ob/gyn


Ok, I’m back online. This rotation is nearly over, which is a good thing, because honestly I’m more depressed, miserable, and angry than I’ve been in residency so far (except maybe on trauma; and that was made more tolerable by having friends around, residents and nurses I knew and trusted). Now I’m trying to figure out what to say when I get back “home,” because several of the residents were teasing me that I’m so optimistic, but the peds rotation would destroy me. They were mostly right; I’m just hoping it’s not permanent; and I don’t want to admit it to them. There were three rotations of second year that I knew would be absolutely horrible; one down (almost), two to go.

Anyway, I’ve been remembering the things that made me go into surgery in the first place (a decision that I’m not up to defending right now, just hoping I’ll feel better about it once I get away from this place). One particular story I remember because at this hospital we had a child develop a wound dehiscence after an abdominal surgery. Supposed to be pretty rare in kids, and the M&M on the subject was protracted, to say the least. A dehiscence is when the fascia (not just the skin) comes upon. There are two main reasons: you didn’t sew it properly to start with, or the patient’s tissue, for various reasons (debilitation, radiation, steroids, infection, to name a few), is so weak that it simply doesn’t hold even the best suturing.

I was on call on ob/gyn, and in between the deliveries and an ectopic pregnancy case, the team got called about a patient in the ER. She’d had an abdominal hysterectomy about a week previously, and had gone home shortly afterwards, apparently healing well. She dehisced at home, fortunately only to a minor degree, and came in to the hospital. As a medical student, of course I was fascinated, and tagged along the whole way; but I was also frustrated by the OBs’ response. The intern went and looked, and paged the senior; he went and looked, and called the attending. She didn’t believe him, and went to look too. At that point they agreed that they supposed it was a dehiscence, and called the surgeons to ask for advice.

I’ll never forget the surgery intern (who was after all tall, handsome, clever, and only not cocky because he was smart enough to warrant his own confidence). He strolled in, looked at the wound briefly, and remarked, “Yes, it is dehisced, sure enough. You’re taking her to the OR, right? You don’t need us for anything, do you?” The OB attending agreed that this was her plan, but insisted that the intern bring his senior, and even the surgery attending, in to look at things in the OR. Her explanation also sticks in my mind: “I never saw anything like this, even in residency. I’m not sure what to do with it. And maybe we ought to run the bowel [surgical speak for starting at one end of the small intestine and looking carefully till you get to the other end, to make sure there are no injuries or other anormalities], and I forget how to do that.” So the attending surgeon, being dragged out of a sound sleep (they were required to take in-house call, but counted on the seniors to shield them from any disturbance except a trauma requiring a laparotomy), came in to the OR and explained to the OBs that when the fascia comes apart – you should sew it together again. The end. And if you want to run the bowel – you start . . . at one end. . . and proceed . . . to the other end.

I’m not trying to make fun of the OBs, because they were overall good at what they did (that attending was one of the weakest), and I understand that dehiscences would be much rarer in a population of relatively healthy women (overall younger than the general surgery population) having elective hysterectomies. But to a medical student, it was noteworthy. Even then, several months before I did my surgery rotation, and got swept off my feet, I started to think that I’d rather be sure of the basics.

I still hate this rotation. But I expect I would have found at least one occasion to be equally miserable if I were doing ob/gyn, as I originally planned.

I ought to tell another story, where the joke is on us. We had a pregnant woman staying with her sick child at the hospital. One evening, the nurses called the fellow in a bit of excitement: the mother was having contractions, with increasing frequency. He ran upstairs, and became quite excited himself, and eventually with great commotion hustled the lady off to an adult hospital with an OB ward. Myself, I regarded it as less of a problem. First, unlike the fellow, I’d known she was pregnant prior to that night (just by looking; I guess he didn’t notice). Secondly, I considered that with her contractions still 8-10 minutes apart, she was unlikely to deliver within half an hour, which was plenty of time to arrange transfer (second pregnancy; maybe I was being too pessimistic). Thirdly, I privately thought it would tremendous if we did have to assist with the delivery after all. Of course, that was the thought that was really upsetting the fellow.

(I’ve been hoping and hoping that my wild emotional connection to deliveries is not a sign that I should really be doing OB. I think it’s partly my desire for action of some kind, other than the office, and partly my desire to actually be part of the healthcare team, instead of continually out of the loop.)

This experience has taught me one thing: Don’t trust people, you’ll get burned. I used to wonder where the interns got their cynicism from. Now I know, because I got it too. If there’s something you want or need, do not trust anyone else to help you with it, no matter what their promises or responsibilities are. You doublecheck as though it all depended on you. Of course, I ought still to be as nice as I can, and help other people, the way I wish but no longer expect them to do for me. We’ll see how long that second half of the equation lasts. Having learned the first step, I’m afraid I won’t be able to forestall the second one forever. One month of internship, I’m thinking, will about do it.

One last circ this morning, which I did to my own satisfaction. It was easy because the baby was nearly 10 pounds.

This morning I went to the ultrasound office, which was as empty as usual, so I got a good deal of my boards studying done, and read a few chapters in At Dawn We Slept too (authoritative history of Pearl Harbor, from both American and Japanese perspectives; the sequel is Miracle at Midway). I’m going to have to add military tactics to my list of subjects I need to get educated on (the short list currently is: theology (orthodox and heretical), church fathers, English civil war, WW2 (which is an endless subject), Vietnam, and of course surgery).

This afternoon Dr. Knight actually let me attempt to insert an IUD (he ended up doing it over my shoulder, but only because of my usual incapacity to find the cervix at vital moments). I also met a surrogate mother for the first time.

And finally, I think I found a good explanation for Dr. Knight’s behavior: the university practice is having tremendous problems of all sorts, and he’s distressed about it. I think, in the beginning, he was that very rare bird, a solo OB/GYN. So just being in a group practice is contrary to his usual method, and then having another member of the group making the decisions, in a way which tends to decrease his personal knowledge of, contact with, and loyalty to, the individual patients, is very difficult for him. So I guess I have to admit that he has a lot on his mind. I’m still ready to be done with this place.

I have nothing to say today. This morning in the office with the other midwife, I found out Betsy’s mother is in the hospital, on a ventilator. Then I called L&D, and found out that Dr. X and Dr. Knight had delivered two babies, one of them after an overnight induction, without telling me anything. I called Dr. Knight and politely requested that he let me know about any other patients. I’m sure those were the last two for the month. I was extremely pleased with myself, I managed to finish office hours without crying or looking too particularly disturbed.

My car CD right now is Beethoven’s Mass in C. It’s impossible to stay too upset while listening to his magnificent, fierce, challenging setting of “Et resurrexit tertia dies, secundum scripturas, et ascendit in caeli, sedet ad dexteram patris; et iterum venturus est, cum gloria, iudicare vivos et mortuos.” And he rose from the dead on the third day, according to the scriptures, and ascended into heaven, and is seated at the right hand of the Father; and he is coming again with glory to judge both the quick and the dead.

This evening I decided to call the attending and check if anything was happening. That instant, the midwife called to say a lady whom I’ve seen three times in clinic was in labor, 5cm dilated, and expected to deliver within an hour. It takes me 45 min. to get from home to the hospital, parked, and in scrubs. . . Fortunately the highways were pretty empty, this time on a Sunday.

This lady was the quietest I’ve ever seen. She was just breathing and moaning softly, lying on her side, but wanting to hold somebody’s hand tightly the whole time. After a trip to the bathroom, she had some difficulty getting back in bed, and I thought we might just have the baby on the floor. Betsy is great: helping the woman do what she wants, but at some points moving her beyond what she can think about right now. Betsy knew this lady was not interested in having the baby right on the hard floor, so she just about lifted her back into the bed, and helped her get on hands and knees, leaning on a birthing ball.

And that’s how the baby was born: after five minutes there, she said she wanted to push, and was begging Betsy and me to tell her how to do it. This being her fourth child, it took Betsy and me a minute to stop laughing, and repeat for her what she previously knew. With the third push, the baby crowned, and slid out slowly and smoothly – Betsy and I both had our hands on it, since I was again so astonished at the idea of the baby coming out in this position that I wasn’t sure how to hold it. Then we had some juggling, with the cord still attached, to get the baby to the mother’s front, and mother lying down on the bed. She immediately wanted her children and parents who were outside to come in, so we threw a blanket over her as she lay holding the baby, and the three little children were brought in by the father, who then cut the cord. Dad shooed the younger children out as she pushed the placenta out easily – one of the boys didn’t realize why he was being shooed, and left abruptly when he saw what we were producing, poor kid. The oldest boy was very interested, and came over with dad to examine the placenta. The mother had only a tiny laceration, not even worth sewing. Her mother came in, crying; she’d been too upset to come earlier. We left the whole family looking at the new baby as mom started nursing it

Beautiful. I’m happy now: one final natural birth. I’ll try not to mind if nothing happens this next week.

Also: I’m beginning to think I really have some sixth-sense connection to “my” patients, and it’s finally in tune enough to call at the right moment. I hope it works for surgery patients, so I can tell when I need to go double-check on them, not just for ladies in labor. (Although, being halfway through my large stack of books on Mormonism, I am very wary right now of claiming any non-obvious sources of intelligence.)

This morning, there were four patients to round on. I had been at the Csection of one; I knew why I wasn’t at the other Csection, since it was the relative of a big surgeon; then there was the lady who specifically requested that nobody but Dr. Knight deliver her (he didn’t make it in time). And finally, Betsy delivered a baby yesterday evening of whom I never heard anything. So that was the only one I had any right to be upset about; but rounding on four patients, of whom I had even been aware of only one, was difficult. I got all riled up, and then smoothed myself down in order to round with Dr. Knight. Betsy idolizes him, and had with great concern for my education arranged for me to work with him yesterday afternoon. We politely stumbled over each other all during office hours, as a result.

He was going to be in L&D all morning. Together we went to check on another patient of Dr. X’s, who started being induced last night. She was about 4cm, and was having her epidural put in. I told the nurse my name and phone number, and said that I would rather be at the hospital three hours early, rather than miss the delivery. She promised to call me. So, figuring that I had impressed on both the nurse and Dr. Knight that I wanted to be involved in this delivery, I proceeded to the office.

Drove back, arrived at noon, walked into L&D to check on the lady, and heard a newborn screaming. (I need to get a handle on myself. I can’t do surgery if I get emotional this easily. Bother it, I’ve been waking up all night for the last week, imagining that my phone is ringing; I’ve been telling everyone how much I want to be at another delivery this week. Why does it seem like everyone is cutting me out of the loop? One day I’m going to be a real grownup doctor, and people won’t do things without me.)

Dr. X had been in the OR area, and had been called with just enough time to run over and catch the baby, without even gowning up – and he hates not gowning up. Ok, I understand he couldn’t call me. But bother it, I do not believe that a lady can get from 4 to complete and pushing in three hours, and the nurse have so little idea that she’s at least dilating.

I called Betsy and asked her to call me when she hears about a patient over the weekend. Then I resolved that I will sit in L&D around the clock, when there’s a patient in labor, rather than miss anything else for my last six days. Forget about being five minutes away from the hospital. If no one will talk to me, that doesn’t work. I can’t think of anything to make Dr. Knight or Betsy call me when they don’t feel like it, and I can’t call the nurses’s station every few hours and ask what my attendings are doing. But once I hear of a patient in labor, I am not going to leave that building again.

Betsy seemed to know that I was about to cry on the phone, and offered to take me out for a drink. Ha. First time anyone ever asked me that one. :) Then she asked if I’d ever told Dr. A or any of the others what I told her, that if I do an OB/GYN residency I would do it in the Other Big City, not here. Well, I said that as far back as February; this program has uncertain accreditation, and other big issues. Besides, I admitted that I’m at least half thinking about surgery. So if they would seriously treat me differently because I’m not coming to their program, then they have plenty of grounds for it. But they never said anything like that to me. I don’t know; maybe the fact that the month is about over, and I haven’t asked them for letters of recommendation or anything, has tipped them off about my plans. So if all the things that are frustrating me are really coming from their disinterest in my learning, then I have not much further use for this. I keep trying to avoid it, but bitchy is the word everyone uses for ob/gyns; I know that’s what I sound like here, and that’s what Dr. A would be if Betsy’s suspicion is true.

On the other hand, I know Betsy has major issues with her employers. . . which she confided to me the other day. So I don’t know if she’s imagining things on my behalf.

I want out of this atmosphere. Just a few more days, please God a few more babies, and I’ll be done.

Finally, the longed-for moment: I left clinic early this morning to go over to the hospital for the Csection. This lady had far too many reasons for having a Csection: it would be her fifth delivery; she had a bicornuate uterus; and the baby was breech. She kept reminding us, in clinic and in the pre-op area, that she wanted her tubes tied. She didn’t mind being pregnant, she said, but she was tired of having surgery to get the baby out, and the stress that her recovery put on her family.

As she lay down after the spinal was put in, she remarked, “I’m feeling really nervous. I never felt this way the other times.” Everyone hastily tried to reassure her. I wonder whether the fact that, as we’d progressed down the hall to the operating room, three separate nurses had inquired of Dr. X (European-born chairman) whether he had a resident coming, whether he wanted them to call a resident, whether he was sure he didn’t need a resident. . . And he cheerfully said, “I’ve got Alice. No, I don’t need a resident. No, we’ll do just fine.” I had asked, outside, whether he would let me do some. I seem to have a knack for picking the wrong cases on which to verbalize my desire to participate. He gave me a gentle lecture on how complicated repeat Csections are, and wordlessly implied that I was lucky he wasn’t asking for a resident.

So for the entire case, I was swinging wildly between greed – “skin incision right through the old scar, I could have done that” – and repentance – “ooh, look how close that bladder was to the rectus muscle, and how stuck it is to everything, good thing I haven’t touched anything sharp yet” – and resentment of the scrub tech – “you could let me dab with the lap sponge, I know how to do that” – to gratitude for her presence – when she started suctioning the blue baby, as I was too astonished and clumsy to do anything (will I ever get over that reaction? you would think by this time I would be used to seeing a baby appear and start moving).

It was after the rectus muscles were divided that things got interesting. As I retracted (barehanded; Dr. X doesn’t go in for either bovies or retractors; he likes scissors and hands), Dr. X started snipping away at the mass of fibrous tissue which seemed to reveal pockets of fluid underneath. The bladder seemed to be extending far into the abdominal cavity. At length, he had exposed two apparently separate watery pockets. Then it clicked for both of us: we weren’t looking at the bladder, we were looking at the amniotic sac. There was, in fact, no uterus between the amniotic sac and the peritoneum. Dr. X and the scrub nurse exclaimed, and we had some difficulty to assure the mother at one and the same time that it was a miracle she was still alive, but there was nothing to be concerned about at the moment.

Her uterus had a huge anterior window. After the last Csection, it never healed, and was left with a hole in the middle. This fetus somehow implanted, and grew, without floating far enough out the window to hurt itself. The really miraculous part is that she was 37 weeks along: almost full-term. It’s amazing that her uterus held together that well. But if she had gone into labor, her uterus could very well have ruptured on the spot, without warning. None of her doctors realized that she had this window, so they had no reason to hurry the Csection along. After it was all over, I started wondering how many weeks earlier they would have wanted to section her if they’d known that was there.

After we stopped exclaiming, Dr. X incised the sac – largely ceremonial, since after all this manipulation it had started spurting out one side. He reached in and extracted the baby’s breech (=bottom) while I exerted as much fundal pressure as I could. Voila, large blue baby boy, who immediately started crying and kicking.

Then we went to work sewing up the uterus. Besides the fact that we hadn’t made an incision, and there didn’t seem to be any tissue in the lower uterine segment to sew to, and the fact that the cervix got torn, it wasn’t too bad. At least, with no uterine incision, we didn’t have much bleeding. Dr. X even let me put in a few stitches on the least complicated section, and then finished up himself with some very fancy footwork around the cervix and a couple bleeding spots. Then, we tied and cut the tubes. I’m not much in favor of permanent sterilization, but this was one lady in whom I felt that it was completely and totally indicated. Plus, it was simple enough that I got to do most of it. I am always in favor of those procedures.

Fascial closure, Dr. X let me do all but the very middle segment right over the bladder. I don’t know if he himself was sure where it was. I couldn’t tell where the bladder was in all that mass of fibrotic scar tissue. The general principle seemed to be to stay far away from anywhere it could even potentially be. For the skin closure, Dr. X produced a straight needle, like a huge fabric sewing needle with a cutting tip, and proposed that we should sew the skin with that. I saw that needle (Phillips, I think it’s called) once before in my brief surgical career. I don’t think it was on the skin then. He started it off on one end, creating a huge dog-ear, and then had me sew across. Of course I managed a blatant buttonhole almost immediately, and generally made a very raggedy closure. I was disgusted with myself, and with him for using that needle. I, myself, incredibly limited as I am, have done much neater, prettier closures with a plain vicryl and curved needle. Tsk. And then he tried to fix it by redoing and redoing the steri-strips. Straight needles have their place – in fabric. Humans need curved needles. I need to get back to the real surgery. . .

Overall, an exciting operation, good outcome (baby went to the nursery with a little tachypnea and retractions, but was expected to do fine), I got to sew on the uterus, which was a first, and I certainly learned about straight needles. Also, Dr. X forced me not to touch the curved needle with my fingers, but to adjust it in the needledriver with the forceps; which was good; because I needed an attending to give me permission to take the extra time to not use my fingers. Next, I need someone to make me take the time to palm instruments, and I’ll be all set.

Ok, it’s definite, I am not going to change my mind again: I do not want to do OB/GYN, anymore, at all. Two days of clinic without being in the OR or L&D, and I am bored to tears, falling asleep on my feet, right in front of patients (horrible!), and struggling to keep up with my preceptors. Either I have narcolepsy (I checked in Merck Medicus on my PDA), or I need to not do OB/GYN. I do not want to do another annual exam. I do not want to discuss vaginal bleeding anymore. Listening to babies is still ok, but I won’t miss it.

(Yes, ok, I’m trading for a discussion of rectal bleeding, but I somehow feel that that’s more solid: it shouldn’t be happening at all, so if it is we need to investigate. Whereas vaginal bleeding, you never know what’s normal or not, and you have to wait for months to go through a couple more cycles and see how things change after your intervention.)

I want to know: how many days can a practice of four academic ob/gyns and three full-time midwives go, without having a baby? I can just tell they’re all piling up for this weekend, when I wanted to be home for family things; but if these are going to be my last deliveries ever, I don’t want to miss them.

If my life becomes more interesting, I’ll blog more. Until then, it’s just one blurry day of endless clinic after another.

I can’t believe it: still no babies. Grand Rounds this morning was on pregnancy-induced hypertension and pre-eclampsia, so well organized a review of the literature that I stayed awake the whole time. Then I watched two gyn ultrasounds, and took the afternoon off. Went and picked more blackberries, some of them 4cm in diameter, warm and juicy. . .

I also picked up from the library Richard Abanes’ One Nation Under Gods, a history of Mormonism, having read Fawn Brodie’s biography of Joseph Smith, No Man Knows My History, the past few weeks. I’ve met a surprising number of Mormons here, for being in the East (relatively speaking), and I got frustrated with them telling me they’re just regular ol’ Christians, when I know quite well it’s a little more complicated than that. I figured I better know what exactly Joseph Smith said, so I don’t get confused. My main lesson so far: never vote for a Mormon politician; just as dangerous as having a Catholic king right after the Reformation. Second lesson: careful delineation of how my beliefs about revelation are different from Mormons’ is in order. So far it’s been pretty easy.

There better be some babies tonight . . .

The rest of the weekend was unbelievably quiet. I kept thinking, “They had so better not be delivering more babies, and not telling me.” But I had a great time, reading books, playing Risk and Monopoly (my brother and I conceded mutual victory on Risk, having wiped out our 9yrold sister; everyone ganged up on me for Monopoly, so I lost – it’s not my fault I got hold of a third of the properties!), sleeping through the night.

Today, no patients in the hospital! In clinic this morning with the midwife I saw a dozen ladies – all only 34 weeks; they won’t deliver till I’m gone. This afternoon, working with the chairman, I observed two things: I need to figure out a tactful way to tell him and the other attendings who have taken an interest in me that I’m not interested in OB/GYN anymore, don’t need advice about residencies, don’t need letters of recommendation.

Also: I need to learn to handle constructive criticism better. He was correcting my method of doing pelvic exams. I have been so far influenced by the residents – and all the other attendings except him – that I do them fairly quickly, with some descriptions of what I’m doing, but less than I was taught to give. His area of expertise, on the other hand, requires him to go very slowly, observing all the textbook steps of physical exam, and he describes in detail everything he’s doing. So, of course, I fell short of his standards, and he told me so. That has to be the gentlest, most correct, most valuable, most warranted criticism I’m going to receive for the rest of my career, and I was having a hard time with it. I need to fix that before I spend much more time with the surgeons. I like them, but gentle and constructive criticism is not their strong point.

I don’t have anymore birth stories to tell (this has to break, I expect to be called tonight), so go read Dr. Whoo’s story of eight babies in four days.

I’m having too much fun for a medical student. Friday night I went to a ball game with my family (I left after the twelfth inning, feeling morally obliged to get some sleep for a night on call). The next morning I picked blackberries with my sisters – which are the best possible berries to pick, since they’re large, have no thorns, and grown on tall, shady bushes. I just started a new cross-stitch project, which I might finish in time to hang in my new apartment next year. And I have a nice stack of good books which I am progressing slowly through.

On the other hand, I spent a while Friday afternoon being furious because the Csection was cancelled (an amnio done the day before showed fetal lungs not completely mature) – and no one told me, so I spent two extra hours in the hospital instead of driving to see my family, and only found out about it incidentally when I came over to the surgery area. I wish people would tell me things. Someday, I will be a grown-up doctor, actually contributing something to the patient’s care, and then few things will happen without me knowing it. I hope. In the meantime, I need to stop stressing out about this stuff. If I hadn’t wasted the time talking to friends instead of studying, I would have felt better about it.

Saturday morning around 1am the midwife called me: “We’ll be having a baby in about an hour. She’s a multip, about 8cm. Oh, and it’s going to be a water birth.” Aha. I’ve been longing to see one of those. I raced over to the hospital, and found that I had previously met the patient in clinic. (Always much better than meeting the lady as she’s absorbed in labor.) The couple were in the tub together, and had three female friends watching/helping/encouraging, besides the midwife, the nurse, and me. The mother had headphones, and seemed to be doing very well lying in the tub and breathing. Pretty soon she became a good deal more uncomfortable. Everyone always feels very bad at that point. I know from the medical side I feel the least bit guilty for having wanted women to do labor naturally. The friends and husband seem to feel pretty upset too, just seeing her in so much pain and not being able to offer much besides words of encouragement, and warm and cold water (externally and internally). I know from accounts that just general “support” is helpful, but it feels inadequate in the face of so much pain.

Soon she was ready to push, leaning back in the tub. The midwife and I had sterile (for how long!) gloves on, and were leaning almost into the tub, in order to be able to reach her. One aspect of water birth that I had not considered before was . . .  something that necessitates a “fishnet” being produced. You medical people know what I mean. I decided, on the spot, that I myself will never give birth in a tub. Labor, ok; birth, no. After about 15 minutes of pushing, the baby crowned, and came out easily. Amazingly, after we got her out on the bed to do the placenta and dry the baby off, she had no tears. Certainly not my fault, since I was spending more energy not falling into the tub than supporting the baby’s exiting head.

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