A full moon and no prenatal care!

The doctor i admire most on my rotation just got back from a two week trip to Ghana where she performed all types of surgeries/ deliveries. On her first night back i decided to stay and hang out while she was on call (i am not required to take call because they have no beds for students, so i decided to stay around and see what happens). The whole day seemed to be very busy, and full of crazy people. esp crazy people who obviously think that prenatal care is an optional method of care.

So I am sitting with the doc looking at her pictures from her trip to Africa, listening to the interesting cases and crazy debauchery that happened and a page comes in from the ER. There is a 17yr old pregnant women seizing. So we basically run down to the ER, and find a 17yr old seizing, intubated, a crowd of people in the ER room, and no where to stand....

withing 10 minutes we had an ultra sound done, a vaginal exam, and she is being prep'ed for the OR for a stat cesearen. During this i am trying to talk to the family to get some history information since the patient is sedated, intubated and currently unable to communicate herself. The only information i am able to ascertain from the family is she is due on sept 3rd, and has not seen a dr yet, she lives with her mother and brother, dropped out of high school, the father of the baby is not in the picture, and she is only been taking prenatal vitamins for the last 2 months. This is not a really good state for the patient and the only thing running through my mind is, THIS IS AWESOME!!! i have just seen an ecclamptic seizing patient, and now i am going to learn how to manage someone with untreated pre-ecclampsia....

unfortunately this happens to me a lot, where my thought process is opposite of normal. As a med student, when a patient is in bad shape/ sick, i get excited and get even more excited when the patient gets worse! its slightly disturbing to say, but its def true. there is always a part of me that hopes that the patient gets worse. When i sent off labs i secretly wished the labs came back with elevated LFT's, low Platelets and hematuria, high uric acid and possible mag toxicity. I know that i should want the patient to get better, but i learn by seeing, and if i dont see a patient with a certain problem than my only experience is what i learn from a book. And lets face it, treating people is not as simple as the book makes it seem, so having some hands on experience is better than reading it from a book. But in order to learn from those rare, and difficult cases there has to be a patient on the other side actually experiencing disease process.

Then there is another part of me who thinks, if this person had been seen by a physician on a regular basis for prenatal care, the likelyhood of seeing a patient like this is low. Similar to another patient i saw who is from Haiti. Speaks no english (typical) and doesnt speak Spanish (which is getting soooo much better since starting rotations)...she is postmenopausal and has had vaginal bleeding for the past 3 months. Well, lets just say you could diagnose the cancer from outside the room due to the smell of necrotic tissue. She has a stage III cervical cancer, than is non-operable. She also has kidney failure are a result and is basically not doing well....the family wants everything done, so we will spend a lot of $$$$ trying to prolong her life a few months.

I have a friend who had been diagnosed with cancer halfway through our second year of medical school, tried treatment, got sicker from the treatment, treatment is not working, so he decided to stop the treatment and just live his life (whats left of it) as he wants, with his friends. Here is a man who is 23 with an entire life ahead of him, who has accepted that nothing can be done. And has put quality of life ahead of quantity of life. Juxtapose to the women who is 76, weak, dying and is going to have difficult aggressive treatment with lots of side effects to prolong a life that has already been lived a few more months. I think my friend is handling his life/death with such dignity and positivity that i truly admire him. Its really sad, esp when you hear him talk about knowing he is going to die, but there is still that same life spark in his eye, that just makes you smile and keep going.

those rumors are true....

Before starting medical school, i heard the stories about attending physicians grilling med students, the sexual harassment that goes down in the OR, and the caddy drama that goes on around the nurses station. In the world of hospital medicine there are two different worlds, and one of them has nothing at all to do with patient care...

For the past few weeks i have been speaking to some fellow female classmates also on rotations in different hospitals to find out what types of experiences they are having working with their male attendings....and it definitely has been getting a little interesting.

Here are just a few of the stories that i have heard in the last week...

- my attending while in the OR mentioned to me, that "because you are a smart, bright and driven woman, you are going to have a hard time getting married. But on the bright side, you will never get divorced" its nice that a surgeon has taken the time to find a silver lining in my love life.... he also mentioned that in order for me to find a man i should try and dumb myself down....instead i am hoping to find a man that isn't so insecure about his position in life...if i don't find one, than i will be glad i decided not settle for less than i deserve...

- a friend while on a peds rotation at a childrens hospital, was standing at the nurses station with another med student, when her attending comes up from behind..smacks her ass and gives her an order to complete in the same breath..."we need to cancel the clindamycin and start on PO antibiotics" ...i am sure that there are better ways of getting a students attention without subjecting her to sexual harassment. Esp because the student was caught so off guard she completely forgot to write the order in the first place...so here is an example of how sexual harassment can directly affect patient care...

- another friend of mine happened to be wearing a button down shirt, and about halfway through the day noticed that a lot of the male attendings were paying more attention to her than normal, and even smiling at her in the halls, and elevator....finally she ran into another classmate who told her that the top 3 buttons had come undone on her shirt!! she figured it had been about 3 hours before someone had told her about the fact her shirt was totally open, and she had no camisole on that day either...


- unfortunately there is a classmate of ours giving the rest of the women in the class a bad reputation....there is a girl who has decided to cross the line of appropriate behavior with her attending....lets just say the story line for McDreamy and Meredith didn't come from thin air....

Anyways, still loving rotation, and still making a fool of myself on a daily basis, but i think i am learning and getting better too. In the last few days, there have been over a dozen babies born, and about 5 ectopic pregnancies....so do the ectopic cancel out the new babies and make the net total for the week 7 babies??? or does baby math not work the same way....more questions to ponder....

my attending also used an old joke the other day during morning sign out.....the night before we had delivered a baby that had a fetal anomaly, and had been born with a short femur on one side.....so in morning sign out he mentioned that the parents should probably name the baby girl, Ilene!! (pronounced I - Lean) for about the next 20 minutes we could barely contain the laughter. For some reason at the time i had never heard that joke be so amusing....

not sure if i mentioned earlier how the service OB always gets the crazy patients....well yesterday was no exception....we had a G7 P6016 give birth vaginally to a 9lb 7oz baby...here is the interesting twist to the story, we were given explicit instruction not to tell the husband about the other pregnancies because he thinks its her first baby.....she married a man and he doesn't know that she has 5 other children in another country (only in south florida), so she ended up pushing a 9lb baby out of her vagina in just 2 pushes, not to mention there was no vaginal tearing.....that is def what happens in a nulliparous women (first pregnancy) JUST KIDDING, plus if anyone actually looked at her vagina can see that she has pushed multiple children out of her vagina...maybe he is truly living up to the stereotype about black guys, and he actually could not feel the difference....

well those are all the stories i have for you tonight!! more next week!

there is no way that is going to fit through that small hole......

As most of you know, i am half way through my OB/GYN rotation... during the course of this rotation so far my amazement of the how the human body can tolerate stress is absolutely ridiculous. Today is no exception. While rounding on one of our consults who has been in the hospital for the past 4 days with abdominal pain without alleviation, medicine has consulted everyone from surgery, to gastro to gyn to determine the cause of the pain that doesn't get better even pain meds only reduce the pain. Anyways, this is a process we like to call the TURF. A friend of mine is currently rotating on internal medicine, and has been trying to TURF the patient for 4 days. She is a handful and difficult to examine and a pain for the nursing staff. First medicine TURFED to surgery, surgery did not accept and attempted the TURF to gastro who sent back to medicine. Medicine tried for two days unsuccessful to TURF to gyn, and today we decided this is getting annoying so let's just poke a hole, stick a camera in the belly and find out what is causing the pain. Before starting surgery my attending secretly hoped to find an inflamed appendix so he could call surgery and give them the TURF. Unfortunately for us, its a gyn issue. She has an ovary attached to the abdominal wall, its oozing brown pussy fluid into the pelvis....she is now our patient....the successful TURF!


The highlight of my day is the surgery itself, i got to handle the laparoscope, i got to irrigate and suction (its kinda a big deal for me as a third year student) and I LOVED IT!!! i knew playing video games would pay off....so tell your kids to play their video games because it makes operating with a laparoscope a lot easier. (you get to watch it on TV while using your hands....so fun!! and to think one day i may actually get paid for this :) ) While washing the cavity the dr warned me to be careful because i could potentially perforate the bowel, bladder or something else...for a moment during surgery i forgot that its a patient and not a computer or something...a little strange, but since only a tinny bit of skin is actually visible it makes sense that you don't realize its a person under the blue drape. The coolest part is when we removed the ovary..i always wondered how they got an organ out one of those tiny little holes..and now i feel like i am in on the secret...they put the ovary in a little bag they placed through the hole. Then pulled the bag (like an empty balloon) through the hole....the ovary did get stuck, but with a little maneuvering we managed to pull it through the belly button!!! it was awesome!! who ever would have thought that an ovary can fit through a hole in your belly button...

well another day down....only a few weeks left :(

Day 3 and 3 babies!!

Finally...today i saw my first vaginal delivery, and 2 c-sections (now on referred to c/s). The group of doctors i am rotating with has 5 Dr's in the group so each day i spend time with a different. I think its great because i am learning to adjust on the fly, each has a different personality and different way of handling patients, charts, calls and each other.

While one of the Dr's is on a medical mission trip to Africa, they have a Dr from Canada come down to cover. He takes 2, 24 calls back to back with a 8 hr day in between...its absolutely absurd in my opinion. The day started off with tumor board at 7am, and a lecture at 9am. After that i saw service patients, and wrote discharge orders on all of them. Now its only 1pm and i have no patients. So i decide to call the OR and see who is working and whats going on....

Turns out the Canadian has scheduled a suction D/C and a c/s in the afternoon. So i decided to find him and ask if i could scrub in....Jackpot.

Since i still had 2 hours to kill before the OR is ready, i went by L+D to see if any babies were being delivered....right place right time, the only midwife that doesn't hate me is on today, and saw me in the hall, grabbed me to help with a delivery. This was a woman's 3rd vaginal delivery so the midwife said it will be an easy uncomplicated delivery and i can help. It was awesome, kinda gross, and a little intense. The husband and her 2 other children were in the room at the time, i thought having the kids in the room was a little odd, but they were well behaved and sat on the couch, didn't even make noise. The husband stood on the opposite of the room, and i was the one who held her hand, and leg back as she pushed a 7lb baby out....its pretty amazing to see how much the vagina actually stretches, but the amount of fluid, blood and poop that comes out is a bit much for me, and the baby comes out looking kinda gross....like a wet puppy or something....in the end, i still believe that natural childbirth is the most unnatural natural process i have ever seen.

After the delivery was over, i made it over to the OR to find my Dr a little lost, he couldn't find pre-op holding...luckily i have worked at the hospital for 2 days, so i showed him were to find the patient, the chart and the scrub nurse. after seeing the patient, he got lost again trying to find the OR....luckily i was there, or he would have just wondered the halls....i show him what OR we are in, go in to the OR to set up my gloves and gown before the patient is brought into the room. I come out and the Dr is gone, missing and cannot be found anywhere. I grab the scrub nurse and we start the Doc Hunt...we have a Canadian in blue scrubs on the loose. (everyone else has green scrubs on, so he is easy to spot) After we page him and find out way back to the OR, he is there scrubbin in....lets just say this D/C didn't have my soaked in blood like the one yesterday....

my first scrubbed procedure was yesterday, an easy missed abortion D/C on a 14 wk preg. I got squirted and covered in blood projecting from the patients cervix......it was a very strange feeling, imagine a cervix or vagina projectile vomiting blood on you...that was me yesterday...Carrie had nothing, this is what true horror movies are made of my friends.


I then got to see my first c/s. They anticipated the baby being large roughly 10lbs so they opted at the last minute for the c/s instead of trying a vaginal delivery and running the risk of getting the baby stuck. All i have to say, bloody bloody mess, with a side of hot warm amniotic fluid....

those were some of the highlights.....cant wait for round 2 on Monday, hopefully we will have some more patients come in this weekend since i discharged all the service patients, including the 4 consults we had today.....

but on the bright side....i still LOVE this rotation, and think that i am going to end up in ob/gyn

seriously.

Today was my first day working in the labor and delivery at the hospital. A little disappointed because i happened to just miss all 3 of the vaginal deliveries, because i had to deal with a group of post-op and gyn patients. Overall today was interesting....

started off rounding a group of post-op patients, nothing too exciting. no complications, healthy babies. easy patients.

then things started getting interesting. We saw a patient with a nasty, disgusting, dry heaving infection. She is in quarantine, so we had to put gowns, masks and sterile gloves on before entering to change the dressing on her wound. It was my job to remove the existing covering and expose the wound. My jaw nearly hit the floor when i saw what we were dealing with (thank god for the mask). She has a MRSA infection of her c-section scar, that started to become necrotic and form a fistula. (describing this is tough....imagine a c-section scar across the lower pelvis, now imagine a circular HOLE above this open scar the size of a silver dollar that actually connects with the original scar. And then envision black/dying tissue inside this hole, deep enough to stick your hand up to your knuckles). basically a horrible looking wound with an even worse smell.

Even when i did autopsies i had never smelled anything this horrific. I wanted to dry heave each time we removed more dead tissue from the wound. We finally got finished, it was one of the most horrible experiences of my day. usually my stomach is pretty solid, but the smell alone nearly killed me.

another patient disturbed me today. This one is actually famous on the service.....she came in last week for abd pain, she thought she was about 20wk pregnant.

here is what actually happened......24yr old, 43 wks gestation, 12lb baby (overcooked, dead). She also weighed 580lbs, is diabetic, hypertensive and by definition severely morbidly obese.

its strange but the only part of that i found disturbing....is that someone actually had sex with her to get her pregnant! I had a hard enough time removing the Foley catheter and all i had to do is follow the tube to the vagina!! cleaning the incision was a team effort as well, esp because the pt stated that she is unable to wipe herself so you can imagine how much skin had to be held up to clean and bandage the incision.

one of the last patients gave me practice in giving information to the patient.....we had to tell a patient that she had a severe gonorrhea and chlamydia infection that has spread to the abdominal cavity....not to mention she is pregnant so clearly my treatment plan of choice is no good unless i want her kid to be deformed.

anyways.....things are still going well and i still love OB/GYN even if things are quite gross at the moment.....no OR yet, but maybe tomorrow i will get to see a delivery or be in the OR..i will keep you posted.

Down the Rabbit Hole...

before we get started I just want to say, I'm sorry for not giving daily updates, or even weekly updates. I will try to do better, but sometimes (gasp) i don't have much to say. usually i have already ranted, vented and told about 5 people what happened, so i have no more need to speak about it in blogger world. If you know me, than you are fully aware of my need to constantly share my opinion and tell others what i am thinking. Currenly on my Ob/Gyn rotation the doctors are AWESOME, and i rarely have something to get off my chest at the end of the day. Fortunately i am going to be starting a 2 month rotation on trauma surgery, i have a feeling there will be lots more to discuss in the next few months. there is no need to be at a loss for postings...and now onto what i like to call, a trip down the rabbit hole..

in my opinion life starts out as a trip down the rabbit hole, and there are times when the patients that i am in contact cause me to question the reality of my existence. sometimes i think i may be in an alternate universe that is guided by some other force different and very backwards to the one we all think is true. let me give you a quick glance of what i have seen in the past week..


- 15 year old girl 38 weeks pregnant who walks in sucking a lollipop and twiddling her hair. My take on her is a mix of pros and cons. At least she is smart enough to seek prenatal care, understanding she will qualify for medicaid and welfare. What about the fact the state of Florida doesn't think this girl is mature enough to operate a motor vehicle but at the same time is capable of taking care of a child. I guess the school system has failed this child. unfortunately there are handfuls of girls just like her.

- 37 year old 3 weeks post-partum. She is a christian scientist who doesn't believe in modern medicine. She ended up going into labor at 42 weeks after refusing to be induced. She delivered a beautifully healthy baby despite there being no heart beat. the only thing that killed this baby is that it wasn't delivered on time. While talking to her, she told me that her baby was doing well, and that she has even started walking. At this time i thought i was talking to the wrong patient because i knew that her baby had died. Nope i had the correct patient, she was just a little off center and she felt her baby was with her spiritually.

- 42 year old G8 P0080 (that means she was pregnant 8 times, and had 8 terminations). Now she is sitting in the room crying because she wants to get pregnant. She recently got married, thinks her husband may be cheating on her, but wants to get pregnant anyway. This would be what my attending calls, 'making a bad choice'.

- 25 year old, primagravid (first pregnancy) who is 498lbs, and thought she was only 14 weeks pregnant. In reality she was closer to 43 weeks pregnant. The baby was slightly overcooked, meaning it was 11lbs and had no skin (the skin had pooled around the wrists and ankles). It took over 4 doctors to pull the baby out. Not to mention that OR tables are only approved for up to 350lbs, so they had to bring in a special bariatric bed for the patient, who had a plethora of medical issues to deal with post-op.

well that is a nice sampling of what i deal with on a daily basis. And even after all that, i still want to do this everyday for the rest of my life. I love gyn, not so sure about the OB part but i def want to do the gyn part.

i start in the OR on wed, i have been practicing tying knots so hopefully they will let me close on one of the surgeries.

So in the end i am still not convinced that i have not accidentally slipped down a rabbit hole into a world very similar to our own, but with a slight twist on the morality scale.

Things your doctor doesnt even want to see

Today was my first day of OB/GYN. For the first half i work in a gyn clinic adjacent to the health department, so you can already guess the fantastic crowd i have the pleasure of seeing each and every day. As my first day, they took no time in throwing me directly into a room with a patient i like to call, "the train wreck"

to clarify - you know the feeling, when you are driving along and happen to come across a railroad crossing, just as pass the last possible turn before crossing the tracks, the lights flash and the gate comes down. You have now reached the point of no return. You can do nothing at this point except wait for the long, slow moving, boring train to pass. As you sit there patiently, you begin to notice the train slowing down, and then realize that it has stopped. This is the point where you know you are screwed and you cannot get out. All you can do is sit back and wait.

I had a patient like this today, i had no idea what i was getting myself in for when i first knocked on room 3. As i entered the room, i noticed she brought a shopping bag with her. Normally patients are helpful and bring in their medication bottles, this way they wont have to worry about messing them up when the question arises, "what meds are you currently taking?"

Sometimes you dont want to know what patients bring in those bags...today was that day. I have been used to internal medicine, where patients are sick, and usually complicated sick. Today i had just sick....

when i asked the first question, "why are you here today?" i got a response i wont forget.
"i want you to remove my uterus because i am sick and tired of bleeding."
I only wish i could provide you with the irate, demanding and angry tone the woman had with me, as she preceded to open her bag, take out a Ziploc filled with used tampons and pads, to fully illustrate the point of how much she was bleeding.

(and really, she had about the same amount i go through in a normal period, nothing more)

Instead of gaining the sympathy she wanted from me, all i could think of is how crazy it is to save a weeks worth of tampons and pads, to complain about heavy bleeding. You can tell me how many you go through without the visual. Really i know how to count. After discussing with her the results of her pelvic MRI, pelvic U/S and CT of the pelvis (all demanded by her), telling her that her uterus was normal without any evidence of fibroid or tumors and that she should try the oral contraceptives that had been prescribed to her upon each visit she made over the past year. Her only response is, "just please take it out, i am in pain every time i have my period, and i bleed so much that i am in pain." This woman was more than a little irate, and even when told she could have a referral to another gyn for a second opinion because the dr i work with refuses to perform an elective hysterectomy. She just yelled at the doctor and demanded pain medication....

what a drug seeker, a woman that is willing to have a part of her body removed to score drugs...