The Manic, the Delusional, and the Histrionic/Borderline Personality

One good thing about Terrell: there’s an outlet center about 5 min drive away, so I did a little shopping before going to work on Friday night. Our Friday night shift was supposed to last from 5 p.m. to 8 a.m., but the attending, Dr. P, said that she wanted to get us all out of the clinic by 2 a.m. She had no intention of keeping us at the clinic all night because she wanted to get some sleep, too; her son was having a birthday party on Saturday. Everyone was all for getting out early, especially David, since his son has a soccer game on Saturday that he has to attend.

We had about 7 patients to admit for the night, and they arrived in two separate groups from other mental hospitals. Dr. R had originally told us to work in pairs, but it was so much faster if we saw the patients individually, so with Dr. P, it was “divide and conquer.” We figured that if there were 7 patients and each patient took about 1.5 hrs to interview and dictate, then we could be out in 7.5 hrs (Goal: 2 a.m.) Sadly, that wasn’t to be. The first van of patients didn’t arrive until nearly 7:00 p.m., but we were able to review their charts before they arrived.

The Manic

My patient was a 28-year-old Japanese woman named NF whose last hospitalization at TSH was two years ago (many patients at TSH have been there previously); she had been diagnosed with undiffentiated schizophrenia. Sadly, she first started hearing voices when she was 18, and the younger the onset of symptoms, the poorer the prognosis. Still, she managed to stay out of the hospital for 2 years, so something was working for her.

I don’t know what I expected her to be like, but what I saw was an extremely hyperactive woman running up and down the halls giggling and laughing, sometimes locking herself in the bathroom for the heck of it. After the 4^th or 5^th time the orderlies asked her why she kept going in the bathroom. “Because I got to go, I’m constipated,” was her reply. She then called the staff “lame asses” and said, “I’m gonna escape from TSH, I’m gonna get the f*** out of here.” I wondered how the heck I was supposed to interview her if she couldn’t even sit still, and I excused myself to use the restroom. While I was in there, I could hear her laughing and running down the hall, and at one point there was a huge THUMP! that scared the crap out of me. When I went to see what was going on, David said, “Oh, you just missed it. She just jump-kicked the door leading to the ward and it didn’t even budge.” I wish I could have seen that for myself. =( Anyways, NF was surprised (and even a little impressed) that the locks at TSH actually work (and thank goodness they do; I think David, Sital, Kyle, and I all have a new appreciation for locked doors now), and she was directly taken the wards and given medications to make her calm down and fall asleep. Ladies and gentlemen, that is what true mania looks like. I wondered how I was supposed to complete her psych eval without ever talking to her, but Dr. P said I can write it based on what we saw of her behavior. Her new diagnosis: schizoaffective disorder, bipolar with severe mania.

The Delusional

My next patient was a 21-year-old girl named KS with a history of drug abuse and bipolar disorder. Her case, much like with NS, was very serious and very sad. She presented with three different types of delusions: paranoid, somatic, and grandiose. She was sexually abused by her stepfather so she always feels like someone is watching her in the bathroom or when she’s in the shower; these are paranoid delusions. She believes that she is pregnant (she claimed to have seven sons, but asked me where she could find their birth certificates because she didn’t remember their birthdays) and is afraid her medications will harm her baby (her pregnancy test is negative). She also believed there was a metal plate with a loose screw in her back and that she had liver cancer; these types of delusions pertaining to the body are somatic delusions. And she gave me two different accounts of her occupation: first she said she was working on a music album and then she said she got accepted to Harvard and was going to major in science law. At the other hospital, she also said she won American Idol when she was 5; these are grandiose delusions. When I asked if she ever attempted suicide, she said she attempted suicide 45 times, the first time when she was 2.5 years old, but when she showed me a supposed scar where she broke a mirror on her hand, I didn’t see a thing (yes, she has both auditory and visual hallucinations). I could go on and on about the things I heard come out of her mouth, but the saddest thing is that she really believed what she was saying.

After I interviewed KS, I presented her case to Dr. P, who told me that I had a tough one based on her observations of KS in the waiting room. Based on her delusions, I thought KS was paranoid schizophrenic, but as I was explaining my findings to Dr. P, we heard sounds of a scuffle in the hallway and ran out to see what was going on. One of the patients had attacked the orderly guarding the door because “he looked like the devil,” and he, like NF, was taken directly to the wards for sedation. David was asked to talk to him since he spoke Spanish, but his explanation for why he attacked the orderly made no sense (something about a monk and the devil). And just like that, David got to do a dictation on a patient he never interviewed (like I did with NF) based on observations alone. Afterwards, Dr. P took a look at KS and later asked if I noticed that KS had tardive dyskinesia. I hadn’t, but her TD was continual lateral jaw movement. To have TD at such a young age, I hope for her sake that it’s not permanent.

The Histrionic/Borderline Personality

Sometime during the night Dr. P got an “emergency” admit, a 39-year-old woman named “Cherry” who had threatened to kill herself. After I finished my dictation on NF (more on dictations later), Cherry walked up to me in the hall and demanded to see the doctor. “They told me the doctor would see me in a few minutes, but I’ve already been waiting 3 hrs,” she said. She then proceeded to tell me that she wants to get out of here so she can go to work in the morning and that her husband and son were driving her crazy and that she needed to get as far away from them as possible. As she spoke she got closer and closer to me and I was starting to get scared, but I couldn’t show it. Cherry was clearly irritated and believed she didn’t belong in the hospital, and she demanded that we call her son and tell him what was going on here. She asked anyone in scrubs who passed by if they were the doctor, and when Kyle was sent to interview her, she said, “Well, about time. Say, you want to go out with me?” (Kyle’s married) I couldn’t help but laugh at that one; talk about a turn-around.

I only heard snippets of Cherry’s “bitchfest” as she described her life to Kyle before I went to dictate my psych eval of KS. By the time I finished it was close to 3:00 a.m., but thanks to two weeks of nights at ob-gyn the early hours didn’t bother me. I was sleepy, sure, but not to the point of falling over. When I left the room where I was dictated, Cherry was once again grumbling about having to be at work tomorrow morning. I went to Dr. P’s office (where everyone was “hiding”), to hear Kyle talk about his findings on Cherry, and her story is pretty sad. She has a 22-year-old son who once stabbed her ex-husband for the heck of it and blamed her for marrying the guy in the first place (her son is most likely antisocial). Because of that incident, Cherry and her son are not on good terms, but her son did call TSH to see if she was “suffering or still alive.” David spoke to the son on the phone and said that he seemed pretty emotionless considering his mother threatened to inject herself with unknown chemicals, and we wondered if he had anything to gain by her death. So finally, after a long time, we brought Cherry in to see Dr. P.

Cherry entered the room in a defensive manner, but after seeing Dr. P slouching in her chair and listening intently to her story, she began to relax, too (that, and the Ambien CR she took prior to her admission was finally kicking in). She said that her latest husband (this is her 2^nd marriage) just left her b/c he couldn’t put up with her “bitchiness,” and that made her angry enough to threaten suicide. When asked if she’d actually do it, she said no b/c she’s Baptist and believed that people who suicide go to hell. That, and she’s afraid that she wouldn’t “get the job done right” and end up a vegetable in a nursing home, a fate she sees as worse than death. She did have scars on her wrist from previous “suicide attempts,” but the cuts were superficial and were most likely cries for attention than real suicidal ideations. She also told us that her son wanted her locked up, yet alive, just so he could have a place to live. Her story went on and on, but Dr. P was such a good listener that by the end of the interview Cherry was calmer and looking forward to going home so she could visit her brother later on. After she left, Dr. P asked us if we should admit Cherry or release her. There was no real reason to admit her, but in case she were to kill herself shortly after admission, we had to be able to cover all the bases so that we wouldn’t get blamed for her death. Together we put together a case of a woman who, based on our interview, was not suicidal and had plans for the future, and we described the son as a less-than-reliable witness given his criminal history and her exact words that he once said, “If she dies I have no where to go.” Because if she does die, her son could sue TSH for not taking care of her, but if he’s not a reliable witness, then no judge would find it fit to rule in his favor. With cases like these, you have to plan ahead and treat each case as though the person might die and you might get sued. In other words, cover the bases.

Dictations: these are rough. A psychiatric evaluation is about 9 pages long front and back, and currently it takes the other med students and me about 30-45 min to go through all the questions and dictate the case. With dictations, you have to talk about the patient’s history of present illness, psych history, what kind of psych symptoms they have, suicide risk, mental status exam, thought process exam, the diagnosis, treatment plan, etc, so it is a lot of work. It took me almost an hour to dictate KS’ file because she had so many quotable things to put in the evaluation; you want to take quotes directly from the patient’s mouth if possible b/c it gives other doctors a picture of what you were seeing when you were interviewing this patient. All four of us moaned that our dictations were less than stellar, but we’ll get copies of our dictation later and get to critique our work. =(

The time we left the clinic: 4:15 a.m. Time I fell asleep: 4:35 a.m. Time I woke up because of annoying nursing students coming in: 6:30 a.m. Time I got up to drive back home: 8:00 a.m. *sigh*

One thing for sure: there’s almost never a dull day in psychiatry =)

Going to Court: The Bipolar Patient

This morning we were assigned to go to a mental health court in Dallas to watch a psychiatrist, Dr. G, testify for a patient who was refusing to take her meds. David and I both spent the night at the dorms so we carpooled to Dallas (met some nasty traffic) and arrived about 10 min late. Fortunately the court proceedings hadn't begun yet, and we saw a group of orderlies haul a man about my age in a straightjacket into the waiting room. He looked like he was fighting the orderlies at first, but once he was released he was as polite as could be. Naturally we were interested in why this young man was here, and after Dr. G (who looks like a Marine) presented his case (it was straightforward since the patient wasn't present), he encouraged us to stick around since this case was going to be more interesting if the patient got to testify.

The way the courtroom was set up: the ADA sat at one table, the defendant and his lawyer sat at another table, and the orderlies sat near the defendant in case he acted out. The judge faces everyone, and the "audience" consisting of the defendants parents, some nursing students, and some med students (us) sat along the wall. The defendant (a 25-year-old I'll call JR) was a successful consultant who suddenly "quit" his job around April-May and since then became reclusive from friends and family. The few times he did talk to his mother, he made comments about "wanting to put an end to it" and "being filled with darkness." His parents were concerned, and finally, one day when he was supposed to go to his parents' home, he ran out of their car and locked himself in his apartment, prompting his mother to call the police and put him into protective custody. Throughout the doctor's testimony I was staring at the back of JR's head so I couldn't see his face (but Sital later said he was smirking), and when the ADA asked whether any examples of outbursts could be described, JR suddenly leaped to his feet, let out a scream, and shoved the table over, spilling water on the floor and scaring a whole bunch of people. "There's your example!" he yelled before the orderlies cuffed him and led him out of the court room. "Five minute recess," said the judge. Yikes...

We thought they wouldn't bring JR back into the courtroom, but they did, this time in a straightjacket. By this time the table had been set up again and the judge warned JR not to make any more outbursts. "That was a nervous tic," he said (yeah right). The doctor finished his testimony, and when the judge asked the defense if they had any witnesses, JR requested that his mother be called to testify. His attorney allowed it, but made a point of saying that this was against legal counsel. So JR's mother (who was seen crying after his outburst) took the stand and described her son's downward spiral from the time he quit his job (and apparently lived off his savings for the next 4-5 months b/c he wasn't job hunting), the dark comments he'd made threatening to kill himself, etc. She was calm on the stand and told JR that she was doing this out of love for him, and she and her husband would personally take care of his medical bills even if they had to sell their house to do it (now that is devotion). They wanted to keep him in the mental hospital in Dallas, where they work, instead of sending him to TSH.

Throughout this testimony, JR remained silent except at one point where I wasn't sure if he let out a sob or a snort. When it was his turn to talk, he denied most of the things that his mother said (even though she has nothing to gain from having him hospitalized), and practically bragged that he was able to live comfortably "like a teenager" watching movies and sleeping in the months since he quit his job. At one point he challenged the ADA's question about what he did all summer (he said he was too lazy to find another job), and the judge said he had no right to talk to her like that (he didn't know she was the ADA) It was obvious that he was well educated and had made lots of money before he was diagnosed with bipolar disorder. He insisted that there was nothing wrong with him, that there was no need to hospitalize him, and that he did not want to take medication because he didn't need it. The judge ruled to hospitalize him, and after that there was another medication proceeding in which the doctor described the medications he would like JR to take in the hospital. The ADA asked questions about the drugs' side effects, benefits, and whether or not JR would benefit from taking these drugs, and in the end it was ruled that JR would take whatever drug was given to him.

So yeah...that was a really interesting case, and it had to be so difficult for JR's parents, especially his mother, having to testify against him while he was probably smirking and saying nothing. JR goes against the norm of most psych patients because he had loving parents, a successful yet stressful job, and an excellent education, and yet he still ended up bipolar. The worst part is, this could happen to any of us. Maybe someday halfway through residency, the stress will get to us and make us snap, and then it'll be us in court denying everything that happened while our parents watch us and cry. It's heartbreaking to think about.

This afternoon I stopped by Dr. R's office and she told me (rather analytically; nothing gets past this woman) that I needed to be careful about falling asleep in front of attendings because it's very disrespectful. I apologized and told her that it wasn't the first time, that I've been sleepy ever since rotations started, and after asking me if I had narcolepsy (I was quick to say no), she told me to adjust my sleeping schedule or do something to stay awake. "You got more rotations ahead of you," she said, implying that I can't keep going like this. I really appreciated her honesty and concern; not all attendings will talk to students one on one about things like this. She also said that she just dictated a 44-min letter to Dr. Budd regarding the last group of students who were here; apparently they did some less than stellar things that reflected poorly on them. She listed a few examples of how students in the past have fared badly on their rotation by not taking it seriously, and I said, "I don't intend to be one of those students." Her response. "You won't be." I'm really starting to like Dr. R now.

We had an evening of "mini-call" in which the four of us were split into pairs to interview a patient. I was paired with David since we've been partners all week, and he got to interview a lady about my age who was either paranoid schizo or delusional. She said her babies were 7 months and 10 months old, that men have tried to "whore her and s***" and that she didn't know which teeth was which. She also contraindicated herself a lot to the point where we weren't sure what to think. We also eavesdropped on Kyle and Sital as they interviewed a suicidal alcoholic with possible Cluster B (borderline) disorder, and when she said that her last job was working in a liquor store, we had to try really hard not to laugh (an alcoholic working in a liquor store is asking for trouble). After that the guys had to dictate; David and Kyle started at around the same time but David finished first, so they both agreed that their dictations probably sucked. Tomorrow it'll be my turn, and Sital's, so we'll see how that turns out.

Next update will be on Saturday (hopefully)

TSH: Aggressive Patients

This morning David and I were back in the treatment room interviewing the male patients (we interviewed females yesterday). They were a fairly interesting bunch. One guy was manic and rather incoherent, but at one point he took my hand and Dr. R asked, "Are you flirting with my med students again?" At least he was harmless. There was another patient who mumbled and spoke so softly that it was hard to understand him; he denied ever killing anyone, yet his chart says he's guilty of jabbing a pen into a person's skull (that's why you are careful about giving pens to psych patients), so that was an eye-opener. Another patient had an obvious case of tardive dyskinesia; he couldn't stop grinding his teeth and had obvious tremors. There were two notable patients, BB and RS, who each stood out in their own way.

BB was a schizo who was prone to violent tantrums, and he kept asking Dr. R for a weekend pass so he could go home to his parents. Dr. R explained (not for the first time) that in order to get a weekend pass, his parents had to call the social worker by Monday, and today was Wednesday so it was too late. Not to mention his parents haven't called the hospital because they obviously don't want to take him home on the weekends, which is a bit sad. Then BB said he wanted to live with his brother, which was a bad idea b/c his brother has been in and out of TSH himself. Then he got angry and said he was doing everything right with his meds and stuff (except going to classes), so Dr. R should "make him happy." Dr. R got annoyed and said, "I've been here since 6:30 this morning! Why don't you make me happy!" One thing about Dr. R, she tells it like it is and is not afraid to argue with the patients.

RS was the last patient we saw, and he was the scariest patient I've seen to date b/c he was so loud and aggressive. I was the one who interviewed him, and here's how some of it went:

Me: Can you please look at me, Mr. RS? (I could only see his side)
RS: I am looking at you! (no he's not)
Me: How has your appetite been?
RS: I don't care how your appetite's been!
Dr. R: RS, that's not nice!
Me: Do you know your doctor's name? (Dr. R)
RS: (yelling) I am my own doctor! (he also keeps pointing furiously at something on the ground that we can't see)
Me: Do you know the name of the hospital you're in?
RS: This is not a hospital!
Dr. R: Then what would you call it?
Me: Have you ever had thoughts of hurting yourself or other people? (I'm pretty sure I knew the answer to the last part of the question)

At this point RS just gets totally pissed and is looking at me like he wants to kill me, but I didn't back down. I wasn't afraid of him because he hadn't moved from his seat yet, but mentally I was getting myself ready in case he should lash out. Fortunately Dr. R said it was obvious we weren't going to get anything out of him when he was pissed like this, so he was allowed to leave. Whew. Afterwards, however, when David and I had to walk through the common area to the exit, I thought I saw him glaring at me and walked a little faster (David's observation, not mine).

A group of drug reps for Seroquel took David, me, and other doctors to lunch at a Cajun restaurant called Fat Catz that had some pretty good food for a decent price. Then all the med students sat down for an afternoon with Dr. R. It was pretty interesting. She gave us all a placebo pill of a oral disentigrating pill (a form of pill given to patients) so we could see what it was like. Then she told us to put on earphones (with loud voices talking in the background) and answer some questions while wearing the earphones, and the rest of us were to watch each other's reactions. There were times when the voices were loud, and other times when the voices were soft; this was so we could see what it was like to be schizo. David talked louder when the voices were louder. Sital started giggling more when the voices got louder. Dr. R said that I was more relaxed and had a more positive affect when I had voices in my head, but without the voices I was more calm, reserved. Does this mean I'd make a good schizo? I asked her what that means, and she said, "You tell me." Among the questions I was asked: my history, my favorite subject in school (I couldn't think of one and said MOD, and Dr. R agreed that Dr. SLP was an excellent professor), and what I do for fun. When I said I play the violin, she strongly suggested that I bring my violin to one of their music classes and play for the patients. I think I'll do it =)

It took us two hours to run through a full psych evaluation with Dr. R, which consists of many many questions to ask the patient to gauge just how bad off they were. We have a mini-night call tomorrow evening and an overnight call on Friday. It turns out that Dr. M, the prof who normally makes students' lives hell during a week of nights, will not be with us next week b/c his brother passed away, so my classmates and I will not get the same night experience as everyone else. On one hand I'm relieved, but on the other hand I'm disappointed not to get the Dr. M treatment that everyone else who's been here did. But who knows...Dr. M just might come back for our last night. By them hopefully we'll all be able to impress him.

I'm typing this from Dr. R's office; she has a computer that med students are allowed to use. Fortunately it doesn't block me from blogging. I don't know when I'll have time to come in here for the rest of the week, but rest assured there'll be lots of stories to tell when I do =)

TSH: C'est Pas Mon Jour

Today was my first real day of psych at TSH, and boy was I off to a bad start. First I went to the wrong building, and in my hurry to get to the place where I was supposed to be, my beeper fell off my belt loop (and we're supposed to keep these things with us at all times) and I heard the sound of breaking plastic. All I could find of it was the clip, but I didn't have time to look for it b/c I was already late (and Dr. R, the attending in charge, knew it). It doesn't help that Dr. R is a real stickler for punctuality. I'm usually on time, but again, today was not my day.

I was paired with David, and our job was to take turns talking to the patients as they are brought into the interview room. Aside from us, we are accompanied by Dr. R, a social worker, and 2-3 nurses. The nurse did one interview and then David and I did the rest. My first patient was schizophrenic and didn't talk very much, but at the end of the interview she gave me a hug, which I thought was sweet. One of David's patients was a paranoid schizo named S who, when asked what regrets she had, said she regretted making love with 44 men in her lifetime (down from 45, the number she gave last week). She was approachable at first, but when Dr. R said she was putting her on a certain medication (clozapil), she got really pissed.

S: I'm not taking that drug.
Dr. R: That's fine, but for each day you don't take the drug, you got to get a shot.
S: Now look, Mrs. R, I don't like the way you're talking to me.
Dr. R: You're projecting, do you know what that means? You're bitter.
S: I am not better!
Dr. R: I didn't say better, I said bitter. And your medication is court-ordered, so you have to take it or else we're going to give you a shot.
S: Fine by me.

After this patient was a lady who didn't talk at all, just nodded yes or no (and they were very tiny nods so I had to watch real closely), and at some points she'd write her answers on paper. When she got up to leave, one of the nurses noticed menstrual blood on the chair and said, "Now I know that wasn't there a few minutes ago." Dr. R thought S had peed in the chair and said, "Did she pee? She would do something like that." But no, we said it was menstrual blood, so that chair was taken away and replaced with another one before the next patient arrived. We had lecture at 1:00 at JPS so Dr. R let us go at 11:15 (after giving David and me a very serious talk about how we are going to take our psych rotation seriously, we are not here to be breastfed and have our hand held b/c we are adults, and we are going to do a good job), but I still had to take care of my missing beeper. Fortunately I found it lying on the grass, so I won't have to get a new one after all. But...I ended up not leaving TSH until 11:45, and didn't pull into the JPS parking lot until 12:55. I had to call Anita and ask her to buy me something from the cafeteria or else I wouldn't have had a chance to eat lunch. (David didn't eat any lunch)

The JPS lectures were almost the same lectures we had last year (no surprise). I found myself nodding off after a while; driving more than 2 hrs in the span of 6 hrs can do that to you. After tonight, I'll be staying at Terrell until Saturday morning. So there'll be little to no blogging until then.

Terrell: 1st Day

Today was the first day of my psych rotation at Terrell State Hospital (TSH). We had to be there at 8:30 and I left around 7:00 and arrived with about 30 min to spare. There I met up with David H, Sital, and another 3rd year named Kyle from KCUMB. We had a brief orientation and then walked around the hospital grounds getting our dorm keys, parking permits, ID badges, bag full of psych necessities (beeper, video on extrapyrimidal symptoms, reading handouts, etc), and orientation to the computer system and dictation system. After that, we got some lunch at the local cafeteria, the "Chuckwagon," and our choices were very limited b/c the grill was out of order. Free food or not, if I live off the Chuckwagon I'm going to be as big as a blimp by the end of the rotation, so I'm planning to bring some snacks and food of my own.

TSH has a lot of land and buildings. Students are assigned to dorm-like rooms (built in the wing of the geriatric center) with three beds and two armoires. It's a very boring room (I've considered bringing my own TV but I didn't see a cable connection anywhere) where I'll probably do nothing but study (since there's nothing to do in Terrell). The bathrooms are community baths, even more scary-looking than the community baths at Jester (much to my dismay). I can put up with it, but Sital has never used a community shower before and was a bit horrified. Needless to say, since we got out around noon, no one is spending the night at Terrell tonight. I plan to commute and live at Terrell equally if possible. The drive is slightly under one hour, so commuting is definitely do-able.

Final thoughts on Ob-Gyn

On Thursday, the day after the departmental exam, my other eight classmates and I met with Dr. A to go over our exams. When I saw my grade, I knew it wasn't great, and I was even angrier when I found out that I changed about 5 correct answers to incorrect ones! That scared me into doing a more intense review for the shelf exam. But for people doing their ob-gyn rotation at JPS, commit this to memory: for the departmental exam, focus on the lecture material. Many of the exam questions came straight from the case studies in the powerpoints, especially with Dr. A's lectures, which I did not review in thorough detail the night before the exam (I'd read Case Files instead). So for the dept exam, know the presentations well, and then go over Case Files for extra stuff. Also, Pretest did not help me very much; the lectures at JPS covered just about everything we needed to know for the shelf.

The shelf exam: alas, time and dysmenorrhea were my worst enemy (a little TMI there, but after hearing other girls talking in the bathroom I knew I wasn't the only one). The level of difficulty was about the same as the dept exam, but hopefully I did better on the shelf. I got my peds grade back, and I passed with a fairly comfortable margin, but we'll see what ob-gyn does for me.

Now...onward to psych. I'll be at Terrell State Hospital and have gotten some info from Asuka and Andrew about it so hopefully I won't be too unprepared. I also hear there's only one computer with internet access there so I may not be able to blog on a regular basis (though still more regular than other peeps, hehe). I'll take some pictures, too =)

ObGyn Departmental Exam

Well, the departmental exam was this morning, so Marcus, Jedd, Blakely, and I went to the (craptastic) JPS library to study. Marcus and Jedd have delivered a total of 30 babies between the two of them (Marcus wins at 17 deliveries). I don't know how many babies I delivered; somewhere between 5 and 10. Those two had a major competition going. We were discussing birth control at one point and Blakely said one of the Dr. R's said if she ever needed an IUD, she could ask N. Boozer to refer her to him. How awkward would that be, having a doctor whom you shadowed put an IUD in you?? I wouldn't do it. Marcus said that there was something seriously wrong with Blue Team, with Blakely getting contraceptive advice from the profs and one of the other girls getting a vag sonogram done by one of their residents (again, don't go around quoting my blog to others since the stuff I write is pretty personal)

The exam itself wasn't difficult, but I knew I didn't study enough. There were a lot of percentage questions on the exam (i.e. what are the chances of cervical cancer recurring?) <--not an actual question, by the way, and there were even two questions where the answers were clearly right below the question (copied and pasted from another source, most likely). So I don't think I failed, but it won't be a high pass. We'll see.

Last day of OB: "My Baby Died"

This morning during rounds I was sent to 2South to see if there were any patients that could be seen. All were complicated: 2 pyelos, 2 placental abruptions from my last night shift, and a 26 week PPROM who had a C/S yesterday. I decided to see the PPROM (preterm mature rupture of membrane) patient, and everything went well until I asked her how her baby was doing. To my surprise (and horror), she burst into tears and said that her baby died yesterday.

My thoughts? Oh sh**. The last note in her chart was a delivery note documenting that she'd delivered a viable baby girl, Apgars 5/8, yesterday around 6 a.m. There was nothing in there that the baby died, nor was there a picture of a purple flower on her door (the picture tells others that the woman inside the room has lost her child), so I had no clue what I was getting myself into and instantly felt both embarrassed and ashamed. Afterwards I told Dr. C what happened, and she asked me if I'd seen the chart beforehand. I said yes, but there was no indication that her baby had died. Later Dr. JC (the attending who listened to our student presentations) rounded on patients with our team, and we got to see the patients I mentioned above. Both placenta abruptions were housed in the same room, and coincidentally, they'd known each other for years. When Dr. JC got confused about which patient was the "murderess" (what we nicknamed the mother who'd inadvertently killed her baby by doing cocaine), the woman in question said, "My baby passed on." There was no remorse, no regret, nothing. She just wanted to leave the hospital to see her other children. Later on Dr. JC asked us, "So, what'd you think of that mother?" It was easy to get the two moms confused, except, as Dr. C pointed out, the "murderess" had the "crazy hair" =P At any rate, that mother is being reported to CPS and they'll probably take her other 8 children away from her...if they're even living with her.

Afterwards we had lecture and then some time to study before lunch. The library at JPS sucks. It's small, doesn't have enough tables, and loud. You can hear carts rattling from the floor above, and the librarian talks so loudly on the phone that you have to wonder if she knew the meaning of the word, "Shhh." Anita and I got a more peaceful study done at the HCW. While most teams had the afternoon off, my team was shortstaffed (Dr. P was put on terbutaline for her contractions and couldn't be here) so Anita and I stayed until 5. We saw some pretty interesting cases, too. I had two patients with pelvic pain and each time I forgot to ask some key questions (as Dr. T made sure to point out). One lady presented with what looked like pelvic pain, but Dr. T found out she had had rectal bleeding for a year. My last patient had a lump in her mons that disappeared when she lay down and became prominent when she stood up. That screamed "hernia" to me, and I was glad when Dr. T confirmed that it was indeed a hernia. Finally, I got something right!

At the end of the day, Anita and I were a bit sad to leave. As much as we complained about the early hours, the required attendance at most C-sections, and the two weeks of night shift, we both learned a lot with Drs. C, D, B, K, G, and M and we both became very fond of our team. So for those of you doing your OB rotations at JPS, Green team is a good place to be =)

L&D: Last Day

We just got off nights, and we're immediately back in L&D for one day. Anita and I got to the floors at six and found only 4 charts (good), and we later learned that Dr. P was at Harris b/c she started having contractions. She's only 35 weeks along so I hope she's not going into labor. But...that left only Dr. C and Dr. M on the team, since Dr. D is on vacation. To help with that, they pulled Dr. C from Gyn-Onc. Anita and I didn't get to L&D until almost noon due to lecture. Dr. C had five C/S today so we barely even saw her, though she did say she talked to the woman who'd lost her baby at our last shift due to cocaine. And guess what? The woman didn't care that she'd just lost her child. She had no attachment to that baby she carried for 38 weeks. Guess some people aren't meant to be mothers. Anita got to deliver a baby with one of the midwives, but I didn't b/c my patient's cervix refused to dilate. Oh well. I don't know how many babies I delivered altogether, but nowhere near Marcus's grand total of 14 =P

Night Shift: Saturday-Sunday

My last night shift of ob-gyn was definitely memorable. Not long after we arrived a woman delivered a 15 wk old miscarried fetus, and Dr. D carried it out in a little basin for Anita and me to see. The poor thing was only about 2 inches long, but its features were perfect. The arms, legs, and toes were all well-formed, and it was just so sad b/c it looked like a real baby. Later on, Triage was practically empty and our patients were L&D were nowhere near ready to deliver, so we were mostly hanging around the lounge talking when suddenly there was a call for doctors to triage b/c a patient had passed out in the bathroom and was bleeding badly. Anita and I were headed there when Dr. JP (the chief taking Dr. C's place for the night) said, "Where are you going?" and told us to stay in L&D with Dr. P. We discussed possible causes for her bleeding and it sounded like she had a placenta abruption. We heard a call for anesthesia to the OR, stat, but no one followed through. We asked one of the CRNAs what was going on, and she said the baby had no fetal heart tones. The mother had been 38 weeks along, and because she did cocaine about 2 days ago (also the last day she felt fetal movement), she lost her baby, making it an IUFD (intrauterine fetal demise). It's sad, tragic, stupid, and avoidable all at once.

Then, shortly after midnight, there was another call for anesthesiology to the OR, stat. We were all like, "Another one?!" Yes, it was another placenta abruption, but this time they acted fast. Anesthesiology ran to the OR, and a few minutes later a woman in a bed was wheeled to the OR with Dr. P, Dr. D, and Dr. S running behind it. Anita and I debated whether or not we could go observe the stat C-section, but decided against it since there were already at least 3 residents and 1 staff doctor in the OR. We didn't want to overstep our boundaries (though Dr. P later said it was a good teaching case and we could have observed from afar). Dr. S, one of the OB interns, later came out and said that the stat C/S was one of the most exciting things he'd ever seen. They had one minute to get the baby out, so Dr. P did a vertical incision (slash, slash, slash), pulled the skin apart, then did a classical uterine incision (slash, slash, slash), then pulled out the baby, all in about 45 seconds. The baby weighed a little more than 900 grams (about 2 lbs?) and was about 26 weeks along, but its blood gases were excellent (not acidotic) so its chances of survival were good. Thank goodness we had at least one happy outcome.

Dr. D was on an adrenaline rush as she told us what had happened in Triage. The woman had presented with vaginal bleeding and wasn't even sure if she was pregnant (how do you not know if you're pregnant after 26 weeks?), so they decided to do a sono on her to date her pregnancy. Initially Dr. D saw the heart beating, but somewhere in the middle of her exam, the heart stopped. She and Dr. P exchanged "Oh s***" looks and immediately called anesthesiology and all the others to get the OR ready. It was just one of those crazy coincidences that happened at the right time; if the woman had been sent home without the sono, her baby might have been lost. Dr. S told us another story that happened earlier this month (I think) where a mother coded in L&D (not the operating room), and one of the older attendings, Dr. B, sliced open her stomach while others were giving compressions in order to get the baby out. Baby survived, mom didn't.

We had 18 charts to see in the morning (Blue and Green), so Dr. JP sent Anita and me to the floors around 4:30 a.m. so that we could be out by 8:00. We've gotten pretty good at these notes, so with Drs. P, S, and D writing behind us, we were pretty much done by 7-7:30. Dr. D was especially glad since she flew to Nicaragua today for a week of vacation (I'm writing this late, but her plane left at noon) So it was an interesting way to end nights =)

Night Shift: Friday-Saturday

Another semi-slow night in L&D. I got to scrub in on one repeat C/S and the woman had a whole bunch of adhesions that complicated the delivery just a bit. Other than that...not much aside from H&Ps. We got started on rounds around 5:00 and worked all the way beyond checkout. One of the patients I saw was an African lady who spoke French (sadly I never learned OB French; I don't even know if a French interpreter exists at the hospital) and enough English to answer my questions, so before I left I wished her felicitations. Then Dr. S cracked us all up by saying that he's asked patients if they ever had a "bebe retardo" or something like it (mentally-retarded baby). It just sounded so wrong. XD

Night Shift: Thursday-Friday

Yeah, so I've gotten lazy with the blog...ah well. Today was a bit more interesting because of the two deliveries I sat in on, neither were normal. In both cases, the moms were in their early 20's and G1P0. In the first case, the delivery proceeded as expected (I helped deliver and came close to dropping that slippery baby but caught it in time), but afterwards, the mother had a few lacerations that would not stop bleeding no matter what. Dr. D threw lots of sutures without success, so she removed those and then went deeper. It stopped the bleeding somewhat, but there was still oozing at the site. It seemed like the more she tried to sew, the more bleeding sites the lady had, yet her platelet count was fine. Then when we tried to put a vag pack in her, an earlier laceration that Dr. D sewed properly reopened and more blood spilled out. Poor Dr. D was stressed to the limit since Dr. C and Dr. H (attending) were in surgery, leaving her on her own. On top of that, the woman was developing major labial and vaginal swelling (hematomas?) so rather than attempt to sew anymore, they stuffed the vag pack in there and hoped for the best.

The second case was a woman who had been pushing for almost 2 hours and was so exhausted she couldn't push anymore. Somewhere in the midst of all the pushing, she suffered a huge tear, and her sister was terrified for the baby (who was in the canal for quite some time already). In the end Dr. H had to cut an episiotomy and use a vaccuum to pull the baby out (it did not look fun), but once that baby was out, both mom and aunt burst into relieved and happy tears. The bad news: Mom suffered a 4th degree laceration that went straight to the rectal muscle. Dr. H immediately called Dr. D into the room to repair it, saying she "needed the experience."

Tonight was a busy night in both triage and L&D; there were lots of admission H&Ps to keep us busy. I did get a chance to put my head down, but I wasn't sleeping; when Dr. C told Anita, "Wake your counterpart," I heard her perfectly. Dr. P still does most of the deliveries; if Anita and I want to deliver any more babies before this rotation ends, we have to latch on to Dr. D or Dr. C. Anita and I were pretty much in charge of postpartum charts today since our "three-man team" was stuck in L&D, so together we saw 8 charts before rounding with Dr. A on the patients in 2N. Can't believe it's already Friday.

Night Shift: Monday-Tuesday

As expected, my entries during night shift will be short b/c 1) I'm typing them quickly so that I can get to bed, and 2) by the time I get home I've forgotten half the things that happened during the night. It was another slow night; Dr. P did all the deliveries while Anita and I did H&Ps. There were 2 C-sections, so I went to the 1st one. When the scrub nurse asked me if I got permission to scrub in, I said yes, b/c in our team a student is required to be present in all non-complicated C-sections. When I went in, Dr. C and the attending had not arrived and Dr. D couldn't make the first cut without them, so Dr. D and the scrub nurse began drawing pictures on the plastic portion of the sterile drape covering the patient's abdomen (which read "es un nino"). When Dr. C saw what we did, she was all, "Oh, for the love..." This C section was pretty much like the others. Then Anita went in for C/S #2, and my words about "being required to scrub in" came back to bite me when they were counting equipment b/c the nurse added, "Med student present: check."

We had some downtime from 4-5 a.m. in which everyone had a change to sit down and sleep. Later Anita and I ran into Dr. K in the halls en route to the resident lecture, and we let him know that we missed having him on our team. The good thing about today: we don't have to come in until later!

Night Shift, Sunday-Monday

I stayed up until 5 am on Saturday/Sunday night in hopes of getting adjusted to a night schedule faster, but I ended up waking up 4 hrs later anyway so it was all for nothing. I did have an on-and-off nap that lasted 2 hrs, but it wasn't enough. Our night shift started out all right; got a few H&Ps off the bat, but most, if not all, of the deliveries went to Dr P b/c she still needed the practice. The Yellow team told us about a woman who needed her vulva examined b/c there were "blackheads" down there? "Were they moving?" asked Dr. D (implying crabs). "No," the other person replied. Sometime around 10, we were given the opportunity to order something from Olive Garden, so I got 2 appetizers (and I wonder why I've gained weight on this rotation?) For the most part, this was the most laid-back night ever in L&D. Even Dr. D marveled that she rarely had the luxury to sit down and eat without rushing. Dr. C also found Trichomonas from a patient and showed it to Anita and me. We saw it moving, but I didn't see any flagella (didn't look close enough). The sleepiness didn't hit me until around 4 a.m., when I laid my head down for a quick nap, and at 4:30 we were dispatched to the floors to count charts. I did 3 postpartum notes before we were allowed to go to lecture, where again it was hard to stay awake (but I tried). And later tonight I get to do this all over again.

The Shortest Day

This morning my team was supposed to round with Dr. A (again) at 7:15, but instead Dr. M met us at 7:30. Anita and I had lecture at 7:30 (Anita had a presentation to make, too), but out of respect to our team we stayed on the floors until we were allowed to leave around 8:00. When we arrived at the lecture room, Chris had just finished his presentation and Dr. C was not pleased that we were late. "What was so important that Dr. A would keep you?" he asked. "You're expected to be on time to lecture and presentations every time." Fortunately he wasn't mad at us, but he was annoyed at Dr. A for thinking that rounding was more important than lecture (when it wasn't) just b/c he was the department chair. Ah well.

By the time lecture was over, Anita and I only had time to see about 1-2 patients at HCW before our residents let us go early (since we start night shift next Sunday). Fine enough. We stopped by a scrub store to get some Klogs (my Nikes are not made to stand in for 13 hrs) and then did lunch. Now we'll see how I can adjust to a night schedule over the weekend.

L&D: The Usual

This morning rounds began at 5:30 a.m. and lasted just barely past 7:00 a.m., so we made it to check-out in time. The Blue team chief immediately warned us about a 15-year-old in arrested labor (of some sorts), and her dad was pissed that the baby wasn't coming out as expected. News flash: babies don't always arrive on schedule. The L&D board was full and triage was packed as well, so we immediately started writing up H&P's. Shortly after 8:00 one of the nurses sent me to the Family Health Clinic to pick up "goodies" from the drug reps. I got lost and arrived a bit too late, but I was still able to pick up a few pens for one nurse and several students as well as a burrito for Dr. P. We had a PA student named Russell join us today; it was his second week in L&D. The first C-section came rolling in around 11:30, giving me just enough time to finish up an H&P before scrubbing in. It was a usual C-section, though my duties as a student are increasing with each additional C-section I see. Instead of the usual retracting, blotting, and stapling, this time I got to massage the uterus, hold it during the suturing step, and hold the thread while Dr. D sutured. Not much, but more than before. Maybe next time I'll get to tie knots =)

L&D had its usual craziness. There was construction going on outside that sealed several doorways, making it hard to navigate through the halls, so when Cristy came into L&D trying to get out of the building, I was able to help her out. Then in another room another woman was in major pain and screaming so loud we could hear her many feet away. One of the nurses couldn't help but laugh, and the woman's husband poked her head outside the room saying that it wasn't funny. I got to deliver a baby with one of the midwives, and it had to be one of the smoothest deliveries I'd ever seen. No lacerations, no excessive pain from the mother, nothing. The only setback: I wasn't wearing a face mask (we had to gown in a hurry) so I got some bloodspatter on my cheek. Nothing a little soap and water couldn't take care of. What did piss me off: on the way out of the OR, my arm got slammed by the closing OR door, leaving two bruises on my arm near the elbow. It hurts a little to move my elbow now, so I'm hoping that nothing's broken.

More good news: round start at 6 tomorrow instead of 5:30 =P

HCW: Pelvic Pain

This morning my team had rounds with the department chair, Dr. A, but Anita and I couldn't stay too long b/c of lecture. Dr. H lectured on material that I'd just read in our textbook so I was glad for the refresher course. The girls on Blue team were exhausted from night shift and desperate for lecture to end so they could go home and get some sleep; now they know how the rest of us felt =) Well...Anita and I have night shift again next week so...

Work at the clinic was fairly light today. The FPs weren't there in the afternoon, so Anita and I got to work with Dr. T on the noncomplicated cases. We each got a case of pelvic pain. In my patient, her pain was most likely due to dysmenorrhea/possible PID. One concern she had was why it hurt to have sex, and when we felt for her uterus, I couldn't feel it b/c, as Dr. T said, it was "midline." He then said that for women with midline uteruses, lying down is the most painful position to have sex. His advice for now: get started on the pill, and try other positions. Wow. My next patient was postmenopausal with a hx of vaginal itching and burning post bladder sling surgery. She was using Vagisil to relieve the itching, which turns out to be one of the worst things you can do since it sometimes makes the itching worse. Dr. C said many people are fine just as soon as they stop the Vagisil. So we gave her an Rx for clobetasol instead.

Dr. D expects us to be in L&D for rounds at 5:30 am tomorrow. Guess that means I'd better be in bed by 10:00 or 10:30 at the latest.

L&D: Understaffed

This morning Anita and I arrived too late to do any charts b/c Dr. C had told us the wrong time to arrive (6:30 instead of 5:30). Fortunately my team was in L&D today so we didn't have to attend resident lecture; someone had to stay and catch babies, after all. The attending today was Dr. R (Dr. GR, I should say), whom we'd met previously. He immediately took Anita and me under his wing and went through one patient's chart with us. "You think we don't look at H&Ps, but we do," he said before proceeding to critique one FP resident's H&P. Then the door to that same patient's room burst open and we heard, "Delivery doctor in room 5!" Anita got to deliver this one (as well as suture a lac or two), and I wondered when I'd get a chance to suture.

A C-section was scheduled for around 10:00; I barely had time to finish an H&P from OBT (OB triage) before I hurried to the OR with Dr. D and Dr. R. One thing about Dr. R: the man loves to have "pimp sessions." He asked me how many C-sections I'd seen and I said 4 (but it's probably more like 5-6), and he immediately proceeded to ask me to name structures around the uterus. Round ligament, mesosalphinx, mesoovarian, arcuate line, cul-de-sac, fimbriae, serosa layer of the uterus...few structures were spared. Some I knew, some I didn't (like the infundibulum pelvic ligament, though I did feel the pulse within it). Dr. R asked me what my grade in anatomy was, and I told him anatomy was integrated into systems now. So he asked what my practical grades were, and I said they ranged all over the place. "60's...70's?" he asked. Ouch. I actually did pretty well in repro anatomy, and at the end Dr. R said that I was among the more knowledgeable students he's pimped (whew). One thing that stumped both Dr. D and me, however, was vernix, aka the cheesy substance that babies are covered in when they're born.

After the C section, it was back to writing H&Ps for a while. I wrote one on a lady in triage who was brought to room 5 in L&D shortly afterwards (yup, same room from earlier). A few minutes later, someone yelled, "We need some help in room 5!" My patient, who had previously been calm, was suddenly screaming and writhing like mad. Apparently she shot from 5 cm to 8 cm in a matter of minutes; not good. It was too late for her to get that epidural. I barely had time to get her to sign the vaginal consents before it was clear she was ready to deliver. Delivery doctors were paged to the room, but no one came! I was in a panic and ran out into the hall to see if anyone was coming (Amy, the L&D nurse, later said she thought she would have to deliver the baby after I ran out). Fortunately Dr. D came and we both gowned up. Shortly before this deliver, Dr. R had taught Dr. P and me how to catch a baby properly, so I felt ready for this one. The baby that came out was huge, but amazingly the mom got through birth with no lacerations whatsoever. Wow. Even better was when Dr. D said I did well in both in the delivery room and in the OR (surviving Dr. R's pimp session, not necessarily for retracting the bladder)

Not long after we left that room to write postpartum notes, we heard "Delivery doctor to room 1!" Dr. P asked if she should go, and Dr. D said, "Yeah, Dr. C will be there. You'll learn something from her." Then..."Delivery doctor to room 3!" Dr. D swore under her breath as she and Dr. P hurried toward room 3. Then..."Delivery doctor to room 12!" WHAAAAAAT?! Talk about insane. Dr. D then sent Dr. P to room 12, where hopefully KD was there to supervise (we're all still learning). If there had been a fourth baby about to come out, then I don't know what would have happened. Dr. R went from room to room checking on the patients' progress, and the transitional resident doing his peds rotation was frustrated b/c he couldn't be in three places at once. But yeah...that was crazy.

A 3rd C/S was scheduled for a 45 year old mom who'd already had 2 miscarriages in her quest to become pregnant, and I went to see her C/S after writing her H&P (Anita saw the 2nd C/S earlier in the afternoon). Dr. R was "all pimped out" and didn't ask me any more anatomy questions, thank goodness. This baby was a big one, too (all the babies today were big), and when he was given to his mom, his mother couldn't stop laughing and crying. Now this was a long-awaited baby. Unlike other doctors we've seen in the OR, Dr. R doesn't staple his C/S incisions; he does subQ sutures. In the end though, I think they look the same.

Whoo...long entry today =D

L&D: Slow Sunday

Yesterday my team was fairly busy admitting patients and doing H&P's, but not much else. All those women we admitted (and more) gave birth after our shift ended; the Red Team (who's doing night shift) delivered a grand total of 15 babies last night. Their 2nd year resident, Dr. E, deliverd 8 babies, and one of the moms he treated got a 4th degree lac. That must have been a sight to see. At any rate, after doing charts, Anita and I returned to L&D to find the board practically empty. Dr. C was happy about that; she was still tired from being overworked yesterday and a near-empty board was a welcome sight.

Just in case, though, Dr. C called one of the 4th year OB fellows, Dr. M, to come in since the Green team is currently a 2-person team + one intern. Today was a fairly dull day. I got to watch Dr. D do one delivery (and she showed me the correct way to deliver a placenta) and wrote two H&Ps, but that's about it. One good thing came from this day: Dr. M took the time to sit down and teach Anita and me how to tie knots. It was about time we learned, and if I practice enough, maybe I'll be able to sew a lac on my own before this rotation is over =)

New Month, New Team

Now that it's a brand new month, the interns and FP residents move on to other rotations. We lost Dr. G to ER, Dr. K to clinic, and Dr. B to medicine (I think). In their place, we gained one 1st year FP intern, Dr. BP. This is probably her first time doing OB since her third year in med school, so Dr. C immediately took her under her wing to teach her how to deliver babies, write notes, etc. In the process, she also taught Anita and me a few things to improve on our note writing. Hopefully that means we'll get more teaching time with Dr. C and maybe learn to do sutures (Marcus and Blakely have already done those).

Because the Green team (me and Anita) was working L&D today, we had to write postpartum notes for the Blue Team (who starts their night shift tomorrow), so Anita and I were told to get to the hospital by 5:30 a.m. That was early. We lost track of how many notes we wrote, but in the end, poor Dr. D had to see all 12 patients on her own since there were no other doctors to help her (Dr. BP is still learning and Dr. C was still in L&D). To thank Anita and me for our work, Dr. D got us all breakfast on her account. But...when we were back in L&D, we were restricted to writing H&Ps since Dr. BP was getting all the deliveries. Altogether, I don't think we ever wrote so many notes in one day before. But that's what happens when your team is shortstaffed. *sigh* Dr. C said another resident will be joining us in future days and weeks. Hope so.

There was one emergency C-section today, and since Anita went to OR yesterday I decided to scrub in for this one. This time I caught the scrub nurse just as she entered the OR and she was able to pull a pair of gloves for me. It was just me, the nurse, Dr. D, and Dr. S (who lectured on antepartum and postpartum bleeding). It seems that with each C section I watch, the residents expect more of me (Dr. D even called me the "expert retractor.") My job involved more than just retracting and blotting this time around; I also had to hold the thread tight between suture reloading and learn to cut sutures correctly. Yes, there is a proper way to cut thread; you can't hold the suture scissor like a regular scissor and just cut. I did that the first time and Dr. S said that was clumsy. "Only cut at the tips, and with a small turn of the wrist," she said. I had three chances to redeem myself but each time I'd make a mistake in some form or another. On the last one, Dr. S even lightly slapped me on the wrist for "turning the blade the wrong way." *sigh* No one ever told me there was a method for cutting thread. Well, now I know.

After getting off work, I went to Panera Bread to meet with old friends and exchange rotation stories, news, gossip, the usual =P It was nice to see familiar faces again.