Thursday, February 25, 2010

I gotta warn you, I'm a puker.

So many things happen in a day in the hospital, but I usually only have time to write about one. So here's the one that stuck out today:

After a relatively unremarkable surgery day, we were called to consult on a patient upstairs. An 84 year-old patient. "Sooo she's not pregnant?" Nope. Which means it isn't the usual, pretty harmless, "she has a slight cough, but she's pregnant and I've forgotten how to look up the pregnancy classes for antibiotics myself." It was most likely something narsty.

The story we got: She had pneumonia, then had C.diff diarrhea from the antibiotic, and now has copious clear discharge "from we don't know where". The stuff coated her from waist to knees and soaked her bed. But they didn't think it was urine because she has a foley in. And diarrhea wouldn't be clear. Are you seriously asking us to go poke around an 84 year-old's Dirty South and to find out where your leak is? UUUuuuggghhh it's a bad day to be on Vagina Patrol.

We trudged up to the floor and sought out the nurse to have her describe it to us. Before she started, I decided to give up on looking dignified and just told my attending, "I've thrown up twice in medical school, and they've both had to do with smells. One was directly vagina related. This is just a warning." When the nurse used the words, "Just keeps coming", "Thick sticky"-- I can't type this anymore. Let's just say I started to gag and the attending turned to me and said, "Stick to the wall and mouth breathe."

When the internist who called for the consult said the lady was "Mostly with it", he was mostly delusional. This poor lady was drawn up, limbs barely able to move, and she didn't really respond to our questions. With a patient like this it's even more important to examine her, because she probably can't vocalize if she's in pain or uncomfortable. Which still sucks because I'm sure she was confused as to why two strangers came in with gowns and gloves (did I mention she's on contact isolation precaution due to a positive MRSA swab?) and started prying her legs apart.

It was everywhere. I Darth Vader-breathed in the background until I pulled myself together enough to go comfort the patient. That's probably what did it for me; I used to work in a nursing home and really do like to take care of the elderly. They can't fend for themselves in the healthcare system, and no one ever looks like their best version in a hospital bed. It's not her fault she has ice cream all over her chin; someone should have cleaned that up.

It was evident we would need to do a speculum exam. We had to do it in the hospital bed because we didn't want to take her to Labor and Delivery with MRSA. Unfortunately that's not the ideal place to do a Fire in the Hole. "Wish I had my headlamp" I muttered. "That really would be useful," my attending agreed.


"If I'm not back out in 15 minutes, call Search and Rescue. And the Ghostbusters"

While going back to Labor and Delivery we talked about possibilities. What could cause a clear, non-odorous vaginal discharge like that? "Well, she might have a plugged Skeine's gland". "I didn't feel any plug or mucocele." "When women get aroused, plasma seeps out of their vaginal walls for lubrication." "That would be a lot of arousal." "I mean maybe she has a clot that's causing a weepy vaginal edema." "Or a cervical stenosis could do that." "You know, it reminds me of that opening scene in Ghostbusters where the librarian gets totally lubed." "Wasn't that green though?" "No, I thought it was clear and pink." "We should go back in there with boxes strapped to our backs and laser-lassos." We gathered the goods, tried to arrange the patient, and my attending did the exam while I held the flashlight. This time the patient had a few things to say, mainly that it hurt to move her legs. I felt so bad doing this to her.

In the end, I think it's either cervical stenosis or a mucous-y urine leaking around her Foley. I'm pretty excited to see the lab report tomorrow. And hope it does NOT mean that we have to go in there again.

Wednesday, February 24, 2010

"Train Wreck" doesn't even begin to cover it.

What do you call a 37 y/o woman with looks like she's been rode hard and put away wet, with congestive heart failure, COPD, diabetes, new-onset chest pain, 7 miscarriages, 2 stillborns, 3 live children (none of whom live with her I was told), and a 5-week old embryo cooking in her well-used oven?

My patient.

She was also belligerent, insistent on repeating how horribly she was being treated, and seemingly unaware that pregnancy could very well kill her. And no, she didn't want to hear about it. Even saying, "This pregnancy is considered high-risk" got her hopping mad--not that she should hop in her condition. "YOU'RE SAYING I SHOULD HAVE AN ABORTION AND I WON'T!"

Actually we weren't. Not to her face definitely. Yes, she has a good chance of dying with this pregnancy. Yes, she has three living children. No, we would not have ever recommended pregnancy to a patient like this. Draw your own conclusions. Honestly, she'll probably miscarry again due to her poor health.

Nobody in the practice wants to touch her. When I went in with the doctor I was working with for the day, I stood in the back with my arms folded and a serious face so that maybe she'd get a bad feeling about that doctor and not ask to see her when she left the hospital.

"I want morphine! And 13 more pregnancies! And a pony to ride out of here on!"

Tuesday, February 23, 2010

Denial really won't help you right now.

Friday as snow started to fall wet and heavy I eyeballed the parking lots wondering how long I could safely stay there without destroying my weekend going-home-to-hubby plans. Of course, that's when one of the wildest patients I've seen yet decided to come to Labor and Delivery.

By decided, I mean felt like it was the optimum place to go after feeling strong continuous contractions while in labor with a child she didn't know she was pregnant with. Contractions strong enough to dilate her to 7cm and 100% cervical effacement. Yeah.

She didn't know she was pregnant Al? For realsies? Well, that is what she said. Also, she told me her last menstrual period was 3 weeks ago.

Before you say "OH she was LYING!", she might not have been. Several women who didn't know they were pregnant say they had periods all along. They aren't really periods (there are a lot of reasons women bleed during pregnancy), but if you had irregular periods all along, or if you didn't think you were pregnant and tended to see life as if you couldn't possibly be, you could probably take any sign of bleeding as your "period".

Sometimes pregnancy tests can be negative as well. I have a friend whose doctor told her she wasn't pregnant, put her on a medicine to make her have a period, and then she found out she actually WAS pregnant.

The next question people ask usually is, "Was she really fat?" Nope. She was the degree of skinny only methamphetamines can get you. Which, after looking at her mouth, I'm pretty sure she'd sampled once or 500 times. So I don't know what she thought the squirming mass beneath her belly button was, but I after seeing the needle marks on her arm I wouldn't have been surprised if she told me Barney had taken up residence in there and was inviting all of his pink elephant friends over for tea and crumpets. Oh yeah, she told me she didn't use any illegal drugs either. When I asked how much she smoked (No need to ask "if", she smelled like a truck stop) she said, "A lot." As in 2-3 packs a day.

She didn't have any STD's two years ago when she spawned her other child, but who knew what happened after that. Since she didn't have prenatal care we didn't know if she had Group B strep (some women have it in their vaginal canals, it can give babies meningitis, sepsis, and horribleness). We also didn't know how far along she was.

After mid-pregnancy, you can use a tape measure to estimate fetal age. you start at the pubic bone and go up and over the fundus. Cm=weeks gestation. She measured 29 weeks which put all of us on high alert. At 29 weeks, it was very likely that the baby was going to have problems breathing. We couldn't give steroids to speed up baby's lung delivery because that baby was coming out before they would have had enough time to take effectShe was dilated to 7cm, so she was too close to delivery to send her to the city and it's specialists.

We got an ultrasound, which is accurate + or - a few weeks in the third trimester. Radiology said just over 33 weeks, which was an improvement. It's very possible the fetus was growth restricted due to all the chemical insults Mom was slinging at it. As an aside, when you read about preterm labor, one of the reasons theorized for it is that the fetus recognizes a "hostile environment" and in layman's terms decides to get the heck out. Of course this is not the reason for every pre-term labor, and sometimes hostile environment can mean something happened to the placenta or umbilical cord. I'm definitely not saying it's always Mom's fault. But let's be honest--this time, if I could bet my imaginary month's salary, my money would be on blaming the crack addict in the stirrups.

We called the on-call pediatrician and alerted the Children's Hospital down in the city. Did I mention it had already snowed a fresh three inches in the last two hours with no sign of stopping? It would take them at least an hour to get here in good weather.

All in all, it was a crap situation. It was interesting to me how the nurses, who I would have expected to be taking turns cutting each other with needles out of frustration, treated this patient like she was a child, coddling her and comforting her and absolutely NOT letting it show that she might have done a few stupid things. Which was totally perfect. And inspiring. Here are some of the snarkiest of snarks, but after seeing someone truly needing support, they were just awesome with her.

That may seem like a departure from the somewhat ranting tone I took early in the post. Don't misunderstand; I still think she couldn't identify a healthy decision if it walked up and pierced her nipples. But what would the use be in bringing that up now? That horse left the barn...and got pregnant. We have no idea what she went through leading up to this. People who abuse drugs stop developing emotionally at the age which they start abusing. In my mind she was a child. And as much as I rant, when I see someone suffering, even if it's as a consequence of their own choices, my heart hurts. Yes, I have one. How can you make a woman feel bad when she's in pain and confused and scared? Yeah, dumb as a sandbox, but is that not even more of a reason to show compassion?

They were unwavering in their support, even when she cursed and screamed and her head spun around her neck. Ok that didn't happen. But she did yell, "I'm gonna SSHHHHHIIIITTTT" and did. The nurse said, "It's ok honey, everyone does it." Another said, "It's just part of life honey" It is, they all do, and none of the 30 other deliveries I've seen have bothered me, but while they were saying comforting things I was gagging behind my mask and wondering how I could excuse myself if I actually did throw up (you know how sensitive I am to smells and this was the WORST).

When that baby was born, amid her cursing strong enough for the doctor to actually say, "You have a problem.", it was the first time I had seen a birth and didn't think of it as a miracle. Watching that happen, in those circumstances, I felt like I was watching an unfortunate consequence of biology. There was no thought of baby's future, or a family welcoming it. It was purely a byproduct of nature, unexepected and unprepared for. You have an action, sometimes this happens after it. The baby might as well have been vaginal discharge after an STD. I understand that sounds crass, especially to those black-and-white types (who probably have never seen a situation as gray as a meth addict's teeth). I'm just explaining how it felt.

The baby actually had APGAR's of 8 and 9. But then she (we were glad she was a girl--they are tougher and have higher survival rates after preterm birth) started to have retractions (trouble breathing). And she was a peanut, weighing in under 5 pounds.

The nurses started calling her "Chloe", but then the Mom said some name I've never heard of combing the top three most popular syllables and consonants (K's are very in fashion right now, by the way). I can't believe we were just going to give her back to that woman. I guess that is pending the urine drug screen results.


"God, why did you give me THIS woman as my mother?"

Sometimes when I leave the hospital I'm just sad. I feel like I have a weight on me when I think about some of the situations I've seen during the day. I passed the ambulance going towards the hospital as I drove out of town. The mom left at 6:00pm that night. I'll just have to rely on word of mouth to hear how they are doing.

Except for one thing: The Children's Hospital called on Monday to let us know the Mom had tested positive for HIV. I guess our hospital lab didn't think it was important enough to call us directly. The patient hadn't known and hadn't gotten any anti-retrovirals, so the baby has a 25% chance of having acquired the virus during the vaginal delivery. I'm very fastidious about personal protective equipment, but it certainly would have been nice to know what I was dealing with when I was standing in a puddle of blood and amiotic fluid. What a way to end such a fantastic case.

Sunday, February 21, 2010

Shots! Shots! Shots!

While on call the other day we were paged to the ER for a confirmed ectopic pregnancy. She was fifteen years old.

She had known for two weeks that she was pregnant. Her mom was in the room with her, and they both knew at the time that she had forgotten to put in a new Nuva Ring around Christmas. Folks, this is why teenagers should never be put on the pill. The Nuva Ring is something you only have to remember twice a month. Once to put it in, once to take it out. If she couldn't remember THAT, how do you think she'd ever manage something you have to take every single day? Remember, teenagers are generally idiots. I recommend the Depo shot. Sure, some people say it makes them fat and crazy, but I think that's a great side effect when you want to stop teens from getting pregnant.

Not the point of the story. The point is that she was 15 and had a large extrauterine pregnancy that had to be dealt with. She was too far along for methotrexate (a chemotherapy drug that stops rapidly dividing cells, such as a fetal cells), so we had to go to surgery. Now we had to talk to her and her mother about how she was going to lose a fallopian tube and possibly an ovary at 16. She would still be able to have children, but it would probably drop down to an every other month chance. I hate it when dumb decisions affect young people for the rest of their lives. Someday (hopefully!) she was going to be in a happy stable relationship, maybe with one of them working a real job (I can dream), and she was going to want to have a baby. I feel the same way about STD's. Kids don't realize you can get them without having "real sex"--vaginal sex--a lot of teens don't count oral or anal sex as "real sex"--and don't think about STD's either. It is so sad when a patient got chlamydia from her high school boyfriend, and didn't realize it could make her infertile later. Or that HPV, which you can get even when using condoms, could give her cancer or warts for the rest of her life.

Mom and daughter were both in tears, nearly hysterical, but there was no other choice. So we got an OR spot, and the staff took them back to the holding room. The patient asked us to wait until her boyfriend got there before we took her back. This kid showed up looking like he'd walked out of a Calvin and Hobbes comic. Spiky hair, oddly short legs (or just really low pants), kid sneakers, and the dumb bewildered look on his face that I've come to expect from teenagers who found out that even blind squirrels find acorns once in a while. If I were her mom the only way I'd let this kid come to the hospital was through his own trip to the ER.

She told us when she'd gone to the bathroom before coming back to the hold room, all of a sudden she'd felt very sharp pain that continued to get worse. As far as we were concerned, that meant she'd ruptured her tube.

Sure enough, once we got the laparoscope in she had a pelvis full of blood (500ccs). The crazy thing about her ectopic though was that it actually wasn't in her tube. It was ON her ovary. It looked like a swollen purple sac of blood sticking out of white ovary--it was bigger than the actual ovary. And the placenta had begun to attach itself to her abdominal wall. Ovarian ectopics make up 3.2% of all ectopics. I never thought I'd see one. Her placenta attaching to the wall was very dangerous. Placentas invade by nature; that's how they wrangle blood supply from Mom's uterus to feed the parasite, I mean, baby. If the placenta had invaded her abdominal wall, it could have put its sticky fingers into a number of blood vessels. We needed to remove all the pregnancy-related tissue, but had to be extremely careful we didn't open up a blood vessel by removing placenta.

Lucky for all involved, the placenta had not yet invaded. It pretty much peeled off the peritoneum. And since the gestational sac was on one end of the ovary and didn't touch the tube, we actually just removed the sac and were able to leave the tube and remaining part of ovary intact. She still has two tubes and two ovaries to try to get pregnant with. Which I was excited about until her nurse told me that she had actually been trying to get pregnant at fifteen by Little Boy Wonder.

I always wondered if I'd be able to see a little fetus in what we brought out. I didn't try. I thought it would be creepy and upsetting to see it. My attending said one time a lady came in so far along, and the fetus was actually still alive, that you could see it's heartbeat and hand waving on ultrasound. There's nothing you can do; you have to save the Mom and you have to take out the pregnancy to do it. But if it's a desired pregnancy I think that would just be a heartbreaking surgery.

Friday, February 19, 2010

Why?

Another long day. But here are a few highlights:

One lady scheduled for a c-section had not been told to remove a piercing she had in her..ahem. Nope, not the belly button. You aren't supposed to have any piercings in you during surgery because we use electricity to cauterize just about anything that bleeds.

A nurse came out of the room exasperated, "We can't get that piercing out! I tried to turn the ball around and around and it didn't come off!"

I had the choice of watching yet ANOTHER vaginal deliver (my sixth today), or trying my hand at the thing. "I'll catch up to you later Dr. H. I've seen a delivery, I've never seen a clit ring." "OH Thank you!" the nurse said.

I go into the room, introduce myself confidently (you can't f#$^ around if you're going to go after someone's clitoral ring), kick out the 14 family members who are there to witness the birth (hah, imagine explaining that to your in-laws...or the unmarried equivalent), get the needle driver and hemostat, put on my gloves, and take a look.

What the what? I had not expected this style of ring. After some detective Googling (and a lot of firewall-blockage by the hospital's internet), I discovered this was a captive-ball style. The ball is just for kicks. Ooookkay. Next search: "How to remove captive-ball piercing" (I found that leaving the "clitoral" part out sidesteps a lot of the more offensive listings out there). The answer "Go to your jeweler. Attempts to remove the piercing yourself often result in infection and tearing of the pierced tissue."

Oh hell no. I was not about to go yanking around a woman's genitals if that's what I had to look forward to. "Call surgery and get a metal cutter," I asked the nurse. Done.

I expected a straightforward cutter like the metal cutters my dad had in his shop. What came was a bizarre circle and lever contraption. I couldn't even find a picture from the internet to post. "I have never seen this cutter. I'm not comfortable using this--I'm going to go find someone who is." As I explained to the nurse later, if she were pierced in her ear or nose, I'd go have a crack at it. What's a few tugs here and there? But I did not think it was going to advance my medical knowledge to go willy-nilly around her non-expendable parts. Especially with the 15 members of her family so close outside the door you can see the shadows of their feet outlined below it.

I asked the hippie anesthesiologist I'd done several surgeries with if he knew how to use the thing, saying I wasn't comfortable doing it myself. He'd apparently been waiting three weeks to talk down to me, as he basically ignored my question and started his reply with, "I know it's all cool to be a medical student and go take care of things, and you feel like you know some stuff, and next year you'll have to pretend while you learn Man, but I'd ask someone who knew how to do this to help you." Thank you for your astute observations and your help. If I see you wearing Birkenstocks in the OR again I swear to God I'm calling OSHA.

Just then someone was delivering, and I never turn down a change to get my hands on a fresh baby. By the time we were finished, the ring had "just fallen out" in the woman's hands. Oh yeah, that's after the nurse picked up the cutter and took a stab at things herself (it didn't work, by the way. And the patient wasn't too happy about it). I think after getting man-handled, the ring just gave up the ghost. Thank goodness. Proceed with C-section!

The other piece of fantastic for the day? Over in Antenatal it's almost like an ER for pregnant ladies. It's supposed to be for labor or directly pregnancy-related issues only, but since every time the ER physicians see a positive pregnancy test they assume it's pregnancy related (diarrhea? Oh the fetus probably has Crohn's disease. Sore throat and runny nose? Well, you're pregnant, so it's probably amniotic fluid leaking up around your Eustachian tubes while you sleep. Better call OB) the OB's end up having to see everyone who even might be pregnant.

This time it was a lady who was 30 something weeks along with twins. Her complaint? I can't even keep a straight face while I type this. She'd had some cramping in the morning, then she and her boyfriend had sex and now she's "leaking something". Who wants to go down that rabbit hole? One of the older nurses said, "It's been a long time since I've had sex, but if I'd had it this afternoon, I'd be leaking something too."

My job is so gross.

Wednesday, February 17, 2010

Room Full of Class

I'd like to take you on a walk in my shoes today. I will be narrating a few of the day's events, with my thoughts in italics.

One of the C-sections today was a 309 lb woman. I knew what my job would be. Another hour of vagina curtain retraction. Oh wait, I think I said that out loud to a nurse.

If you've never seen a C-section from the surgeon side of the drapes (and I'm assuming more people haven't than have), there comes a moment as you are cutting through the uterus, gently and lightly slicing through thin layer after thin layer (so you don't cut anything you aren't supposed to), when the amniotic sac bulges out. Everyone takes a deep breath before the surgeon ruptures it: Alright, where's she going to pop? I gotta aim the suction wand right place so it doesn'tAAAUUUGGGHH it splashed all over me it's a fountain of ICK!! AAAUUGH IT KEEPS COMING!! Since there was an extra amount of pressure from her fatness, the stuff came out like a fire hose.

After surgeries were done for the day, we had a delightful delivery. I don't really mean delightful of course, I'm being snarky. It's just as delightful as you'd expect a 17 year-old's second baby by her second baby-daddy to be. The nurses had to keep switching around to take care of her. As soon as one was about to strangle the teen, she'd press the call light and another nurse would show up to gently pull Nurse 1's fingers from around Baby Factory's neck and send her off to the patient kitchen to pull herself together and maybe chug a Puddin' Cup.

I've seen several deliveries that made me want to cry, but not because they situation was so freakin' sad that I wanted to take the baby myself. For the love of vernix they were DDDUUUUMMMBBBB. This girl just laid on the bed saying things like, "I just want to put my clothes back on and go home." You should have said that nine months ago "I can't do it" I don't know who else is going to give birth for you. And you should have said that nine months ago. "Is it going to hurt?" How the hell should I know kid? You're the one on your second baby. But I sure hope so.

Did I mention that her biggest question before the delivery was whether her boyfriend and the father of the baby could both be in the room with her? Ehhhhhh you really suck at life. During the pushing and delivery, FOB and BOGHB (Boyfriend of Girl Having Baby--maybe I'll just say SOB) were both present, along with the girl's excited picture-taking mother (Ma'am, may I talk to you outside? Ok, so I'm going to slap you around for a little bit. Still, we should take a walk). FOB sat kind of shell-shocked in a corner, absolutely quiet, probably wondering how he got himself in this (I know) and thanking God he was just the baby daddy. New Boyfriend (SOB), was by the girl's side, holding her hand and chewing a plastic spoon like it was the last dip of Skoal at a demolition derby. (What are you, a kindergartner? Do you know how stupid you look with that spoon all flat and tooth-marked hanging out of your mouth? Would you like a pacifier from the nursery instead? I can't even look at you right now. As soon as I see something disgusting, I'm going to trick you into looking-If I'm lucky you'll pass out, if I'm luckier you'll never want to reproduce.)

I should mention that I was hungry during these thoughts.

She finally gave birth and I got the heck out of there, tripping on the 10 family members(ish) outside. I'm pretty sure I heard that the new baby had two older sisters, though Mom only had one other child. So Dad must have another baby too. There was another teenager with a 2 year-old mini-me on her hip outside the door. Mini-me was screaming, demanding to see her new sister. Would the mother of the dad's OTHER child really come to see the birth of the new baby? DO THESE PEOPLE EVER WORK?? I don't know. All I know is that they kept trying to come into the damn room while the mother's legs were up in stirrups, bleeding like, well, a woman who just gave birth. That is a disgusting enough simile, no need to be creative. Someone's sandwich isn't getting made at Burger King because you all called in sick to be here.

That is all.


Tuesday, February 16, 2010

Posts coming!

Last night was a 12-hour day followed by a phone call at 9:30 asking if I wanted to come back to help out with a surgery. I got home around 12:45 last night and went in at 6:30.

I have posts coming; it just takes me a while to write sometimes. Especially when I'm comatose.

Meanwhile, I fixed some of my pictures. Let me know if they still aren't coming up.

Toodles,
Your Pal Al

Thursday, February 11, 2010

I'm sorry, you no longer have a life.

I don't know how long this post will be; I have to go back to work in two hours.

Several of the doctors are back from their various tropical vacations, which means s#$ got real at the hospital. The attending who is in charge of me thinks its a great idea for students to see "what it's like to practice medicine after an entire day and night on call." I like my husband's description for it: "F#$@ing stupid." The only thing that might save me from having to sleep there tonight is that there is no bed for me to sleep in. That might save me. Another med student slept on a couch when she got assigned to this doc.

I can't go into how little I ate today. So I'll just say breakfast never happened (Doc wanted surgery to start early today unbeknownst to me), lunch didn't really either. When I asked (hinted) if the Doc wanted me to go get lunch for her, she replied, "It's call day. The adrenaline really keeps me from being hungry. Now let's go do another 2-hour hysterectomy." AAAuuuGGGHHH.

At the end of the day, I had planned to go snowboarding with my roommates. It was the light at the end of the tunnel. Unfortunately, there was an avalanche. "Well, surgery is over for the day," (4:30pm from a 7:00am start-the only break we took was to see an ER patient for a suspected ectopic pregnancy). "It doesn't look like anyone's going to give birth for a few hours. I'd come back at 8 tonight and give the night shift your phone number." Oh I did that yesterday. "I'd still come in again tonight at eight. Now go relax for a few hours." At least I get the few hours--if I didn't eat soon, I was going to beat somebody. Like that new mom who wasn't in her room during rounds because she was out smoking.

"I find that I operate best when I've neither eaten or slept for 48 hours. Also, I never have to go to the bathroom. But yeah, sure, I'm safe."

Tomorrow is going to be awesome. If you think I'm a loudmouth now...go back and read my night shift blogs.

Wednesday, February 10, 2010

Nugget

Those who have ever heard of Chelsea Handler should know that's her name for midgets. Which is the name for Little People for the rest of us without our own cable show.

Who cares? I care. Because yesterday a dwarf was born.

When I hit the floor Tuesday morning after surgery, I went over to antepartum to see if anything wild was happening. Antepartum is always an interesting mix of sick and crazy. When pregnant women get to the end of their "confinement", they are completely unpredictable. Sane women are nuts, nutty women are flinging poo; you just never know who's going to walk in and demand two fingers in their cervix. Which is what you do when you check to see if they are in labor you Sicko.

Yesterday my curiosity was rewarded. "There's a dwarf baby?" "Excuse me?" "We've got a lady in there, 5'9", and her husband is a dwarf, and so is the baby!" Well I gotta see this.

They were very friendly, and I legitimately had a reason to introduce myself (I generally try to make my first patient contact before they are actually pooping and popping in the stirrups--meet the face first, I always say). So I went in and chatted for a while. Mom was tall and thin thin thin. Laying on her back, she looked like she was 6 months pregnant at the most (she was actually 38 weeks). Dad had achondroplasia, the most common type of dwarfism. During the conversation, Dad, who clearly wore the shants in the family, casually referenced her as "Chubby". At 5'9" and 38 weeks pregnant, she weighed 120lbs.

"What did you say?" I couldn't quite see the funny in calling a pregnant woman weighing nearly 30 lbs less than me "Chubby", especially since I think someone that thin and nervous might have an eating problem. "Oh, I have the kids in on it too. They say "put down that sandwich Mom, you're so fat!" I paused, contemplating how serious I was about threatening a man half my size. Never having engaged in dwarf-slapping, I figured this wasn't the time or place. Plus, after a quick glance at Dad's hypertrophied arms, I'm not sure I would have won. Instead I said, "I'm amazed that you'd dare to call a laboring woman chubby! Try saying that when she has another contraction."

Determined to see the occasion, I gave the OB on-call and all nurses my phone number with explicit instructions to call me if it looked like she was going to deliver. No call came; they had sent her home because she wasn't technically in labor. I guess overnight she'd had enough, because later that afternoon she was back and we were scheduling her for a C-section.

They remembered me, because Dad (who some nurse said was a stripper) starting trading cracks with me as soon as I walked into the prep area for C-sections. "You're in on this? I hope you're not the first thing she sees!" he said, "I hope she doesn't look like you" I retorted, followed quickly by the thought "Damn it, that's not something you say to a dwarf who's about to have a dwarf baby."

I've seen women rocket out 9 lb babies au naturel with less fuss than this lady. She had a 5 lb-er cut out of her numb pelvis. I know it was numb because I pinched her with an Allis clamp before the surgery started and she didn't feel it.

Finally the moment I'd waited for: BABY!! She was pretty little, with shortened arms and legs and the facial features of dwarfism, even as a newborn. Oh but she was darling. She opened her eyes and looked around before letting loose. She couldn't keep her O2 sat up however, and had to get oxygen by mask. I don't really know if babies with achondroplasia routinely have problems right after birth, especially if they're a few weeks early, but this little one was headed to the NICU.

As I walked home, I looked up into the sky to see if there was a new or particularly bright star in the sky. "Surely a new star comes out when a dwarf is born" I thought. But alas, it was cloudy.

This morning she was out of the NICU and doing well. Of course I went to the nursery to check on her. I've fallen into my old Peds habit of starting the morning by greeting every baby I saw being born. I try to say comforting things, since the last time they saw me their heads were getting squeezed as hard as the butts at Hooters. I don't know how they feel about seeing me, but since I delivered two of the babies in there currently, I really love to see them!

"Shut your big gob and get out of my face; I haven't forgotten you."

Tuesday, February 9, 2010

Welcome to the World, You Adorable Screaming Little Monster.

I delivered a baby today!! I actually did the pulling and everything!

That is why I came to this rural hospital again. At my university, I delivered a few placentas. One kind resident let me put my hands over his while he delivered a baby. But this time I was the one delivering with my attending coaching me encouragingly behind me. It was awesome.

A lot of credit goes to the lady actually giving birth. This was number two, 13 months after number one btw. Crap she had skinny legs. I can't believe she had two babies in a year and looked that good. She made it look easy too.

Last week a physician gave birth. I think I mentioned her--I was excited to see someone older than me married and giving birth to her first child. Then she mentioned she was a doctor. I should have known.

She was the biggest whiner I've ever seen in stirrups. Actually she wasn't even in those yet. She knew it too. She apologized for being a whiner right before screaming bloody murder and cursing everyone in the room. "We need Anesthesia and a Priest" I thought as I crawled out of the room, trying to stay underneath her line of vision. She was in Labor for a good 20 hours.

Her baby was born a little small, under seven pounds, and on inspection had a two-vessel cord. That was a surprise, he had a 3-vessel one at an earlier ultrasound. That may have been why he wasn't growing like expected at the end. Now, being a doctor, she naturally heard "2-vessel cord" and flipped her sh#%. She wasn't a pediatrician or an OB, so she had my level of understanding--2-vessel cord=bad. We know just enough to list the bad outcomes, without the experience to recognize the (overwhelmingly) good outcomes. The doctor and I had to go in several times to talk to her about possible reasons for it, meaning we repeated the same "it probably just atrophied for idiopathic reasons". We did an in-house cardiac and renal ultrasound, which were normal, and still she couldn't get the skeptical/worried/anxious look off her face. When we told her about another baby born perfectly normal who weighed less than hers, she turned to her newborn and said, "Well we beat somebody kiddo!" "Look," my doctor said, "If you don't want him, I'll take him!" "I want him, I just want him to be perfect!" she whined. My God, if this is how the kid's life starts out...he's going to have a nervous tic by preschool.

So the lady I helped today was the opposite. She probably could have done it without me. I saw her and her family roll in around 9:30 that morning, looking for all the world like they were walking in to a shopping mall rather than L&D. She didn't even look like she was in labor. Two hours later we went in and broke her water-she was dilated to 4cm. She did seem a little uncomfortable then, but I don't even know if she had an epidural. An hour later she was completely dilated at 10cm and ready to push. I think the woman pushed 4, FOUR times and that baby was born. I had my hands on his head as he started to come out; he had so much hair under my fingers! Then I gently pushed down and up to deliver the anterior and posterior shoulders. He felt warm and soft, and slimy :-). I had to grip him around the back of the neck and help pull the rest of him out. I looked down at him as he took his first shuddering breath. I was in awe. Then I snapped back and put him on his mom's belly as she, her husband, and her sister all cried and welcomed him into the world.

After that I still had work to do. I clamped and cut the umbilical cord, drained the placental cord blood into a test tube, then clamped and held the remaining cord until the placenta separated. Then I delivered the placenta, holding pressure on the fundus (placing a hand on Mom's abdomen to make sure the uterus was shrinking and firming up, and not inverting!) and checked it to make sure it was complete-no chunks left in the uterus to become septic! Next we inspected the vaginal vault to make sure she hadn't torn anywhere--of course she hadn't, I already told you she was amazing at this. Then we got out of our gowns, congratulated the family, peeked at the baby again, and chatted for a bit before I could tear myself away from it.

It was such an amazing thing to be a part of. I don't want to be an OB forever, seeing as they a. stay up late at night, b. deal with dumb fertile people and c. sometimes lose babies, which would just kill me. But how awesome to get to do this a few times before I move on. I was the first person to ever touch that living breathing human being. I was the first person to look at his face and say hi. He only opened his eyes for a second, but I was his first glimpse of the world.

Maybe I should try to look prettier for the next couple of weeks.

Monday, February 8, 2010

Don't Make Me Pull this Surgery Over!

Today was one of the most difficult C-sections I've been a part of. There weren't technically any complications, the problem was that the lady was in her forties, and so was her BMI. She had also had a previous C-section, and plenty of scar tissue to prove it.

Apparently her thyroid had been on the fritz. When her doctor so helpfully set it to rights, she ovulated. And got knocked up (by her husband. My hubby says I can't use the words "knocked up" now that we're married). So here she was, with two teenage kids in the waiting room, about to become a parent again. The Insensitive Ass of the Day prize goes to the anesthesiologist, who contributed "I'm about your age, and I can't imagine how awful it would be to go through this again. Yuck. But good for you!" to the pre-surgery conversation.

Lately the scrub tech has been training new scrub techs (Crap, I think you're supposed to call them "Surgical technicians". I probably sound like those old coots who still say "stewardess". Though I do NOT indulge in any ass-grabbing. Woof. Anyway, this sometimes means there isn't room for me to scrub in. Today's trainee was especially panicky and hard of hearing, but they still needed me to scrub in for my favorite job: pannus-retracting.

I've talked before about how much I love a good pannus. And how it always falls to the medical student to deal with it, as if there is no other reason for us to be in the OR except to grab huge hunks of obesity and wrestle it until our arms shake. I try to think about how I'll never let the cafeteria lady talk me into the fried pickles again. I try to think of all the skinny suburban housewives in my gym, and how maybe this will help me reach my goal of wearing leopard print in child sizes. But the truth is when you have to retract anything for someone else in surgery, your comfort and structural stability is not what matters. You find yourself in the weirdest positions, squeezed between the patient's arm, the surgeon's hip, an elbow up your nose and head hitting the lamps if you try to straighten out, trying to hold 25 years worth of Big Macs at a 45 degree angle with your arms outstretched. Nothing is right with that.
"If I can just hold this position, nobody will know I have an enormous pannus!"

Methinks the patient was a bit thinner the last time she had a C-section, because the surgeon's now faced a dilemma: If they made the incision around the old scar, it would lay right in the pannal fold (I made that term up). It would hold the meat and cheese in the pannal taco (that one too). It would be subject to sweats that don't evaporate. Air that doesn't circulate. Not something you want an incision to sit in.

So they cut, and cut, and cut. The woman has a lot of scar tissue. Not her fault, just a pain in the ass. The fact that she had so much adipose tissue (I don't know if that's actually nicer to say than "fat globlets", but I tried) meant there were many more small vessels oozing and making a mess of the field. Plus, the attending had to keep cauterizing them, so the event smelled more like a barbecue than a birthing. Which I don't know if I minded; birthing isn't exactly a pleasant smell. Still, it held up the procedure because we had to keep stopping to burn the fat. During the surgery I shifted my grip and accidentally flung one of those little fat globs off of her and onto the surgical towel. "You're welcome" I thought to myself.

Once they finally got down to the baby, I thought my luck was going to change. The doctor assisting was going to take a turn holding the pannus while I pushed on the baby (I had the better angle). Unfortunately, because the woman's abdomen was obese, that little squirt was deep in there relative to where I thought, and quite frankly I don't have the experience to find a butt the size of a baseball in a belly the size of a featherbed. So I switched places and went back to retracting the ol' vagina-curtain while they worked to get baby out.

During this whole time, FOB (father of the baby) was nervously running his mouth. He had the video camera in hand, and it took 3 nurses to convince him that he couldn't videotape the actual delivery (too much liability involved). Sir, you can't take video or pictures until after the baby is born. No sir, you can't tape the baby coming out. No sir, not until the baby is born and with the pediatric nurse. No sir. No. NO. Every few minutes I'd hear him behind the drape, "Is he out yet?" Or "I don't hear him crying yet." "Is he almost here" "Does it usually take this long?" Or I'd see the video camera come peeking up over the drape as the guy tried to stand up and see the baby the very second after he came out. "We haven't even started yet." "We're still working on getting to the baby" (you don't want to say "we have to cut through 5 inches of fat, then the scar tissue before we get there). "It won't be long sir" "PUT THE #$@$ING CAMERA DOWN!" It was like being in a car with a child; I almost said, "Don't make me pull this C-section over"...or asked that he be seat-belted to his stool.

After we finally got the kid out, the anesthesiologist made a few "You'll never sleep again!" comments, and Dad took the baby out to see family. Mom was apparently so relaxed, she fell asleep. P.S. You don't get ANY sedation during a routine C-section. All she had was a spinal block. I knew she was asleep because I could hear her snoring on the other side of the drape. "I think our lady has a little sleep apnea" the anesthesiologist said. "While she's been snoozing here her sats have routinely gone down to the 80's, and twice they've been down to 60%." Holy Snap! Her brain is taking a hit. When she woke up he asked her if she experienced any daytime sleepiness (a common symptom of sleep apnea). "No, not really," she said. Well, you know, except that she fell asleep at 9:30 in the morning while three people were wiggling their hands in her pelvis and oh yeah, she had a baby too.

I can't imagine having a suprise baby at 44. And it makes me sad that she already has some scary health problems. I think since her O2 sats were so low the OB attending was going to have a pulmonary consult on her while she's in the hospital. I see daily reminders of why it's important to stay at a healthy weight. It affects so many things you don't realize, from how well you sleep at night to how well you tolerate medical procedures.

Now, if you'll excuse me, my Lean Cuisine is calling. Sigh.

Sunday, February 7, 2010

Pregnant or fat?

If you've never found yourself wondering this question in public, you probably don't live in the Midwest. Most people know better than to actually ask it to anyone other than themselves or a very quiet friend (it helps if they have bat-like hearing so that you can mumble the question under your breath. If you don't even have to say the question out loud for them to know what you're thinking, you should marry that friend.) If they're pregnant you're probably safe (but with those hormones a-ragin' you don't really want to point out that they are ballooning around the mid-section-just a tip). If they aren't pregnant, well you've just pissed off someone bigger than you, you idiot.

In the labor and delivery ward, you would think it would be a pretty safe place to assume people are knocked up. But even in the medical field, even in the OB profession, you never assume a woman is pregnant unless you are actually seeing a fetus come out of her va-gingo. New moms' uteri have not yet recovered from the indignity of 1. Being occupied and 2. Getting pummeled day and night by the little squatter. Even the skinny moms leave looking 7 months pregnant. You only know they aren't by the fact that they're awkwardly carrying a angry little human with them.





"What do you mean pregnant? There was birthday cake in the breakroom!"







You can't assume any parent with a child over six weeks couldn't possibly be pregnant either. One of our patients gave birth to her second child in less than a year. I bet that was an awkward conversation at the doctor's office. "Ok, now that you're six weeks post-partum you can have sex again. So what birth control were you thinking? Not the pill because you're throwing up every morning? Uhhhh yeah....we should talk."

Sometimes one has to take advantage of these sorts of social oddities. On a recent outing that involved birthday dinner at a Mexican restaurant, I knew things could get ugly. There was queso dip involved after all. So I sweet talked my hubby into wearing his thrift-store "Daddy to Be" shirt (he was actually wearing it the day we met-it wasn't true then either Thank God). As long as I kept my drinking surreptitious, I could eat as much as I wanted that night, and NO ONE would be wiggling their eyebrows behind my back. Hah.

In short, this is a situation that often requires finesse and professionalism. So sometimes I just back out of the room quietly and go get a nurse who knows who is the patient, who is the father(-ish) du jour, and whether any of the other people in the room happen to be pregnant.

Wednesday, February 3, 2010

Alien!!

Gyn surgeries include C-sections. Which I love! Despite the "Will I puke/Will I cry?" questions in the back of my mind, I love seeing babies borned.

We did a C-section today on a woman who might possibly be missing her rectus abdominus sheath. I don't really mean that, but from what I could see, she had nothing but a layer of skin separating that baby from the outside world.

The doctor doing the surgery tried to warn me as we were heading to the OR. But I thought she was just making conversation, not giving me a heads up so I didn't yell "WHOA WHOA WHOA" when I saw the baby's facial features clearly through a stretch mark. Which would be totally unprofessional of course. And hopefully something the mom wouldn't remember it once she got the anesthesia.

I have never seen anything like it. When the nurse undraped her abdomen, it was like seeing a baby laying on the woman's stomach with a layer of brown silly putty stretched over it. A baby pushing on the walls to get the heck out of there! I didn't know if she was pregnant or had unhinged her jaw and swallowed a baby.

Once we started cutting, I actually saw her rectus sheath. It did exist. But holy schlamoley did she had some work ahead of her. I bet when she stands up she can grab her colon and squeeze out a fart.

I'm sorry, that is a disgusting thought. Maybe I should just stop typing.

Monday, February 1, 2010

Back in the Saddle

Day One of my gyn surgery rotation.

I saw a lot of vagina today. I was expecting to see the isolated surgical species, but the attending I was with also happened to be on call. Which meant more vagina than you could shake a...I just went to the gutter. Fill in your own joke.

As usual in the town where I am working, most of the patients were either some flavor of crazy or unmarried, 20 years old, and G3+ (meaning they've been pregnant at least three times). Some of these women are having tubal ligations before mine even get broken in.

There was also the inevitable teenager. This one was particularly great as she was one of the most outta-control diabetics I've ever seen. We're talking a hemoglobin A1c of 13.7%!! That means she had so much glucose swimming in her insulin deprived bloodstream that a certain type of hemoglobin in her blood was glycosolated (glucose-ated) at an obscene level--normal is below 6%, diabetic control is 7%, hers sucks.

It's pretty common to have poor control in teenagers. They are generally idiots. And I include myself in that assessment, as a teenager I sprained my ankle twice, then when it got better I sprained it again by purposefully cleating a 3rd baseman in the mitt (while not wearing my ankle brace--to be fair, she deserved it). Then 6 weeks after the surgery on it, I sprained my other ankle playing "one-footed basketball" because I was so stir-crazy. Luckily my boyfriend at the time could carry me back to my dorm.

Anyway, teens think they're invincible. Teens don't want to do what someone else tells them. Teens don't want to stick out by being diabetic. Teens are morons. Lots of reasons for them not to follow their regimen. But when teens get pregnant and are diabetic and possibly morons, it is a bad deal all around. I guess it's not intuitive to some people that pregnancy and diabetes are not pals. At least, not to anyone who hasn't seen STEEL MAGNOLIAS! I bet doctors in the 80's didn't have to deal with this shit. Not after Julia Roberts so classically portrayed what can happen if you're uncontrolled and pregnant (in case you didn't see the movie--unfortunate haircut, coma, and death). Long story short, we now have a teen mom whose baby is got shipped to a Children's Hospital weighing in at a whopping 4lbs. The risk of congenital birth defects in a patient like that are as high as 18%. This was a lucky baby, all things considered.

Oh, and now for the funny part. I usually assume the bewildered looking guy in the room is the father...ish. Teen Mom's besties were going to the cafeteria for Mountain Dew and bags of fried crap (DANG your teen metabolisms!), and when they came by they helpfully said, "Um, a nurse said she needed to sign some kind of afa-didi? They're ready". "You mean an affadavit?" "Uh, yeah, she can do it now." After they left, the nurse said, "Weeeellll, we're ready for them to sign, but she's not sure of the paternity." "Hmmm...does he know that?", I asked, now understanding a bit more about why that guy in the room looked confused. "Yeah, he knows and she knows (that's good), but no one else does."





Perhaps not the best way to determine the father of your child.




My doctor said she has more and more teenage patients unsure about the paternity of their babies. They want to know exactly when they would have conceived, or how soon they can have paternity tests done. Yikes. Tell me again why sex education is a bad thing?