December 13, 2015

OB/GYN Carols

The twelve OB days of Christmas

On the first day of Christmas my attending gave to me an intern in triage!
On the second day of Christmas my attending gave to me two prolapsed cords...
On the third day of Christmas my attending gave to me three shoulders...
On the fourth day of Christmas my attending gave to me four Foley bulbs..
On the fifth day of Christmas my attending gave to me five stat sections!
On the sixth day of Christmas my attending gave to me six TOLACS...
On the seventh day of Christmas my attending gave to me seven cerclages...
On the eighth day of Christmas my attending gave to me eight undelivereds...
On the ninth day of Christmas my attending gave to me nine pelvic pressures...
On the 10th day of Christmas my attending gave to me ten rule out ruptures...
On the 11th day of Christmas my attending gave to me 11 Mag recoveries...
On the 12th of Christmas my attending gave to me 12 BPPs...
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Beta song (Dreidel song)

Beta beta beta
Getting higher every day 
Beta beta beta
An ectopic you might say!
-------------
Silent Night

Silent night, Foley bulb night
All is calm, all is bright 
No pitocin for mother or child 
Only accels so gentle and mild
Sleep a Benadryl peace
Sleep a Benadryl peace

Silent night, foley bulb night
Toco calm, dim the lights 
Residents gaze at tracings Cat I
Nurses hope their work will be done
Please don't ask for ice
Please don't ask for ice
------------
The L&D song (The Christmas song-Chestnuts roasting on an open fire)

Ferning drying on the microscope 
Nitrazine so deeply blue
Pools of fluid so pearly and clear
And not a drop of mec in sight
Everybody knows
The triage will be full tonight
Moms-to-be across the board
Tiny hearts beating oh so fast
And cervixes open wide. 

They feel contractions 
On the way
They've tried to walk and walk and walk the pain away
But all the father's jokes
Are getting old
He'll never feel this pain! They start to scold...

And so I'm offering this simple phrase
To moms +1 or -2
Although it's been said many times,
many ways-
Today is baby day for you!

November 16, 2015

Stat

Sometimes your best is not enough.

Sometimes your best is not enough and the hand that holds the knife and cuts through skin and flesh and muscle is not enough, and what hurts more than anything is the hopelessness of knowing that you did everything you could. Doing everything you could doesn't feel good enough when the outcome was bad.

A stat c-section is a gamble, a Hail Mary pass, the last option when all other roads lead to disaster. It's not something undertaken lightly; it's never something we want to do. It galvanizes everyone to action and leaves hearts pounding for an hour afterward. From the moment someone flies out of the room to yell "Call anesthesia stat!" until the baby practically flies into the arms of the pediatrician, it's a headlong race against a clock where a baby's slow heartbeat ticks off seconds.

Most of the time, we get lucky. Babies are resilient; the wonders of medicine are enough to produce miracles more consistently than saints. But even with ultrasound and advanced fetal testing and genetics we cannot predict the things that take that resiliency away. We cannot predict the cord that wraps too tightly around a neck; even if we could, we can't do anything about it. We cannot predict - sometimes we cannot even name - what causes tiny kicks to cease without warning.

Sometimes, the fastest time is not fast enough. When the heart slows to a crawl and you can see its movement stop, seven minutes is a lifetime. When there is no time for anesthesia and the skin incision is under local before the patient is completely asleep, a minute from skin to baby is eternity.

When you cut to save a life that hasn't yet begun, you gamble. Most of the time, we win; but sometimes the house has the odds.

October 31, 2015

Melted, poured, molded

I used to think a crucible was a form of torture device; it sounded too much like crucify for comfort. But a crucible is a tool, a vessel: a contained place for malleable material so that it can be melted down and poured into a new form. It's no wonder that the word is applied to difficult situations often as a metaphor - the experience of being shaped by circumstance or events is a powerful one.

Residency is a prime example. I can actively feel how my training is changing me. My opinions are stronger; I demand evidence for almost all decisions; I make my choices based on logic and demand high standards of performance from those around me, just as I demand them from myself. My tolerance for poor work ethics or for poor ethics in general has diminished. I can be aggressive when someone crosses me; I try to limit that aggression to cases where it will accomplish something for my patient. I am less "crunchy-granola" than my idealistic former self was about birth and healthcare and patients. I trust no one; I double-check everything; I know that patients lie or hide the truth from me.

Yesterday was a particularly chaotic afternoon. I did a c-section on a woman with twins - exciting in and of itself! and surgery finished around sign-out. I was hoping to simply fill out the paperwork documenting the surgery itself, put in her orders, and go home. Unfortunately, she was not doing well immediately after surgery. Her heart was racing, and she continued to bleed. I couldn't leave - this was my patient and the on call team was only three people, one of whom had been called to another emergency. I had to activate the "Exsanguination Protocol," which is what our hospital calls the massive transfusion protocol used when a trauma or otherwise patient needs large quantities of blood products. It was only the second time I've ever done such a thing; it was the first time the patient truly needed that quantity of blood.

She needed to go back to the OR. We took her back to see if we could remove the clots keeping her uterus from clamping down. We did, but she continued to bleed, and decided to open her up again to try and surgically control the bleeding. The attending called for a hysterectomy tray and the senior resident went to scrub with her.

I left the OR at this point: only the intern was watching labor and delivery. Granted, there were only 3 patients on the board, but it's still early in the year. I realized that while the senior was in the OR, it was up to me to manage the unit and to corral the chaos into order. For the first time, I thought that maybe being a senior resident next year wouldn't be so bad. Somewhere in the midst of all of this I became aware that I was actually enjoying myself. The adrenaline coursed in my veins. There was the thrill of making decisions on my own, the need to stop worrying about decisions and simply do what needs doing. A part of me was excited and surprised that yes, I did know what to do. The labor patient could keep laboring. The patient who was completely dilated should start to push. We were going to keep on delivering babies, because babies don't stop for other people's emergencies.

I got home at 9:30pm. Just documenting all of the chaos that had happened with my first patient had taken forty-five minutes or so. I came home and sat motionless on my couch, dumbfounded by the day. Pizza delivery took twenty minutes and I was just barely starting to come out of my shell-shocked state. I inhaled a few slices and fell asleep on the couch, watching TV. I woke up sweaty and with a crooked neck, and went to lie down in bed. My mind was racing: what had thrilled me hours earlier was now replaying like a trauma. The rapid and changing status for the hemorrhaging patient had imprinted itself on my mind, and I kept reliving the things that had happened. The delivery that I did on my own - no backup available, attending scrubbed in the OR, just myself and the nurse and the patient - was no small thrill before, but now I remembered the flash of terror as I gowned up. The brief run-through of shoulder dystocia maneuvers; the realization that it was just me who was going to be at this delivery; the fear mixed with confidence that this could actually be done and I could actually do this by myself; these moments linger in my memory, looping around every few minutes when I lull myself into a sense of calm.

It took almost an hour for me to fall asleep again in the middle of the night. I woke up alert but aware that I had tossed and turned, my body mimicking the unrest of my mind.

This is not my final self. I retain the essence of my personality - I hope - but I will not emerge from residency unscathed. This is a time of tempering, molding, hardening - of turning iron into steel.

September 18, 2015

Let me go home

I walked through the empty rooms of our house and everything was strange. Time made a loop and it was as if we were looking at the house again, seventeen years ago, when we were moving to Kansas City; but this time with a hint of bittersweet in the air, as I wandered the rooms, searching for any lost ephemera. For the last time I looked at my childhood bedroom, with the faded place on the wall where my collection of tiny figurines was held; for the last time I looked at my teenage bedroom, dents in the carpet the only evidence of where my bookcases once were. I passed by nails in the walls and remembered the pictures that had hung there. All the traces of our lives had been wiped away.

As I went through each room, I did not feel exactly sad; instead, it felt right to move on. Having lived away for many years now, this was no longer "home," but rather my former home. Thinking about it now, though, there is sadness in leaving all that behind. This is the setting for my coming-of-age, the backdrop for all the stories of my growing up. My memories of family are rooted here, and now they must pass to another location. Years of doing homework on the couch, or family dinners, or holidays in the living room, or sleepovers in the basement…These will all be filed away behind a veil of time. Not all of this is bad though; there are hard memories here that have softened over years. Fights with my brother, fights with my parents, teenage angst, last memories of my father…these are ghosts I am ready to leave behind.

The further I move away from "home," the tighter I cling to a midwestern identity. Even as I myself change from that archetype, part of me holds tight to the picture of myself where the Midwest is where I belong. Just listening to overheard conversations in the airport made me realize how much I've changed since leaving home; but it won't stop me from claiming my roots, no matter how far I stray.

August 16, 2015

Communion

Spine curved around precious cargo
Hold still, they ask, staining
your back brown with betadine.
Shoulders slouch obediently,
your forehead pressed against mine.
Fingers grip me tightly as I stand
before you, murmuring small words
or remaining silent, syncing breaths.
This last calm moment –
before anesthesia finishes,
before we swing into action,
positioning legs and painting orange
the moon of your belly.
A cascade of azure paper
sequesters you from view.
I step to your side and rest
one hand upon the prize.
I call for a knife and cut.

July 24, 2015

Nectarine

Sun-colored meat blends into
smooth crimson skin.
A center stone
detaches with slight pressure.
The flesh dissolves on the tongue,
nectar coats the mouth with
summer heat and lush lawns and
heavy humidity in every bite.
Perhaps the forbidden fruit
was not an apple.

May 3, 2015

Reading "House of God"

On Saturday, I finished my rotation in the MICU and left around noon, trying not to run as I left the hospital on my way to a week of vacation. On Sunday, I boarded a bus for Boston and settled into my seat with that now classic book, House of God, on my phone. The first few hours on the bus flew by. I was completely engrossed; it was satisfying but also horrifying to read about things I had seen and felt as an intern written on the page with such honesty. In some ways, it's depressing that so much of what is written in House of God is still true today, forty-five years later. The terror of starting in the hospital, the overwhelming feeling of uselessness, the callousness that starts to creep in so that you can deal with patients that day after day have issues you cannot solve - all of these are the same now as they were then. 

It is so hard to convey the way that the medical hierarchy is so firmly entrenched, the way that each level firmly socializes the one below it into strict conforms of behavior. The resulting impulses - toward hedonism, toward fatalism, toward no longer having any f***s to give - and the resulting loss of humanity - the inability to have regular conversations, the inability to talk to anyone outside of medicine, the inability to follow the news - are isolating. The most horrifying arc in the story tells of the intern who beats himself up over an initial mistake that affects a patient's care, a mistake that gets thrown in his face repeatedly. When the patient dies, the intern is distraught, having blamed himself for six months or more, and throws himself off the roof of the hospital. 

While many aspects of medicine have changed - the interns' unrelenting call schedules are certainly different from ours, and the constant level of near-exhaustion that is described is almost never experienced now (a change for the better, I would argue) - the gradual loss of empathy in the interns is shocking and not surprising to anyone who has worked in the hospital. It is a necessary adaptation, one that Dr. Campbell warned about at my White Coat ceremony at the beginning of medical school. He warned us to "keep our white coats thin" around us, that our empathy would continue to help us connect with patients; he might have done us a better service to explain why it would be so tempting to let our coats shield us from the demands of our patients and our superiors. Sometimes, they are our only shield.

The laws of the House of God are the most telling. Some of them are perfect - still usable, still pearls! (*) - but some of them are reprehensible, showcasing the way that medicine can trod on your humanity when the work overtakes the pleasure of it (**)
1) Gomers don't die
*2) Gomers go to ground
*3) At a cardiac arrest, the first procedure is to take your own pulse
*4) The patient is the one with the disease
*5) Placement comes first
6) There is no body cavity that cannot be reached with a number-14 needle and a good strong arm
7) Age + BUN = Lasix dose
**8) They can always hurt you more
**9) The only good admission is a dead admission
**10) If you don't take a temperature, you can't find a fever
I've heard attendings say rule #3, and it's true: when anything goes wrong, even on L&D, the first thing is take a deep breath and clear your mind. Rule 2 is why so many patients have bed alarms and are listed as "fall risks." I've had an attending quote Rule #4 on MICU rounds. Rule 5 has been stated before as "discharge planning starts on admission." 

Other quotes stood out to me, truer than the Laws:
-"the worse the Private [attending], the better the bedside manner, and the higher the patient's regard."
-"The profession is a disease. It doesn't care what sex you are. It can trap us, any of us."
- on intern friendships and survival: "We were developing a code of caring, helping each other leave early, not fucking each other over, tolerating each other's nuttiness, and listening to each other's groans. Each life was being twisted, branded. We were sharing something big and murderous and grand. Sensing that, I felt close to tears. We were becoming doctors."
- "What sustains us is when we find a way to be compassionate, to love. And the most loving thing we do is to be with a patient, like you are being with me."
- "I'd thought of how his life had fluttered round me like a butterfly in dying autumn, chilled, beating against my lashes, frantic, calling me to still the birth of winter."
- "It had become an unwritten law among the terns: don't tell what you feel, 'cause if you show a crack, you'll shatter."

Luckily, I think medicine has slowly started to recognize the caustic erosion of this kind of internship on the soul of those who endure it. Duty hour changes, perhaps with the entry of more women into medicine, have forced the establishment to recognize the harmful effects of confronting mortality day in and day out, especially when physically exhausted. There is much more hullabaloo paid to the mental health of interns, with resources and emphasis placed on how we are adapting to our new roles and how we are coping with the stresses of medicine. No increase in meetings or educational sessions can take away all of these struggles; in some way, they are the crucible that forges us into true physicians. While empathy and close connection to patients makes for a beloved practitioner, the healthy physician must learn to distance herself from her patients. A short distance makes decisions more rational, more impartial, and better for the patient. Get too close, and you risk your sanity as each patient's tragedy becomes a part of you. 

Ultimately, the book ends with most of the interns having survived the year and moving on. At this point in the year, I, too find myself looking forward eagerly to July, with the arrival of new interns. No longer will I be the bottom of the medical totem pole. The chance to move up (however slightly) is intoxicating. Already, I've started to do what the interns in the book do at the end: they start to rationalize, to excuse. "It wasn't that bad!" is the dismissive cry of everyone about to finish intern year. The only way to feel okay about what happened is to deny what it was, to move on. In some ways, House of God still resonates because that drive is always there, in any difficult passage. The only way out is through - and so we continue. July 1st can't come fast enough.

April 20, 2015

Intensive caring

I thought the Medical ICU would be depressing.

My first week went relatively well, with patients whose prognoses were good and no deaths. Patients got better, they awakened from sedation, they improved their lung function, they started to breathe on their own. We sent them to a less acute floor and occasionally, straight home.

The second week was rough. I almost cried on rounds more than once during the week. I seemed to have all the hopeless patients. Lots of neurology patients on service - people whose brains had bled, whose brains were so swollen and damaged they would have no chance of waking up. I spent very little time in their rooms, hastily examining them and leaving as soon as I could. Their bodies did not even require sedation to tolerate the ventilator; not a good sign.

It was disheartening. I had forgotten how spoiled I was in OB/Gyn, where many of our patients are healthy young women in the prime of their life, able to handle massive physiologic changes (or even extensive hemorrhage) and go back to normal within a few weeks.  Speaking to patients' families made it worse: here lay a father, a mother, a son, transformed seemingly beyond repair, kept alive by machines.  My eyes welled up when one woman heard that her husband's prognosis was unknowable, but that he would likely be forever changed. Every day was a confrontation with mortality and futility.

I pronounced my first patient death. I was afraid to look foolish; I felt again the imposter fear of the novice. Was I going through the motions? What if she drew a breath at the last second?  I was almost relieved that it was true, and she was dead. Her family had decided to withdraw care, and so they were all crowded in her ICU room around the bed as I listened. I turned to the nurse and asked him if he had the time.  "Time of death: 11:46," I intoned, trying hard to give my voice weight and gravitas and not to let it quiver.  A few days later, I pronounced another patient; it barely registered with me as I called his family, and I felt as though a small part of me had hardened.

Through all this, I learned to participate in the gallows humor of medicine...and truly know it as gallows humor. We laugh to keep ourselves from disappearing into the abyss of sadness and futility that lies behind the curtains of the ICU.  Each patient has their own particular tragedy, and to take them all in is to lose hope in the world. 

Today seems brighter. The patients are sicker than yesterday, but there are reasons to be hopeful. A few of the neuro patients have, against the odds, woken up. They still cannot talk to us yet, but their eyes follow me when I examine them and they mouth words to me around their endotracheal tubes. Some of the ones I felt sure would not make it are getting better, almost despite our care. In the end, perhaps that is the best lesson of the ICU: those who were going to get better do so, if we just give them the time and support for their body to do the work. Those who weren't going to make it pass away, despite doing everything we can to medically prop up the blood pressure and keep the lungs moving and keep the electrolytes balanced.

Today, I feel better about the fatalism of it all.  Maybe the goal is just this: try not to kill the patients who aren't going to die, and try to let those whose time is up die with dignity. 

March 31, 2015

Out like a lamb

Every year, when spring rolls around, I feel the promise of a new season soaking into my skin. It's not January that makes me want to be a better person; it's March with its promise of fresh breezes, and light, damp air, and new flowers pushing through the earth.

Maybe it's because my intern year is circling around and drawing to a close, but now I finally feel more comfortable in my skin. I feel grounded, the way flower bulbs are nestled in the dirt yet are able to push forth new leaves.

Maybe it's the increase in sunlight and changing from night shift back to days that makes my heart lift up a little and feel more optimistic about everything. Maybe it's just literally spring fever, and I'm ready to believe in romance again. Maybe it's the fact that even when you're surrounded by very sick people, you can still find a way to celebrate life.

January 24, 2015

Trapped

On the 42nd anniversary of Roe v.  Wade, I admitted a drunk woman to labor and delivery. She was full-term, had had no prenatal care, and this was an undesired pregnancy. She had never planned on keeping the pregnancy. She had wanted a termination, but by the time she found out she was pregnant it was either too late or too expensive, and so here she was, contracting, having come straight from the bar where she "got credit from the bartender." I forgot to mention--she was also homeless; she had been living with the father of the baby but sometimes he would kick her out, and this was one of those times.

Part of me wanted to be angry, that this woman had jeopardized the life inside of her; but mostly, I couldn't help but feel a terrible sadness for the stark limitation of the choices in her life. How could I not be touched by her agonizing tragedy? She had no place to go: she was trapped by her pregnancy which continued despite her desires, despite her resources, despite her best efforts with drugs and alcohol. Her hopelessness was immediately apparent; she freely told her story with little prompting, and her expression made it clear that she had surrendered to fatalism. She had no control over her life, no resources at her disposal, and things had spun out of control until she arrived here, in triage, drunk after three drinks and a beer.

You can argue for or against the availability of abortion. But arguing against allowing abortion is to look at this woman and say that she was required to go through this ordeal, that whatever the other circumstances in her life, this pregnancy--because it represents a "life"--takes precedence over her already suffering existence. If abortion were more accessible instead of less, this woman would not have tried with drugs and alcohol to do what she could not afford to do medically; we would not be admitting a woman who was drunk to labor and delivery; and the state would not be faced with the burden of another child, potentially disfigured by the substances she used during pregnancy, who would stay in an orphanage or an adoption agency until the baby could be placed...or not at all.

Women with means will always have options, while women with nothing will always struggle. I advocate for abortion access for all women because I'm a feminist, because it is the right thing to do, but in particular because women like this one should not have to struggle so hard to obtain something with the potential to so drastically alter their life. I love labor and delivery, where there's nothing more sacred than ushering new life into the world and shepherding mothers through the process of birth; but nothing is more heartbreaking than seeing a woman trapped by her body, betrayed by physiology, and cornered into childbirth.