Fluishly Yours

Dear ABOG;

Although I specifically set aside time this week to study for the upcoming MFM Oral boards, I hope you will accept, in lieu of passing that exam, this monograph entitled: "Care of the Sick Toddler(s) and Kindergartener: A Case of Cognitive Decline". Although not randomized, and an unethical experiment performed without IRB approval, I believe this study represents an important public health finding this winter, relevant to many parents of child-bearing age. It may even represent a delayed (2-5 years) form of postpartum depression. Of course, more research is needed; sadly, I seem to be deeply involved in advancing the field. 

Feverishly yours, 

Me

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Recreational

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Back!

You may (or most likely not) have noticed that this blog disappeared for a few days. Basically, several of you were kind enough to email me and say: "Hey, it's not that hard to figure out who you are."

And that was helpful. And it also required a reaction. So I took down the blog while I thought a bit. And what I ended up doing is taking down most of the old posts.

This is not because I'm not proud of them (although, wow, some of them are really longer than they need to be). And in truth, I never thought I was completely anonymous. But I was perhaps not terribly cautious, and from now on, I wanted to be a bit more careful.

I don't have the time right now to edit those old posts and make sure I'm ok with them being seen by a wider audience, so away they went to a secret hiding place. Those posts still exist, along with your treasured comments, in a more private area of the digital world. Really, truly, your comments are the best part, and part of what made taking everything down so very hard. But part of what made this fun was I just went through all of them and reveled in those comments, and they are still wonderful.

Anyway, the site is back up now - edited, redacted, but I think better. Because now I can keep writing, if with more awareness. And I'm hoping this new setup will mean that I am, in the end, less paralyzed.

Thank you all.

(Oh! If you were following the "other" blog - the one about saying Kaddish -  I made that one "invitation only". I believe I already added the people who emailed me last time wanting access, but please feel free to do so if I left you out.)

Publish able

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Radioloab followed me to work

Not really, but you should go and listen to this. You should not, however, do so on an emotionally fraught trip to visit an ailing family member, because you will sob uncontrollably in seat 9C for most of your transcontinental flight, which will make the impeccably groomed 20-something in 9D very uncomfortable. Theoretically speaking.

Regardless, it was beautifully done, I thought, in that it bypasses a lot of the unhelpful rhetoric, and did so with tremendous respects for all the options presented. I don't agree with absolutely all the counselling or medical management in this story, and I have some unresolved questions (why the cesarean? why?) but so very worth it.

GI rounds

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

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.

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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.

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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.

This joke is requiring a lot of explanation

Much of life on labor and delivery revolves around The Board. This is a big white board with all the patient rooms on it, and rows for their name, their gestational age, and other important info, like how dilated they are. The last row is for "Comments", which means it gets filled up with everything: epidural, magnesium, history of chronic hypertension, etc. The Board serves as a communal brain for the L&D team - attendings, residents, nurses, everyone.

It's rather universal (or it has been at the hospitals I've worked at) that when you put a "to do" on The Board, you put a little empty box, like this:
 [] start penicillin.

Then, once you've done it, you put an X in the box, like this:

 [x] start penicillin.

That way, everyone knows that this patient a) needed something and b) it was taken care of. The x'd boxes are, of course, the best, because they're done.

So that being said, much time on L&D is spent adding little boxes to The Board, or staring at little boxes on The Board, or just kind of loitering near The Board while thinking about the little boxes .

And when I was doing those things last night,  I saw this:

And it made my night.*

*Partly because it was funny, and partly because it was DONE. We are efficient even in our humor!

Pleasing tone #4*

We've probably all slept through our beepers before. I know I have - it was once, when I was the chief on Labor and Delivery, and my third-year resident couldn't get hold of me. Nothing terrible happened; or rather, it did, but it was nothing terrible that I could have prevented (although I still maintain that I would have diagnosed it a bit earlier).

But we all have ways of making sure this doesn't happen in general. Sleeping on call is a sketchy proposition in any case - you're in a strange room, on sheets that have never known fabric softener, sleeping in your day clothes. They're scrubs, which are essentially pajamas, but you know, you've been wearing them all day. So, ick.

You can't control the temperature; it's too hot, it's too cold. There aren't enough blankets, the bed is tiny, and the bathroom is really far away. It's too dark to find your pager, but it's too light to sleep properly, and the anesthesiologist/pediatrician/midwife keeps slamming his call room door on the way in and out. There is never a reasonable place to put your eyeglasses.

But because you are terrified that you could sleep through your pager (even though everyone knows where you physically are and if necessary could actually WALK OVER and wake you up, but Lord, it's such a terrible feeling that sometimes it's not worth the risk), you perhaps add tricks to make sure that won't happen.

I know some people sleep with their shoes on, claiming it adds just the littlest bit of discomfort that keeps them out of deep sleep. I had one friend who would only sleep in the chair, rather than the bed. I myself have multiple strategies, but at my current institution, in the window-less call room, I've resorted to leaving a desk-light shining near my head, and clipping my pager to my collar. You know, so if it goes off, it goes off directly in my brain, and even I couldn't miss that.

But the real problem, for me, is that you can be woken up at any time. AT ANY TIME. By a shrill pager about 2 inches from your inner ear. (Yes. I know that I've created this problem.) I wake up feeling a bit like I'm in a movie, or a nightmare, or an insane asylum, or a movie about a nightmare in an insane asylum - panicked, wearing a uniform, wrapped in scratchy linen, with shrieking in my brain.

And if you hate getting woken up then it's a real incentive not to go to sleep.

So if you have such amazing luck as to have some quiet time, the incentive for someone like myself is to stay awake anyway: fooling around on the internet; wandering around the vending machines; avoiding any productive work. Partly stupidity, partly because unpredictable sleep is perhaps preferable to the terrible pager.

And if you have such terribly amazing luck as to have a lot of quiet time, you feel stupider and stupider as the clock ticks on. Because you could have been quietly sleeping in a chair with your shoes on and a desk light in your eyes and a plastic pager digging into your neck, and who wouldn't want that?

You know, of course, that I don't do all of this (or any of this) all the time. Details have been conflated in the interests of blogging art.

*You can pick the ring tone of your pager; this is the one I use. Needless to say, none of them are really interested in being pleasing.