Dysplasia Clinic: Lots of Laughs!

This morning we had to sit through a conference with attendings, residents, and nurses as they discussed cases in which patients met with less-than-great outcomes. One case in particular stood out: a febrile woman went into labor at 27 weeks, but had to stay in triage (I think) b/c all the beds in L&D were taken. One of the nurses took off the fetal monitor, and by the time L&D had a room, the woman had to stand up and walk to a wheelchair for transport. By the time that happened, her umbilical cord had prolapsed through her vagina and the baby's heart rate was slowing down bigtime. They rushed her to do a C-section but the baby's Apgars were 0/0. It took 15 minutes to get its heart beating again and the baby is currently on life support in the NICU. Nurses and doctors were both throwing out harsh criticisms at each other, and the moderator (another doctor) said it's useless to assign blame now; rather, it's important to prevent a similar tragedy from happening again.

The Green Team had Dysplasia Clinic today, so after a drug rep hosted lunch, we trooped down to the pathology lab to look at some slides of cervical dysplasia. Dr. T, an older physician, and Dr. MB were there to supervise. Afterwards we went back to the HCW to do colposcopies on women who presented previously with abnormal pap smears. One LEEP was done but Dr. C forgot to call Anita to the room to see it. And apparently it was just as well; family members are normally not allowed at LEEPs, but for this patient, an older woman insisted on being there. Dr. MB wasn't pleased since he has a rule against family members being with patients during LEEPs, but Dr. C didn't know the rule. When he called her on it when she stepped into the office briefly, she looked around quickly and whispered, "They're lovers." Then before we could process this information she said she'd fill us in later. But after she left, Dr. MB filled us in on how his lesbian patients got pregnant (mail-order sperm, artficial insemination, getting a male friend to have sex with them, etc).

I got to watch several colposcopies (and try to find the areas of dysplasia) and winced when I saw the punch biopsies. The cervix can bleed a lot. Later Dr. B shared another hilarious story in which his patient sneezed and the speculum shot out of her vagina and skidded across the floor ("Projectile speculum. There goes your Valsalva maneuver," joked Dr. K). Dr. MB came in shortly afterwards and, upon seeing some "bloody egg-yolk substance" on the ground, made a strange face while Dr. B frantically signalled him not to say a word (I didn't witness this; but Dr. MB and Dr. B both talked about it while the rest of us roared with laughter). Then Dr. D said that her cat has pneumonia and needed erythromycin eyedrops for its eyes, and Dr. K asked if her cat had chlamydia (since babies born to chlamydia moms need erythromycin). That was pretty random.

The best part had to be at the end of the day, when Dr. C came in to fill us in on her LEEP patient and her lover. Dr. MB commented that he never picked up the fact that they were lovers, and Dr. C related the conversations they had in the room that made her realize it. The next few lines come straight from Dr. C's recollections, with some of her thoughts in italics. And this really did happen:

Dr. C: (to the lover) Are you sure you want to be in here?
Lover: Yeah, I'll be fine. I just had a stroke two days ago (she was middle aged)
Dr. C: (thinking) That's not good.
Lover: (looking at the TV screen featuring the patient's cervix) Is that where a man's penis goes?
Dr. C: The vagina?
Lover: No (points to the cervix os)
Dr. C: No, it just goes in the vagina (Unless it's a really thin penis...)
Lover: Does the penis touch it? (the cervix)
Dr. C: It could...(If it was really long)
Lover: Can women get HPV from oral sex?
Dr. C: (realizes that the women were lesbians even though the patient has had children before) [I forgot what she said]
Lover: Can a tongue reach all the way up there? (to the cervix)
Dr. C: (desperately trying to think serious thoughts to keep from busting out laughing) Um...no (not unless it's a freaky long tongue...)

Thank goodness Dr. C closed the door to the office before telling us this story, because all of us--Dr. MB, Dr. G, Dr. D, Dr. B., Dr. K, Anita, and I--were laughing sooooooooooo hard afterwards! Dr. B then said, "Back to what we were saying earlier..." and changed the subject by talking about African countries (we had a patient from Nigeria earlier, and Dr. MB started talking about different African countries and their dialects), and Dr. MB said, "Dude, we were talking about lesbians." LOLOLOLOLOL!!!

Man, after today, I love my team. It's just too bad that next month Drs. B, G, and K are moving on to other teams and clinics, and we'll get a new intern and new FP resident (or two). *sigh* Better enjoy these last few days with them while I can.

HCW: First Day at Clinic

All the power was out in the parking garage today (definitely not safe for 6 a.m.), so I parked at the Health Clinic for Women (HCW) parking lot. This morning we had a lecture on multiple gestations with Dr. S, then had a 90 minute break before another lecture with Dr. C on family planning and pap smears. To our dismay, it was the exact same two lectures he gave us last year for repro! We were in lecture until noon, and I was really feeling bad for Jedd and Marcus, who just had their first night shift last night and had to be back in L&D in less than six hours! I hope they get at least 5 hours' worth of Z's this afternoon.

Anita and I were assigned to work at the HCW today. There we got a nice surprise: our chief, Dr. C, was back from vacation. Dr. D was definitely in a happier mood now that she doesn't have so much responsibility on her shoulders anymore. I worked with Dr. C with a few patients; she has a really great bedside manner and is pretty cool to hang out with. At one point I winced when a staple came out of a woman's vagina (she had a Nabothian cyst repaired), and Dr. C cautioned me not to make weird faces in front of patients, "especially when their legs are open." Good point. Also, Dr. B keeps asking me when I'll be back at the hospital for my internal medicine rotation. "I should get you on my team, it'll be fun," he said. Hmmm...as long as he doesn't keep taking my patients...I'll have to think about that one.

L&D, Boredom, and Meconium

Anita and I both beat our residents to the floors today, so no one can say we're lazy. =) Afterwards we went to the lecture room to hear Marcus and Kimberly give their student presentations. Marcus talked about Group B strep for less than 5 min, while Kimberly talked about a leimyosarcoma she saw in the OR. Then...we were treated to 3.5 hrs of lecture by Dr. R, the same prof who gave that 100-slide lecture on repro genetics last year. If you thought two hrs of slow monotonous lecture was hard to sit through, try three and a half hrs of facts, charts, and statistics that were at resident learning level, not med student level. It was hard to stay awake, and Anita and I ended up exchanging notes reflecting how boring it was. Dr. R started speaking at 8:30 a.m., and it was noon before we got out.

Later when we returned to L&D, many people sympathized with us when they found out who our lecturer was, especially having to put up with him for nearly 4 hrs. "So that's where he was all morning," one resident mused. "That means he'll be tired of talking." LOL. I got to work with a midwife named KD and she told me to do an H&P on a patient who had zero prenatal care and was 40 weeks along. I interviewed her only to have Dr. B take my H&P again, but KD called him on it, thank goodness. Then another woman in labor rolled in, so I was allowed to deliver her baby (yay!) This woman took a long time to push the baby out. The first time I delivered a baby, it slid out on its own, but this one I literally had to yank out. And out it came...followed by a bunch of greenish meconium. I got to clamp the cord before pulling on the umbilical cord to remove the placenta. Normally this doesn't bother me, but this time the smell of the meconium got to me and I had to tell myself to breathe normally and not pass out. Fortunately the placenta was out in 6-7 min and I was allowed to leave to write my note.

In the middle of my note writing, Dr. K sat down and told me how he thought I was doing on my rotation so far. For the most part he had positive things to say except that I was too timid and should work on building my confidence. I'm just glad he doesn't think I'm a total idiot. Things slowed down after that, so Anita and I ended up passing time by going through Internal Medicine questions with Dr. B, and at 6, when Dr. P said we didn't have to stay for check-out, we were all happy to leave. Happy Friday!

PCC: Last Day

Rounds didn't begin until 6:30 today, but I got to the floors by 6 to get a head start on writing progress notes (given how slow I am). In the end I talked to two patients. One of them was admitted with opiates and cocaine in her system, so when I went to interview her, she was barely lucid (she fell asleep and started snoring in the middle of my interview) and her child was nowhere in sight. Social Services will probably get involved. For the other patient, I wrote what I thought was a good note and presented it to Dr. K at his request, but when he found out I forgot to put blood lab values on there, he told me (rather sternly) to write them in and come back to him when I was done. Can't I ever do anything right on this rotation? Now I'm dreading next week, when it's Anita's turn to go to the PCC and I'll be at the mercy of my team.

We had Grand Rounds in the morning at another hospital, and then Sharon and I drove to school to work in the PCC. Dr. B had a lot of patients this morning so he put us all to work. I had to write SOAPnotes on all my patients, which took a while, but eventually I remembered what to write. Dr. Bu must have thought I was an idiot, but fortunately he was nice enough not to let it show. Dr. C would not have been as kind. Tomorrow it's back to L&D. Maybe I'll finally be allowed to deliver a baby on my own...after I get some practice, bien sur.

PCC: LEEP anyone?

We had morning rounds again at 6:00 a.m. I had two charts to work with, but Dr. B took one even though I'd already interviewed the patient so that he could write his own note. On top of that, Dr. K wanted all our postpartum notes to be at least one page long, so by the time we were done I'd only completed one chart. What a way to impress the residents, huh. This morning's resident lecture over hirsuitism was actually interesting and I didn't fall asleep once, so I guess my daytime clock has been set. After lecture I drove straight to school and ran into former anatomy lab partner Mike, who's studying for his surgery shelf, in the library. In the morning I worked with Dr. B (the obgyn, not the FP resident at JPS) and a FP intern from Plaza, but we only saw about 1-2 patients since it was a slow day. I then took a nap at lunch, then returned to the PCC to watch Dr. C do two LEEP procedures.

LEEPS were interesting to watch. The women were prison inmates, so they were brought to the clinic in handcuffs and had a female guard nearby when they were on the table. Dr. C had a videocamera attached to the colposcope so that I could see everything that he was seeing on a laptop nearby (rather than trying to watch over his shoulder) First you swab the cervix with acetic acid to see the white dysplasia spots, then wash with iodine. The LEEP itself was pretty cool; as in textbooks, a wire loop is used to scrape off layers of cervix which are then collected to be sent to pathology. Depending on the amount of dysplasia, the amount scraped off can be a lot or very little. The first patient had dysplasia all the way into her os, so by the time Dr. C was done her cervix resembled a donut. The second patient (who was only 20 and in jail for "being stupid;" she gets released next week) only had a minor dysplasia so she just had a small excision. Dr. C's nurse had told me that sometimes it's hard to sympathize with these women b/c they've robbed, raped, and beaten others (usually for their men), but it was hard not to sympathize with the 20 year old b/c she was crying before the procedure. The lithotomy position alone made her nervous, and the guard and the nurse tried to cheer her up by saying stuff like, "Oh, you think the penis is the largest thing that can fit in a vagina? Think again. Just wait 'til you have a baby, then you can park a bus in there." It worked; she started laughing. At any rate, I'll have to be sure to read up on LEEPs, since Dr. C hinted that he'll be asking me questions about it in the future.

PCC and Dr. C

It was nice to go to bed last night while the sky was dark, but the downside to that was that when I woke up this morning at 5:00 a.m., it was still dark outside. Anita and I arrived at the parking lot at around the same time and we walked together to the hospital to help Dr. G with postpartum notes. Only later did we hear from Kimberly that there was a shooting not far from the hospital around the same time we arrived; scary thought. We had two lectures in the morning, and I was impressed that Aaron was able to stay awake after doing night shift (he's a self-proclaimed night person). Chris was nodding off a bit, but so was I (as usual)

Anita stayed in L&D today while I joined Sharon in going to the PCC to work in the Ob-Gyn clinics. We would be working under Dr. R (whom I saw at my last shift) and Dr. C, who has been known for not getting along well with students. I was a bit worried about how he'd treat me since I hadn't been to a single clinic since the beginning of the rotation. But Dr. C was not the monster that most people made him out to be. Sure, he pimped us and made us squirm a bit, but as far as I could tell he never yelled at us or talked down to us. Even Dr. R joked around with us, and Anita and I were walking on eggshells in front of him on Saturday-Sunday night. I guess these two docs were in as good a mood as we could expect from them today. There was more teaching, less yelling.

I ran into Erwin and Wendy during lunch, and we all had a nice chat about our rotations. I told the two of them the "slap some dick" story from yesterday and they thought it was hilarious. I guess Erwin doesn't read my blog; otherwise he'd know the story already =) I also ran into Ilona outside of the gift shop, so I saw three friendly faces today. Next it was back to the Ob-Gyn clinic. One of the things Dr. C made sure Sharon and I knew was how to distinguish bacterial vaginosis from yeast infections and Trichomonas infections (b/c we were "pulling answers out of our ass" when he pimped us), and we were also taught to identify clue cells under the microscope. I got my first real taste of doing Pap smears on patients that were not standardized, but I still have trouble getting the cervix on the first try. It also didn't help that I'm afraid of pinching the patient and don't know how to use the metal specs too well.

We had a few interesting patients. One girl was 21 with four kids (first child at 16) and wanted a tubal ligation; Dr. C tried to talk her out of it by saying she was still young, and suggested she try an IUD instead (she has a week to decide). There were several cases of BV in which you didn't need a whiff test to know the patient had the disease. One expectant mother's name was Melody and she named her daughter Lyric, which I thought was cool. Hopefully the daughter she's carrying won't be named Harmony. Overall, I think I like working at the PCC.

Night Shift: The Nightmare Patient and More

Last night shift of the week! It started out rather slow; I did one H&P and had Dr. K look it over; he had lots of comments on how I could improve my H&P so that was good. Dr. B, on the other hand, makes us do H&Ps and barely even looks at them. I also saw Dr. G insert a balloon catheter into a woman's cervix b/c she wasn't dilating properly, and the patient was grateful b/c there had been two previous attempts that were unsuccessful. She was also glad that Dr. G took the time to explain what she was doing and what she (the patient) was feeling, which the other doctors had apparently failed to do. Tonight's attending, Dr. R, also works at the PCC and I may have to work with him next week. Either him or Dr. C, whom no one wants to work with because word is that he's not very student friendly and he pimps students to death. Later Anita and I got to watch Dr. K repack a woman's hysterectomy incision after she developed an infection. Now she has an open wound in her stomach and has to let it heal by second intention (repacking and keeping it clean) for a month. Wow. We also learned that when something is oozing pus, in the world of ob-gyn, the correct term to use is "purulent," NEVER "pus-sy." (You get the idea)

The "nightmare" patient in the title was a 22-year-old in her first trimester (accompanied by her prison-tattooed bf) who complained of abdominal pain radiating to her vagina, yet all lab tests showed nothing wrong with her except for anemia. It was noted in her history that she had been treated for abdominal pain at another hospital for similar symptoms but when the doctors found nothing wrong with her, she left against medical advice b/c "they weren't doing anything for her." The doctors and nurses were smelling either a malingerer or a druggie in search of some painkillers, but they didn't know what to do lest she accuse our hospital of "not caring for her" as well. In the middle of the discussion, there was a loud scream from the triage rooms (where she was staying), and everyone was all, "Oh, hell no, she did not just scream to get attention!!" Turns out the woman next door to her was going into labor (and that was the scream), so she was wheeled to L&D (labor and delivery) while Dr. K and I went to do a pelvic exam on our "nightmare" patient (I just watched). She certainly looked like she was in pain, but when I told Dr. K that, he shook his head and said, "Inexperience." (Meaning me) We looked at her cervical swab under the microscope, but saw nothing but epithelial cells. Dr. R's advice: give her some Vicodin and sent her home, but tell her to follow up with the doctor.

So we did that, and she didn't complain about getting the Vicodin, so we thought that was the end of it. Wrong. One of the triage nurses came back a few minutes later and said that the girl and her bf didn't want to leave b/c they had walked to the hospital, and would now have to walk back to wherever they live. The nurses didn't want to give her Vicodin if she was going to walk home, but on the other hand, the bf said that if the girl were to collapse while they were walking home, he'd call 9-1-1 immediately to bring her back and he'd "slap some dick" for putting her life at risk. First of all...what the hell does it mean to "slap some dick?" The nurses said he could slap his dick all he wanted, that was his problem, and we all got a good laugh out of that one. In the end, the nurses ended up calling them a cab using a cab voucher, so they did leave.

I got a chance to deliver a baby today, but Dr. K took over when he saw me hesitating about where to place my hands over the vagina to catch the baby. *sigh* I know the rule in ob-gyn is to be aggressive and get down and dirty, but I am not about to jump in and catch a baby without knowing exactly how to hold it and what to do, so sorry for being careful. Later we went with Dr. K to write post-partum notes, but because my knowledge of Spanish stunk, I had to see the same patient about three or four times (I saw her deliver a baby on my last shift) to ask her questions that I'd forgotten to ask the first time. So...must learn obgyn Spanish on this rotation or else. -_-

Still, my week of nights has come to an end. Now it's time to get used to getting to the hospital by 5:45 a.m. for daytime L&D. But next week, I'll be at the PCC for three days. Hopefully the profs will be merciful of my ignorance, but somehow I doubt it.

Night Shift, Little to Do

Yesterday's shift was crazy, but today's was just plain boring. Nothing happened. For the first few hours, Anita and I had nothing to do but sit in the lounge practicing delivering babies with "Cletus", the model baby. There were few vaginal births, but several C-sections scheduled back to back. The first C-section was a high risk delivery with an HIV mom (they pronounced it "high-five" as to not alarm other patients) so we weren't allowed to sit in. Good thing, too, b/c during the surgery her uterine artery was lacerated and it took them about 2 hrs to stop the bleeding and fix it up. The attending, Dr. Boone (aka Dr. MB; he showed us the video on childbirth), later said there was so much blood "you couldn't see shit" and said he asked the anesthesiologist to give the patient more Versed to totally put her under b/c he was "throwing F-bombs everywhere" and didn't want her to hear. And if you remember this guy from lecture and can picture him saying these words, it sounded pretty hilarious. But he brings up a point: if any female med student or doctor were to have a C-section and hear stuff like "oh ****" on the other side of the curtain, they'll know something is wrong, and that's not a good feeling to have.

The second C/S was a delivery of twins, but neither of us went (I'd already seen a twin delivery). The third one was the delivery of a 27-week old so once again we weren't allowed in. Later Dr. D told us that Dr. MB wondered why no med students had scrubbed in on the C/S with the twins and suggested that we be more active in asking to scrub in on future C/S procedures. Easier said than done when the charge nurse makes us feel totally unwelcome in the OR; if she were nicer, I wouldn't be so hesitant to ask to scrub in. Anita did scrub in on a fourth C/S while I hung around and later helped Dr. K in a delivery by holding the patient's legs while she gave birth. Not as glamourous as delivering the baby, but still necessary.

Tonight was interesting in that Dr. B took Anita and me to the ER to see if there was anything "interesting" to see. Along the way, we saw Desiree in the hall, Doug at the ER for call (medicine), and Dustin D with another doctor talking to a patient. Three classmates in one night. One more night of night shift, and then I can live like a normal human again =)

Night Shift: JWs and C/S

One of the first things Anita and I had to do when we started our shift was do an H&P on a pregnant fifteen-year-old girl. That went along well until Dr. B (one of the FP residents) came in and started listing all the things that could go wrong in childbirth (hemorrhage, C sections, etc.) She looked really scared (wouldn't any kid?), but when Dr. B mentioned blood transfusions, she said, "I can't get blood transfusions." That sounded like something out of Ethics; sure enough, her aunt confirmed that they were Jehovah's Witnesses and don't believe in getting blood transfusions (for fear it'll damn them to hell). Everyone else's thoughts: so this girl is allowed to get knocked up, but not allowed to receive someone else's blood? Still, since she's a minor, if she does need a transfusion, a judge is a phone call away and they can get one for her. Toward the end of my shift, she was having trouble with labor and had to have a C-section (more on that later)

I was allowed to scrub in on my first C-section today...of twins. (Jedd was all, "Quit stealing my twins!" when I told him later at lecture; he wants to deliver twins) One baby was breeched (hence the reason for the C-section, or C/S), that that one was pulled out first, followed by its sister. But...the uterus kept bleeding. In a lapse of judgment, Dr. D (2nd year resident) let me feel the uterus to feel how boggy it was when I asked, and Dr. C (4th year resident) quickly told me not to do that since the uterus was in lousy shape. Oops. Turns out it was a bad case of uterine atony; they had to give lots of oxytocin and other drugs, and ended up having to do a B-lynch tie (which make the uterus resemble "rump roast") to stop the bleeding. Needless to say it was not your everyday C-section. I got to retract for a while. Later I was called to help in another C/S, but I ended up not going b/c I was so exhausted. If I had gone it, I probably would have passed out and that wouldn't have done the others any good. Dr. C shared a story about how one med student fainted in the OR once and no one could get to her for a few minutes b/c they were all sterile.

The triage room was really busy and the nurses were a lot crankier than usual. Kids kept wandering into the triage area from the waiting room looking for their moms and they'd be sent back to the waiting room. One girl used the patients' bathroom and one of the older nurses, thinking she just wandered in out of nowhere, told her she can't use that bathroom. "But she said I could!" said the girl, pointing to a younger nurse. Turns out the girl's mom was a patient. And the second time I was supposed to do the C section, I poked my head into the ER and asked the charge nurse if she could get me some gloves. The nurse glared at me and threw up her gloved hands (she was sterile), but another nurse said she'd get me a pair. Turns out I didn't go anyway, so I hope those gloves weren't a total waste =( Dr. B had to go around writing tons of H&Ps b/c of all the new admissions, "scutwork" he called it. I started about 2-3 H&Ps today but each time he told me not to bother finishing them. Then how can I practice doing them? Anita and I ended up following him to do charts, but nothing came from it. We did see Justin in the hall (around 5:00 a.m.) and waved.

Oh yeah, I got to deliver my first baby today! I was in triage doing the mom's H&P when her contractions started getting worse and it was clear she was going to give birth real soon. "Keep your eyes on the prize," was what Dr. B told me, and this baby just slipped out on its own without any pushing from Mom. I was able to pull him out, and boy, was he slippery! (No, I didn't drop him). I had some trouble maneuvering him to cut the cord, but I think I did ok for my first delivery. Hopefully I can deliver another one in the next shift =)

Jedd and Aaron had case presentations today, and Dr. C was there to pimp away. That means whatever I do my presentation on...I'd better know my stuff forwards and backwards.

Night Call Parte Deux

There was Grand Rounds at Harris Methodist today, but Melissa, the intern on our team, told Anita and me that we didn't have to go, so we didn't. I'm just hoping we don't get in trouble later.

Things were definitely more busy last night. All the L&D rooms were occupied, so one of the first patients I saw was a nineteen year old who had to give birth in one of the triage rooms b/c she didn't have a room. And people in triage don't get epidurals, so she had to deliver naturally. Yikes! I watched a grand total of four SVDs (spontaneous vaginal deliveries) and got to deliver the placenta in the last one. Which isn't too bad, but considering how Jedd and Marcus have each delivered one baby apiece, I feel like I'm behind. Three of those four needed episiotomies (incisions made in the perineum to enlarge the vagina if the baby can't come out), and those look painful. To say that childbirth is rough would be an understatement, and yet in the end, when the parents are beaming at their newborn baby, it makes everything seem worthwhile. It's also interesting to see how fast babies move through the canal. Some slip out easily, while others require a lot of pushing from Mom in order to get out.

Other notable things: there was a patient on the floors that had secondary syphilis (the painless lesions on the palms and the soles of the feet), so Jed, Marcus, me, two interns, and the attending all went to take a look. When she saw us, the patient said, "Whoa, too many people!" and jokingly asked if we brought her flowers. Still, it's rare to see secondary syphilis nowadays since so many people treat it early with penicillin (she was allergic), so it was pretty cool. Later on, another of our patients had a friction rub, and it sounded like paper getting crumpled. Anita and I spotted Jenny talking on the phone near the elevators, but when I said hi she barely acknowledged us. Gee, thanks. We came more prepared tonight with more food and more caffeine, and we managed to last until 5:15 am before the really huge waves of sleepiness hit. Maybe if I go to sleep in the next hour or so, I'll be wide awake all night tomorrow. But I got to say...ever since I started night shift, it seems like I've been working for one extra long day with no real time to rest in between. And it's weird telling Anita "See you tonight" when we leave the hospital in the mornings. Ah well. Three more nights to go =)