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 =)

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.