emesis basin, 500 mL to fill a delivery drape, etc. Then we went through the original dioramas again and guessed our numbers again.

I found that the teaching about EBL did not really help me feel more sure of my numbers. In fact, if anything, reviewing how off I'd been on my original guesses made me lose any confidence in my estimate. And my response to that is essentially to make a guess and then up it by about 50%. See, I'd rather be wrong and give a transfusion that's not needed than ever miss a large blood loss that needed serious resuscitation. So it appears to me that this simulation served as a Rorschach test of response surgical uncertainty.

To be honest, the whole thing reminded me of those Piaget developmental milestones. Remember the stage where a child thinks that the liquid poured from a short fat glass into a tall thin glass is now more, simply because it's higher? Yeah. I think we don't actually grow out of that.

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

By the way, do you know why I have to get donuts? Because I didn't realize that my house staff usually gets fed breakfast on Tuesdays. And then I got a cute email: "Is part of the Bad News Simulation breaking the bad news that we don't get breakfast?". And then I said shoot, and felt terrible, and now I will go buy them carbohydrates.

*Those fabric or plastic-backed sheets that hospitals use to keep things from getting too messy

Misc.

2011-01-19T23:12:00.000-05:00

We're going to New Orleans tomorrow! I have a conference on simulation. This is all very exciting.

We are all going. Smoosh, Bearded Economist. I cannot travel alone when I am 25 weeks pregnant with twins. That is all.

Bearded Economist is calling it a babymoon. Babiesmoon? I don't think it counts when we're bringing the existing baby with us. And I'm spending all day at an academic conference. However, his point is that this is probably as good as it's going to get. Point taken.

On a related note, I hate to pack. When you have to drag around this much stuff it a) makes me want to reconsider becoming a monk and b) wonder at what point you just call it "moving" and forward all your mail.

You know the game where you add "while in bed" to all fortune cookie sayings, and it makes them sexy? Try adding "while pregnant with twins" to all other statements. It makes them...exhausted.

We did a day of simulation yesterday, and I will talk more about it at length, but the funniest part was when they taped our post-partum hemorrhage simulation, and showed it to us. As one of the more senior members of the team, I get called in by the nurse close to the end. And so, upon reviewing the videotape, we watch me...waddle in. I put on some gloves, I assess. I take a deep breath. They look like they've got it under control, so I...sit down and make helpful suggestions from the corner.

Apparently pregnant lady behavior = team leader behavior! Nice rebranding, that is.

And people, that was my fast waddle. I've got fast, I've got slow, I've got medium-urgent. And when pressed, I discovered I can still run, but I do believe it's a crime against nature. Anyway, the ability to run is something I discovered while on call, and I'm not ready to tell that story yet.

Do you want to know why I'm crazy? Another post not for the anxious or anxiously pregnant

2011-01-12T20:52:00.002-05:00

So, really, I should not read this post. Too late.

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

I have had a terrible time on call these few weeks. It is not good for my physical or mental health, if you were wondering.

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

Two calls ago, I diagnosed a fetal demise in someone with a due date the day after mine. She was 22+4, I was 22+3 weeks. She came in for something absolutely benign - it had been a complicated pregnancy, and she was just being careful. No bleeding, no drama. The nurse had actually documented a fetal heart rate during her triage intake, so I didn't need to check again, but something about what I saw on transvaginal ultrasound when I was looking at her cervix made me look again.

When I looked by ultrasound on her abdomen, I couldn't see the fetal heart move. For a good five minutes, I didn't trust myself. Do you know how hard it is to make sure you're NOT seeing a heart beat? To feel absolutely certain about this diagnosis, it's best to get a picture of the four chambers of the fetal heart, not moving. But her fetus was curled up on top of her cervix, like a little snail, and she had fibroids, and was obese. And the fetus wouldn't move into another position, of course, not in the whole time that I was looking.

I was pretty sure. No, I was absolutely sure, but I was desperately wishing that someone older and smarter and wiser than me were there to decide, to say the words, to be the judge. But I was the only MFM in house that night.

I looked for a long time, and then I told her I thought the baby was gone, but that I wanted to take her to a better machine for a better look. I had to have security open up our Maternal Testing Center on another floor; I wheeled her down in a wheelchair myself, and opened up the office. I scanned her again, and then had another attending come in. The other attending is less experienced with ultrasound than I am, but I just wanted another pair of eyes. We all agreed. Gone.

The patient underwent an induction, and you'll all excuse the fact that I didn't take care of her during that time. I needed to not be there; I needed to not deliver her baby. The next afternoon, I awoke at home in a sweat. What if I was wrong? If that fetus showed signs of life at delivery? I think I would have to quit my job. I think I would leave obstetrics. I called the labor floor.

"Oh, yes. She delivered, around noon. Thankfully, she didn't bleed too much."
"Yeah, um. Yeah. I mostly was wondering how the fetus looked."
"It was..bad. Completely macerated. I think it had been dead for a long time."
"Ok. Thanks, I guess. I mean, thank you. Have a good day. Take care of yourself."

I got off the phone. Now I was 22+4 weeks. I sat on the sofa for a long time.

-----------------------------------------------------
I guess I want validation. C, you're not crazy!, I think you all should say. You have PTSD or loss-of-innocence or completely-reasonable-fears-about-pregnancy-based-on-your-experience, aka wackadoodle. Thank you, C, you'll say, for doing this, since it's a terrible job, and takes quite a toll on you.

I used to be able to say: You're welcome. I love my job. It's a privilege to be there with people. I manage. It's worth it.

But right now, I think I need a break.

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

That's only Part 1 of the crazy. I'll tell you more another time.

It's a human baby!

2011-01-05T20:55:00.001-05:00

Thank you for all the support. I appreciate it tremendously, and have been feeling markedly less crazy, at least for the moment. It's quite possible that keeping my secret was adding to all the anxiety. In any case, I really appreciate the outpouring of general good feeling that y'all sent my way. 23 weeks, and we keep on trucking.

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

To respond briefly: Denali, you absolutely do not have to know the sex of your unborn children just because you're a doctor! First of all, I don't know that any non-ultrasound trained physician would feel absolutely sure (After three months of intense ultrasound training, I still get the senior tech to check that for me, every time, because it's the kind of thing that will make people SO MAD if you are wrong, even though it's not usually medically relevant.) Secondly, it is absolutely possible not to look. For example, we didn't look, this time or last, and I don't plan to.

This all dates back to my pregnancy with Smoosh. At the beginning, I had a long and complicated lecture that I delivered to the Bearded Economist. It went like this: I'd rather not know, if that is ok with you. Why establish gender roles so early? Why allow this tiny part of their body to dictate everything we think about them, even from before the beginning?*

But more importantly, I felt that it was just, well, loving not to know. There was something unconditional about it, for me, something of unlimited acceptance: whoever you are, come out and we'll take you home. You're ours. It was emblematic of the kind of parent I wanted to be.

(Of note, the Bearded Economist immediately pointed out the philosophical incongruities of my approach. Yeah, yeah. Sure, very accepting. But then, why ultrasound at all? Why accept genetic testing? Not very unconditional, that love. Hmm. Unconditional AFTER health has been established, I guess is what I meant, I said. But that's not really as beautiful. So please shut up, and don't mock the pregnant lady, I said.)

Anyway, here we are, roles reversed. It's twins. There are TWO. I need to PLAN. I wanted to KNOW. And the Bearded Economist says: Well, I'd rather not. It's so nice, not knowing, and just being loving.

Apparently, I won my argument overly definitively. So we didn't look, and I won't, even when I scan myself. (My self-scans are limited to fetal heart checks - not near the area of interest in any case.)

If, like us, you go through pregnancy without knowing the sex of your unborn child, you will need to come up with responses when people ask you what you're having. There's the old chestnut: A surprise! We're having a surprise baby!

My current, response though, is: Humans! We are having human babies. (Lower voice to confidential whisper) We hear that those are the very best kind.(Smile in conspiratorial manner. Leave quietly.)

*C = old-school feminist, if that was not clear prior to this post.

Semper wackadoodle

2010-12-30T21:42:00.001-05:00

You may have noticed that the tired post:nontired post ratio in this blog has dramatically increased.

Or you may have noticed that I'm just posting...less frequently.

And this is because I have big news.

Big BIG news.

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

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

See what I did there? It's not the same picture twice. That's two different babies, people.

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

I'm 22 weeks pregnant with twins, and I feel incredibly blessed. Also tired, so tired, so so so tired. And also, unfortunately, increasingly wackadoodle.

And so I wasn't going to share this news, at least until I hit viability, or some nebulous place where I just felt that - maybe - everything was going to be ok. But instead of feeling better and better as we get farther and farther, I feel worse and worse. I'm more and more scared. I'm less and less calm. That place of ok looks increasingly mythical from here; I'm not sure we're going to get there, ever, really.

It's worse this week. Some of this is a result of things I have seen recently at work. Some of it is the result of terrible things that have happened to friends recently. And some of it is the result of things that have happened to people that I don't know but that I care a lot about, most of whom I read on the internet.

And the end is result is that, again, I seem to be losing my mind.

So I thought I'd tell you. Because maybe it will help. Maybe I can stop feeling anxious and crazy and wackadoodle, and go back to feeling so very lucky, at least for what I have right now.

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

AA and BB: they're beautiful, no? I thought so too.

Professionalism, with toddler

2010-12-26T14:00:00.002-05:00

It's Christmas Eve. You, weirdly, have the day off, but your husband has to go to work and do some last minute economizing. So you and Smoosh are having a lovely day of playing and reading books. However, you saw a patient yesterday in clinic with elevated blood pressures; they were normal on recheck, but you decided to send labs. "I'll call you in the morning with the results," you said, and then sent yourself an email so you wouldn't forget.

But now it's 11:30 a.m., barely morning. You looked at the labs in the wee hours of the a.m., and they were fine, but didn't have a chance to actually call the patient. Smoosh is recently fed, recently changed, and playing with Legos. So you think: This might be the best chance I get. You pick up the phone. You dial.

You get voice mail. You leave the following message:

You: "Hi, this is Dr. C. I just wanted to follow up on your results from
Yelling toddler voice (YTV): Mama! Mama!
You: Yesterday. I looked at them
YTV: Mama! Mama! I make you garbage truck!
You: And they are all normal, which is great news.
YTV: Mama! Mama!
You: [hushed adult voice: Thank you sweetheart. Mama will be with you in a minute.] In any case, this means that I don't think you have pre-eclampsia right now
YTV: Mama! Mama! It ORANGE garbage truck!
You: So unless anything changes, we can just see you at your appointment next week. [Hushed adult voice: I'll be right there. Just a second, honey. I promise.] Remember that if you get a headache that doesn't go away, abdominal pain, or visual changes, to come to the hospital. See you next week.
Pause.

You, thinking that you have hung up phone: Oh, honey, that's a lovely garbage truck. Who's going to drive it?
Toddler voice, now close: Mama come PLAY!
You: Ok. Do you want to drive trucks or read book? [Noticing phone still on] Shoot.* [Hangs up]

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

So, clearly not the height of professionalism. And some logistical misjudgment on my part: I should have waited until naptime. But it absolutely could be worse (I was not yelling at the toddler or being mean to child or actively changing diaper).

To be honest, if I had gotten this message from MY doctor, it would have cracked me up and I would have appreciated them for trying to take care of me while performing their other duties.

So I think it's fine, mostly because the patients I work with are, generally, in the same situation as I am: mothers of young children who will not be denied.

What do you think?

*Not what I said.

ultrasound pettiness

2010-12-23T21:56:00.001-05:00

Well, I'm finally getting a handle on that pesky fetal heart. It turns out the trick is to think LESS. Now I just kind of wander around a bit, and eventually the right shape turns up, and bam! That's the right ventricular outflow tract. Or, at least that happened once, so perhaps I can do it again.

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

Dear ultrasound patients;

I will not -- no, I CANNOT - discuss with you how many months pregnant you are. In gestational age, months are meaningless, and worse than useless, and confusing. A month is 4 +2/7 or 3/7ths of a week; this creates ugly and unnecessary math. And this, by the way, means that 40 weeks of pregnancy is closer to 10 months than to nine, which means that your calculations will never, ever, ever work out. The use of months also deletes much of the subtlety that I need, the difference between, say 37 and 39 weeks, or (perhaps more importantly) 23 and 25.

In short, asking me to think in months is like asking me to weigh people in stone, or figure out my gas mileage in leagues. It's antiquated and makes my head hurt and, most importantly, does not communicate much useful information.

I know that like my colleagues who adore the metric system, I am fighting a losing battle. I have explained my desire to have all the women of Large Urban Area start talking in gestational week rather than months approximately twenty times today, and I can't get even a single person to use my desired terminology. But I will go down with my ship.

Yours in calendrical simplicity,

C

The med student serenity prayer

2010-12-15T23:06:00.002-05:00

I survived fetal diagnosis rounds. I even finished my genetics final, although I do feel a bit like I'm daring him to fail me. This is NOT how I used to do school, just for the record, but it seems to be what I've got for now.

What have I been up to? Oh, I"m on ultrasound, where I pursue the fetal heart with such ferocity that I'm seeing ventricular septae against my closed eyelids when I go to sleep. Little progress has been made - I'm not a terribly visual learner - but the sweat equity is there, my friends, and that's to be respected.

---------------------------------------------------------
I did something like 15 amniocenteses today, in three hours, during our genetics clinic. My last one - it's always the last one - was for a young Latina girl who was sent from her outside clinic. They saw something bad on her very early scan, and sent them to us, but she didn't really know why. She's 17. Her 6-month old first child waited in the waiting room with her sister, because our tiny ultrasound room doesn't have space for a stroller.

The fetus looks bad - markedly abnormal, and with signs of hydrops* at 16 weeks. Dismal prognosis, and I tried to explain this to her in my Spanish. And she understood, I think, and she held my hand, and she cried, and we did the amnio, and she knows we'll have more information for her next week. She's coming for a more formal ultrasound then, a full anatomy scan, and if the fetus is still alive, well, we'll be able to talk more about what's going on at that point.

------------------------------------------------------------
Amnio number 10 today was actually for a patient of mine. She's also young, and started seeing me in high-risk clinic because her fetus has been diagnosed with a complicated cardiac defect. She's already past 20 weeks, beginning to nudge up against the limit of termination in most states, so I busily went about getting her workup completed: sending her to myself in genetics, referral to our pediatric cardiologist for a consultation and a discussion of what post-natal life would be like. She was considering a termination, so I tried to get everything in place for her fast.

And yet, when I saw her today for genetics, she told me that she still hadn't gotten an appointment with the pediatric cardiologist. "I don't know what I want to do," she said. "I need to hear about it more".

I panicked - how could I have missed this important part of a workup for a patient, for my own patient? A piece that might lead her to make or not make or have the inability to make an incredibly important decision? I started calling around, trying to track down the peds cardiologist appointment number. This was NOT OK. This was MY PATIENT and she had not gotten appropriate resources or counselling and time was running out.

I finally ended up paging our specialist. He's lovely, and understanding, and tremendously kind. And he had already seen this patient, two weeks ago. He had, in fact, been the one to refer her to us. "I remember her well, of course. I spent more than an hour with them." he said. Oh, man. I was so embarrassed. She had not realized who it was, or in the subsequent doctor-go-round that she's been on, has since forgotten. I apologized, he was terribly helpful, and she's going to see him next week for follow up and further counselling.

---------------------------------------------------
So: a study in contrasts. You'd think Story #1 would be terribly draining, and sad, but actually, it was fine. And you'd think Story #2 would be a comedy of near-errors, and no big deal, but it was truly stressful and distressing and completely exhausting.

By which I think I mean: tragedy is not my enemy. Tragedy is manageable, at least when I understand it, and haven't caused it. I am more comfortable with Story #1's narrative - I understand what's going on, there's nothing I can do to prevent it, or not do to cause it, and I'm free to just be with her and help her understand it while it happens.

But wrongful inaction, or wrongful action, causing harm to a patient, or limitation of her understanding - that is, somehow, a tragedy in which I am culpable. And that I was unable to tolerate.

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

I think I've made this point approximately a hundred times before in this blog; it's not new, and I know it's not rocket science. But it came to mind recently becuase I have a friend in med school who asked me how I deal with all the bad, and how I keep it from coming home and going to sleep in my bed. And I think this is part of it for me: not all bad is equal. There's bad I can help with, and there's bad I can just be present for, and knowing which is which takes time and experience, but keeps it from hurting so very much. A serenity prayer for the med student, then.

The other part, is of course, that the bad comes home with me all the time. But those are some other posts.

*Essentially, fetal heart failure.

To Do List

2010-12-06T21:12:00.000-05:00

Make list of everything
Become less stressed out
Finish final for genetics class by 12/30
Wait, was that the deadline? Never wrote it down. Hmm. Email guy from genetics class about that. Maybe it was 12/20.
Late-breaking news: apparently I am presenting at Fetal Diagnosis Rounds next week. This will involve presenting every single patient with an anomaly that's been diagnosed in the last two weeks
Just kidding. It's all of the patients for the last month, because we didn't have one two weeks ago because of Thanksgiving.
Make sub-list for Fetal Diagnosis Rounds prep
Update all list of ultrasound anomalies for presentation
Learn everything about prenatal lung lesions
Apparently genetics final due 12/10. Ha! Move to top of list.
Finish research stuff that you promised to people by this week
Learn how to ultrasound the fetal heart. How hard can it be?
Pretty frickin' frackin' hard.
Forget about it all
Go to sleep instead.

2010-11-29T21:29:00.002-05:00

[SCENE:
6th floor, antepartum service, nursing station.
C, on telephone.]

C: Hi, is this the renal consult?

Renal: (grumble) Yes.

C: Ok, so I have a patient who is 31 years old in renal failure from diabetes, now thirteen weeks pregnant, getting admitted for blood pressures in the 220s.

Renal: Uh huh.

C: Um, ok She has been getting daily dialysis, and I think we'll need to set her up as an inpatient tomorrow.

Renal (suddenly extremely cheerful): Oh, you don't need me. You need the DIALYSIS consult.

C: Sure. Ok, then. Thanks.

-------------------------------------------------
C: Hi, is this the dialysis consult?

Dialysis: Yes, this is.

C: I'm the high-risk obstetrics fellow. I was told to call you by your colleague, Renal.

Dialysis(warily): Go on.

C: I have a 31 year old patient with renal failure secondary to long-standing diabetes, now on daily dialysis, being admitted for blood pressure control, with systolic pressures as high as 220 persistently today. She reports compliance with all her meds. I think we'll need to get her dialysis set up for her as an inpatient tomorrow while we optimize her control.

Dialysis: Ok.

C: Oh, and this goes without saying, because I'm the MFM fellow, but she's at thirteen weeks gestation.

Dialysis: (silence)

C: (silence)

Dialysis: You. Are. Effing. KIDDING. Me.

C (cracking up)

Dialysis: Really?

C (still laughing): Um, yeah. Really. Sorry, Dialysis. Welcome to my world.

[END SCENE]

Thanksgiving blergh

2010-11-27T22:35:00.000-05:00

I really never do know what y'all will like. Glad that last post was such a hit, although I am still somewhat bewildered as to why. Guess it just goes to show you that time spent writing does not correlate with quality.

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

So very much call over Thanksgiving. No neurons left for posting. You've heard this before. That being said, I haven't felt this overwhelmed since I was a resident (when I felt this overwhelmed pretty much every day for 2 years.) It's bad mojo, actually, this feeling: it's a potent mix of being overworked and feeling under-appreciated. That particular geyser of emotion came to a head when, after two calls this week, running a busy hospital service, and a third call to come the next day, I found that due to several misunderstandings and despite a rare outbreak of forethought and coordination, I had on my schedule exactly double the patients I was supposed to on Friday morning. It ended up being about 35 patients, in three hours, between me and my lone attending. That's too many, especially when the attending has to see her own patients as well as precept me with mine, and that no one else was around to help us.

I usually just tolerate all of this - is it really worth getting upset, I usually think, and usually come up with a "probably not". The patients need to be seen, after all, and I usually just put my head down and get through the session somehow.

But something really hit me that morning, and so I threw a hissy fit in person, and then to the higher-ups on email. And in the end, I received better treatment than I deserved, in that the nursing staff really tried to make things better. Together we made the executive decision to hold to our if-you're-more-than-30-minutes-late-you-don't-get-seen-today rule (we never abide by it, usually). I'm not happy about that rule - it seems unfair in a bus-dependent population, especially on the day after Thanksgiving, especially when I myself am usually running more than an hour behind schedule. But it didn't end up mattering; no one got turned away thanks to our 50% no-show rate.

That's not good, either - I spent at least an hour after clinic writing letters and trying to coordinate care for all the patients who didn't make it in - but we got through the morning. So, I guess I'm thankful for that.

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

There's a longer post here, that I'm working on in my head, about being appreciated, or feeling appreciated. The lack thereof makes work very hard right now.

This week, I had several patients sign out Against-Medical-Advice (Thanksgiving being a really unpleasant time to be in the hospital), some quite reasonable and lovely (and who I expect back next week), but some quite hostile. I had several more patients who had unrealistic expectations about what we could accomplish for them in a short period of time, and expressed that frustration freely at me. And there are even others who I feel terrible about, because I gave them those unrealistic expectations, I think, and led to their subsequent frustration and disillusionment.

Regardless, by the end of the week, I felt used, abused, and relatively ineffective at getting good care for people, and I don't feel much better going into call tomorrow.

In a word: Blergh.
------------------------------------------------------

On an unrelated note, what medical apps would you guys recommend for an Android phone? I have to at least pretend this thing has some sort of professional uses besides watching YouTube videos of Smoosh while I'm on call. So far, I've got a nice OB wheel, and that's it. Any thoughts?

Unrelated letters

2010-11-16T21:31:00.001-05:00

Dear ICU nurse;

If you are taking care of a very sick (now postpartum) patient, who is intubated and fluid overloaded and we ask you if she received a transfusion overnight, the correct answer is never: "I don't know; that was the overnight shift." Nor would any acceptable answer be followed by a huff, a figurative tossing of your bustle, or by walking away.

I will be removing my patient from your care as soon as you guys manage to get her to breathe properly on her own, ok? But in the meantime, she's your patient too, and it's both of our jobs to know everything about her. And to play together NICELY.

Yours in huffiness,

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

Dear twins born today;

I have mixed feelings. It was nice of you to come down head-first, and I know your parents appreciated it, but I was a little...let down. I know it's not about me, but I was all jazzed up to perform a breech second-twin delivery. I changed into scrubs, and stayed late! Instead, vertex/vertex*, and the third-year resident delivered you both, and I just handed out cord-clamps. You are very cute, though.

Upside-downily,

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

Dear Smoosh;

You are quite welcome to start sleeping past 6 a.m. It's lovely, in fact, and feel free to continue this practice on weekends. However, if indeed you are going to make a habit of this, please let your parents know, so that that can dust off their old alarm clock. And plug it in. And set it.

Although perhaps I am equally appealing to you unshowered and with unbrushed hair, it is quite possible that Mama's coworkers do not agree.

Somewhat disheveled but still your,

Mama

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

Dear labor floor,

Honestly? You're just a little too riled up right now. Maybe a bit of decaf? One of the residents noticed that the huge snowstorms of Winter 2010 were just 9 months ago, so perhaps we're reaping the harvest of all that alone time in the dark. That doesn't explain all the pre-eclampsia, or the cardiac patients, or the preterm labor, so I think you should just take it down a notch, and share some of the wealth with December. You know, there's a whole other fellow on call that month, and they'd be happy to be all educated by some of this.

Just a thought,

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

Dear ladies-with-cardiac-problems;

Honestly, thank you. One of you with a structural defect was supposed to get an "assisted second stage", with a vacuum or forceps to reduce your pushing time. But you pushed so well (baby number 3 for you, you know) that I didn't have time, and I think that's fantastic.

And one of you with an arrhythmia behaved impeccably during your cesearean section, and allowed me to get the correct meds on board to prevent any untoward events from occuring post-partum. Not a sure thing, of course, but all reductions in labor floor frenzy are quite welcome.

In deep gratitude,

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

Dear NICU;

Well, you know that we all love you, right? But I am really grateful for the time your fellow spent talking over one of the term babies who is having a somewhat inexplicably hard time, requiring a ventilator to breathe, and not really acting like a term baby at all.

Thank you for trying to help us figure out if we could have done something differently, and explaining the baby's course and likely diagnoses. It's still upsetting - although the baby is doing a bit better today - but we learn a lot from each other this way.

I want you to know how incredibly precious we find this kind of interaction. It's important intellectually,so that we can learn to be better obstetricians, but also emotionally, so that we can come to some peace, or at least some understanding, about the damage we see.

Thank you,

p.s. If you'd like to give a tutorial in collegiality, I know an adult ICU that could use one.

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

*Head down/head down

Happy Blogiversary

2010-11-12T09:13:00.005-05:00

(image courtesy of Google Images)

As of today, I've been blogging for a year. Yay!

Anyway, I just wanted to, you know, mark the occasion. Say hi and thank you to all you faithful readers. Celebrate.

Happy birthday to us. Thank you for reading.

Punchy post-call

2010-11-01T15:10:00.001-04:00

Oh, my dears. I have SUCH fantastic and fantastically bad stories for you. But I think that they will wait a little bit longer, and this will be a little clean-up post. Is that teasing? Is that not nice? Sorry about that?

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

I'm post-call/post-call - there were two calls in close proximity, and now I'm post both of them, thank the dear Lord. One was bad (= much story-ing!) and one was boring (= some sleep!) but they are over and I get to sleep at home for another week.

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

I am madly working today on a presentation for tomorrow, for our Maternal Medicine conference. This is a really wonderful session where we discuss all of our medically complicated patients, and make sure that we all understand the plan on everyone. It's pretty awesome, and I think, a rare opportunity for a division to work so collaboratively.

We recently had a successful, uneventful delivery of a patient with a history of childhood osteosarcoma, who had survived multiple surgeries and chemotherapy regimens and radiation, and then managed to get pregnant (a not-so-small miracle in itself) and have a baby. So my presentation tomorrow will be on childhood cancer survivors, and the challenges they face in pregnancy.

These challenges are myriad, even if you exclude (as I did) the fertility issues given by so much toxic therapy so early in life. There are chemotherapies that damage the lungs and heart permanently, and how does that work when you add the stressors of pregnancy, and labor, and delivery? There is radiation that seems to limit forever the development of the uterus and its blood flow, and gives an increased risk of pregnancy complications, such as babies that are too small or pre-eclampsia. And there is surgery, which can make any procedures we need to offer positively fraught.

And yet, amazingly, this woman experienced almost none of this, and had a wonderfully normal delivery. Which, frankly, she very much deserved.

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

Writing about all of these terrible cancers predictably makes me undeniably anxious about Smoosh. Well, what is that giant lymph node in his groin? It has been there FOREVER, and his pediatrician is not concerned. But he always has some enlarged lymph nodes in his neck (because he always has some sort of cold/runny nose/cough, and his pediatrician says it's day care, and he'll be superman by the time he's six, and I generally agree) and is that something we should do something about?

And you may ask: why are you feeling your son's lymph nodes*? And I will tell you: never go to medical school. Or hang out in a hospital. Both of those things do bad, bad things to your brain. Non-gestational wackadoodle, PTSD, whatever you want to call it: it's the syndrome of never again quite trusting that the human body of those you love will behave itself.

I promise to stop checking his lymph nodes when he goes to college.

-------------------------------------------------------
Hi D-Love;

Of course I read your comment! I obsessively read comments.

Here's my short answer to your more complicated question (which OF COURSE is not to be used as individualized medical advice but a more generalized discussion. Ahem). So even if the absolute experience of c-section vs. VBAC is equivalent to you, then I think it's relevant if you think you're going to have more kids or not. On a this-pregnancy basis, c-section is probably very slightly safer for the really bad stuff (mortality of mother/baby); but has higher risks for little stuff (wound infection, mild transient newborn breathing issues, etc). You seem to state that the little stuff doesn't bother you, so then I think your choice - based on this delivery alone - might be a cesearean section.

However, my point about the cesareans is that they become progressively more risky. So if this is cesearean #2 of 4, your overall lifetime reproductive utility may be maximized** by considering a vaginal birth.

But not if it makes you really scared. Anxiety is a true utility-buster, for sure.

- C

*In my defense, that groin one was big enough to see. I didn't go looking for it, it found me during a diaper change.What?
**Put your hands up if you're married to an economist. Woot!

A post!

2010-10-28T21:06:00.001-04:00

Ok, first let's address last week.

You guys. I KNOW that this patient would
a) benefit from a doula
and
b) probably benefit from spending more time in early labor at home.

But in the land where I live (land not that far from where you live),
these things, along with many others are not possible. People do not
have doulas, or much education about their bodies, or supportive
partners, or fresh produce, or (sometimes) a safe place to sleep.
That's how it goes here in Large Urban Area. We do what we can with
what we have, you know? So because of this we tend to keep people; and
honestly, because of this, people want to be kept. It's not so easy
out there.

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

So what did I do? I asked her what she wanted; she really didn't want
to go home. So I admitted her, but told the RNs she didn't need to be
first priority. This meant that she spent the whole night in triage,
watching active multiparous women get the last labor room, one after
the other. But she knew this might happen, and she was ok with that.
Her contractions briefly went totally away, and I was going to send
her home, but she had fallen asleep, and I'm not that mean. She woke
up contracting again, finally got a room, received an epidural at her
request, and went on to deliver vaginally about 24 hours after I had
first examined her.

----------------------------------------------------
I saw her in the elevator later in the week when she was leaving the
hospital with her baby. She didn't recognize me. She looked fantastic,
and the baby is a beauty.

Another quiz!

2010-10-20T14:32:00.001-04:00

You know what's really annoying? Labor. I don't mean that in a it-hurts-and-why-would-that-be-a-smart-evolutionary-move kind of way. I mean: it's hard to predict in a that's-how-bodily-functions-just-are kind of way.

The classical teaching is this:

(courtesy of Google images)

Which is to say: early labor (often defined as less than 4 centimeters dilated, but not really) is long, and unpredictable. And then at some point, you hit the force of nature known as active labor, and bam! things get moving, 1 or 2 centimeters an hour, at least, and then you have a baby. More or less.

I am taking issue with the diagnosis of active labor at 4 cm, as most clinicians would, because many women can walk around at 4 centimeters for weeks. So what is active labor? Active labor is the dilation at which, for you, the rate of change becomes more dramatic, where the slope of the line hits 1 cm/hour or so. For many women this is 4 centimeters, but for some, it's 5, and for others it's 2.

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

So. With that background, welcome to my triage life. Because this is the fundamental question of triage (if you take out all the crazy cardiac stuff and pulmonary embolism and general boyfriend drama and all the other stuff), which is: who needs to be admitted to the hospital in labor?

Now, as I explained above, I don't really care about the graph because maybe YOU are in active labor at 3 centimeters. And I also don't care about the graph if you're in terrible pain and requesting analgesia, because then you're coming in for SOMETHING, because it's unethical to just tell you to deal with it (unless you want to, that is. Then, great! I love it! Go home and be a rock star, and come back in a few hours.)

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

But it becomes difficult when you add social/psychological/other medical factors. So, for example, what do you do when a 27 year old having her first baby comes in at 2 centimeters, 80 percent effaced, -2 station. She is group B strep positive, and will need at least 4 hours of antibiotics to avoid needing to give the baby an IV and antibiotics. She is moderately uncomfortable with contractions every 4 minutes, but is handling well. She lives an hour away by bus, and can't afford to take a cab home and back again. The baby looks great on the monitor.

So what do you do?

I hedged my bets and had her ambulate. She came back almost 3 hours later, markedly more uncomfortable although handling it really well, and with some slight cervical change - now pretty much 3 centimeters, maybe 2-3 centimeters if I'm feeling really honest and stingy. Hmm. Not really making a lot of change over that time, you know, and with that small amount of change in 2 hours, pretty solidly in the latent labor arena. But: she's uncomfortable, and she lives so far away, and now it's 11 o'clock at night.

So what do you do now?

a) Send her home. If you bring her in, we'll end up doing something to her, and we all know that interventions in a first pregnancy increase morbidity. She'll end up with a million exams and a fever, or with "augmentation" that's really more like an unindicated induction and increases her chance of cesearean. You're not doing her any favors. Send her home. She can take a warm shower, maybe you'll give her a gentle sleep aid to take with her and she'll try to get some rest at home. She'll almost definitely get back in time for her group B strep antibiotics.

b) Admit her, but as an observation patient. If she wants, she can have some IV morphine. We'll put her somewhere out of the way -maybe the recovery room, instead of a labor room - and just let her sleep a bit. In the morning, she'll either be in real labor, or well-rested enough to go home. Unless she's not, but then the day team can deal with that, right? Yes, this will provoke hostility in the day team, but too bad, you know? Be clear with the patient that she might go home still pregnant in the morning if her labor is still pokey, so she won't be too mad.

c) Admit her to a labor room. She's made change, goddammit, and she's in labor. It's just, you know, early labor. This way she'll be comfortable. Just fudge the exam a bit and tell the charge nurse she's 3-4 centimeters (hitting that mark, which means no one will fight you for the bed). Start the antibiotics, and give her either IV analgesia, nothing, or an epidural - whatever she wants. It's not clear that it will make a difference, and she's really working pretty hard.

OF COURSE you will ask the patient what she wants - that's always y'alls favorite answer. But it's cheating, because that conversation needs to be guided by what you're willing to offer and what you think is a good course of action for her.

And so? What are you willing to offer?

I didn't think I was a jerk

2010-10-14T20:46:00.001-04:00

You know, when this happened, because I called 911 we ended up at a hospital near my house - an excellent, academic, very large hospital - but not one at which I have ever worked. And I was talking about this with a friend, about how the whole experience was terrible, but also how this was the first time in a long time that I had received care somewhere that I wasn't at least known professionally, a bit. (I find that I do feel more comfortable getting care at my own institutions. I repeatedly refer to this as the trade-off of privacy for love. So that everyone knows my business - as in, I took the elevator ride up to the postpartum floor, wearing a stained hospital gown with my new baby and my profound anemia, and my department chair stepped in and rode with us making awkward small talk for two floors. But the other side is this incredible care that I get, flavored with a genuine like and familiarity during a time of great strangeness, and where I always feel that people really want only the best for me.)

Anyway, as I was recounting the whole seizure drama for my friend, I mentioned that I felt...uncomfortable at this other institution. At loose ends, I guess, without any connections.
"Oh," she said. "I get it. You like the VIP treatment."

"No. No!" I said. "That's not it." Because I don't think it is; I don't think I'm that jerk. Even when I got care at my own institutions, I never wanted VIP care. In the throes of a surgical emergency, when one of the Emergency Medicine interns started to take my history, and then realized I had been his chief on the labor floor, he asked if I wanted attending care. No, I said between bouts of vomiting. Residents give excellent care. Treat me like normal.

I then bullied him (and his attending) into getting me a CT scan that I didn't really need, but thought I did. Anyway, that's a long story, the moral of which is: do not let the delirious woman in bed 12 dictate her own medical care.

Regardless, the point for me of being treated at a center where I am known was not, I thought, that I wanted to be a big-shot, or get special treatment. Although I did like that they didn't make me wait in triage when I came in in labor, and that I got the nice big corner delivery room, that wasn't the deal. What I liked the most was that when people talked to me, they knew that I know what I know. That is, they knew that my opinion is formed by certain experiences - in the Emergency Room, in labor and delivery, in the operating room- and that, because of that, I know that there are clear-cut rules, but I also know that nobody's body ever follows all of them. I guess I want them to take normal care of me, but realize that I might not be normal. Weird things happen. I have weird opinions. Adjustments might need to be made.

While explaining this inarticulately to my friend, I realized that what I wanted, then, was individualized care. A discussion that noted that I was a person, not just a patient, and that I might have strong feelings about what happened to me.

And as I was explaining this to my friend, I thought: well, maybe I am that jerk. Because I think my point is that that is VIP care, and that only people who know the right people get it, and not everyone else. And that is more than just a little bit sad.

2010-10-05T22:12:00.006-04:00

I publish this post with some apprehension. One, talking about miscarriage as a "clinically insignificant" event always has the effect of making me feel like I am a completely insensitive boor, even if I am referring only to the medical thinking that surrounds these losses. For that I am sorry; I am trying to clarify, actually, why medicine thinks this way. But of course, always, sorrow has never been a suitable area for gradation, and all valuations of sadness only cheapen the valuer.

Secondly, I am having a lot of trouble articulating. So help me out, if you can, in the comments; if I'm not clear, please tell me. These ideas are really important to me, and I'd like to say them in a manner that is clear and, hopefully, constructive. I'm not going to even hope for poetic, tonight.

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

Today we had MFM division meeting, and we reviewed this article. I love this article, for a variety of reasons that are too technical and nerdy to really delve into right here and now, but I highly recommend it to OB/GYNs for its general philosophical and clinical clarity - rare finds, indeed, in academic writing.

In any case, one of the things that is so wonderful about this article is that it makes the very cogent point that our historical treatment of pregnancies of different gestational ages - of different trimesters! - might be very wrong.

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

We currently divide pregnancies into those before 20 weeks, and those after, most obviously in our Gs and Ps notation. The subtext in that notation is this: Pregnancies before and after 20 weeks are fundamentally different. Pregnancy losses before and after 20 weeks are fundamentally different. Historically, losses before 20 weeks are considered miscarriages. They are sad, but unless "recurrent" (and whether this means more than 2 or more than three is always a discussion) carry very little in the way of clinical prognosis. That is, you are quite likely to go ahead and have a happy future pregnancy. So they can arguably thought of as terribly sad, but not tragic. A common sort of awfulness, but one that you can leave in the past.

Losses after 20 weeks, however, are serious badness. That's usually preterm labor, or cervical insufficiency, and they carry with them high risks of recurrent terrible events in future pregnancies. These diagnoses have with them the worry, then, that this patient will have this happen again in the future.

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

But the article that we reviewed points out that the twenty week deadline is, as far as we can tell, rather arbitrary. That is, pregnancy losses after 16 weeks are not necessarily an entirely different process than those at 20 weeks, or at 28 weeks or at 32 weeks. That makes them pretty serious, and scary. The author makes the case that patients with these losses should be granted the same clinical seriousness in their future pregnancies.

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

I think there's a sub-sub-text to this, though, which is even more interesting. And it is this:
When does medicine consider a pregnancy important? And a pregnancy loss terrible? Many years ago, a loss at 19 weeks was, well, not acceptable, but definitely perceived differently. In the absence of reliable pregnancy tests or ultrasound, perhaps you would not have realized you were pregnant yet. Even if you did, there was no opportunity to see the baby dancing around in your belly, with little perfect fingers and toes and a name all picked out and a nursery theme chosen. But now we see that, we have a thousand times more information than our grandmothers, and I think this has changed the experience of pregnancy, as well as its expectations.

There other examples of this shift in the valuation of pregnancy. For one, (and this one is addressed in the article), women with cervical insufficiency - painless dilatation of the cervix, resulting in loss of the pregnancy, usually before 24 weeks - can be treated with a cerclage, or a stitch around the cervix. There is mixed data about cerclages, and about how well they work, and the only group to have been definitely proven to benefit from them - to decrease their loss rate in future pregnancies - are women with three prior losses. Yes, that's right: THREE. Three pregnancies that proceeded for five months, and then...gone. Three worst days of your life.

But who would stand for that now? None of us would tolerate it, without treatment or workup. One mid-trimester loss is terrible; two is unthinkable. Almost all doctors will act long before we get to three, whether the treatment is proven or not.

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

So it is arguable that over time, medicine has come to value each individual pregnancy more, and value it earlier and earlier in the pregnancy. Some of this philosophical change is medically mediated: we have different evidence, and ongoing investigations and those make treatment more reasonable, even if the data is still less than entirely convincing.

But I think that's only camouflage. Because I think the real reason is more basic, and less science. And it is this: as patients, and as doctors, we no longer find it acceptable to lose pregnancies.

I don't know why this is. There are a million possible reasons: Is this because of early pregnancy diagnosis, and because we become assured of our roles of parents so very early in the process? Is it because of ultrasound and the emotional punch it can wield, as you visualize a real, live fetus just a few weeks after it formed? Is it because more doctors are women, and unable to watch cold-heartedly as women grieve?

Is it because we wait longer for pregnancy, we are older, and so each one is, quite possibly our last and only?
Or because our ideal family has shrunk - to two, or sometimes even less than two children - and that leaves so little room for error? Or is it because in the twenty-first century, we are so lucky, and so used to controlling all our outcomes, that the unacceptability of losing a pregnancy has just become too great? Or, because, as advances in neonatology have progressed, and the gestational age of viability has shrunk, we move all our other deadlines earlier as well?

Whatever cultural reason it is, it becomes the medical reason. Because one necessarily leads to the other. After all, why is this data coming out, and why are these studies being done? Because socially, and emotionally, we are unwilling to tolerate these losses. And thus, we pursue treatment and prevention - sometimes to the achievement of greater harm, and hopefully more often, to the achievement of greater good, but always because the disease process we are looking at cannot be borne.

2010-10-03T18:14:00.000-04:00

Hello, dear neglected readers.

Hello?

Are you still there?

I left you for a long time; I'm awfully sorry. Believe it or not, there was more vacation, and then some nasty viral illnesses, and gosh, time kind of just got away from me.

If you're still here (and not a robot), then thank you.

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

I've decided to count my blessings today, or rather, one large blessing: Ways In Which It Is Lovely Not To Be The First-Year Fellow:

Clinic is better. Oh my good Lord, clinic is so much better. There were a couple of adjustments made by the administration (that in itself, a sweet sweet miracle) and some of it is just my increased experience, and some of it is that you can't honestly have that many cardiac-patients-with-quadruplets-and-gestational-diabetes in a row without at some point running out of them, and getting some more run-of-the-mill people with uncomplicated chronic hypertension. Whatever it is, I still find myself bracing for terrifying awfulness at the beginning of each session, but it just...doesn't come, and hasn't for three months now. As it stands, I take care of my patients, I talk to my attending, and then we're done. My head almost never explodes. I am almost at the point where I can stop assuming it will be terrible; the healing has begun.
Call is better. Oh, I still wish I didn't take quite so much of it, and I still wish I was in charge, you know, as would be commensurate with my experience and training. But I am not dreading it (which is nice) and of course, as always, removing the apprehension makes the call more pleasant, and thus less worthy of dread. Hurray!* Some of this credit goes to my new interns - the old guard felt that triage was, ahem, below them, and not worthy of their time. This new crop told me that they were told their job was "triage intern", and they take it to heart. And because of that, I teach, and they learn, and a good time is had by all. (Except at 3 a.m., when I do still dread. It's natural. I don't think humans are really supposed to be up at that witching hour. Ah, well..)
Smoosh is just awesome. AWESOME, I tell you. The twos, they may be terrible, BUT they also (generally) sleep through the night, and have wonderful discussions with you (yes, ok, mostly about garbage trucks, but still, discussions! With a question-and-response flow! It's amazing.) And they are expressive, and give hugs, and are (mostly) so very happy to see you. There is so much deliciousness, and still with his old content of total smooshiness. Highly recommend.
I got a new phone. It is a Samsung Fascinate. I am in love with this phone, and I would marry it, and the Bearded Economist might totally be ok with this, since he is kind of in love with my phone too. Honestly, it's a toy, and it's so new that I have not even brought it to work yet, but I can already see that it's going to make me completely unproductive but cheerful. A good deal, I think.

I think that's it. Writing this, I think you can see vacation satisfaction oozing from my pores, and as we all know, it may not last. So I'll read this again when I feel like I've made no progress, or that fellowship will not end. And this week, it's back to real work, with (hopefully) lots of stories to tell.

*A lesson that I seem constitutionally unable to learn, no matter how many times it is taught to me.

Research Update. And other stuff.

2010-09-20T13:07:00.000-04:00

Hey, guess what? That's it for call for a solid month. Granted, it's because I did three months of call in 3 weeks (note: this is now contraindicated) but it's all done, and life is better. Hurray!

So what am I up to? Clearly, not posting - sorry about that.

Here's what I've been doing:

1) "Breaking Bad News" research project:

This is the project where we are using simulation to teach house staff (and eventually, we hope, everybody) better communication skills, specifically when talking about adverse clinical events.

You know, it makes me much happier to call this an educational project that we're just observing and quantifying. Because as research, it's kind of boring (did I say that? I'll unsay it before I submit for publication). But as teaching, it's really awesome and exciting.

The IRB agreed, because they "deferred" (= did not very much like) my application; upon review, I think we made it sound too much like A Very Big Deal and sort of Threatening to Residents with all the simulations. So now I've spent 2 weeks rewriting this enormous document to say: We are doing some very friendly teaching! And hey, we'd like to ask some questions to make sure we're doing it in the right way, but it's no big deal! No residents will be harmed in this educational initiative!

The funny part of this project is where this is taking me; I'm making an acting curriculum for our actors, and oh yeah, I have to hire actors. (Am I a casting director? Do I get a couch? No? I didn't think so.) And I have to make a budget and figure out where we can do this. Ideally we need a place with 10 small rooms coming off a central hallway, but I don't think that exists in the med school, so I am coming up with alternatives. Meaning: I am also the set designer. This has gotten weird, but fun and creative.

2) The Walk-In study:

This study has been a bit on hold - it's a record review, so in theory can just happen whenever I have time for it, as opposed to collecting actors and residents and holding a Teaching Event. Of course, the problem with things that can happen anytime is that it's hard to make time for them, eh? But I made some serious progress in late August, and hope to finish data collection in October. I ended up (for right now, anyway) making the decision to compare low-risk walk-in patients with low-risk "consistent" care patients; I just don't have the volume to control for such a heterogeneous population, if I included everybody. Thanks for commenting and helping me think that through.

Some nice IT guy offered to help me with the data collection, and I got all excited that my brute-force chart-review might be over, but so far it's gone nowhere. We'll see. I should really get a med student involved.

3) Sundry other stuff:

I started walking for exercise, on the grounds that I don't hate it. I listen to podcasts when I walk, which means that if you see someone wearing shabby running pants and goofily grinning around at nobody, it might be me, or it might be a homeless person, but it's often me. Any podcast recommendations? I seem to prefer scripted stuff - "Wait,Wait Don't Tell Me" is a good one, as is "The Sporkful", and "This American Life". And funny is better than not funny. What else can I listen to? Help expand my world beyond NPR.

I made enchiladas and my dad's potato soup. I took Smoosh to the doctor for a checkup, where I was told that he is doing beautifully (I knew, but so nice to have it down as an official diagnosis, right?) I slept, and then I slept some more. We bought Smoosh a doll (heretofore known as "Doll-baby") for his birthday, as well as a basketball - these were his choices at the toy store, basically - and he is in love, mostly with Doll-baby. Toilet training is in nascent stages, and will likely stay there for a long time, as I am not motivated to get to the messy part that looks like it involves a lot of bribery and laundry. (Also he's still really little.) We played in the dirt in the playground. We went to the beach once, and played in more dirt.

And I think that's it. I seem to be more boring and happier. It's good right now, but makes me wonder if those are necessarily correlated.

Walk-in Fall-out

2010-09-12T14:28:00.002-04:00

Because this was like a nuclear walk-in. Boom!

-------------------------------------------------------------
And it's my third call in 6 days, and it's 6:55 a.m., and I just need to live through 65 more minutes before this whole hateful, sleepless week is behind me. My pager goes off, and I call triage back, and one of my favorite residents starts talking. She tells me that there's a patient here that usually goes to Reasonably Large Nearby Hospital, and is 39 weeks, and is 4 centimeters dilated, and has broken her water. This patient has had 6 deliveries before, all vaginal, and apparently has some bleeding problem where she hemorrhages after all of them. What should we do?

My enterprising resident has already gotten the records from Reasonably Large Nearby Hospital. Our patient has been receiving care there since second trimester. She has some terrible bleeding issue - it's not clear what - the hematologist thought it might be Von Willebrand's disease. However, since Von Willebrand factors rise in pregnancy, the diagnosis of true Von Willebrand deficiency is impossible to make unless you can test between pregnancies, which has not been true of this patient.

Now I go talk to the patient. Yes, she's had heavy menses, and sometimes gets nosebleeds when she's not pregnant. Yes, she bleeds with all of her babies and has always needed a blood transfusion. (She has a lovely South African accent, and says things like, "Oh, I get terribly ill, and it's quite concerning." Goodness.) She was getting care at Reasonably Large Nearby Hospital, but they told her she should show up here for delivery. No, they had never gotten her an antepartum consult; she's never been to our hospital before.

The notes from Big Nearby Hospital initially state that they're ordering all these blood products for her, and readying themselves for delivery. And then, at some point, they seem to just give up, print out directions to MY hospital, and send her on her way.

So at this point, it's not clear what this patient has. She could have a bleeding problem with her blood, but frankly, the diagnosis seems pretty tentative. She could also just have had issues with uterine atony, where the uterus does not clamp down properly; perhaps she has fibroids? Honestly, we don't really know what is going on with her, but we only have a few hours to figure it out.

What is clear, to me at least, is that this was handled TERRIBLY. Because, of course, we're good, but as a hospital, we're all much better if we can plan. And there are ways to get this patient care; there a many consultative physicians she could have seen, and any one of us would have made time for her long before 39 weeks. But that's not what her primary OB providers had decided to do, so here we are. I am literally shaking with fatigue and rage at this situation.

But that's not important right now, so I'm looking frantically through her stuff (because, of course, she has also had hypertension and it's unclear if she was appropriately tested for diabetes and lots of other things. Oh, and her platelets were sort of low during the last trimester of pregnancy) and stat paging hematology and OB anesthesia and my MFM attending and the oncoming MFM fellow. OB anesthesia kindly comes by to perform a consult - they will be in charge of letting her know if she can have an epidural or any other regional anesthesia, which is safest but can have dangerous consequences if she has bleeding problems. They will also be our partners in her resuscitation if she starts bleeding.

So I'm sitting there at the desk in triage. It's now 7:42. I've been frantically working on this patient for almost an hour. The anesthesia attending comes in, and begins, frankly, freaking out. We need hematology! he yells. I need a hematology consult YESTERDAY! There is no way in freaking hell this woman is getting an epidural!

I know, I say. I've paged heme 4 times. I am having them overhead paged right now. I'm working on it. I hear you about the epidural. Thank you for seeing her.

I realize the anesthesiologist is not angry with me, more with the situation. I want to say: Believe me, buddy, so am I. But honestly, I'm not up to dealing with him right now - this patient's mismanagement is certainly not my fault - so I let the oncoming MFM fellow soothe him and diplomatically make a plan.

I write my note. It's a pretty shameful note; my plan consists of the idea to "consult hematology. Have extensive IV access and blood product availability as well as uterotonics." I'm not going to be the one to figure out this medical mystery. I leave and go home to sleep; the patient actually does quite well, despite the hubbub and does not bleed terribly much.

In any case, though, after I slept and awoke, I was occupied with the following question: what is this travesty called? She's not a walk-in; she's a send-in. Somebody I talked to later said: "Well, you were turfed, big time. So I would call that dirty pool."*

*Yes, I did tell my division chair, and hopefully this incredibly inappropriate patient transfer will be addressed at higher levels than my own. I remain livid.

Guilt, a post.

2010-09-06T19:53:00.001-04:00

Rather than Guilt: the novel (which I could easily write) or Guilt! The Musical (well, I couldn't write, but would totally go see.)

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

Being on call has become progressively harder on me. I don't know whether it's that I enjoy Smoosh more now that he's older, to the point that missing two Sundays a month with him seems really awful (he will say new things! and bonk his head! and I will NOT BE THERE!). It may be that he has (at the same time) become a little more interactive and high maintenance, and therefore in need of more attention. So there's the guilt that I'm not with him, and the guilt that my partner has to manage the whole day alone. And together they add up to this potpourri of unpleasant momma-guilt and partner-guilt, all mixing up right under my sternum. It's building up to the point that every call I take feels unbearable and terrible, completely out of proportion to the actual time it requires. The mixture is very potent, and ends up feeling very much like anger, anger that I have to be here and do this, when I just want to go home.

It's not very professional, you know?

I'm under no illusions that I'd want to be a stay-at-home mom. In fact, maternity leave was very hard for me, as someone who doesn't do well with the combination of sleep deprivation and unstructured time. I was lonely, and not good at getting out of my isolation, and it took me a long time to get comfortable in that setting. And honestly, I think part of why I enjoy Smoosh so very much is because I don't deal with him 14 hours a day; and because of that, the time that I am with him is really joyous.

I don't know if this feels worse now because at my old job, we lived close enough to the hospital that I could sometimes run home and give the baby a bath and nurse and put him to bed. And when I couldn't do that, The Bearded Economist could bring him to see me and we would have dinner together. But now my work is far away, and we only have one car, and my time on call is very much away from both of them for 24 hours, and it makes me very sad.

I called home tonight, and the Bearded Economist had a lovely day with Smoosh; one of those days, where, with very little planned, you bump into friend in the playground and catch the ice cream truck together and find live music in the park on the way home. Organic, sweet, summery fun. And I said to him: "I'm so glad you had a good day. Now I can feel jealous instead of guilty." And he said:"Ok, if those are the only two options, then I guess that's good."

So. Yeah. Why are those my only two options?

I've been thinking about this because we recently hung out with friends who have two kids, one on either side of Smoosh in age. This couple are loving, involved parents. Both have time-consuming jobs, and one of them had recently - and unapologetically - taken an exciting new career opportunity that required a lot of international travel. And while discussing this new schedule with them, what I was struck by was the absence of guilt. No guilt about having bedtime be done by one of the babysitters once a week, or about having your partner fly solo with both kids for 10 days at a time - no parent guilt, no partner guilt. And I wondered if this was because these friends are a same-sex male couple.

I don't mean that this is a double-X chromosome thing. I mean that there is almost definitely some element of cultural/nurturing/socializing/Barbie-doll-dressing behavioral conditioning that has gone on for most of us, and for most women, it translates into guilt whenever we hit some unclear limit of time away from home, or of the ambition that takes us there.

You know, Smoosh seems unscathed by my short absences, and The Bearded Economist couldn't be more supportive. So clearly, almost all of this is self-generated. And for the next two years, I have almost no control over my hours, and less than that over how much call I take. I would just like to stop feeling so very hateful about it. Any ideas?

Three calls in 6 days, or: Whose bright idea was this?

2010-09-03T15:04:00.000-04:00

(It was my bright idea. Oh well.)

1 very nice call room. Hey, it makes a difference. Big plus: the computer in the call room seems to have escaped institutional control. You can go shopping! Read blogs! Hit up Facebook! You'd have to have time to do all that, which I didn't, but still nice.
2 patients attempting vaginal birth after cesearean. Neither did much on my shift, but the nice thing about coming back so very often is that I got to look them up, and bam! they both had lovely successful vaginal deliveries
3 conversations with Smoosh on the phone; he's getting better at that. Actually, he's quite chatty, if not always intelligible. However, last night, he told me last night that he ate olives and Cheerios for dinner (only partly true).
0 cesearean sections so far. I mean, that's good luck, but I haven't even really seen the OR at this new hospital, and I'd kind of like to break it in, in a non-emergent way.
1 dumb mistake I made during signout, presenting my one patient to the oncoming attending. Nothing important, nothing that changes management, but just made feel like I wasn't making the best impression at a new place. I worry far too much about this - feh.
3 residents and 2 med students at my beck-and-call. Actually, I'm at their beck-and-call, and they get very annoyed when I actually try to do something. Which I guess is a sign of clinical maturity. I'm still finding the golden mean that allows them to think and practice while still being completely supervised.
1 time that I was scolded - scolded! - by my chief for putting something up on the white board. I finally left the floor and just spied on them from afar because the resident in me is still strong, and I find it very hard not to just do everything myself.
2 diabetics, requiring enormous amounts of insulin between them. Like, ENORMOUS. Like, 50 units of aspart with meals. What is that? That's like taking an insulin bath before lunch. I guess it worked, because both of their babies escaped the usual terrible growth of diabetes and were under 9 pounds.
4 women presenting with dizziness and possible fainting after another heatwave day. They all got my hydration speech. One of them, I think, actually just fell asleep: she says she was sitting, closed her eyes, and then felt herself waking up. As my second year residents said: If that's fainting, I do it every morning at rounds. Regardless, we checked her and her baby out before sending her home
180 was the unexplained fast fetal heart rate that my induction started to exhibit for absolutely no reason. I flipped her, I put her on her side, and we gave her oxygen, but it was weird. I told her that I couldn't watch this fetal heart abnormality forever, but thankfully the baby started to calm down. I still don't know what that was, but am grateful.
24 more hours of call to go, starting in 36 hours. Wish me luck.

Panic! At the Disco

2010-08-29T21:55:00.000-04:00

That would be more fun. I'm just panicking on my couch.

So, welcome to fellowship year 2. Two months into this year, and I have accomplished close to nothing. I'm working on my research (more below) but I am realizing that I will be on the job market in approximately 10 months. And here's the problem. With no research, I am having a hard time knowing what I want from a job. You know? All of a sudden this fellowship is feeling very short.*

And aside from research, there's the clinical/patient care side of things: will I know enough? (I'm still kind of sucky at ultrasound). Will I have done enough? Will I have seen enough? Will I be confident enough?

I am pretty much done with training after this - as my grandmother points out, there's not much more school I can possibly go to.** And although I know from my attending experience that the learning never ends, and you can almost always ask someone to teach you more, it's pretty scary anyway.

________________________________________________________________

Anyway, here's the short story on my most active research project, and I'd appreciate any help I can get. (Some others are languishing in IRB land.) I started this project, but now I think I may not have thought it through well enough, and well, I guess that's how we learn.

So I started this walk-in study because I really wanted to look at hostility and how it impacts care. Because I like thinking about communication and feelings, but with some math to make it more scientific!
In any case, to give some background, walk-in patients are those who are admitted for labor at our instituion, but have not recieved prenatal care at our instituion. At Big Urban Hospital, this is up to 10% of our patients. There is very little literature about this pattern of care, although I think it must be relatively common in almost all urban areas.

When these patients walk-in, they are accompanied by a tremendous amount of hostility. Firstly, there's anger that we have to reconstitute 9 months of care in the next hour or so, and in so doing repeat a lot of labs and spend a lot of money. Secondly, there's a judgement about this patient and their ability to reliably get care, or get care in one place. (And yes, most of these patients are poor and on public insurance, etc.)

It's my assumption that walk-in patients get worse care, and have worse outcomes, and yet cost more money, but this has yet to be proven. This study is my current focus - Step 1 of the larger project.

Step 2 will be implemented after a large regional electronic medical record system (LREMS) comes into play. See, a lot of the bad care/expensive care comes from not having records available (for various logistically concerning and stupid reasons). But what happens after the LREMS is up and running? Will these patients still cost more? Will they still have worse outcomes for the money? I think so, and some of that will be hostility.

Not all of it, of course. Many of these patients are disadvantaged in other ways - drug use, domestic violence, etc - all of it leading to a transient life. I'm going to have to control for all these confounder somehow.

I am considering constructing the study as follows: everyone is term, everyone is "low-risk", and everyone has gotten consistent care. Oh, and everyone is on public insurance. Controls will have gotten their prenatal care at our institution; cases will have gotten their prenatal care at a neighborhood clinic (but consistently). Get outcomes/cost both before and after LREMS.

The problem with this is that it makes the study so specific as to be less interesting to the larger world, I think. I don't know.

The other big issue is that our big awesome computer system that can just pull data for you? Is not so big, nor so awesome. I can't get it to pull the data that I need, so I've been doing extremely painful chart review. Thankfully, the charts are all scanned in, so I can do this anywhere, and not in the dank basement of Medical Records, but honestly? Didn't I go to medical school to avoid data entry as a career choice? My brain has melted out through my ears, and I still have gotten very little done.

*Except for overnight call, which lengthens and dilates time as we know it. It's true. Ask Einstein.
**Ha! Little does she know - I can ALWAYS go back to school. MPH, anyone?

Bam!

2010-08-26T17:22:00.001-04:00

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.
----------------------------------------------------------------------------------

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.

______________________________________________________

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.

2010-08-20T16:02:00.001-04:00

I'm on vacation, and using most of my creativity to try (unsuccessfully) write a toast for my sister's wedding. Because she's getting MARRIED!

Anyway. So instead of working and having a lot of new stories to tell you, I spent the morning in a playground with Smoosh putting rocks into toy trucks and taking them out. Then we had a cookie. It was pretty awesome.

--------------------------------------------------------------------------
In other news, I am getting a lot of job-emails from a company called Assurgent Solutions. I know I'm approximately a five-year old in terms of maturity, because my first thought was Ass Urgent? Honestly? And my second thought was that this was spam. But I looked them up, and I think it's a real company.

So my third thought was to tell y'all. (If any of you are from this company, I'm really sorry that I'm so childish. I'm sure that by the time I'm actually on the job market, I'll be able to act more appropriately.)

-------------------------------------------------------------------------------
In other OTHER news, I think I was overdue for a vacation. I was working in triage with a medical student, and she came up to me and said: "I think this patient is going to make you upset." It was a walk-in patient, with a questionable due date, based on a poorly recalled last menstrual period putting her at 28 weeks. But I had the intern scan her (and I then confirmed): oh, she's 37 weeks. She is 16, she knew she was pregnant, she made no effort to get care until 9 pm on a Wednesday night, and yeah, I was upset. But neither the med student nor the patient should know that.

So. Vacation. Hoping to come back, you know, less mean.

Drumroll, please

2010-08-11T19:31:00.003-04:00

Well, I'm glad you enjoyed that. It was nice for me too; welcome to my life.

----------------------------------------------------------------------------
So, of course, this could go any which way.
Answers could be:

1a) You admit the patient, because she's 40+ weeks and something is up. An induction is started, but doesn't get very far; she is sectioned for arrest of descent at 6 cm about 30 hours later. The baby is healthy.

1b) Same as 1a, but the induction goes well, and after 2 cyctotec, the patient is 3 cm dilated. She is started on pitocin, progresses nicely and delivers a healthy 7 lb baby boy less than 24 hours after the induction was begun.

2a) You send the patient home. She re-appears in clinic with blood pressures of 170/90. Aha! Now you have a diagnosis of pre-eclampsia! She is sent to labor and delivery, and is placed on the monitor, where she is noted to be contracting but unfortunately is having repetitive fetal heart rate decelerations with each contraction. Is she abrupting? Maybe. Resuscitation with fluid hydration does not really make the tracing look better, and the patient is not really changing her cervix. Also her liver enzymes are now really high - 120s - and her platelets have started to fall. Shit. This is HELLP syndrome. She is taken to the OR and undergoes an uncomplicated cesearean. The baby is a bit stunned but perks up in the NICU and is in the well-baby nursery by day-of-life 2.

2b) You send the patient home. She re-appears in clinic in labor and with an elevated blood pressure. She comes to labor and delivery, and requires meds for her hypertension, but her labor is now active. She progresses on her own (with a wee bit of oxytocin) and has a vaginal delivery of a vigorous infant.

---------------------------------------------------------------------------------------------
The way you feel about what you chose probably has to do with what happened. But you had to choose before you knew the future. (I didn't even give you any terrible outcomes: maternal seizure, compromised fetus, although those are possible as well. Think about how we would feel if those came to be. Think about making the decision when you know those are possible.)

Medicine without prognostication: difficult.

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

So what really happened? I did send her home, only after I had a long discussion with her offering her an induction. She really didn't want to accept the higher risk of cesearean. (This is a whole topic in itself, because the manner of counselling is, of course, going to influence what the patient chooses.)

After she left, I discussed the case with one of my MFM attendings, who felt uncomfortable with my management; she would have induced her. And she's not wrong - after 40 weeks, the number of things that can go wrong goes up, the number of advantages to staying pregnant goes down. Although I knew this was somewhat subjective, I ended up calling the patient but not being able to reach her.

The patient did come back to clinic about 12h later with very high blood pressures (165/101 in clinic, 150s/90s in triage) the next day, and no labor. Her liver enzymes were very, very high, but her platelets, although lower, were within normal range. She got started on magnesium, and an induction was begun. She reached 4 cm of dilatation, but the fetal heart tracing became non-reassuring, and she was sectioned. The baby is fine.

Something to note: It's arguable that her chance at a vaginal delivery would have been higher with the induction, because the baby would have had a slightly less diseased placenta, and perhaps would have sailed through the labor that it couldn't tolerate a day or so later. Meaning, I could have given her result (1b) instead of (2a).

There is, then, an argument saying that in this situation, I may have increased (or at least, not decreased) her risk of cesarean by sending her home.

But I didn't know she was going to get sick.

So I made the best plan I could.

----------------------------------------------------------------------
Anyway, thanks for playing along. We'll do this again sometime, I think. Comments, as always, welcome.

Choose your own adventure

2010-08-07T23:54:00.004-04:00

I thought I would start a new series of clinical scenarios (either loosely based on something I have dealt with or made up out of whole cloth.) And then you - all of you, clinicians, or not - would tell me what you think I should have done. Or rather, what you would do in the situation.

This is the joy and pain of triage, and this is the way that I think it's scarier than any other part of the labor floor. Because deciding to send someone and their baby home is an act of terrifying confidence, and in some ways, resisting the urge to admit every single patient is either an act of bravery or of denial.

I'll post the "answer" - what I ended up doing, and what ended up happening (with some creative license to protect the innocent, of course) - in a future post.

Let me know if you enjoy this post and if I should do it again.
-----------------------------------------------------------------------------------

So here's the background:

Pre-eclampsia is a bad, bad disease, affecting up to 10% of women, and is more likely in women having their first baby. The diagnosis of pre-eclampsia requires elevated blood pressures (>140/90, on two measurements over 6 hours apart) and protein in the urine, 300mg in a 24 hour collection period. It can affect any organ system, it can cause seizures and strokes and abruptions, and rarely, death of mothers and fetuses.

However, all that being said: Pre-eclampsia is a weird, weird disease. It comes in two official flavors, mild and severe, and then some "not quite pre-eclampsia" flavors (such as gestational hypertension, with elevated blood pressures, but no protein in the urine.) But the truth is that pre-eclampsia can act in any old way. Some people have mildly elevated blood pressures, and nothing else ever happens; some have some warning signs and then eventually (minutes, hours, days, or weeks later) they and their baby get awfully sick, and some people go straight to eclampsia (seizures, brain swelling) without ever having the high blood pressures or protein of pre-eclampsia.

You can see the difficulty, here, and we spend a lot of our time head-scratching over where any particular patient is going to go with her disease.

The only cure is delivery (although some people present with the disease after delivery, and some people have worsening disease for a while after the birth, but let's dispense with that complication for the moment.)

The other thing you have to know is the risk of induction. In a primiparous woman (one having her first baby), induction of labor, especially with an unfavorable cervix, increases the likelihood of c-section, probably to about double what it would have been for the same patient with spontaneous labor.

_____________________________________________________________________

A 29 year old pregnant with her first baby presents to triage at 40 weeks and 2 days of pregnancy (thus, 2 days past her due date). She was called at home because the fetal testing that she is getting - a routine fetal heart tracing and limited ultraound to assess the well-being of the fetus once the gestation goes past 40 weeks - showed a "possible" deceleration, and the person staffing the testing unit didn't catch it until later. The patient was at home, reports normal amounts of fetal movement, no painful contractions or loss of fluid, no vaginal bleeding.

Upon reviewing the chart, you see the following: the patient has had multiple lab visits for "rule out pre-eclampsia". The patient's blood pressures over the last month have been running in the 130s/80s, with one single 130/90 measurement about three weeks ago. This is above her baseline, yes (she was 113/70 at her first trimester visit) but does not technically meet the cut-off for "high blood pressure" She has had a 24 hour urine protein collection 2 weeks ago, which was high at 281 mg, but still technically negative. Her labs have been sent multiple times, looking for other effects of pre-eclampsia - in the blood, in the liver, in the kidneys. The results have all been negative except that her liver enzymes have been slightly elevated (in the 50s and 70s), but this has been true for the last month, and in fact, there are no normal liver enzyme values for her in the computer. She reports no tylenol or alcohol use, no other funny drugs that can cause liver enzymes to rise.

The fetal testing from earlier in the day actually looks really good; the "deceleration" looks like it was a baseline shift after an extended acceleration, and the rest of the fetal monitoring looks gorgeous. The baby is well-grown (about 7 and a half pounds) and has normal fluid.

Today, her blood pressure is 122/78. The fetal monitoring is textbook beautiful, Category 1, reactive. You do a bedside ultrasound, and the baby is dancing in there, with lots of beautiful fluid; she gets all her points within 3 minutes. Her cervical exam is fingertip/long, very unfavorable. Her labs were sent by the day team before you got there: the liver enzymes are still up, but actually slightly improved, at 44/64, and her urinalysis shows negative protein.

The patient really wants to go home. She also really wants to avoid a c-section. She has an OB appointment tomorrow and repeat fetal testing in 2 days.

Do you:

1) Admit her for induction. Yeah, it will increase her risk of c-section, but too bad. She's past her due date - when sometimes weird things happen with placentas, even in normal pregnancies - she already had a sort-of decel with her baby, and something is up in her liver. Her blood pressures aren't quite normal for her, also. I think this is pre-eclampsia brewing, I want to deliver her before she gets sick, and I think the risk of c-section is worth is.

2) Send her home. She never really met criteria for pre-eclampsia - no formal proteinuria, no official blood pressures above 140/90. She came in for fetal testing, and that has been totally reassuring; there's no reason to change the pre-existing plan. The patient is really reliable, and she's really reasonable, but she really wants to wait until her own labor starts if at all possible. Her liver function testing is a bit scary, but goodness, that could be anything - perhaps a liver problem that predates the pregnancy? You plan to send her home, where she'll continue to assess fetal movement, and has close follow up, in 24 and 48 hours. You recommend hepatitis testing and possibly a right upper quadrant ultrasound to check out her liver if she doesn't deliver first.

3) Admit her to antepartum service and have her stay in the hospital. Yeah, you're not quite ready to deliver her but you're not ready to send her home. You want to watch her closely in-house for a little bit and pull your hair out about this. Maybe you'll repeat the 24 hour urine, and if it's positive, you'll call this "atypical pre-eclampsia" and deliver her. And if it's negative? I guess you'll pray that she goes into her own labor before you have to think about that.

___________________________________________________________________
So, what do you do? Please comment - I'm kind of dying to know what you all think.

Bonus question (more for people in the biz, because I cannot equalize the playing field by going through the pros and cons of various gestational ages): what would you have done at 38+ weeks? 37+?

____________________________________________________________

I'm so curious to see if you will find this interesting/accessible/fun/nervewracking. Let me know.

I used to be a gynecologist

2010-08-04T14:39:00.001-04:00

Not long ago, in fact. Many people do not realize that gynecology is an operative discipline. That is, we are surgeons. I was not a natural-born surgeon, but after 3 years of residency, it was sort of beat into me, and by the fourth year I loved it. This, in fact, was a large part of my decision not to proceed directly to a maternal-fetal medicine fellowship. I wanted to operate a little more, to be sure of what I was giving up.

Maternal-fetal medicine doctors do operate, but we perform a much more constrained list of procedures, at least most of the time. We do operative deliveries (vacuum, forceps), c-sections, dilations & curretages, cerclage placements, and the rare cesearean hysterectomy (which strikes fear into any surgeon's heart, as it should, given the general amount of blood loss in these cases.). I've done ovarian surgery during c-sections, rarely, and removed fibroids (rarely), but only in the most dire of circumstances - the ovarian mass looked like cancer, or the fibroid was in a location that made it hard to open or close the uterus. But I don't get to do much of these anymore.

So last week, when a 23 year old at 27 weeks gestation came screaming into triage, yelling "I'm having my baby, I'm having my baby!" but thankfully was not having her baby, we put the ultrasound on her belly, at the site of her pain. And lo and behold, my co-fellow very sagaciously diagnosed her with a large 7cm simple cyst on the left side, likely ovarian, likely twisting and cutting off its blood flow. And this is an indication for immediate surgery, given that the ovary will die if left for too long. In addition to liking to keep all of our organs breathing nicely, it also is unwise to let so much inflammation build up: it can not infrequently lead to pregnancy complications.

So we packed up our lovely patient (now calmer after some morphine) and took her to the OR. She ended up with a large vertical incision, because she weighed 350 pounds, because minimally invasive surgery is not possible when the uterus comes up so high, and because having a short surgical time is less traumatic for the pregnancy. I put my hand through our incision and into her belly, felt for the mass, and gently brought it to the surface. It was a simple cyst, a paratubal cyst, coming off of her tube and not her ovary. The tube was wound about itself 3.5 times, but was still a nice healthy pink color. We untwisted the tube, and gently dissected off the cyst; it was about the size of a large peach. There was almost no blood. We sewed her up, and were closed about 30 minutes after incision time. She went upstairs on some prophylactic indomethacin, to calm any contractions, and is doing well, as is the fetus

Very satisfying.

The one dollar post

2010-07-27T20:33:00.001-04:00

Post Number 100, that is.

Well, this was going to be a navel-gazing (I initially wrote nazel-gaving. I am tired) post about blogging, and why I'm doing it and how I didn't realize how important self-expression and creativity were to me, neglected as they had been for the last 15 years. But also, where do we go from here? and I don't really want to be rich and/or famous but I wouldn't mind writing in a, let's say, more organized or guided fashion. So, not a book, maybe, but perhaps some magazine articles? But it's intimidating because everyone I know has a blog and they're all funny and well written, and so, my goodness, what makes me special, right? Also it looks like publishing, or trying to publish, requires a lot of hustle, the kind where you energetically sell yourself and your work. And that is the kind of thing I am bad at because one, I am congenitally predisposed to self-deprecation and two, I am over-subscribed at my current job.

So.

That leaves us here:

If any of you happen to be famous magazine editors, feel free to let me know.

(There. That was my hustle.)

------------------------------------------------------------------------------------------
Maybe when I'm done with being on service, I'll have the energy to formulate or pursue my literary ambitions in a better way. Right now, I seem to be in a persistent low-energy state, and I'm just treading water until the end of the month. I am sorry - I wish it weren't true - but I cannot wait to be off service, to not be taking care of patients, just for a little, tiny bit. I think I need a little bit more care taken of me, that's the truth, and so taking care of others right now just feels like giving what I don't have.

Anyway, on that note, here's a nice story about why working in hospitals is sometimes good. Surrounding yourself with caregivers is often a pretty bright idea.

---------------------------------------------------------------------------------------------------
I was in the cafeteria, simultaneously talking to the NICU fellow about having to deliver a 25-week pregnancy* while trying to get lunch at 3:30 pm while my pager goes off. I get out my wallet and I'm still talking on the phone, and I'm trying to put the pager away in my white coat pocket, which means there's not enough room for my Snapple, so I pull out the Snapple, and bam! it hits the floor. Glass, iced tea, aspartame everywhere. I apologize profusely, my offer of help is refused, I gather up my sad little lunch, and run away.

It's only when I'm upstairs on the antepartum floor trying to snarf down the rest while talking (now in person) to the NICU fellow and my attending about that 25 week gestation that the wonderful PA notices that I am bleeding, just a small bit, from my ankle. And the wonderful nurse, T, who is a darling and a delight, and who I bother a million times a day (and vice-versa) gets down on her knees to wipe it off with alcohol and put a bandaid on my boo-boo.

And right then, honestly? I could have cried in gratitude.

I didn't though. I did, however, ask T to put a smiley face on my bandaid, because I believe that completes the "all better" cure. (She told me to behave myself.)

*I was OF COURSE NOT discussing any private patient details; mostly whether we we had NICU beds or were on diversion and stuff like that. HIPPAA compliant, yessirree.

That Patient

2010-07-22T21:09:00.001-04:00

Is is just me or are difficult personalities more prevalent in the summer? As in, we get hot, and we get ornery?

I have had a patient on service who does not seem to grasp the significance of her current condition (24+ weeks, uncontrolled blood pressure, I am hanging on by my toenails not to deliver her). She is That Patient, the one where when my pager goes off three times in less than thirty seconds, we all say: Oh. That Patient.

(Sidebar: Well, really, is she 24 weeks? Because she didn't know she was pregnant until 4 days ago, and has no recollection of her last menstrual period. So that gestational age is based on her current estimated fetal weight. Meaning: she might be carrying a chubby 23 weeker. Or a growth-restricted 28 weeker (more likely, given her blood pressure issues). Or an average sized 24 weeker. FYI, this does NOT feel like a great way to make extremely important decisions.)

In any case, she is pretty sick, but always on the phone, and tells me (and it's always me, she won't talk to the resident or the PA, so I'm called to her bedside 2-7 times a day, depending on the orneriness) that her blood pressure would be just FINE if everyone would just stop AGGRAVATING her. And I'm calm, and gentle, but tell her that she really needs to think about how she can keep herself calm, and you know, do some yoga breathing. And that, as I've repeated, I'd really like to maintain her pregnancy to, you know, give her kid a shot at a normal life, but I need a bit more time to do that.

In any case, I came home and told The Bearded Economist that we now have a second child, that she is 33 years old, and that she has some serious behavioral issues.

________________________________________

This is followed, today, by a patient who showed up on the postpartum floor (which is also the antepartum high-risk obstetrics floor, and thus, where I am almost always to be found.) She came to advocate on the part of her friend who was discharged yesterday, and who still has swollen ankles, and thus was clearly sent home in error. She was very, very, very angry. She was very, very, very loud. I should have just hidden in my corner and let the nurse manager deal with this behavior (inappropriate on about three different levels: location, volume, time.) But I spoke up about how the swelling after cesarean sections is pretty normal, about how it takes anywhere from 1-2 weeks to resolve, and that it's not really dangerous unless the patient is having trouble breathing.

Anyway, I think we all see where I should have just kept quiet. I must remember to bring my instinct for self-preservation to work next time.

___________________________________________

And then there's me. I needed Smoosh's record to be sent to another doctor (oh, for such a tiny issue, but after this, there's really no messing with me.) I had requested the record two weeks ago, and had not received it. I called, and oh, there's a delay, the doctor needs to approve it and she is on vacation. And (because there's no messing with me), I just blew up. Those records? Are my property. You? Will fax them over immediately. And I? Will need to speak to your office manager or supervisor if this does not happen before close of business today.

Honestly, I was pretty terrible. I am filled with remorse, and well, satisfaction. Satisfaction, because of course it worked. But also I didn't really increase the good mojo in the universe with that phone call, so I'm remorseful, because now I'm That Patient.

Self-limited

2010-07-18T17:52:00.001-04:00

The moral of this story is:

1) Always wear your pants

2) Never let your spouse leave the state

3) Never buy brand name medications

4) All of the above.

________________________

So, this is how it went down: The Bearded Economist was leaving town for a few days to go to a conference. My mom came in to help on Thursday, although she had to leave 24 hours later, and we had backup babysitters for Friday in case I didn't get home for day-care pickup by 6.

So far all was going well. And then, at 11 a.m. on Friday, I got a call from day-care. Smoosh was running a fever. Of course he was, on the one day where we have no daytime backup plan. I start calling around for sitters, but my attending says: You know what? It's quiet. Go home and be a mom.

You don't have to tell me twice; I ran home and picked up the baby (getting one of my fabulous co-fellows to cover for me on the way, since quiet never lasts.) His temperature was a pretty mild 100.8 when I got him home at 1pm, so I gave him some acetominophen*. I would have given him ibuprofen**- I know most people think it's more effective in fevers in young kids - but we didn't have any in the house, as we had ever-so-responsibly thrown ours out with the big recall a few months ago (and it's odd that we even owned the brand name version, since everything else we own is the down-rent generic version.). Anyway, we never got anymore. Smoosh was doing ok, so I didn't think much of it.

The rest of the day, we had multiple abortive attempts at napping, resulting in tears (mine and his). He cheered up substantially when I stopped trying to get him to actually nap, and at 4, I found myself on our bed with him, chatting and singing "Twinkle Twinkle" ("Winkle, winkle, lidul 'tar.") For some reason, he thought this song was hysterical, and laughed at the end of every line. I guess no one told him it's not a comedy number. We call my parents to say hi, and to check that my mother has gotten back ok; I turn away to hang up the phone, and Smoosh is asleep on my pillow, butt up in the air. Ah, well, I think. He needs it.

I go into the living room to get some stuff ready for dinner. I text the Bearded Economist about the events of the day. As I press send, I hear a cry and a cough; I go to the bedroom, and Smoosh is sitting up, crying, and vomiting all over the bed. Poor child; he gets very upset when he throws up. He feels pretty warm. I pick him up, effectively getting vomit all over myself, and bring us both to the bathroom, where I throw the faucet open, and sit us both in the tub, fully clothed. I start to pull off his clothes, rinsing them in the water, and then hanging them over the edge. I take off my bottoms, too, since they have a slick of white gunk all over them. I step out of the tub and grab a towel. Smoosh is still crying; I pull the slippery baby out of the tub and into my arms.

That's when it happens. His eyes roll back in his head, and his teeth start to chatter and his whole body starts to shake. At first I think he's joking, my funny baby. Then I know what's happening. I know it's a febrile seizure, he's seizing, he's seizing. I run us into the bedroom, with him still wrapped in a towel; I note the time. It's been 30 seconds of seizure, then one minute. I know these things are supposed to be self-limited; I'm trying to be calm. But then he's gray, and his lips are blue and I think: Fuck calm. I run with him to the phone and dial 911. I can't get the phone to work. He's still seizing. I get the phone to work. I tell the lady what's happening. She tells me to put him in recovery position, and I say: I knew that; I'm a doctor. I just forgot, I'm forgetting. He has stopped seizing, two minutes, the seizure is over, but his breathing is still raggedy and irregular and wrong, and he's still gray. He has a pulse. I think he has a pulse.

The ambulance is coming. I somehow get a dress over my head; I think I must have put him down on the bed. I take him to the door; I can hear the sirens; I open the front door and I put a doorstop in so that help can get in. I take him to the living room, put him on the floor, and kneel next to him on the floor, talking to my sweet baby. His breathing is a bit more normal now, but he's not responding to me, his eyes are still rolled up in his head.

The EMTs come, and they take his blood pressure. I notice that the dress I put on is something that is meant to be worn with an under-layer, and I am extremely exposed. I feel stupid that I care. I mess up the baby's birth date, transposing the month and the year; then I realize it's not right and correct myself. No, no medical problems. No history of seizure. No, he didn't bang his head. They are taking his vitals; his oxygenation is normal,, it seems. That's good, he's breathing nicely. I leave him, I run to the bedroom and become frenzied - I put on a tank top under the dress. Then I go to the bathroom. Then I strip the vomit-filled sheets off the bed±. Then I get clothes and shoes for Smoosh,and a toy in case we're in the ED for a long time, because then we'll need it, because he'll get bored and want to play. Because this is self-limited.

"Ma'am?" the EMT says "We have clearance to go." I ask if I can carry the baby, or if they need to put him on the stretcher; they say it's ok if I carry him. I take him to the ambulance, and talk to him about it; he loves ambulances, isn't this exciting? He is beginning to wake up, but only to cry and arch his back; he does not know me.

We get strapped in together, one seatbelt, on the back bench of the ambulance. The EMT asks me if I think he'll be able to put on an oxygen mask, and I say I'll try. Smoosh is screaming, screaming, and I don't care, it's the loveliest sound of breathing, of air moving. I must have called the Bearded Economist and the pediatrician, and I'm fielding calls from them and from my sister but I can't hear anyone over the baby screaming. I ask the Bearded Economist to fly back right now; I don't know what will be: lumbar puncture? Overnight stay? Head CT? Nothing? I tell him I'm ok, but I would like to not be alone. My sister offers to come - she's wonderful - and I keep saying I don't know if I need her, I'll tell her later. By the end of our very, very long rush hour ambulance ride, I sing "Twinkle, twinkle, little..." and he says "'tar". Now that's the loveliest sound. I text the Bearded Economist that we're going to be ok.

We get to the ED. The baby looks too good to go straight to a room, and we are sent out to triage, where his temperature, a full 30 minutes after the seizure, is 103.5. He tries to lie down on the scale, and then he tries to kick the triage nurse, and me. The triage nurse tells me that she'll call me soon, but if anything changes I should come up right away. I say, ok, but can I have some ibuprofen so it doesn't happen again? She give me a syringe full of orange medicine, and tells me to keep him from eating or drinking, in case the doctors want to do procedures. He is still upset, and crying but now asks for milk. I decide that water is ok, and I go buy him a bottle from a vending machine. He is so, so happy to hold the cold bottle, and now allows me to drip the motrin into his mouth. And now he's himself, he's pointing to the kites hung up in the atrium of the lobby and saying "Sky! sky!" and then he falls asleep in my arms, and now I can handle anything, we can be here all night and it doesn't matter.

An hour later, we are seen by a lovely doctor, and my lovely baby so clearly does not have meningitis, and is so clearly the healthiest kid in the room that we are sent home after a full exam with the diagnosis of "viral illness". I text the Bearded Economist; I tell him he can stay at his conference, but he's been stuck on a runway for 2 hours due to weather and can't turn back now. I start walking home with the baby, trying to find a 24 hour pharmacy to buy ibuprofen. Six blocks later, I find an open supermarket with a pharmacy aisle, and pay them enormous amounts of money

We take a cab the rest of the way home. I wash Smoosh's face. We read his favorite book. I give him more tylenol. I say evening prayers with him. He goes to sleep quietly. I go to our bedroom, pack up all the dirty laundry. I don't cry until 24 hours later.

__________________________________________________________________

Epilogue: He's fine. He's really fine. I dosed him with ibuprofen every 6 hours for 36 hours, and he was grumpy but never got above 100.8. The Bearded Economist came home. I, however, am still in recovery.•

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

*Tylenol

**Motrin

± Honestly, this is the part I'm having trouble forgiving myself for. Why did I think the sheets were important? I know I'm being too hard on myself, but I feel terrible about this one detail. Feel free to forgive me if you have it in you; I think it would make me feel better.

•Please don't tell me, as some people have, that it was a less bad experience because I am a doctor and I knew what was going on. Because it was still? Really terrible.

Large print edition

2010-07-13T20:39:00.000-04:00

That prior post was, contrary to popular belief, not brought to you by the bifocal industry. Sorry, people - when I post by email (from work, because blogger is blocked, because they do not agree that blogging is a legitimate work activity. Harrumph!) weird things seem to happen. Like tiny text size, and font changes, and strange paragraph breaks. In any case, I couldn't fix it from work, but now that I'm home, I can't fix it here either. So. Sorry. I am grateful to those who cared enough to get out their magnifying glasses.

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

I'm on service which is usually kah-razy busy, but we currently have this magical mix of a small service (7 patients, only two of whom is truly sick,) and extra providers (me, resident, PA, PA-in-training). It is lovely, I have to say, except for the part where it's July and so I quadruple-check everything. Still, easier to do with 7 patients than with our usual 15 to 25.

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

July is also interview season for MFM fellows. Sadly, I have been busy enough (yes, even with only 7 patients) to not be very involved in meeting these black-suited candidates. I remember back to my interview days for fellowship: I was 38 weeks pregnant, so no black suit. (My fashion philosophy at the time was as follows: shirt is clean + covers belly = professional wear! If I was feeling really fancy, I added a necklace.) When I interviewed at my current program - my first interview of the season - the tour involved a 0.5 mile walk in July midday heat to the other campus of our hospital, during which I began contracting and ordered a "immediate tour sit-down" in the middle of the campus. Everyone complied right away, despite being in their fancy duds, which is one of the nice things about hanging out with obstetricians. And, for extra bonus points, they hauled me up from the ground after I rested.

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

Despite the 7 patients, July is ugly. Lots of call (damn you, other people's vacations.). Lots of scheduling snafus (The Bearded Economist has a business trip). And not so much sleep (Smoosh: please work on that.).
This is all a roundabout way of apologizing for the dearth of posts, as well as their, um, wandering quality. But this one, at least, should be legible.

Disenfranchised

2010-07-09T13:58:00.004-04:00

I'm going to have to write about my research again in a little bit, but I think I was able to winnow down my interest, so that I can articulate it better. I'm interested, I think, in the delivery of care. That is, not the basic science that produces the antibiotic, or the epidemiologic study that establishes its efficacy, but in the interaction where the doctor decides to prescribe it (or not), and the patient decides to take it (or not).

I think an interesting phenomenon we're seeing is the portability of medicine.And what I mean by this is the placement of diagnostic/therapeutic modalities in the hands of the patient, without the necessity of physician or pharmacy input.

For example: can you imagine a time when you had to go to the doctor to figure out if you were pregnant? I can't. We're so comfortable with home diagnosis at this time that reasonably good urine pregnancy tests are sold in dollar stores (I carry 5 in my purse. No, not for personal use. They come in handy in the oddest times, I'll tell you that. For one, it's faster to rule out an ectopic in the ED and get general surgery to fix the true culprit with my $1 pregnancy test than wait for the lab result. For two, I have effectively treated a number of colleague and friend panic attacks with a negative result. Honestly: get some. They are THE accessory to have)

Anyway, here is exhibit A of why I think that this is (mostly) a good trend.

___________________________________________

I'm in triage. It's 11 pm. The intern and I are running ragged, and I ask her if she's had a chance to eat. She says: "Well, no, but that's ok. I can't really eat today anyway, because I had a root canal." Poor child*. She seems to be in a bit of pain, and it turns out that her dentist had put her on antibiotics for a possible abscess. No fancy antibiotics, nothing new, but something she was supposed to pick up before coming to work. "But I couldn't get them." she said. "The pharmacy said they weren't covered, so they couldn't give them to me." Hold up there, pardner, I say. What? Because if the prescription is not valid, that's one thing. But if your insurance won't cover it, they can't withhold if from you. That's just about, well, money. And for an old-school antibiotic like this? It should cost less than 20 bucks. Really, it should.

Her eyes got wide. "Shoot. Really? I feel so stupid." Don't worry, I say. I impersonate a dentist all the time.

The number for a 24-hour pharmacy is by the triage desk, because I have found through much experience that getting patients to go home and stay there correlates highly with their ability to get their meds filled in a timely fashion. I call the number, and say that I'm from Dr. So-and-so's office, and I'd like to call in a prescription for a patient. How much will it be? Fifteen dollars without insurance? And it will be ready in 20 minutes? Great.

I cover triage, and send the intern over 45 minutes later, she's back, medicated, and feeling MUCH much better.**

____________________________________________________________

See what happened here? See how easily even a physician, even someone who had symptoms, someone who wanted to get her medicines filled was dissuaded? And how she didn't even realize WHY?

And, most damagingly, do you see how an attempt to help her ("I don't want you to get stuck with a big bill" - and it is true that for most residents of Large Urban Area, $15 could be extremely hard to come by) became, through the magic of poor communication and overactive bureaucracy, a ridiculous barrier to care? I think that this last one is the most difficult problem that we have in the modern American medical system; it's a systems issue, and it makes me crazy. Safety is important, yes, but putting it all in OUR hands (us being the medical establishment) can infantilize the patients and make it difficult for anyone but the most savvy and sophisticated to actually get anything done for themselves.

I thought of this because there has been a lot of headway in making emergency contraception available without a prescription.That gets a big yay from me. More recently, there have been a few editorials about making the birth control pill an over the counter medication. I have slightly mixed feelings about this. The medication in birth control pills can be less benign in some cases (although the progesterone-only pill has few associated dangers), but overall, the risks are usually much less than th ose associated with an unintended pregnancy. I would vote "aye", in my completely under-qualified way, for the progesterone-only pill going OTC***. For the combined pill, I would be more cautious (the addition of estrogen makes it more dangerous for certain patients), but I enthusiastically applaud any innovative ideas for getting increased access to this contraceptive for a low-risk population.

Of course, there is the other side: the excessive access to information (paging Dr. Google!) which leads to anxiety at the least and unhealthy options at the most. But I still think this is a reasonable idea, and worth, at the very least, some research.

What do you think, fellow colleagues/readers/FDA-employees out there?

*I'm sorry, I know she's a big bad doctor now, but the July interns bring out my maternal side like nothing else. I did refrain from bringing her chicken soup or making her call her mother.

**Yes, I know it's the placebo effect; since the abscess would take a while to respond. Very effective, though! As is feeling like somone cares about your general well-being. Poor interns. It also helped that I snagged some ibuprofen from her from the secret nursing stash. Thank you, noble triage nurses.

***Over-the-counter - as opposed to a prescription med.

Titles are exhausting

2010-07-08T15:57:00.002-04:00

Hi neglected folks.

Sorry about the silence. Busy over here in gravity circus land. Lots of overnight call (2 in 3 days! 5 in 8 days! The awesomeness never ends!), which conspires to give me both too much to say and not enough energy to say it. Then there's the other stuff going on in life, for which there's neither energy nor time, and of course, that's part of the problem too. All of this? Leads to a predominance of subject-less sentence fragments. Very serious condition, you know.

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

What is happening at work? The usual:

* A woman who has a placenta that is honestly trying to kill her. She's not pregnant anymore (unless you count this ongoing three-week third stage of labor) and the delivery went relatively uneventfully, the baby is out, and so far, everybody is doing well. But the placenta is still there, and what do we do now? I have read, I have presented, I have coordinated multi-disciplinary meetings. We are still struggling to make a permanent plan, and taking care of this patient feels a little bit like having a time bomb on your service, ready to go off.

*A patient with a demise who had reassuring fetal testing less than 12 hours before. We are left with the following options for making sense of this: 1) It's our fault, and we missed something on that testing. or 2) What is the point of fetal testing, anyway? (Probably closer to the truth, but leads to such nihilistic anxiety as to cause complete paralysis. Which is a problematic way to practice unless you are willing to deliver everyone at 34 weeks just to avoid anxiety. This is, of course, a whole post to itself.)

*I thought the heat wave would cause a ton of premature contractions in triage. Wrong! You know what we got instead? Dehydration + pregnancy = kidney stones. At least four women admitted, writhing in pain, but not in labor. A fifth woman looked a whole lot like a kidney stone, but none to be seen on imaging and negative urinalysis. I am treating her for her phantom stone anyway cuz you gotta respect that level of pain.

* But you know who's doing well? My patient with HIV (well controlled), chronic hypertension (not so much), heart failure (in between), diabetes (we're trying), and kidney disease (surprisingly a non-issue so far). Yay.

*And let's try to remember the good stuff: I'm going to order Smoosh this for the wedding of one of his favorite aunts and one of his favorite soon-to-be uncles. Congratulations M&J! We are SO bringing the cute.

2010-07-01T22:22:00.004-04:00

I'm sure that if I did a dedicated cataloguing of my blog, it would look like this:

a) I love my job! Yay! Who has a cooler job than me? Nobody, that's who!
b) Something bad happened. Sad. Job is sad.
c) I think I hate my job.
d) I am so tired and want to sleep for a year. I need a break from my job. Like, several months break from my job.
a) Oh wait, I love my job.

It probably usually goes a-b-c-d-a (love-bad-hate-tired-love), but I am sure that I can also spend a few weeks in depressive mode, thus: a-b-c-d-c-d-c-d-e (love-bad-hate-tired-hate-SO TIRED-love). I could actually go read my archives instead of just guessing, but I'm too deep in "d" to even contemplate doing so.

____________________________________________

It's July 1. Technically, I'm a second year fellow, but I'm starting out the year on a very heavily clinical (read: time-consuming) rotation, so it feels like remedial first year. It's that time of year, the medical New Year; July 1 has come and gone, and now we have new rising second year residents on my service, and even newer (like, fresh-out-of-the-box new) interns everywhere. This means that I check everything, and then check everything again, and then just in case, I check again. In turn, my attending is checking me. So yes, because everyone asks: yes, you're safe if you decide to have a baby/pregnancy complication/triage visit in July. I'm going to be honest: it's wiping me out. But hey, you're welcome.

____________________________________________

The truth is, these new doctors and medical students? They're new and they're scared, but they are so gosh-darn energetic. And excited to be here. Wow! So, that's kind of awesome, as the rest of us drag our sorry carcasses around. Also: they are very easy to both impress and to rescue, so there's just generally good energy wafting about. So that's nice.

______________________________________________

This post is a bit of a wanderer. Can I end with some randomness? It's not medical, and it's not obstetric, but this person? Is totally winning the internet. She made me laugh out loud - in a public, socially unacceptable way - multiple times, and that, I think, is always worth sharing.

The head bonk is what led me to refer to myself in the plural nominative case of the pronoun of the first person

2010-06-28T15:49:00.001-04:00

I'm not sure if this story will make you a) feel sorry for me or b) hate all Western medicine or c) both. I'm basically feeling (c) right now.

It's connected to the whole No/Yes idea, and all its attendant craziness.
---------------------------------------------------------------------------------------------

As follows:

Patient X is pregnant, and thus at higher risk for the formation of abnormal clots.* Patient X presents to triage with asymmetrical leg swelling.

In med school, we're taught that asymmetrical leg swelling is a pretty common way to present with a deep venous thrombosis (DVT). And if she has a DVT, a clot in her leg, it potentially break free and travel to her lung, and become life-threatening. That is scary.

We wisely decide to examine the patient. And it turns out that yes, her right leg is slightly more swollen than her left. But both her legs are pretty swollen, because she's 36 weeks pregnant and it's summer. There's no redness to the skin, no painful firm cord under the skin to suggest a blocked vein, and no tenderness to the back of the calf, all signs we look for when we are diagnosing a deep venous thrombosis of the leg. She is breathing fine, denies chest symptoms, and has perfect oxygen saturation on the monitor.

All that is very reassuring, yet here Patient X is, and we, knowing that physical exam is woefully inadequate for making or ruling out this very scary diagnosis, decide to get a low-risk test: ultrasound doppler studies of the lower leg (or what I used to call LENI's.)

So, we call the vascular lab, because after 10 months of this triage business, we know that they close early. It's 4:15pm, and a very cheerful man on the other end of the line says: "Sure! We'll do it soon. I'll call for her in just a bit."

We go about our business. We see other patients. We notice it's close to 5:30; hmm. Doesn't vascular lab close around now-ish?

We call. No answer. We call again, in between patients. No answer.

It's now 7. We've cleared out the other patients in triage. Patient X is waiting very patiently, now joined by her husband (since it's after work) and their three year old daughter (who is extremely well-behaved). Hey, we notice: Didn't we call for that study almost three hours ago? Still no answer when we call the vascular lab, so we decide to go down to the second floor and find out what the deal is. Maybe their phone is off the hook?

Nope. Second floor is a ghost town. Lights off, nobody home, vascular lab locked. They left. We curse, kick the wall, and have a long and yet unhelpful talk with the radiology supervisor.

And then we have to decide what to do. We have the following conversation with ourselves:

Reassured C: On the one hand, Patient X looks really good. Really, she does. Can't she just go home?

Cautious C: Well, she does have the asymmetric swelling; that's not really normal. And a DVT is potentially life-threatening, so let's not mess around.

RC: Fine, we'll make her an appointment for lower-extremity dopplers tomorrow.

CC: Ha! Oh, you optimist, RC. Not so fast; that study is not available in a 24 hour period to outpatients. She'll have to be admitted if you want it done sooner than a week.

RC: Yeah, we should have it sooner than a week. Yeah, I guess I'll admit her. Oh, her three year old is going to be so sad!

CC: True. But. Well. See? Um. If we're admitting her for the suspicion of a DVT, and that DVT is something from which she could potentially DIE, shouldn't we just, you know, treat her? Just one little shot of blood-thinner to hold her until the a.m.?

RC: So, let me get this straight: because vascular lab didn't do the study at 4:15, now I have to a) admit this patient b) get dopplers in the morning and c) give her an injection of blood thinner c) separate her from her family for a night and d) spend lots of money.

CC: Yes.

RC: *Head bonk**

_________________________________________________

This was more meant to be illustrative of how doctors think than anything else. And also of the law of unintended consequences, as true in medicine as anywhere else. Thus, because of the unavailability of a timely non-invasive test, the patient was committed to a much more disruptive and aggressive (although overall relatively benign) course of action.

Well, I'd love it if this provoked discussion but I'd really prefer for it to be of the constructive kind, not the "C, why do you torture pregnant ladies and their three-year-old daughters?" kind.

*Would you like a reference? Here ya go: Ray JG, Chan WS, Chan WS, Ray JG. Deep vein thrombosis during pregnancy and the puerperium: a meta-analysis of the period of risk and the leg of presentation low molecular weight heparin use during pregnancy: issues of safety and practicality. Obstet Gynecol Surv. 1999;54:265-271. No problem. Isn't it funny when I use footnotes for their intended purpose?

Badass obstetrics

2010-06-22T21:47:00.001-04:00

I talk all the time about how I really need more exposure to two particular obstetric skills: forceps deliveries and breech vaginal deliveries. In some regions, these skills are still in full force, but in mine, forceps have been largely displaced by vacuums, and a vaginal breech delivery is only offered for a second twin. You can see how that second situation especially - vertex/breech twins of approximately equal size, being born to a patient who wants to try a vaginal delivery - might be hard to come by. I stalk opportunities to learn these skills, but so far this year, have been entirely foiled.

But this week the stars aligned, the karma was good, and the deity of your choice smiled upon me, because within the last three days I've gotten to do one of each of these procedures. Both were indicated, both were the best choice for the patient in question, both were well-supervised, both went extremely well, and both were SO SO SO FUN that I am still smiling. I did the breech vaginal delivery in my black wedge heels (covered in surgical booties) because I had come to work in clinic clothes and without extra shoes, but there was simply NO WAY I was going to let the third year resident take my case.

It was AMAZING. Or, as one of the chief residents said: That is some badass obstetrics*.

*This is a phrase that's not really going to take off. I know that. Just humor me for this post, ok? Thanks.

No more mixed media for me, no sir.

2010-06-21T21:27:00.004-04:00

OK, this is what I meant to say:

Doctors can eventually become people who think of bad outcomes on a continuum of preventability and predictability. Thus, the worst outcome is not a death. It's a preventable death. The worst sickness is not cancer; it's foreseeable, predictable, preventable cancer.

Patients, interestingly, do not always think this way.

It's not wrong to think that way, mostly. It means that you're focused on action. "What can I do about what's going on here?", not just "what's going on here?" It means that you have a feeling of agency, and of urgency, and of ability to do something to prevent the bad thing.

But it also can mean that we're bad at saying "I'm sorry for your loss." Or "I'm sorry that happened." We say: "I did the best I could with the information I had at the time," which doesn't sound like sorry at all.

So what I wanted to draw in the last post was a visual continuum of badness for doctors: what's worse than this? what's worse than that? And we all have the personal continuum of badness for ourselves - what can I tolerate? what can't I? - and I wanted us to compare that personal one to the prototypical doctor one. There would have been similarities but also differences in what we can and cannot each bear in our different roles. And then we could have talked about it.

That would have been nice.

But that is not what I said/expressed/drew in Powerpoint. Ah, well. So much for experimentation.

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

Speaking of experimentation, though, this is actually quite relevant to some of my other research. (Nice segue, huh?) I'm doing some work in the apparently non-scientific field of "Breaking Bad News". Such a funny name, really - BBN for short - for what's become a pretty methodical way of teaching doctors how to address patients with adverse events. It covers informing a patient of a difficult diagnosis, or a terrible outcome.

Overall, we're trying to be better at breaking news, and bad news especially, and to that end we're going to do some simulations where we communicate with actors and see how it goes. And then because nothing in medicine truly happens unless someone measures it, I'm going to study how doctors function in terms of their communication skills before and after a BBN simulation, and also how they feel about their communication. Because honestly? There are studies showing how stressful this is to do, to tell patients terrible things, and that's why a lot of doctors are bad at it, and it's why a suprising number of doctors burn out.

Anyway, the idea is that one day we will better know how to teach people how to say: "I'm sorry", without saying "It's my fault". Or "I'm so sorry for your loss" instead of "I did the best I could with the information I had at hand".

Anonymice

2010-06-19T23:34:00.005-04:00

Isn't that the plural of anonymous?

Man, I slay me

Bad jokes aside, thanks to all of you anonymous ones, for reading and, more to the point, commenting.

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

I made this visual about three months ago; I was trying to write a post about fault in medicine, and how what doctors feel bad about (preventable, foreseeable badness) is not always related to the severity of outcome. I ended up with this, instead of words. (Please excuse any weirdness in formatting; I had to do some strange things to get Blogger to accept these images. Zamzar, anyone?) If you're having trouble seeing the boxes, click on the images, and a larger version should open in a new window (I think. Man, I need tech support if I'm going to do anything more complicated than type.)

It's clearly subjective, and looking at it now, I think I would make it more clear and consistent. And change some of the order. And I would add more (maternal vs fetal adverse outcomes; an image with a scale of patient-perceived outcomes.) But the computer stuff has been a huge pain in the arse, so I'm leaving it as is. Based on this experience and the slightly wonky outcome, I also think I will not switch to the visual arts anytime soon.

But I was wondering what you think.

Shameful confessions

2010-06-17T20:45:00.002-04:00

One of my friends calls this blog "GC" for short. And? I hate it because in my professional world, "GC" stands for gonoccocus. Like, the bacteria that causes gonorrhea. So, ew. I haven't told this friend, except, of course, I just did.
I call a lot of my patients sweetie. Sometimes (even) Mama. Do they hate me? Am I being condescending? I'm really only loving/dotty/forgetful, and I always resolve to be more careful. Immediately following that resolution, I am loving/dotty/forgetful all over again. Shoot.
I am so ridiculously grateful to only have one scheduled c-section tomorrow that it's a little embarrassing
I hate postpartum rounding. Love the patients, hate the rounding. Why? Don't know. But I do.
I spend altogether too long last week helping a postpartum patient with her latch. Look at me, one baby and I think I'm a lactation consultant. Also, that was five minutes out of postpartum rounding.
I routinely get diet soda all over my patient papers. Don't judge.
I routinely have coffee on my white coat hours before I get to see my first patient.
I hate wearing my white coat, but it has pockets so if I'm wearing a dress, I'm compelled. Otherwise, where do you put your pager?
I've tried putting my pager other places besides my waistband. Like clipping it to the top of my boot, or my bra strap. I have not yet done the grandma-storage-in-the-bra thing, but the time may come; I'm not proud.
I have mild social anxiety about sleeping in the call room.
I have only been able to shower in the hospital call-room shower in the event of a major exposure. Otherwise, it totally freaks me out.
I really like sewing incisions closed. I always pretend to offer to do it so that the resident can unscrub and get cooking on the paperwork, but really? I just dig it.
I check how many readers have visited this blog way, way, WAY too often.

2010-06-13T22:18:00.002-04:00

This all happened a while ago, and since mamadoc asked, I'll tell you that all of the patients I based this vignette on eventually did quite well and went home. One of the amazing things about OB is the resilience of the young, healthy human body. Something I say very often when taking care of someone sick (mostly because I find it reassuring to myself, although I say it to my residents and nurses as well): If we can just keep her from dying, she will get better so quickly and so completely that it will be hard to believe.

Usually that's true.

Chaya got it exactly right. In fact, my essay in my fellowship application was about how I wanted to either become a clergyperson, a novelist, or a doctor, and MFM is how I think I can do all three (or two, some of the time, and the third occasionally). It was what my dad would call a fruity* essay, of course, and as such, led to some interesting conversations during interview season. Anyway, my point here was that yes, I enjoy being with people during these terrible times; not because it's fun, of course, but because it's fulfilling, and because I think I'm good at it.

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

Which means I'm always completely unprepared for the next day, when the patient or her husband angrily asks me why we didn't resuscitate the baby, and I feel as if I was kicked in the gut. It's not the questions I'm surprised by, but the anger always blindsides me, even after all this time. Didn't I explain all this, multiple times? Didn't I work hard to give her a healing kind of birth? But, of course, none of this is about me, and I go down to the ICU to talk again.

This pre-viable discussion is a difficult one. In the earnestness of the moment, I ended up telling her that the baby didn't have lungs - like a fish, I said, an aquatic creature not ready to live here with us. I could have called for doctors to give oxygen and medication, but it just wouldn't have helped, do you see?

But my mer-baby model isn't scientifically accurate, really, although it worked for this patient. It's misleading, perhaps. And though well meant, someone in pain at the loss of their child may find this comparison dismissive or demeaning. Does anyone else have a better metaphor for discussing the previable stage of life?

*Not fruity like homosexual. Fruity, as in: why is there no quantitative data in this essay? Thus, an adjective in the vernacular referring to anything subjective and/or artistic.

Yeah. Don't read this one if you are pregnant, anxious, or anxious about being pregnant.

2010-06-10T22:20:00.010-04:00

Do you like the new design? I'm not sure I totally love it, but it was fun to play around with colors and fonts. Much easier than, say, writing.

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

Thank you, Kate and Chaya for your emails. I always appreciate writing ideas; I hope to get to yours soon. And Chaya - don't worry! I really don't think it's you that's messing up my stats and I appreciate your loyal readership.

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

Patient in the SICU, very ill, 18 weeks pregnant. We are in the midst of trying to decide whether her pregnancy is the source of her infection, when she breaks her water and that decides for us. The pregnancy is, at this point, clearly the source of her sepsis. She needs to be delivered. But she is too sick to be moved out of the ICU; we will induce her here. The ICU is, to put it mildly, freaked out by the thought of delivering this pregnancy here. (I have always found this terror so strange and almost humorous - people routinely die on this unit; why is this what puts them over the edge? But we're all scared of what we don't do.)

"What will we do with the baby?", one nurse asks. "The baby is either dead or going to die." I said. "I will wrap it up and we will grieve." I think I spoke too sharply, or this was too much for her to bear, because her face crumples.

I run upstairs, foolishly in street clothes, and change into scrubs. The nurse manager loads me up with everything I need to be a roving obstetrical unit: medications to induce labor, medications to stop bleeding, delivery instruments, drapes, paperwork. She'll send down a nurse in an hour when she has someone coming in.

I go back downstairs, forgetting to take a cart, and so balancing the metal instruments on top of the draping kit, with the tiny infant hat and blanket above it all; medications in packets and sterile gloves and death certificate papers weighing down my various pockets. I get back to the ICU and start to prepare to place cytotec*, but the patient has become extremely uncomfortable while I was gone. I call for morphine, do a quick exam, and find that she's 4 centimeters dilated; at 18 weeks, she probably does not need much more before the pregnancy will come. Her husband, who I've talked to over the phone, has made it in; he looks young and sleepy; I send him to the head of the bed to hold her hand. I ask the patient if she wants morphine - it may make her sleepy, she may remember less - and she does, so we give it. I have explained to her, to him, that the baby may show signs of life, but at this age, it is not able to stay in this world for long.

Less than 10 minutes later, she feels the urge to bear down, and does so; a small fetus, together with placenta delivers, all at once, onto the clean sheets I've brought. The fetus looks raw, as they do, with skin too thin to really hide the blood vessels underneath; he is silky, and small, and a bit alien, with eyes that are fused close and a head that is too large. Because of course, it didn't have time to grow into its body. There's no heartbeat at delivery, and the baby looks bruised; I think there probably has been no heartbeat for several hours now.

After cutting the cord, I announce this in a loud voice, I say: the baby's heart is not beating. I want the parents to know what to expect. I show them the baby, and then say: I'm just going to take him over and get him ready for you. I clean him off, and put on a hat, and wrap him up. I'm trying to make him look more like a baby, like something they can recognize, like he didn't have a rough entrance into this world as he exited from it.

I ask the patient if she'd like to hold the baby, and she says yes. I hand him over, and busy myself with other things.The ICU nurse draws up the oxytocin I brought. There's very little bleeding. Fifteen minutes later, the father calls me: I saw the baby move! I think his heart is beating. I very carefully unwrap the baby in the father's arms, and look at the body with the father. I feel the umbilical cord again for a heartbeat, though it would be impossible. I touch the tiny chest for a flutter, and feel nothing. I tell the father what I am doing, show him what I am feeling. "I'm sorry, sir." Then as I hand the baby back to the father, I notice; the father's hands are shaking, and it makes it look, just a bit, like the baby has a beating heart.

*a medication that can be used to induce labor

Left-handed

2010-06-06T12:39:00.001-04:00

I am, you know. Just like certain compliments.

____________________

Someone pointed out to me that if your new baby is not wearing definitively gendered clothes, the most common comment you will get is: "Look at that baby! So....alert!" Thus, you see, avoiding the boy/girl pitfalls.

In a similar vein, by far the most popular comment I get from people who know me in real life is this:"Your blog! It sounds just like...you!".

Like those baby parents, I just say: "Thanks!"

_______________________

I took care of a patient who was scheduled for c-section on Friday. She had three vaginal deliveries, and then a c-section, and now presented for her second c-section. No, she doesn't want her tubes tied. Yes, she might want more kids.

So, I asked: why not VBAC?

Hemming and hawing ensued. I'm not sure, I was going to, but then the doctor felt that it was too soon and my risk of rupture would increase.

So here's the thing: she had a very short inter-pregnancy interval (she has a 17 month-old toddler at home), and in some studies that increases her rate of uterine rupture*. But she also has had successful vaginal deliveries before, and that significantly decreases her risk of rupture.

So I hauled myself and my med student over to the computer, and we looked up some data; one study (retrospective, flawed, but large) had some data on inter-pregnancy intervals of less than 6 months** with increased rupture rate, but the population with an interval greater than that had no increased risk.

I came back to the room to find the patient with her legs butterflied open, and the nurse prepping to put in the foley catheter***. Whoa, there. I said. Hold up. Did we make a decision? Her husband just had his head in his hands, sighing deeply. The patient herself said: "Well, I thought. Since I'm already here, and we have a babysitter, that we would just go ahead."

So I said: "Listen. This is not my baby and this is not my body. Based on the research I have just done with my fabulous medical student, I think your risk of uterine rupture is about the same, or better, than other VBAC candidates; usually a bit less than 1%. And if you told me that this 1% made you too nervous to labor, then so be it. But are we honestly going to do major abdominal surgery on you because it's more convenient? Because it seems to me that you need to think a bit farther ahead. For one, the recovery will be far less convenient, especially when you go home with your newborn and your 17-month old.And for two, your future pregnancies may be riskier as well. But it is, as always, your choice."

The nurse was still standing at the foot of the bed with the foley catheter tip waving in the breeze. "Oh, sweetie." she said "Don't be a fool."

The patient started laughing. I started laughing.

I said: "I didn't say that, but maybe take some time to think about this."

The nurse and I de-gloved and left the room. I went to see some other patients, and got beeped 4 minutes later - the c-section patient was dressed and wanted to leave.

"OK." I said. "Wow, she sure makes her decisions fast." I stopped by and I offered to reschedule her section for 41+ weeks, in case she wanted to have a back-up plan^, but she said no. She makes her decisions fast and final.

________________________________

This was going to be long and learned discussion of counselling and how it can change outcomes - the initial doctor counselled in such a way that the patient felt that VBAC was not a reasonable choice; I counselled differently (and, I worry sometimes, too aggressively, because I do really think it's her better option); and the nurse counselled, well, very honestly. But I'm just going to leave it as a funny story.

*The most feared complication of VBAC, which is an opening of the uterus at the site of previous incision, with a small chance of catastrophic consequences for both mom and baby.

**This was actually deeply confusing, because most inter-pregnancy intervals are discussed as conception-to-conception intervals. Which would make this patient's inter-pregnancy interval 17 months. However, this study, although never overtly stating so, clearly was using delivery-to-conception interval, because otherwise how would you get less than six months, given that people are unlikely to start a second pregnancy while still gestating the first one? So, if calculating delivery-to-conception, then this patient has an 8 month inter-pregnancy interval. In any case, this nomenclature led to some silly discussions, then clarification, and now we may all proceed, with the understanding that precise language is VERY important. The End.

***Placed in the patient's bladder, to prepare for surgery.

^Induction of labor in a patient with a prior c-section is a whole 'nother long discussion, and would have depended a lot on the state of her cervix at the time.

My feets hurt

2010-06-02T21:12:00.003-04:00

Yesterday, while walking from one hospital to the other, I got caught in a summer downpour, something like being in a carwash without the car. Then I couldn't get the scrub machine to give me dry clothes, so I ended up in the bathroom with a borrowed blowdryer down my shirt. Then I worked damply for the rest of the afternoon, including 25 minutes of earnest discussion with my patient who is 33 weeks pregnant with pyelonephritis* about why I strongly recommend that she stay in the hospital even though we have only three television channels**.Then I got stuck in rain-related traffic that was so bad that I had to wait almost 10 minutes just to pull out of my parking spot. Then Smoosh felt violently opposed to bedtime (it has always been TWO books, now all of a sudden he's shocked and appalled after the second) and decided to revisit the issue at 2 a.m.

Maybe that explains my malaise? Because it's 9 pm and I'm seriously considering going to bed.

*Kidney infection; these are common in pregnancy and can be quite serious.
**FYI, none of these rank as "premium". Horrors.

Working 9-to-5

2010-05-29T22:53:00.002-04:00

Yes, yes, an automatic coffee pot. Why must you all be so very reasonable? You're right and we probably should get one, but then we have to own coffee and milk and sugar in a reliable fashion, and many of you have already noticed, this is precisely the kind of grown-up, house-aware activity that I both loathe and am terrible at. But I think mamadoc is right; the day where I will give in and get one draws nigh. Because one day, I won't be able to get dressed before coffee fortification, and then I will be in a pickle indeed.

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

To theknittingbea: I have to be honest with you. There are really two reasons I check on patients the next day. One is because I'm worried about them - I care, I absolutely do. But really, the second reason is usually by far more compelling: I'm worried about me. On a medical level, of course: did I do the right thing? Should I have offered that diabetic a cesarean section? Did I watch that deceleration for too long? But also - and here's the terrible part - for medico-legal reasons. Did that baby turn out ok? Am I going to get in trouble? And was I right? (I hate being wrong.)

Not so noble.

---------------------------------------------------
Dr. Whoo brings up another point over which I have been brooding for a while, about how hard and how long we work and the rewards thereof. Now, I've never really had to consistently work a full day post-call; I've done it here and there, and I really hated it, but it's never been an expectation anywhere that I have been employed. So I know it can be worse; I know that I should be grateful for the schedule that I have. But I can't seem to muster that gratitude anymore.

Some of it is that it's been a really long first year of fellowship (combined with second year of parenthood); a year that my family has given up a lot for me to participate in (a move, changing jobs, smaller apartment, distance from family), and I guess I'm tired of asking them to keep giving. Some of it is that there's a lack of control over my schedule that comes from being a fellow that makes me bat-ape* crazy; the lack of advance notice or more general suffrage in this system compounds the insult of whatever hours I'm supposed to work. This week, I finally said to myself: Maybe I need a 9 to 5 job. No nights. No weekends. Just...normal.

This dissatisfaction is not just me, although I seem to be exhibiting a particularly lethargic form of it at the moment. Some of it is a result of the sea change that has happened over the last decade or so; residents now legally have work-hour restrictions. The restrictions are not particularly family-friendly - 80 hours a week is, as I point out altogether too often, five 12-hour days during the week plus a 24 hour shift on the weekend EVERY week - but they are enforced, and this is a huge change. I trained as work-hours were being implemented, and I was by no means in compliance for much of my residency (GYN-oncology pre-rounding at 3:45 a.m., anyone?) but the fact that resident time was valued and counted was different. Now this culture of work-hour restriction is much more enforced, for good and for bad. And the expectations it created extend into post-training life, as most of us are unwilling to work more when we graduate.

First the good of this system: it's good to sleep after working for 24 hours. But it's not for the doctor's benefit that we do this, but rather the patient's. It's good not to have a doctor who has been on call for 35 hours starting your surgery. This is true instinctively as well as data-proven by multiple frightening studies on sleep deprivation and decision-making. It's good to have a doctor who isn't supposed to be anywhere else, and who is fully engaged with the patient in front of them. As a doctor, it's good to feel like you have rights as a medical trainee, and it's good to have some time in your life to do laundry and kiss your wife and buy apples at the grocery store (although, again, 80 hours a week means so very limited apple-buying time).

So what's the bad? The bad from the patient perspective is two-fold: One, the idea of "my doctor" is to some extent, a thing of the past. You may have a team with some consistency, and you may have more doctor availability as someone is always responsible for taking calls, but you won't reach your particular doctor. Two, all changes of shift have some built-in inefficiency. The time spent telling each other about patients is not spent taking care of patients. The more times a day, a week, a year we change off, the more time it takes, and the more error enters the process. (For example: "I knew she had a bad reaction to aspirin, but I forgot to put it on the signout list. The next doctor wrote an order in the middle of the night, and she got sick". Like that.)

And what's the bad for doctors? Well, I think it's complicated. I didn't like working 80 hours a week, and I absolutely refuse to work a whole day post call. With all respect to Dr. Whoo, I have been known to call that practice "in defiance of the Geneva Convention"; I am, in this case, only mostly joking.

But I wonder if there some level of delegation that occurs, by which we hand off so much patient care, as to mean that we no longer feel invested, or feel like it's my problem. I hear this concern a lot from older attendings who trained in the era when "house staff" meant that you actually lived in the hospital, who feel that professionalism has crept away, and that we're all shift workers now without any sense of responsibility or any knowledge of "the whole patient".

I don't think that's fair; nostalgia is evident, I think, in that these attendings are forgetting how much hostility and absent-mindedness they probably brought to their work during this time of deprivation. And more tellingly, I see a tremendous devotion to professionalism and patient care on the part of my resident trainees, children of work-hour restrictions though they are. But there is a germ of truth there, I think; the less you give, the less you get.

One example I have (purely anecdotal) is that I personally know three doctors who are really disillusioned with medicine, and they are all Emergency Medicine doctors. Now their shared discipline may be cause, or it may be effect, but I think something about their work -shift work, great intensity but also great anonymity from the patient perspective, lack of continuity of care for the same patient - leads to some serious burnout. I think the thought process they end up with on their way in to the hospital goes like this: they need someone today. But why does it have to be me?

Another less anecdotal piece of information I saw related to physician choices. One was that physicians are generally working fewer hours than 20 years ago, and are getting paid less; that's a choice that we are almost universally making in all regions of the country. But I also saw another study, addressing the lack of primary care doctors. It turns out it's not a supply-demand issue; when some communities tried to attract more primary care doctors by paying more, many of the doctors were happy to work fewer hours and stay at their old salary; and of course, this didn't solve the problem.

So it's not just economics; it's not just money. We seem as a profession, I think, to be a bit tired. We are more and more choosing time away from the hospital and the office, as much time as we can get, and not enjoying the time we spend there, shorter though it is.

My point here is this: I seem to be a bit burnt out. I seem to not be appreciating how good I have it, but more focused on how good I don't have it. I am not, in my essence, a lazy person; I've also had a tremendous work ethic beat into me by residency, so my current state of mind is making me feel terrible and guilty and self-absorbed.

I also seem to not be alone in feeling this way.

I can't solve this problem on a nationwide level. And really, there's not much I can do about the hours I work, even for myself (see lack of control over my schedule, above). But I've been trying to make it feel less bad. I've started doing that, a little bit - when I see a truly sick patient in clinic, I've become more likely to give them my pager number. I was worried, a bit, that my patients would abuse this number but actually, it's been kind of nice. We all know that clinic can be tough, and instead of resigning myself - and the patient - to the frustration of it, I found that if I give out my number (with the caveat that I won't respond on weekends or after 10), I can sometimes make plans with the patient that are far more successful, functional, and well, appreciated. And so even though it's a bit more work, it's less draining.

I can't make it a 9-to-5 job. I guess I want to make myself not want one anymore.

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

Of course, you know, that I would probably hate a regular job. I had a more regular job, and I left it to become a fellow, adrenaline junkie that I am. So I would hate a 9-to-5 job. I think.

*I am aware that this is not English. Anyone else want to share their favorite non-profanity profanity? The irony is that in real life, I swear like a sailor, but somehow being in print on the interwebs makes me shy and Victorian-like.

The Basic Coffee Paradox

2010-05-27T20:37:00.001-04:00

As there are more of you, and as it becomes more real to me that this is, in fact, a public forum (filled with live people as well as robots), I think I've become less honest in my writing. More sunny, I guess, or more public-relations-aware, more self-conscious.

Do you think so? In any case, I will try to bring myself back a little bit; not necessarily today but more generally.

----------------------------------------------------------
The issues about posting after a crazy night on call:
1) I have almost too much to say. Where do I start?
2) It's very recent, and I like to have some time before I post to help increase anonymity for patients (although I do change - or invent - most details, I think a time lag helps)
3) I"m really, really tired.

---------------------------------------------------------
The post-call day is supposed to be a sleeping day. But of course - of course! - it's not. Because there are several problems with coming home after a night on call and actually sleeping the whole day, One: You are unlikely to fall asleep that night, leading to a rest-of-the-week that is full of insomnia and serious psychic pain. Two: when else would I go to the drugstore/haircut/bank/doctor/eyebrow lady? Exactly.

So I come home in a bedraggled state, smoosh The Smoosh, send him off to daycare and fall asleep for somewhere between 1-3 hours. I then wake up (even if I haven't set an alarm; day sleeping is not my forte), and wander the house in a bleary state of optimism tempered by vague nausea. That is, I walk around with one sock on and halfway dressed, sure that at any minute, I'll start to accomplish productive things, but right this moment, I need to sit down and eat some sorbet.*

Eventually I work my way up to checking my email, reading the paper online, and obsessively looking up some of the patients I took care of the previous night** before I finally get dressed and leave the house in search of coffee. You may ask: Why, C, do you not just make coffee in your own home? The answer, dear reader, is the Great Basic Coffee Paradox - before I have my coffee, I am too exhausted and incoherent to make my coffee. How other people overcome this, I have no idea.. Myself, I have no choice but to outsource the first caffeine production of the day.

I never really drank a ton of alcohol in college (or any other time) but I'm pretty sure that this is what a day with a hangover would look and feel like. I think I might be too old to be doing this once a week.

*Mango or peach.
**I need to stop doing this. I do, and we all know why. But it's really hard not to find out what happened, partially because I care about them, and partially because I want to know if I made the right decisions for them. The suspense is killing for me.
.

The Oscar goes to the lady in labor room four

2010-05-25T16:08:00.001-04:00

Much of medical education is moving towards simulation in order to transmit skills. This move is happening in part to ensure better patient care (you "practice" first in a simulation, instead of on patients!); but it's also a good way to learn skills that don't come up that often but are still important.

To that end, I spent most of last Tuesday seizing in a bed. That is, I was the eclamptic patient (a walk-in with no records with her, naturally) that the residents then had to respond to. Of course, we couldn't make it easy, so there was an eclamptic seizure, followed by a post-ictal* state, followed by a long fetal heart rate deceleration, followed by delivery**, followed by magnesium toxicity. And THEN they were done.

I played the seizing patient for most of the morning, but then switched to being the "new nurse" for the rest of the day. The "new nurse" is supposed to particularly unhelpful: she doesn't know dosages, or how to mix up the meds, or how to call for help ("Exactly who do you want me to call, doctor?") We play the character like this - a complete reversal of the very fast and smart nurses we are lucky enough to work with in real life - because we are trying to teach the residents to think through every step, even if it's just to make sure that it was done.

My acting as the patient, I was told, was not dramatic enough. Well, it's exhausting to seize all day, so by the third session, my eclampsia became more toned down, and then sort of just twitchy. My post-ictal state wasn't combative - I could have challenged them by pulling out all my IVs and being aggressive, but I mostly lay in the bed and groaned.

However, the "new nurse", in addition to requiring very clear instructions, is also supposed to inject a note of hysteria into the proceedings. I think that I was extra dramatic at that.

In any case, this all pertains to some other research I'm doing, but I'll tell you more about that another time.

*A period of 30 minutes or so after a seizure where most people are still quite out of it.

**THIS was interesting. Everyone but one person cut me - that is, went very quickly to cesearean section. It's freaky to have someone sieze, I know, but people - that's not an indication for cesearean. Doctor, I was in labor! I was 5 centimeters! To the one doctor who held off: Thank you. I really appreciated my vaginal delivery

staples != so bad

2010-05-21T20:12:00.002-04:00

In Stata* language, that != means "does not equal".

Alternatively, you can write "~=" - it means the same thing - but in class we all agreed that the tilde made this expression feel like it should mean "sort of equals". I'm sticking with != because computers should be logical. Right?

------------------------------------------------------------------
So, staples, huh? That touched a nerve, no? Thanks for commenting everyone, as well as coming up with the idea for this post.

In any case, it often seems barbaric to close an incision with sharp metal clips, or, it may seem, as my 16-year old goth patient thought, "way cool". But regardless, it's not something we do just to save time. There's pretty good evidence that staple closures are cosmetically equivalent to suture closures, and perhaps superior in repeat incisions (like a second c-section), when the skin is often thicker from prior scar. There's also the advantage of being able to open part of the incision by taking out 1 or 2 staples, for example to clean out a burgeoning infection, without having the whole thing unravel.

That being said, staples can irritate, usually if left in for too long. In my current institution, we have the problem of poor wound healing - high volumes of obesity and diabetes, for example, are a bad combination for this problem. Because of that, there's been a trend to leave the staples in for longer, to allow the skin to close more fully before removing them. Now, skin really re-forms (or, for your million-dollar word of the day, re-epithelizes) within 24-48 hours, and I'm not really sure that in our low-tension cesearean section incisions, leaving them in for longer helps. But regardless, some doctors are doing it, and since the clinic is so overloaded, some patients are having a hard time getting in for staple removal. And then they come in for their TWO WEEK incision check with staples still in, and well, you see where I'm at. I can't make whomever is on call on post-op day four remove my patients staples, but I can sure as hell not put them in in the first place.

*A statistical program I'm learning so that I can do research all by myself.

Perversely cheerful

2010-05-14T16:28:00.005-04:00

I was on call last night. Lately, I've been dreading call. One, I hate being away from home. Two, I think I'm getting too old to stay up all night. Three, my call is basically work that a generalist OB/GYN does, but due to the vagaries of fellowship, I now have to be "supervised" doing the same work that I myself did independently as an attending before fellowship, and that is both alienating and frustrating. (The point of that setup is to protect fellows; well-meant but crazy-making..)

Anyway, last night was terrible and awesome. It was insanely busy - as soon as a room had been cleared out, four women would come into triage, going into active labor like active labor was going out of style. It was stressful.

But man, it was fun.

When I dread call, I forget: I have the coolest job in the world. Now I just have to figure out how to remember that.

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

So what happened? In list form:

A woman came in, first baby, term pregnancy, had broken her water in front of her sixth grade class on her last day of work. Educational, right? She wasn't in labor and since she had been seen and examined before I even started my shift, she was just waiting for a bed and I hadn't gone into her room. She was languishing in triage for six hours (she was very kind about it). For 5 hours and 50 minutes of that time, nothing was happening, and then all of a sudden, she had three contractions. I hear through the curtain: "Something is different, something is DIFFERENT." I go in, introduce myself, and ask her if she would like to be examined. Yup, she's fully dilated. We all of a sudden win the labor room lottery, and go screeching down the hall to LDR2. She is fantastic - terrified, but holding it together. We push for 20 minutes and have a baby girl; her husband and mother get to the room just in time (her husband had gone to move the car - the perils of city hospitals!) and were trembling when it was over. She was really proud of herself, and I'm proud of her, too.
Because of the volume of patients, I do a cesarean section with the intern (we don't often get to operate together). We discuss how we've noticed that although staples are faster, our patients have a lot of trouble getting in to the office to get them removed. We make the controversial decision to use suture - it takes a bit longer, and the tech gives us a bit of the evil eye - but we make the incision beautiful. I think the patient will be happy..
I got some dinner. Pepper beef in the cafeteria - suprisingly not gross! Win.
One patient with abdominal pain - negative workup, home. One patient with contractions at 31 weeks - no cervical change, contractions resolve with oral hydration, given the lecture about adequate water intake, home.
Go up to call room. Lay down for 32 minutes
Back to triage; 3 women in active labor. One asks me to check her blood pressure - the nurses are so busy, they haven't even gotten a set of vitals. History of gestational hypertension this pregnancy, now very very uncomfortable with contractions. Yup, blood pressure 220/99 (I have to take it three times to even get a reading - that's never a good sign). And she's 8 cm dilated. Labs off, mag started, labetalol pushed, baby born. This took about 45 minutes from start to finish, all crisis time, with just me and the nurse available. I think we did a really good job.
Another cesearean section, this one infected. Poor kid. I meet her on the way to the OR, and she only speaks Spanish and looks terrified. The baby turns out to be enormous and has peach fuzz on its cheeks. Everything goes fine. Felicidades, mama.
The postpartum floor calls about a patient - the other attending on the floor leaves to go deal with that, and ends up bringing her upstairs. She stops bleeding, but there's some sort of contagion, because the woman in the next bed in the recovery room suddenly has a lot of uterine atony - we get called for bleeding, and I initially head to the wrong bed, because of course I think it's the first patient bleeding again. It gets a little rocky, and there's talk of heading to the OR. Luckily, some bedside maneuvers and medications worked, but I feel like telling the whole unit not to get any more ideas.
I went to the call room for 46 minutes. I think I slept, because I was woken up.
Two more patients in triage; one is only two centimeters dilated, but so tired and uncomfortable. I try to admit her for morphine sleep, but there's no room on the labor floor. I try to get the triage nurses to give her morphine in triage - no dice, we're too busy to do it safely. I get upset, because this woman is in pain and it's unethical to leave her like this. Somehow the nurse-in-charge magically makes a bed in the recovery room appear, and I admit the patient for morphine. She was still sleeping this a.m. when I left.
More stuff happened
It became 8 a.m.
I got hot chocolate and french toast in the cafeteria. Bad for diet, good for the soul.
I make it home and even find parking. Win, perhaps minor miracle.
Smoosh is very busy with trucks when I get home, but eventually is convinced to snuggle with me in the bed for a few minutes. I mean to get up and shower, but I fall asleep with his lego truck in my armpit.

2010-05-11T17:45:00.001-04:00

There's this, and I probably should be excited about this article. But I'm annoyed instead. Is it because really, she should have gotten the CT scan earlier, and everyone's just really lucky she didn't die? Or is it because I don't think this should be set up as a exemplary case, when her diagnosis was both common and relatively easy to figure out? Or is it because in general pregnant women often get substandard care, as everyone is so busy freaking out about the baby that they forget about the mother? Or is it because I am feeling under-appreciated because I have to make this decision all the time, and it's a bit terrifying, and yet, at the same time, entirely commonplace?

It's probably that last one.

Happy Birthday to The Bearded Economist!

2010-05-05T20:05:00.001-04:00

To all of those who wonder how I do what I do, let me share this example: A few weeks ago, I brought home new shower curtain liners. I forgot about them in the bottom of the shopping bag, which I'm sure I left somewhere illogical, like in the freezer. I only remembered them this morning, when I stepped into the shower to see them hanging up nicely. TBE had found them in the bag, and without even asking me why shower curtain liners might be next to the ice cubes, put them up and (this is key) threw out the old moldy ones. Sweetheart, that's more romantic than a dozen roses any day (for me, at least). You're wonderful, and I don't know what I would do without you.

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

I realized today WHY ultrasound is fun. It's because it's ART. Ultrasonography is self-expressive, in the way that photography is: there's something to see, but you can show it in any number of ways. The exciting thing is to get the picture that shows what you're thinking and why it's exciting, without any words. Thus, it's amazing to get the picture of the fetal heart that shows the aorta coming from the left ventricle (as it should, but as it sometimes doesn't), and show it beautifully wrapping around the pulmonary arteries, and thus say: This left side of the heart is normal.

In any case, I was having a lot of fun doing that today, and it felt a bit like writing this blog. Self-expression. I thought. Art, I thought. That's it.

--------------------------------------------------------------------------
Smoosh is in bed. The sitter is here. Off to birthday dinner!

What she said

2010-05-03T13:30:00.005-04:00

1) First of all, please ignore the typos in this post and the prior one. When I post by email (that is, from work), I can't go back and edit after I send it out. So I find myself wildly embarrassed by the errors - please excuse.

2) To respond to comments yesterday: you're right, you're right, you're so right. In fact, this is exactly what makes me so crazy about most medical writing - the egocentricity, the doctor-centricity. In the end, most people are just having a terrible thing happen to them, and although I can always make it worse, there are sometimes where I cannot make it better. And it's almost always true that I am far from being the most important or therapeutic presence in the room.

That's hard to admit, you know, which is why I think it's not dealt with in most medical writing; it butts us right up against two of our limitations as clinicians: our limitations as doctors and the boundary of our attendant capital-letter-Science; and our limitations as clergypeople/fellow humans/witnesses to suffering.

You're right, and thanks for reminding me.

3) I have often told my med students that counseling is the most dangerous thing they will ever do as physicians. Because what is said, and how it's said, and when it's said are powerful ways to get patients to do something that's not in their best interests, or even safe. Sometimes offering a choice - despite our modern understanding of respect for patient autonomy - can be cruel. This is mostly true when it's misleading, when there isn't really a choice. It's like the old-timey robber question: Your money or your life? But if you give them your life, they get your money too, so why ask?

4) Please don't ever, ever apologize for comments. As you already know, I love comments, in an entirely ecumenical manner: short, long, fat, thin, all of them. The only way to make your comments better would be to keep them as just as long, but parse them into several smaller comments, because then I would have MORE of them. (I'm kidding.) (No, I'm sorta not.)

5) I know, Dr. Whoo - it's Alexa! And also it's Dr. Whoo! And Persephone! OMG! I read you guys all the friggin' time. And Simone is truly a joy for me to see, and her wonderfulness gives me solace for a lot of what I do.

If I wasn't in triage, I'd have a little hand-flapping verklempt moment right now, but um, I am, so I'm keeping it discreet. But as always, thanks for reading, for being kind, and for not being robots.

Hi robots!

2010-05-02T15:54:00.004-04:00

I have a bounce rate of approximately 82%, which I think can be interpreted to mean that only 18% of you are real people and the rest are internet-trolling androids. I wish I was kidding, but such is my understanding after having looked on the internet. Google reports that "a bounce rate above 65% is a cause for concern." In lieu of concern, I offer robot-friendly greetings!

Alternately, this might mean that I should not participate in technology that I do nof fully understand, a lesson that both I and the stars of the 1983 hit movie "War Games" refuse to learn.

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

Ah, so I have another sad one for you. Sad for me, too.

This past month, I've taken care of a lot of women who have periviable infants. Many of them have gotten their pregnancies past periviability - let's say that for argument's sake, that means anywhere from 23+0 to 24+6 weeks.- but many have not. Very, very little babies, threatening to be born very very early. For a helpful look at what that can mean, look here (it's a flawed regression, and not perfect, but a helpful way to start discussing this really terrible time).

But what I wanted to talk about is the appropriate use of hope in medicine and the appropriate use of honesty.

To start, you have to understand this: a healthy pregnancy is the goal. But for most people, a sick kid - and by sick, I mean, never able to live independently, may have to be institutionalized, a life full of possible pain sick - is worse than a dead kid.

I would apologize for the wording, but I have to be blunt. It's hard to understand subtleties when you're having the worst day of your life.

But in the end, I am limited, even if I am clear. I can't KNOW who's going to have the sick kid; as gestation ticks by (and you can play with this on the calculator I linked too), the odds change. How much is enough for you? Because it's your kid, not mine, your kid for the rest of your life.

Over the past months, I have had multiple women living as in-house patients with cervical exams that are open, or almost open, from 22 weeks and up. Some have cerclages in, because they've been through this before - they've lost a late second trimester baby, and we think there's something wrong with the structure or material of their cervix, and we have tried to seal the pregnancy in. We think this sometimes works; as in all research, flaws make it hard to know for sure.

In any case, one of these women had come into the hospital at 22+ weeks for bedrest. The very sane, rational plan we made was to recheckher cervix in a few days; if the membranes were exposed (meaning, that at 23 weeks she had a very poor prognosis, and very likely would get infected shortly), she would accept an induction of labor and terminate the pregnancy. That is, she made the decision that for her, for this pregnancy, no baby is better than sick baby.

I rescanned her the next week and saw no residual cervix remaining. We talked, and decided to do a speculum exam; and I saw what my old colleague used to call "the green marble sign", a 2 cm open cervix, with the light green amniotic fluid visible.

I told her what I saw, now, as she was 22+6, and she started weeping.

Take it out, she said. Take out my cerclage, and take out the baby. Oh! Oh, I can still feel her moving. I can't stand this, I can't. Take her out because I cannot stand this anymore.

I told her that I would certainly do what she wanted, but I wanted her to talk to her family first. I told her that I couldn't be certain of anything that would happen, but I didn't want her to make a decision in haste. I told her, though, that I was terribly sorry that this was happening to her, and I completely supported her decision. No child over sick child; that's understandable, I said. I wish you didn't have to go through this.

One hour later, she still wanted the cerclage out. Now it was late evening, and I transferred her to Labor and Delivery for removal of cerclage and likely delivery of her infant.

But.

Well.

On a busy labor floor, she waited a few hours and then was reexamined, now in deep Trendelenberg positioning (that is, with the bed tilted so that she was essentially standing on her head). In that exam, the membranes were not visualized. This is not unusual; the amniotic sac is subject to gravity like everything else, and with the Trendelenberg had reduced back behind the cerclage.

The patient wasn't sure what she wanted. Three hours later, she opted to come back to her old inpatient room, and wait, the cerclage still in place. We called this "expectant management". But also it meant: I have changed my mind. I want this child, sick or no.

When I came in the next day, she didn't want to look at me. But she looked at her feet, propped above her heart in her Trendelenberg-tilted bed and said: I'm going to keep this baby inside of me. She's going to be healthy, and she's going to be fine.

She was very, very angry at me; she seemed ready for me to argue with her. And it's clear that she saw it this way: I was the doctor who was ready to give up on her child, you see, and I was also, as she saw it, inexcusably wrong about her cervix. This baby was going to make it, in her thinking, and I had wanted to end her hope, and I had quite possibly lied to her.

Ah. Well. She went into labor the next day and delivered an infected baby at 23+1 weeks. Infected, because the membranes had been past the cerclage in the vagina.

You can do the math on the calculator for that yourself, but no matter how I do it, I feel awful. Not because of the baby, but because of my patient. It's quite possible she would have hated me anyway. But balancing the honesty and hope, trust and despair - somehow this time I didn't do a good job, I think, and it hurts that she feels I abandoned her and her pregnancy.

I just had a really good day at work.

2010-04-27T20:55:00.000-04:00

I caught the snack cart not once, but twice today, before it left the floor.

I performed a very appreciated procedure under anesthesia

I performed a very appreciated procedure not under anesthesia - this was the patient's choice, to try one more time to get this little thing done this way, and she was very grateful that we could do it so quickly. I have to admit I took a small bow there in the room, because it was difficult but I did it fast and well. Also because I am a dork.

I spent some time with a very sad patient who had suffered the loss of her 20 week fetus last week. I fixed her pain meds and her bowel regimen and talked about future fertility, but what is the most important thing I did for her? I affirmed for her that if she wants to celebrate Mother's Day this year, she has every right to do so.

I spent some time with our postpartum cardiac patient, teaching breastfeeding (since her cardiac issues are all stable), and she was disheartened but gamely trying. She might go home tomorrow!

My car was only parked behind one other car in the parking lot, and I got out in record time (read: under 10 minutes).

So, a good day at work. Noteworthy.

2010-04-25T15:43:00.002-04:00

Can I give a shoutout to Mamadoc? Thanks for reading; your comments are much appreciated.

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

I remembered this story over the weekend, and really, it's the story of why it was hard for me, specifically, to become a doctor. Sorry, trainee people, for the huge downer. Maybe you'll be better suited for this than I was. On the up side, I now both like my job and am good at it, so there's that.
--------------------------------------------------------------------------------

It was 3 a.m. on a Friday and the labor floor was full. Ten days into my intern year, and I had never worked so hard or for so long in my life. Not even the surgery rotations in medical school had prepared me to come in and work like this, every day, with no weekends, no breaks for meals, no sitting down.

And I had not been prepared to be so, well, stupid. Stupid, and thus scared, because I had so little ability to interpret anything I was seeing, and everything seemed to be an impending tragedy.

That night was one of my first Labor and Delivery; my weekday rotation was seeing gynecology consults in the Emergency Room, so I was more than a bit lost up on the fifth floor where we took care of laboring women. When on call for L&D, you are also the doctor for postpartum patients, so somewhere around 1 a.m. I received a call about a post-operative patient who had a fast heart rate.

"Her heart rate is 123, I just wanted to let you know." said the matter-of-fact nurse.
"Um. OK. How does she feel?" I said. "I mean: I'll come up and see her." I knew, at least, to do that.

So I went up to see this poor, pale woman whose heart rate was fast and whose baby was new, and I sent a hematocrit on her (or did I? I can't imagine that I did that; that level of action would have been overly functional for me at this point. Probably someone else had sent it and I just looked it up.) In any case, her blood level was low. Really, really, really low, around 21, low enough that even a young healthy woman might not feel so well; and if it goes any lower, might have some problems perfusing important organs like her heart or her brain.

So: this patient bled, right? We know that. She bled in the past, in the OR, under relatively controlled circumstances. But what we want to know is that she's not bleeding, now, currently, ongoing problem, in the present.

And I, for the life of me, could not recollect how to reassure myself. Her heart rate was fast, her hematocrit was 20, she must be bleeding to death.Was there any other explanation? Could anything else be going on? I did not know; I had so little emotional reserve left that all I couldn't make a plan. All I felt was fear, all I thought was: this woman was going to bleed to death and it was because I DID NOT KNOW WHAT TO DO.

I remember careening down the stairs, running to labor and delivery and grabbed my chief resident. I remember giving her an unintelligible summary of my concerns. My chief resident that night was a tiny but formidable woman, less than 100 pounds soaking wet, and she was eyeing her takeout Thai food while trying to listen to me and run between labor rooms. She clearly hadn't eaten all night. She did not have time to deal with a non-emergent postpartum issue right then.

I remember blathering on, bothering her and bothering her,because I did not know what to do, and finally, over an hour later, she came with me to see the patient. I remember taking a deep breath: the patient had not yet died. A real doctor was on her way.

My chief resident then did all the things I should have; she checked her urine output (fine), checked on the repeat hematocrit she had ordered from downstairs (stable), asked the patient how she felt (better after some hydration) ,looked at her pulse (now 103) and examined her belly (soft).

She told me it was ok, that the patient might need a transfusion, but that she wasn't bleeding actively, so we could wait and see. She was a bit impatient with me, but kind, which was really more than I deserved.

But the main problem, of course, was that I should have done all of that and should have known all of that. I wasn't a medical student anymore, content to be a reporter. I was supposed to be a doctor, someone who could figure out what was going on, or at the very least, figure out how to get more data. Somehow, at that point in the night, I had gotten too scared and lost, and couldn't put the pieces together, couldn't make a plan.

I spent that night and many others just...scared. Scared I was missing problems that were going to hurt people, or scared that I had caused problems that were going to hurt people or scared that people were just suddenly going to have something horrible happen to them in front of me . Things got better, actually quite quickly - I am a fast learner, and I was motivated - but the terror, I think, is part of the damage of medical training. I think it's also necessary, this comfort with acting during the extreme situations of life rather than just documenting them; but it is a change for the poetic among us, and it is not a completely benign one.

Maybe this wasn't as bad as I remember; I was a pretty capable med student just months before this, and this level of marginal hysteria doesn't really sound like me. But this is how I remember it.

And the other problem was that when we got back to the labor floor, someone had thrown out the Thai food. I am not sure that the chief resident every truly forgave me.*

*I later found out that she was about 8 weeks pregnant at this time, which to this day makes me feel even MORE TERRIBLE about this story.

Would you believe that all my punctuation keys are broken?

2010-04-22T20:08:00.002-04:00

Long story about how I always wanted to do some critical care rotations and then I think I'm too old and have a kid so I probably should just do my electives in genetics or office practice and get home by 6 pm and then my patient who is 29 weeks pregnant in the hospital for something completely unrelated all of a sudden has a heart rate of 200 and feels really terrible and by the time I get there she's more like 150 with stable blood pressure so maybe it was artifact but I don't think so and she still doesn't feel too good and goddammit the EKG machine on the floor is broken and I send people hunting on other floors and by the time I get the leads on her the rate is 120 and relatively normal and cardiology thinks she doesn't need to be seen right then and now she feels ok. And then all of a sudden it happens again and I can see the pulse in her neck fluttering like a crazed hummingbird and its definitely faster than 150 and this time I have the machine and yup, it's really 200 on the EKG, and yup, looks like it might be causing some heart damage, although thankfully her blood pressure is stable, and we throw the fetal monitor on and the baby looks ok. And then all of a sudden it's interesting to EVERYBODY now, huh, look at that, and they all come by and now I have more cardiologists than any one person should really need and they push some adenosine through her IV and two minutes later her heart rate slows and is normal and she feels much much better and then goes to the monitoring unit to be watched after we all agree on a pregnancy-friendly drug to help keep this from happening again and I am remembering how I really wanted to feel comfortable doing this stuff so I guess I have to go work in some ICU for a while after all.

Random numbers*

2010-04-19T20:26:00.000-04:00

- 60 milligrams of daily prednisone to help my patient at 37 weeks get over her asthma exacerbation, hopefully before labor decides to kick in . Three days later, she looks better but not better enough. Hmm.
- 22 patients to be seen in the office while trying to run a complicated inpatient service. It did not go well, thanks for asking.
- 20 minutes of PowerPoint slides that I have to prepare, by tomorrow, on a topic I know extremely little about. Good luck to me.
- 18 weeks of gestational age for this patient, with very little residual cervix let keeping her baby inside despite a cerclage** placed earlier in the pregnancy. Hours of counselling later, she is pursuing watchful waiting, despite a dismal prognosis. Realism is important, I said. But once you've decided to try this, maybe we can think of hope as therapeutic.
- 14 terrible cafeteria meals eaten. So tasteless and yet and so fattening. How do they do that?
- Six new patients for the antepartum service on a Friday afternoon, after my return to the hospital from the clinic session from hell. Nice.
- Five consults called on this patient who has something - but we can't quite figure out what - terribly wrong with her. Come join the fun, cardiology, endocrinology, psychiatry, renal, and social work! One of us has to be able to figure this out, right?
- Four throws of the needle to put in a cerclage this week for a lovely and grateful patient with a history of second-trimester losses. We can never know if this will work, so it's back to my other intervention, hope.
- Two patients requiring immediate cardiology appointments because of newly diagnosed arrhythmias at term, and thus the need to make some sort of delivery plan so as to avert panic on the labor floor when they show up. I am beginning to suspect a cardiology conspiracy as payback for the above consult request.
- One cranky me

*As always, numbers in this blog are suspect.
**Stitch around the cervix

Death and Taxes

2010-04-15T07:30:00.056-04:00

I seem to have moved away from narrative posts to behind-the-scenes posts. I miss the narrative posts; what about you?
_________________________________________________

It's April 15th, so all of you very organized people probably already finished your taxes. Me? I left it to The Bearded Economist, since you know, isn't it sort of his job and in his NAME and everything? Sort of? (He will be very annoyed that I said that. Economist not equal to accountant is what he would say. And he's right, so he got an accountant.Good job.).

________________________________________________

On an unrelated note, I get vaguely threatening emails from my job about once a week for trainings I am supposed to be doing. There is a never-ending process of training in patient safety and computer systems and hand hygiene and everything you can imagine, and each email reminds me that if I don't complete these trainings SOON, I will lose my hospital privileges. (There are days when I'm not sure that's really an incentive, but I move on.) Thankfully, most of these trainings are now online, so I can complete them at 2 a.m. while in triage waiting for labs to come back.

In any case, the most interesting one I've had to do recently was about filling out death certificates properly. Now, fortunately, I don't have to do this very often for adult deaths - maternal death is rare in this country (although not rare enough). But in some states, we do have to report fetal deaths over a certain gestational age, and unfortunately, that happens far too often.

When I was a resident, this paperwork was the part of taking care of patients with pregnancy loss that I hated the most. It added insult to injury, really, in that this poor family was already having the worst day of their lives, but then here I come, barging in to ask the patient how much weight she gained during the pregnancy, and if she smoked, and how many illicit substances she may or may not have partaken of in the last 30 days. No matter how gently I asked these questions, it always felt like they might be understood as some sort of accusation: You only gained 10 pounds? That's why your baby died. I inevitably left the room afterwards a bit shaky. And inevitably I would have forgotten a piece of paperwork or a signature, and would have to go back and bother them again.

In any case, I know how important this paperwork is; I do. Figuring out if pregnancies fared badly because of malnutrition helps tell organizations that we need to implement programs like WIC, or food stamps; data on smoking helps fuel smoking cessations efforts; and statistics about drug use are used for all sorts of interventional decisions, be they right or wrong.

And it's really hard to do correctly. Because doesn't everyone eventually die of cardiac arrest? Sure, so that's an easy way to fill out the paperwork. But it's not right, and it's misleading. Thus we enter into deep philosophical and teleological questions: what most directly caused the death? And what most directly caused that cause of death? And what are unrelated but important but not causative coincidental conditions? Thus: death caused by a heart attack caused by coronary artery disease caused by years of hypertension, with a note of the unrelated migraine headaches on the side. Thus: death from extreme prematurity caused by preterm labor caused by maternal cocaine use; note the unrelated gestational diabetes on the side.

To be this definitive is both important and harder than it looks. Almost nobody has such a clean narrative.

In any case, the training I took online at 2 a.m. was from the city government in Large Urban Area, and I was pleasantly surprised by how helpful, easy, and well-engineered it was. So kudos to you, Large Urban Area - thank you.*

I'm struggling with my anonymity here, because it's a link to a cool educational training - any of you could go and do it in about 15 minutes - but it would clearly reveal where Large Urban Area is. So email me if you'd like it, and I'll send it to you if you seem relatively unthreatening.

_____________________________________________________

I've always been entirely too stressed out by the paperwork at the hospital. Except for billing, at which I am terrible (Oy. so terrible. Without really any interest/incentive to improve. Plus, gah, it is SO BORING to learn about.) But during my intern year, I used to get really worried about the birth certificates - what if I filled them out wrong? I would come home and tell The Bearded Economist,"What if, in 65 years, that baby won't be able to collect social security, and it will all be my fault!". And The Bearded Economist would very soothingly say, "Don't worry, sweetie. In 65 years, there won't be any social security anymore, anyway."

I did not feel soothed. The dismal science, indeed.

*My tax dollars well-spent, right?

GI rounds

2010-04-14T01:59:00.001-04:00

Every program has slang. For example, I cannot seem to stop calling a certain test "LENIS" (pronounced: Lenny's. As in, belonging to that greasy guy on "Laverne and Shirley"), which is what we called this test at my residency training site. The clumsy acronym stands for "Lower Extremity Non-Invasive Series" or something like that, but the rest of the world calls them lower extremity doppler ultrasounds and will persist in not understanding you if you keep calling them LENIS.

Oh, and we used to call pre-eclampsia "P-E-T" (you would say every letter, you would never say "pet"); I think it once stood for "Pre-Eclampsia-Toxemia" [toxemia is a very, very old word for pre-eclampsia], and it's redundant, and not any shorter than just saying pre-eclampsia, but there you are. We said it, it's how I learned to talk OB, and it's awfully hard to get rid of that mother tongue. Multiple times every day, I look up to see a befuddled colleague looking at me, and then I have to translate the language of my residency-country into that of my new fellowship-land.

But here's one term that I have been introduced to at my fellowship program, and I really like it: GI rounds. GI as in gastroenterology. Rounds as in... you know, meeting to talk about patients and weighty clinical issues.

But at Large Urban Hospital, GI rounds means: Let's go eat! Or: the delivery guy from the Thai place is here! Or: the cafeteria closes in 10 minutes - go catch the elevator! *

It's a little bit of a euphemism, but it sounds clinical, so it is very helpful when trying to maintain a professional veneer.

Thus it came to be that in the midst of my triage chaos tongiht, I walked into the room where my intern was performing an ultrasound after running around non-stop since coming on the labor floor 5 hours earlier. I stood by him, and very sternly said: Dr. F, you are late to GI rounds, and that is not acceptable. I will finish up here.

He got all the way to the hallway on autopilot; I think he was really convinced he was in some sort of serious trouble with me. Then I heard him cracking up as he walked to the break room.

*Unless you are actually a gastroenterologist. Maybe they go on OB rounds?

Mind your Gs and Ps

2010-04-11T17:52:00.004-04:00

We talk about patient reproductive histories in short-hand - "She's a G2P1", meaning: she's had two pregnancies (this one counts) and is thus a gravida two, and one delivery; thus a para 1. That's an abbreviation for the longer format, which would be a G2P1001 - again, the G is the pregnancies, and the four digits of the P are various types of pregnancies she's experienced. Many med students use the mnemonic TPAL - the digits stand for, in turn, term pregnancies, premature deliveries, abortions, and live children.

But of course this becomes more complicated. First of all, "abortions" in this and most other medical language refers to any pregnancy loss prior to 20 weeks, regardless of whether is was spontaneous (or what we would call a miscarriage) or a termination. And twins always complicated matters- one pregnancy, two deliveries.

And finally, when you break it down to the short-hand - G2P1 - that one digit after the P refers to the "L" number, the living children this patient has. I was always taught that the "L" digit did not really mean "currently alive" but rather was a reference to children that had survived the neonatal period. That is, it was no longer part of the obstetric history if their 4 year old died in a car accident; that patient, with no living children, would still be a P1. It's tragic, yes, but unlikely to be related to the pregnancy, labor, or delivery we were thinking about now.

I'm seeing my residents, however, use it differently: as a notation for how many live children this patient actually has. The above patient would be presented by them as a P0; she has no children at home.. Arguably, that's a way of melding social history with obstetric history. And arguably, more appropriate.

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

None of this terminology ends up being short-hand, in the end, as the terminology has so many possible meanings that an explanation must inevitably accompany it. That is, is the G3P1011 someone who had a term delivery after a six-week miscarriage? This is medically low-risk, and not a red flag for her pregnancy. Or is she someone who had a term delivery, followed by an 17-week intrauterine loss? Or a second trimester termination? Both of those people would have very different concerns and follow-ups, as their bodies would have been subjected to extremely different physiologic and pathologic processes.

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

In any case, though, I recently took care of a G9 P0. And you don't need much explanation to know how terrible that is. Nine pregnancies; no living children.

Most of these were in other countries, with minimal medical care so far as I can tell. And yet, it is amazing to me that she has the strength to even try again. This time, things seem to be progressing uneventfully, which is really the best you can hope for in any pregnancy.