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.

OR: Hysterectomies

This morning Sharon and I gave our student presentations to Dr. C and the rest of our classmates. Sharon talked about pyelonephritis in pregnancy while I talked about breast cancer. I did lots of research on this topic b/c I was afraid Dr. C would start grilling me but fortunately I was able to answer most of his questions. He was like, "I beg your pardon?" when I said that HRT (hormone replacement therapy) is a risk factor for breast cancer, because recent studies have apparently shown that's not entirely true. "Don't be spreading lies," he said. Oops.

Afterwards Anita and I went to the OR to watch Dr. C do some hysterectomies. Some of it was pretty cool (for the vaginal one we got to see the docs insert a sling for the bladder), but for the most part it was too hard to see anything. We saw the uterus get pulled out, of course, and after seeing giant uteruses in the OR during C-sections, it was pretty amazing to see tiny uteruses about 2-3 inches long. Just goes to show how resilient the uterus is, how much it stretches in pregnancy and how it shrinks down afterwards. OR was rather boring b/c all we could do was stand and not do anything. At least with C-sections, we can get more involved. But we all agree on one thing: we need better shoes if we want to go home without our feet killing us at the end of the day.

HCW: Communication

Today we had Grand Rounds and watched as a gyn-onc physician showed us videos on how to use robots to remove tumors (surgery of the future). It was pretty cool, but also early in the morning so I was a bit tired. He looked familiar and I knew I'd heard his name before, but it wasn't until I talked to Dr. G that I remembered where: at the cancer center where I did a community observation last year. Hard to forget a name like his, after all.

I was alone at the HCW with the residents today, and maybe it was just as well b/c there was nothing to do. At one point I got to interview a patient with secondary amenorrhea that presented after she had unspecified abdominal surgery (don't ask). When I first talked to her, she was charming and talkative, complimenting me on what a good listener I was, but that changed after I told her I'd "bring the doctor in" and left the room. I'd told her earlier that I was a medical student, but when I came back later to tell her the doctors would be there later and offered some explanations on what could be causing her amenorrhea, she turned cold on me. She said she was not interested in talking to me anymore or hearing the opinions of a student since she blamed a student for doing her abdominal surgery that caused her all these health problems. Ouch. I was surprised, but respected her wishes and got the attending, Dr. T, to take a look at her. When he arrived with me, she told him, "You should have done this from the start, have her come in with you." And he calmly explained that as a student, I had to learn by talking to her first (and he wondered why I didn't dare to give her a pelvic exam?) Once he assured her that her uterus was intact and all right, she was a lot nicer and felt better. But...it didn't explain all her abdominal pain, so she needs a sonogram and some labs drawn.

It seemed like everyone was too busy to entertain the med student today. Drs B, K, and G were off doing their own thing and Drs C and D were busy talking to pre-op and post-op patients, so I tried to make myself useful by interviewing some of Dr. C's patients (even after she told me to follow the FPs). Pre-op patients were pretty fun and interesting to talk to. There was one patient that was coming in to hear that she had adenocarcinoma, which was a doctor only talk so I wasn't allowed in the room. Another 81-year-old patient had a cystocele (bladder prolapse) so the doctors had to insert a speculum in her (major "ouch" factor there...) for an exam. She also had a textbook case of lichen sclerosis, which is normally treated with topical steroids but contraindicated for her since she was also diabetic. Dr. K recommended giving her steroids, but Dr. D chose not to b/c of the hyperglycemia it would cause, so Dr. K said okay.

The few patients I did talk to (after the amenorrhea patient) were very talkative and had lots of fun stories to tell about their families, and I liked talking to them. One lady worked at LHS, my high school, and from that conversation I learned that Dr. K graduated from MHS. Pretty cool how we're both from the same town. At any rate I hope I made a good impression on Dr. K, which I definitely did not do in front of Dr. P (who was hanging out in the clinic during lunch). The doors to the break room (where the microwaves were) were locked, so I asked Dr. P how to get there. He laughed and said that if I just walked through the office, there was a connecting door that led to the break room area. *smacks forehead* I knew that...now Dr. P has three reasons to think I'm a total idiot. Ah well, like he said, he won't be evaluating me at the end of the rotation.

L&D: The Longest Day

At check-in, Dr. K stuck a 3D anatomy image of the pelvis and bowel on the computer and told us to guess what we were looking at. "Up there is fecal impaction, and there...foreign body." The "foreign body" in question was a dildo stuck so far up the rectum its tip was in the sigmoid colon (he actually saw this patient last year). A lot of people were shown the picture and asked, "Guess what that is?" Marcus started laughing as soon as he saw it, but poor Jedd was a bit slow on the uptake. (For other TCOMers who are reading this...please don't tell other people about this or ask Jedd about it or else he'll ask how you know and then all fingers will point to this blog, which is for friends' eyes only. I tend to go into more detail than the average blogger so if I get in trouble, this blog will be discontinued)

Jedd: Is that what I...
Dr. B: Yes.
Jedd: What is that thing?
Anita: Oh, he doesn't know.
Dr. B: Well, if you're married, you wouldn't need one of these.
Marcus: Come on, Jedd, you have one at home!
Jedd:...is that a diaphragm?
Everyone: NO!

Well, he got it eventually =) It was a busy day in L&D today. One woman was about to give birth not long after our shift began, so I went to see her with Dr. B. Normally I take my time getting gowned up, but he said, "You won't get to deliver if you don't hurry up." The baby was coming. Sure enough, not long after I got into position, the head started poking out, fast. This time I was able to apply good pressure to the head but had trouble pulling the baby out properly, but it was better than my last delivery so I was glad. Afterwards I did a H&P on a Pakistani woman who had not had her epidural yet and was moaning like crazy. Some of it sounded exaggerated, like she was doing it to make her husband feel sorry for her (apparently a common practice among Middle Eastern women); she wouldn't even let me touch her abdomen b/c it "hurt too much." Ah well.

I got to scrub in on a C-section shortly after 11 a.m. It was not the mother's first C/S so when the doctors opened her up, she had so many adhesions it was hard to see the uterus at all. In fact, the doctors couldn't even pull the uterus out; they had to reach in blindly and grab the baby, and sewing her up afterwards required a lot of work, too. I often couldn't tell what I was looking at. One pleasant surprise: when the baby was brought to her mother, I heard the mother speaking French. In a hospital where Spanish is the most dominant foreign language, it was a shock to hear "Elle est tres jolie" instead of the usual "muy bonita."

Shortly after the C/S I went to a room to help KD (the midwife) deliver another baby. This mother had 3 kids before, so we expected it to be an easy birth. Far from it. We tried to get her to push for up to an hour, but she couldn't do it. KD tried to have her give birth lying on her back, lying on her side, even grabbing onto a bar and squatting, but nothing worked. The baby was occiput posterior and also just plain big. The mother was also doped up on fentanyl to the point where she kept screaming the same phrases over and over again. ("I can't do it! I'm tired! It hurts! I want my mama!" en espanol) Finally it was decided that they would do a C/S on her, and I got to watch. It was just me, Dr. D, Dr. P, and the nurse, and she delivered a 10 lb 13 oz baby girl. After 3 boys, this mom finally got her daughter, so she consented to having her tubes tied. My job as a med student was to help Dr. P blot blood from the organs, staple the incision, and then move the patient's bed into the OR for transport. Good to know

It's been over a week since we've worked 12 hrs in L&D, so Anita and I had majorly sore feet by the end of the day. Time to invest in better shoes =)