India Block 10: First Day Prenatal Care

February 2, 2012

My first few days in India are best described as “sensory overload.” First, there are the colors, everything from the dingiest black to the brightest gold. Then there is the warmth, spicy foods, smells, horns, crowds, garbage & beauty everywhere I look. And finally, the chaos and disorganization. Nothing is quite as expected, which can drive someone mad when she isn’t used to it. Patience and flexibility are not virtues in India, but absolute necessities! Fortunately I cultivated a lot of this in Peace Corps.

However, the population is so condensed and I am such an outsider, that this experience feels much more intense than any other developing country I’ve visited. I can’t even begin to put it all into words, and I’m already sorry that there is so much I won’t be able to share with you.

But, I’ll just begin by sharing something about today. My first clinical posting isn’t what I expected, but it’s absolutely perfect for me. I am at a low cost unit, which is a small division of the hospital that provides subsidized care to the poorest Indians. It is akin to a Federally Qualified Health Center (FQHC) in the USA, although the subsidies are from private donations, rather than the government.

My experience has already exceeded my expectations because the entire low cost unit is run by family physicians, many of whom were trained in the USA.  I didn’t expect to meet any family physicians because I was told that India does not recognize the specialty, but the people I met are full spectrum family doctors in the truest sense, and all identify themselves that way.

I was overjoyed to see "Family Medicine" as I approached the director's office on my first day. He explained that India doesn't officially accredit family doctors (yet), but they are hoping to be pioneers of this discipline in India.

I spent the whole morning doing prenatal care with two female doctors. I learned so many interesting things during this experience, but perhaps the most interesting was that dating the pregnancies was extremely problematic. The doctors had an excellent ultrasound machine and were highly skilled. However, most of the poor women failed to keep track of menstrual cycles, nor realize they were pregnant.

Many of them presented in the 2nd and even 3rd trimester, a time when dating isn’t very accurate. Some women in the USA also don’t realize they are pregnant until late, however this is the exception. At the clinic this morning, it seemed to be the norm. This creates many problems, not the least of which is inability to provide effective prenatal care.

Also, it is a national law that sex cannot be revealed due to the high amount of female infanticide. All the women had to sign special documents saying that we had not revealed the sex.

I couldn’t help but think about the contrast between American patients and the Indian women I saw today.  The Indian women were much more poorly nourished than any American woman I have seen. For example, “obesity ” is defined as BMI>27 (not 30 like the USA). The norm for birth weight at this hospital is around 5 lbs. The maternal mortality is extremely high in India.

The chart about fundal heights for prenatal exams. I was struck by how much smaller Indian babies are than US babies. The average birthweight here is 5.5lb.

I couldn’t help but feel depressed about the terrible allocation of resources. In the USA women are extremely educated and concerned about pregnancy, and wealthy enough to consume prenatal vitamins, take medications, try various types of diets, eat supplemented food, etc. Why do American woman (who are better nourished and healthy to begin with) use so many vitamins which would be better utilized on the women I met today?

3 Comments | 4th Year, OBGYN & Pediatrics, Travels | Permalink
Posted by Liz

Adolescent Medicine Block 9: CC Nausea

January 27, 2012

Her* CC (chief complaint) was “nausea.”  Although I hate to sound like the proverbial adolescent doctor, my first thought was “pregnancy test.” The nurse was way ahead of me, and had already done it.  “Negative,” she whispered to me, before I entered the room.

I rattled through the long list of possibilities in my mind.  Gastrointestinal infection? Side effect of medications?  Abuse? I took a history and performed my physical exam, and exited the room still feeling confused.  I presented the patient to my attending physician.

“A 15 year-old female otherwise healthy, chief complaint of nausea, who reports acutely feeling nauseous while eating dinner last night.  The nausea self-resolved, then she awoke this morning with one episode of about 100ml yellow, watery emesis (=she threw-up a little).  Then felt hungry and ate normally.  No fever/ chills, no abdominal pain, no diarrhea, no light-headedness, no head-aches, no unusual foods.  Her last episode of emesis was ‘stomach flu’ a few years ago and ‘this does not feel the same.’”

“No medications or allergies, no past medical or surgical history.  She lives with mom and dad, has “good” peer relationships- non-smoker, no alcohol, no illicit drugs, she is sexually active with one male partner, denies violence or abuse. Physical exam unremarkable. Beta HCG (pregnancy test) negative.”

Then, I eloquently explained that I wasn’t sure what was going on.  Maybe an early gastrointestinal infection?  But it didn’t really fit.  Puzzling!

“When was her last LMP?” my preceptor asked.  I admitted that  hadn’t taken a detailed menstrual history because pregnancy had been ruled out.  “Well, let’s find out.”  We went back in the room together, and he asked her directly.

“Oh, I just got my period today actually,” she replied.

AHA!  A light bulb went off for us.  “Wow,” I thought, “my preceptor is brilliant.”  Obviously he has been working with adolescents for many years.  He knew not to expect adolescents to volunteer all the relevant information.  His expression didn’t change, and he calmly began explaining how prostaglandin release during ovulatory cycles can cause a variety of symptoms, including nausea and vomiting, and how to block the prostaglandin release with ibuprofen or naproxen.

This illustrates why I love working with adolescents.  They are straight-forward, but do not make health correlations on their own.  This leaves more detective work for health professionals, and requires stronger history-taking skills and critical thinking. They have made the “Sherlock Holmes” aspects of my job much more interesting this month.

*Please note all patient identifying information has been intentionally changed or omitted.  While the details are modified, my overall experience remains true.

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Posted by Liz

Repro Endo Block 7: Transfer

November 27, 2011

The first transfer I saw was in a delivery room, although the woman was not pregnant.  Her position reminded me of somebody giving birth, but instead her belly was full of urine.  She had been drinking water all morning to expand her bladder, straighten her uterus and allow for a better view.  How uncomfortable!  Her husband stood by her holding her hand.  In a room a few doors down the hall, the embryologist prepared two embryos, which were now a few days-old.  I thought of everything she did to get herself here.

I did not know the extent that women must go to seek ART (Assisted Reproductive Technologies).   First, in order to diagnose the reason for infertility, both the man and woman must undergo testing, like uncomfortable imaging of the uterus, blood draws and sperm analysis.  Then, most of the medications prescribed are injected and require ultimate compliance, which can involve alarms during the night.

Finally, in order to assure the timing of ovulation perfectly, women undergo vaginal ultrasounds every 48 hours as their ovaries begin to respond to the drugs.  So a woman might come for 10 vaginal ultrasounds before her procedure is scheduled.  It requires serious commitment to come to the doctor early in the morning to have a probe inserted inside you.  Most women came alone, and had to disclose this very private and sensitive issue to their workplaces.

If the cycle failed (no pregnancy), they would start all over again.  Meanwhile, the treatments were expensive, and the medications made many women feel depressed or emotional.  I wanted these patients to have children dearly, but I was surprised by what they endured to reach their goals.  These women were some of the strongest I have met with hidden stories of trauma, multiple miscarriages, unexplained infertility and rare diseases.

The woman in the bed was undergoing IVF (In Vitro Fertilization), the most successful, but also the most invasive and expensive of all the treatments.  A few days earlier I had helped her when she went under general anesthesia to have her eggs retrieved.  Her husband had been present that day to donate fresh sperm, but he had to leave for work immediately afterwards, leaving her alone in our care.  The fertilization occurred in a plastic dish about 2 inches in diameter.

Now the embryos appeared to be tiny clusters of cells, too small to reveal their genetic content.  The doctor took several minutes to carefully insert a practice catheter (without embryos) into the uterus through the cervix.  A nurse pressed constantly on the patient’s bladder with the ultrasound probe, so we could visualize the placement of the catheter.  When the doctor was satisfied, she was ready for the real catheter with embryos.

We all were quiet as she injected the embryos into the uterus, a process that took only a few seconds.  And then, she sent the catheter back down the hall for a microscopic check to make sure all the embryos were emptied.  We waited.

“It’s clear,” the embryologist announced after a few seconds.  And then, we were done.  It would take about 2 weeks to know whether these embryos resulted in a pregnancy.  I wondered what was going through the woman’s mind.  I imagined babies being made in a loving sexual partnership, but here we were trying to make a baby in a sterile field with uncomfortable probes and catheters.  Yet, I felt warm, and noticed that she glowed with hope.

While many of our patients did get pregnant, this first transfer patient did not.  Two weeks later I saw her, tearfully waiting in the office for a follow-up visit.  I knew instantly the procedure had failed, and I felt a wave of sadness for her loss.  And more importantly I felt her anger and fear that despite all she endured, she may never experience biological motherhood.  I left with a new appreciation for the uncontrollable aspects of pregnancy, a powerful miracle that so many take for granted.

 

 

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Posted by Liz

Repro Endo Block 7: Lessons

November 19, 2011

My month at the Reproductive Endocrinology clinic was not without a few faux pais, and some special new lessons:

1. This clinic is also known as the “fertility clinic,” not the “infertility clinic” (think positive here).

2. Be silent when human embryos are in the room.

3. Embryos are “transfered,” not “transplanted” into the uterus.

4. Put the condom on the vaginal ultrasound probe BEFORE the patient comes into the room.

5. RPL stands for “recurrent pregnancy loss,” not to be confused with RPR (the lab test for syphilis).

6. HSG is a histosalpingogram, not to be confused with SHG, a sonohistogram. Both are imaging studies of the uterus.

7. Eggs are “retrieved,” not “harvested,” thus the procedure is “Egg Retrieval,” not an “Egg Harvest.”

8. Do not leave anything with photos of babies anywhere near the patient exam rooms.

9. Finding the left ovary on vaginal ultrasound is the most difficult part.  Save that for last.

10. Infertility treatments are physically and emotionally exhausting.  Always keep plenty of tissues on hand.

 

 

 

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Posted by Liz

Pedi Neuro Block 3: NICU

July 22, 2011

Many of the overnight patients I visit daily during my pediatric neurology rotation are in the NICU (Neonatal Intensive Care Unit).  I begin most mornings with the secret NICU entry code, rolling up my white sleeves and scrubbing my hands.  Then I perform my neurological exam – the mini version for the tiniest patients in the hospital.

Adapting physical exam maneuvers for infants was an acquired skill.  Even though I’m comfortable with examining newborns now, I was hesitant on this rotation.  The first time I tried to elicit a reflex, I barely touched the dime-sized knee cap with my hammer.  I was assigned to babies who weren’t simply newborn babies – they were premature, and they were sick.

As I saw their tiny bodies connected to feeding tubes, IVs and small breathing masks, I thought of the NICU nurses I know (Melissa and Aunt Sharon).  They must be some of the most talented nurses I know to find those piddling veins and perform miniscule procedures.

And NICU nurses are tough because their lives are full of sad stories.  Babies withdraw from drug-intoxication.  Babies stop breathing.  Babies live inside plastic bubbles.  Babies have genetic or metabolic syndromes that have challenging, predictable outcomes.  Or worse, they have mysterious symptoms that doctors can’t place.

My patients* were particularly sad because their parents had done everything right to have a healthy baby.  Parents held one another, grieving the loss of college graduation, football games and all that could have been.  The stress and sadness were apparent.  Later my attending exclaimed the divorce rate of parents with NICU babies is over 90%.  This was staggering, and I couldn’t find data to back it up, although according to one paper I found (“Effects of Child Health on Parents’ Relationship Status” by Reichman et. al. in Demography, August 2004), parents are 10% less likely to be living together after 18 months.

One of my patients was a baby born early who weighed less than 4 pounds.  She suffered an unexpected injury during birth, which had deprived her of oxygen and caused irreversible brain damage. I was in the room when the neurologists explained the devastating news – she had visible brain damage on her MRI.  She would certainly not develop normally, but it was impossible to predict how.

Another baby I saw was missing a part of her brain.  Her parents had discovered this during an ultrasound, and then the baby had a  prenatal brain MRI.  Her parents had to make the difficult decision whether to end the pregnancy.  They chose not to, and now mom told me the most difficult part was “not knowing what to expect.”

Yet a third baby was a twin who had meningitis, a brain infection that affected his brain stem and stopped his breathing.  When I first met him, his arms, legs and face were twitching.  He was having spasms and seizures, and could barely cry.

The pediatric neurologists have a difficult job.  I watched them explain to parents that talking or walking might be unreachable milestones.  Eating and smiling would be huge accomplishments.  And the worst part would be raising a child without expectations.

I came home and proceeded to think about a question that only a medical student would ask herself.  What if I had a sick baby like this?  Would I want to put a feeding tube in her stomach?  Would I want the doctors to save her life?  I feel like the possibility is real, and the endurance of these babies and their parents is an inspirational feat.

*Please note all patient identifying information has been intentionally changed or omitted.  The details are modified, but the overall experience remains true.

7 Comments | 4th Year, OBGYN & Pediatrics, Psychiatry & Neurology | Permalink
Posted by Liz

Surgery Week 4: Breast Cancer

March 6, 2011

I first met her* during rounds, after she had her right breast removed.  She was lying in bed as our team opened her hospital gown to check the incision and drains.  The sun was rising casting gold mixed with the fluorescent light.

Where there once had been a beautiful round breast, there was a diagonal line coarsely sutured with black stitches. There were two plastic tubes coming out of holes below the incision.  We checked the fluid in the tubes, which was appropriately clear and bloody.

Momentarily I wondered if any suture company has considered making pink sutures or pink drains for breast surgeries?  I’m not sure where these thoughts come from.

She  was filled with intelligent questions about her cancer.  The residents just told her to wait until the official report came back in a week.  But it didn’t matter; she was educated and her mind moved too fast for hospital reports.

She already knew from the needle aspiration what type of cancer she had, and it’s potential for metastasis.  She had read about which chemotherapy her type of cancer might respond to.  She knew her “positive sentinel node” and subsequent “axillary dissection” was bad news.

I saw her again at the Breast Clinic a week later to remove the drains.  She smiled at me and immediately told me she remembered me, something that always makes me feel warm inside.  I remembered her too.

She already had a copy of her pathology report in-hand.  She was stage “3B.”  Her husband was with her, a bright statistician who had searched for information about “3B.”  He said they knew the 5-year survival rates from studies.  There was silence.

Then, they asked about prognosis.  These are the questions every cancer patient asks, but no physicians wants to talk about. The surgeon I was with said, “I’ll refer that one to the oncologist.”  I wondered what the oncologist would say (later did a Google search myself: 5-year survival for 3B  <50%).

Of course, the answer is unknown, but perhaps people hope to hear more than that, even to talk about their fears openly.  As a future physician, I feel totally inept and frightened by these discussions.  Instead the surgeon stayed within the unemotional “comfort zone” and focused on the procedure he had performed, “clear margins,” and number of lymph nodes removed.

She told us how she explained the situation to her 5-year-old daughter.  As we got ready to pull her drains, she told us how her daughter had “helped mommy” empty the drains.  She cringed in pain for a few seconds as the drains came out, and it was over.

The next week, she was back to get her black sutures removed.  She had buzzed her long hair!  Everyone in the office kept commenting on how great the cut looked.  And it did because she had a beautiful face, radiating positivity from an unfathomable source.

“It was going to fall out anyway,”  she told us, “might as well have some fun!”  Then she laughed as she described how her daughter had helped her “chop it off.”  Again she greeted me, making me feel like I made a difference, even though I had just been standing in the room.

There was something particularly horrific about meeting her, and seeing her wounds.  I saw too much of myself in her.  She knew so much about medicine.  She had researched everything on her own, and requested a personal copy of the report.  She was able to list the possible chemotherapy treatments before meeting the oncologist.

Perhaps it was also the sight of a woman’s chest, breast surgically removed, gone.  I imagined my own chest with a diagonal scar instead of one of my breasts. I went home and touched my own breast tissue, feeling for lumps or bumps.  Breasts are made of such soft, fatty, cloud-like tissue.  I take their anatomical beauty for granted all the time.  What would I do if I had to sacrifice them for my life?

I was even impressed by the breast tissue on the inside.  During a “wire-loop localization with sentinel node biopsy” (known as a “lumpectomy”), I appreciated the colors.  The fat was golden-yellow, the blood was bright red, and the ink we injected was brilliant blue.  In the glistening fat, there appeared to be a rainbow.

Breast cancer is so common (1 out of every 8 or 9 women).  Before medical school I thought of breast cancer as a familial disease.  Nobody in my family had breast cancer, so I thought, “I’m safe.”  Now I know most women who get breast cancer have NO family history.  This is why breast cancer screening is recommended for all women.

This could be me.  Even if it is not, this will happen to women I know.  The reality sunk in, especially since I am on the cusp of  my thirtieth decade, when the risk of breast cancer begins to rise steadily. This patient made me see something that pink cereal boxes and wrist bands could never do.

*Please note all patient identifying information has been intentionally changed or omitted.  The details are modified, but the overall experience remains true.

4 Comments | 3rd Year, Death & Diseases, OBGYN & Pediatrics | Permalink
Posted by Liz

OBGYN Week 4: Dilation and Curettage

December 11, 2010

A brief warning: I’m going to describe what it was like for me to see an abortion.  Please skip this post if you think it will disturb you.

Obstetrics is more than the beauty of birth, although it’s difficult to write about the losses.

In fact, this month while I was on my rotation I learned of  two unexpected deaths, a mother and a full-term baby.  I also met many women with tubal pregnancies who were forced to abort their pregnancies with medication or surgery.  And I saw elective abortions.

“Abortion” in medicine refers to any pregnancy termination before birth, even miscarriage.  All OBGYN’s must deal with death and abortion, but few OBGYN’s perform elective abortions.

Types of elective abortions include: operative tubal pregnancy removal, dilation and curettage, abortive medications and dilation and evacuation.  They are surprisingly very different from one another, and different depending on the age of the pregnancy.  A vast majority of abortions are performed before 10 weeks, contrary to most imagery depicting abortion.

The procedure is common.  30% of women have at least one abortion, including many women who keep it secret. Elective abortion happens routinely across the world, regardless of the law.  And today abortive dilation and curettage is the most common surgical procedure performed in the USA (more than C-sections, appendectomies, tonsillectomies, etc.).

Regardless of these facts, observing dilation and curettage was not a requirement for me.  In fact, elective abortion is not even listed as an option on my experience log (an online checklist I must complete for national accreditation).  Most people in my class won’t see an elective abortion procedure.

I had the option, and decided to go.  A week earlier I had seen the same procedure for a woman who had a natural abortion, but part of the pregnancy tissue was retained.  So, I felt prepared.  I went to meet the patient.

My patient was not how I had imagined her.  She was older!  She was married, and she looked normal, lying there reading a magazine.  I read in her chart that she was using birth control pills.  That’s what I use for birth control. Now she was 8 weeks pregnant.

“Hello, I am a student doctor who will be observing your procedure today…”  She smiled and shook my hand, and told me she was feeling “fine.”  I met her nurses, who were  joking with her about dreams during anesthesia.

Moments after we got to the OR she was unconscious, and the nurses lifted her legs into stirrups.  One nurse handed me gloves, and told me to get ready because “it moves fast.”

The procedure began.  The doctor first did a bimanual exam, feeling her uterus to make sure it was the appropriate size.  Then, he had me place the speculum and grasp her cervix with a tenaculum (a special type of tweezers that look like scissors).   He began to dilate her cervix with metal dilators (which are long sticks of metal in varying diameters).

He went quickly up to 27 French (the medical measurement of diameter, French/ pi= mm).  Then he put in the clear tube connected to the suction.  He turned it on and it began to suck.  The tube became filled with bright red blood that flowed into a filter.  The contents of the filter would be sent to the pathology lab.

In a systematic motion he sucked all sides of her uterus.  At one point, he had me place my hand over his, so I could feel the texture, like “sand paper.”  And then it was done.

I looked at the clock.  10 minutes had passed.  This was less time than the procedure I had seen for the women who had had a miscarriage.

I was curious about the filter, so I looked inside.  Would there be a fetus?  Or even a tiny arm or leg? But there was nothing at all resembling a fetus.  Just blood clots.  I almost hoped to see something that might show me what had just happened.

I wondered if some people might think I’m a monster for being able to see this procedure without feeling terrible.  Yet, there was nothing different from the dilation and curettage I had seen for the miscarriage.  The procedure was over in a flash, and within a few hours I was called to a C-section birth.

Life and death are closely intertwined in medicine, and I am becoming less emotional about both.  I feel like the child experiencing Christmas who has grown-up; less emotional excitement and greater understanding.

4 Comments | Death & Diseases, OBGYN & Pediatrics, Surgery & Procedures | Permalink
Posted by Liz

OBGYN Week 3: Two Births

December 6, 2010

I chewed peanut butter on toast, my staple for surviving call nights.  My body was begging for sleep.  My eyes were already losing the fight against exhaustion; fuzzier words as my eyes refused to focus.  I briefly considered telling the nurses I would rest my head on their table for a few minutes, but instead I ate peanut butter.

I had just seen my first delivery at the birthing center, located across the street from the hospital.  The birth was natural, no anesthesia, no IV, no catheter, no fetal heart monitoring belt.  The midwife put on music, dimmed the lights and checked the fetal heart rate with a small doppler machine. The woman labored in a warm bathtub, moaning through contractions while the midwife showed me how to put pressure on her back.  I was surprised by how mobile she was; rocking and leaning during contractions, which improved her pain.

“I can’t do it anymore!” she screamed at one point, “It’s too much.”  The midwife calmly offered solutions.  Take a sip of water.  Change positions.  Encouragement. “I want to get out of the tub,” and we supported her as she got out.  Seconds later she leaned against the bed and out came her baby.  He was big, and still attached to her vagina by the umbilical cord.  The midwife clamped the cord and passed baby through mom’s legs.

“Oh my God, you’re beautiful.  You’re a boy, a beautiful boy!  I love you so much, my baby,” she exclaimed with tears.  The midwife laid mom on the bed to deliver the placenta and examine her for tearing to repair.  This part seemed identical to the hospital births except her legs were propped on two plastic bins, instead of stirrups.  When it was over the midwife took family photos.

I walked back to the hospital at 2:30am, hoping there was nobody in active labor so I could sleep a few hours.  There were four women in labor.  “Pick one,” the Physician’s Assistant told me.  I picked the person who seemed most active.

Like most (87.5% of) women at the hospital, she wanted an epidural.  I took my peanut butter break, then put on a mask, hat and gloves for the sterile procedure.  The anesthesiologist explained the risks and benefits of local spinal anesthesia.  ”Almost no risk to the baby’s health since the medicine doesn’t go into the blood…  5% chance of complications, usually head-ache… might not work… would not take away all sensation…studies show increased pushing time by 10 min.”

I wondered from what I’d seen on this rotation if studies also show slower and longer labors with epidurals, or increased C-section rates.  The doctor also left without explaining that she would have to lie still on her back and get a foley-catheter inserted.  The nurse and I took care of the last part, and instantly she stopped moaning and became quiet.  I left for a while so she could try to sleep.

I noticed her labor contractions slowed on the monitor.  Less than an hour later her nurse called because the baby’s heart rate was bradycardic in the 90′s (normally 140-160).  With the doctor, we tried changing her position, giving oxygen, measuring fetal oxygenation with a scalp probe, but in less than 10 minutes it was decided: C-section STAT!  The sun was rising.

“Thank goodness for the peanut butter,” I thought as I raced to the OR and scrubbed-in.  The “bovie” (electrocautery knife) wasn’t working, but the OBGYN went ahead with the surgery, which was bloodier than usual.  In a flash, the baby was out and doing fine.  I stapled the new mom’s incision, an easy closure to a long night.  Two babies, zero sleep.

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Posted by Liz

OBGYN Week 2: OR Survival Techniques

November 25, 2010

Spending more time in the OR with blood and surgery feels like an experiment with myself.  I think I’ve figured out some “secret” rules that make the job a little easier for me (at least so far it’s working well):

1.) a gob of peanut butter in the morning (or something salty and fatty). I don’t feel hungry at 5am, and don’t enjoy forcing myself to eat, but I do it.

2.) Eating/ drinking at least every 5-6 hours.

3.) Sleeping at least 5-6 hrs.

4.) If I start to think about myself in the patient’s body, I focus on deep breathing.

5.) Don’t tie my face mask too tight.

6.) Always go to the bathroom beforehand (dad’s advice, so true).

7.) Wear comfortable shoes.

8.) Never be afraid to ask questions, talk or leave if necessary.

9.) Forgive myself (this is really hard because I still feel critical of myself every day).

10.) Don’t take it personally (also really hard for the same reasons).

This week I’ve encountered surgical factors exponentially. Lots of OR cases, lots of babies born, lots of blood.  And overall I am excited as I process the memories: putting in my first foley catheter, learning my role in the OR, scrubbing-in, watching people suture the vagina, uterus and abdomen; putting my hand inside the abdominal cavity; watching the inside of the uterus on big screen (like a gorgeous deep sea dive through pink algae); my first laparoscopic surgery; touching a uterine fibroid; helping to suction and cut sutures; removing staples; seeing the ureter’s peristalsis (I didn’t even know the ureter DID this); and pelvic exams.  Wow.

I am surprised by my kind and supportive colleagues, OBGYN doctors, PA’s and nurses.  In one week, my comfort with blood and the OR has grown greatly.  Incredible.

1 Comment | 3rd Year, OBGYN & Pediatrics, Surgery & Procedures | Permalink
Posted by Liz

OBGYN Week 1 Cesarean Sections

November 17, 2010

“Your medical school never had a scrubbing-in session at the beginning of 3rd year?” the physician assistant asks my colleague and I.  We shake our heads.  “That’s so weird.  You should mention it to somebody.  Well you’ll definitely need to learn now.”

Suddenly it sinks in.  OBGYN is a surgery rotation.  Sure, I’ll see plenty of women, babies, vaginas and cervixes.  Yet, pap smears and low-risk vaginal deliveries are often performed by nurses, physician’s assistants and primary care physicians. OBGYN commands C-sections, hysterectomies, fibroid and cyst removals, dilations and curettage (DNC’s), etc.

So I squish the package of soap in my hand, and learn to scrub-in.  Put on mask, hat and shoe covers.  Remove any hand jewelry. (I don’t wear any). Wet arms to elbows.  Open aforementioned soap package.  Use plastic to scoop under each nail.  Then, scrub nails, sides of each finger (thumb to pinky), palm-side and back-side.  Count 1-2-3, 1-2-3, 1-2-3… repeat many times, then scrub down to the elbow.  Rinse so the water flows downward ONLY.  Do not touch ANYTHING.  Walk to the OR, open door with butt, and get gowned and gloved by the OR nurse.  I learn my glove size.

This is my third rotation, so I am prepared to be unprepared.  I am in the new country of OBGYN, with new language and customs.  I am learning a host of new names and where to find everything.  I am adjusting to never writing the sex of the patient in my notes (always female) and using new abbreviations such as “LTCS” (Low Transverse Cesarian Section).  And this rotation includes my first 26+ hour call shift every 4th day (6am to 8-9am the next morning).

The day after I learn to srub-in, I begin doing it for real; my first C-section.  My patient was planning to deliver vaginally, but her cervix stopped dilating 12 hours ago and now she has a fever and the baby’s heart rate is high.

The PA watches me scrub-in.  She tells me that the OBGYN who will be with me is a good doctor to start with because she’s both skilled and kind.  I pass the test with my first scrub-in.

I enter the room, carefully maneuver around the equipment, get gowned and gloved.  Suddenly I feel like I am on another planet.  I am inside a space-suit. looking through plastic, breathing inside a mask.

I am surprised when the OBGYN tells me to stand right next to her, touching her.  Operating is intimate.  A family doctor stands across from us.  She is “first-assist.” I start to feel my heart race before the OBGYN starts cutting.  Almost instinctively the OR nurse tells me, “This is your first surgery, so if you feel like you’ll pass out, just step backwards.  It’s not a big deal.” His words calm me down.

Suddenly I don’t feel scared.  In a flash she is past the skin and fascia (connective tissue).  She removed the deep fascia from the rectus abdominus muscle, which runs vertically down the abdomen. She cuts down the center of the rectus, to avoid cutting through the muscle fibers.  Then, we can visualize the uterus, swollen and exposed.  My job is to retract the slippery bladder.

As she cuts into the arteries, blood spurts out at us.  I’m glad I’m wearing a face mask.  She cuts lightly over the uterus, so the amniotic sac pouches out.  Then she cuts into the fluid bubble.  Fluid pours out- lots of it.  Then she reaches inside, and pulls out the baby, who immediately gets handed to the pediatric team.

Now, we fix the giant incision we just made.  First she massages the uterus, lots of blood pools out.  She clamps vessels and begins suturing the uterus.  I ask about a translucent jelly-like bag at 9 o’clock, “Is that the ovary?”
“No,” she replies, “I’ll show you.”  She pulls it into full view along with the ovary, which is like a creamy cluster of tadpole eggs.  She asks me what I think of the jelly-bag.  A cyst? “A hydatid cyst of morgagni,” she corrects. Then she lets me touch the ovary, which feels firm, exactly like a bumpy testicle. “It’s polycystic,” she announces.

She examines for bleeding carefully.  Then, she begins suturing the outer layers, until we finally close the skin with two layers of sutures.  She doesn’t use staples (which are common closures now) because this surgeon prefers self-dissolving sutures.

It was over in about an hour.  “What did I just DO?” I think as I write my post-op note.  After midnight, I finally go downstairs to the call-room to try to sleep.  As I lie in bed, I think about the smell of fresh blood that reminds me too much of beef, and the powerful image of the exposed female organs.

At 1:13am my pager goes off.  Yikes!  I don’t even know which button turns off the pager yet.  I fumble and race upstairs.  It’s a second C-section, and everybody is ready in the OR.  I scrub-in again, and find my spot touching the same OBGYN.

This one is much like the last, but towards the end I do start feeling light-headed.  We’re almost finished, and I don’t want to take any chances.  So, I speak up, and everybody is supportive.  I step backwards and take a seat outside the OR.  The nurse brings me a cup of ginger-ale.  I realize it has been over 7 hours since I had anything to eat or drink.  How did I let myself do that again?  I am learning this year that eating frequently is vital for me, and somehow it is easy to forget.

After less than 3 hours of sleep, I am back on the floor for morning rounds.  I visit my patients, who are both doing well.  I write progress notes, orally present my patients to a new OBGYN doctor.  This is the longest shift I have ever worked, and full of intense new experiences.

As I walk to my car, I eat a snack and accidentally bite the inside of my lip (I am too tired to eat). This is not a great time to drive home, but I do anyways.  The taste of blood mentally takes me back to the OR.  The flavor immediately reminds me of the smell of surgery.   I am disgusted by my own thoughts.  I not supposed to think this way, am I?  I feel strange, like I won’t ever be the same person who I was before this day.

3 Comments | 3rd Year, OBGYN & Pediatrics, Surgery & Procedures | Permalink
Posted by Liz

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