Ok, so tomorrow I start my first of several months in the Pediatric ED. We are supposed to do two rotations in our first year, and one in our second. Since I started late (in September compared to everyone else starting in July), I am barely doing my first rotation. I will do my second in July as my first rotation of my second year during which I will still unofficially be a first year. And, then I will do my second year rotation in January, great, right in the middle of cold and flu/RSV season.
I really don't know what to expect. Most of the other interns I have talked to have enjoyed their peds rotation. At least one of my colleagues will be on-service with me during that time, so I will have someone to commiserate with. And, I have my honeymoon to look forward to, so it's really going to be only about 3 weeks, 12 shifts in total.
I guess my sense of dread is that, to be honest, I really don't like kids very much. Now, before you pull out the tar and feathers, I was an only child. I never babysat for anyone, and I really was a very mature kid. My "children" as you know are my cats. And, while I enjoyed my OB rotation, it wasn't for "all the darling babies," it was to learn the skills necessary should I ever be faced with a "precipitous" delivery. So, now you know. I am an evil, non-child-loving physician about to be set loose on the children of Buffalo.
Of course, that just means that the kids will be more attracted to me, as is usually the case. We'll see... I dreaded the L&D ward, and that went over well. I'll let you know tomorrow...
Today's Seal Picture:
17,408 seals killed to date:
Monday, March 31, 2008
Sunday, March 30, 2008
Sweet Spring is your
There was a certain something in the air when I walked out of the house this morning. A certain crispness. The snow is almost all melted. It was actually comfortable with just a light fleece and no heavy coat. Maybe Spring is actually coming!
I attended the end of the Geohazards' Conference this morning. At least the lectures were more relevant to what I will be doing in the future. And, on my way home I took this photo on the University at Buffalo North Campus:
The pond is still frozen over, but there is a promise of Spring in the yellowing branches that will soon sprout out with leaves. Since I really don't have a lot to write about, I thought I would share one of my favourite poems by e.e. cummings: "Sweet spring is your"
Tomorrow there isn't a lot to do other than my meeting for EMS in the morning. We'll see if anything else develops during the day... until then!
12,368 seals killed so far
I attended the end of the Geohazards' Conference this morning. At least the lectures were more relevant to what I will be doing in the future. And, on my way home I took this photo on the University at Buffalo North Campus:
The pond is still frozen over, but there is a promise of Spring in the yellowing branches that will soon sprout out with leaves. Since I really don't have a lot to write about, I thought I would share one of my favourite poems by e.e. cummings: "Sweet spring is your"
"sweet spring is your
time is my time is our
time for springtime is lovetime
and viva sweet love"
(all the merry little birds are
flying in the floating in the
very spirits singing in
are winging in the blossoming)
lovers go and lovers come
awandering awondering
but any two are perfectly
alone there's nobody else alive
(such a sky and such a sun
i never knew and neither did you
and everybody never breathed
quite so many kinds of yes)
not a tree can count his leaves
each herself by opening
but shining who by thousands mean
only one amazing thing
(secretly adoring shyly
tiny winging darting floating
merry in the blossoming
always joyful selves are singing)
"sweet spring is your
time is my time is our
time for springtime is lovetime
and viva sweet love"
Tomorrow there isn't a lot to do other than my meeting for EMS in the morning. We'll see if anything else develops during the day... until then!
12,368 seals killed so far
Saturday, March 29, 2008
Of Volcanos and Plume Clouds
7328 Seals Killed So Far
I am attending a conference this weekend that has to do with GeoHazard research. Basically, it's a group of scientists who study such things as volcano activity, create risk assessment models, study geophysical mechanics and then make predictions about where to put or not put structures to help prevent mass catastrophes and casualties. Given my interest in EMS and disaster planning, I decided to attend.
Today was rather dull for me since the science was very much over my head. I have never liked statistics or statistical analysis, and this morning was chock full of word like "vector analysis," "Georgian logic," etc. I knew I was out of my league when one of the speaker talking about volcanoes misspoke and stated that it was the "pliocene" age instead of the "pleistocene" and everyone laughed. I had to come home and look it up. Anyway, tomorrow should be more interesting with the focus being the management of disasters in small communities which is much more relevant to my work.
Nothing much else this weekend. I stopped by the medical bookstore and picked up a few books. A bunch of cleaning to do tomorrow and then preparations for the week. I have my peds ED orientation on Monday morning followed by a meeting. My first actual shift is on Tuesday morning.
Until then....
I've added a new entry to the AOL Community Photo Challenge on my other blog: Enjoy!
I am attending a conference this weekend that has to do with GeoHazard research. Basically, it's a group of scientists who study such things as volcano activity, create risk assessment models, study geophysical mechanics and then make predictions about where to put or not put structures to help prevent mass catastrophes and casualties. Given my interest in EMS and disaster planning, I decided to attend.
Today was rather dull for me since the science was very much over my head. I have never liked statistics or statistical analysis, and this morning was chock full of word like "vector analysis," "Georgian logic," etc. I knew I was out of my league when one of the speaker talking about volcanoes misspoke and stated that it was the "pliocene" age instead of the "pleistocene" and everyone laughed. I had to come home and look it up. Anyway, tomorrow should be more interesting with the focus being the management of disasters in small communities which is much more relevant to my work.
Nothing much else this weekend. I stopped by the medical bookstore and picked up a few books. A bunch of cleaning to do tomorrow and then preparations for the week. I have my peds ED orientation on Monday morning followed by a meeting. My first actual shift is on Tuesday morning.
Until then....
I've added a new entry to the AOL Community Photo Challenge on my other blog: Enjoy!
Friday, March 28, 2008
Sweet Sixteen
I honestly thought I was going to hate it. I thought I was going to be completely miserable for a whole month. Then I did it, and it wasn't so bad. I enjoyed my patients, spending time with them while they labored, and then seeing them over the next couple of mornings before they went home. I continued to master my ultrasound skills as I scanned every belly I came across. I set a challenge to perfect my "cervix feeling" skills, and I think during this last week I gained a lot of confidence in my exam. And, I got a taste of my formal life when I scrubbed in for the C-section yesterday. My hands still feel the tingle of being well-scrubbed.
I caught my sixteenth baby today. Here's a picture of the first and last ones:
And, I delivered the last one all on my own. A boy. Almost at the end of my shift today. So, as the totals stand:
Baby Counter:
Births witnessed: 9
Babies delivered: 16
C-sections witnessed: 3
C-section first assist: 1
That's the end of my OB rotation. On Tuesday I move onto the Pediatric Emergency Department; actually, just down the stairs from L&D in the same hospital. I did a rotation in Pediatric EM when I was a 3rd year in medical school. At that time it was interesting to see the unusual cases that come into a tertiary medical center. From what I've heard, here will be no different. We'll see.
I have the weekend off to attend a Natural Disaster in Small Communities training seminar. My focus in Emergency Medicine is Emergency Medical Systems and Pre-Hospital Care. As part of my studies, I have to attend a number of disaster planning and EMS meetings, both on the local and national levels. This will be my first meeting, so we'll see how it goes.
I have Monday off for several meetings I need to attend for EMS. During some down time, I will continue to work on my scrapbook pages and get caught up on some laundry. You have no idea how many pairs of scrubs I go through during a rotation.
Someone told me it was spring, but this is what I woke up to in Buffalo this morning:
So much for throwing open the windows and doing some spring cleaning this weekend. Maybe next week?
Here's today's Seal Picture: the hunt has started and the Canadian Department of Fisheries and Oceans stalled in giving the Humane Society their permits to film and document the hunt. You can read the latest at: Live From the Ice
Continue to support the efforts to ban the hunt by clicking on my side-link or at the HSUS.org/protect_seals.html website.
I caught my sixteenth baby today. Here's a picture of the first and last ones:
And, I delivered the last one all on my own. A boy. Almost at the end of my shift today. So, as the totals stand:
Baby Counter:
Births witnessed: 9
Babies delivered: 16
C-sections witnessed: 3
C-section first assist: 1
That's the end of my OB rotation. On Tuesday I move onto the Pediatric Emergency Department; actually, just down the stairs from L&D in the same hospital. I did a rotation in Pediatric EM when I was a 3rd year in medical school. At that time it was interesting to see the unusual cases that come into a tertiary medical center. From what I've heard, here will be no different. We'll see.
I have the weekend off to attend a Natural Disaster in Small Communities training seminar. My focus in Emergency Medicine is Emergency Medical Systems and Pre-Hospital Care. As part of my studies, I have to attend a number of disaster planning and EMS meetings, both on the local and national levels. This will be my first meeting, so we'll see how it goes.
I have Monday off for several meetings I need to attend for EMS. During some down time, I will continue to work on my scrapbook pages and get caught up on some laundry. You have no idea how many pairs of scrubs I go through during a rotation.
Someone told me it was spring, but this is what I woke up to in Buffalo this morning:
So much for throwing open the windows and doing some spring cleaning this weekend. Maybe next week?
Here's today's Seal Picture: the hunt has started and the Canadian Department of Fisheries and Oceans stalled in giving the Humane Society their permits to film and document the hunt. You can read the latest at: Live From the Ice
Continue to support the efforts to ban the hunt by clicking on my side-link or at the HSUS.org/protect_seals.html website.
Thursday, March 27, 2008
That Fresh, Clean Feeling
Ok, so I don't know if this technically counts as a birth, but I don't care. I got to 1st assist on a C-section today!
After morning rounds and report, my fellow intern and I divided up the 4 or so patients on the board from the night before. She gave me the one that was the most dilated so that I could surpass my EM colleagues in deliveries with a guaranteed delivery. As the morning progressed, my patient dilated to a full 8 cm (remember 10 is fully dilated.) Her bag of waters was broken. Two hours later she was still at 8 cm. We started her on pytocin to increase her contractions. Two hours later... still 8 cm.
It started to look like I would lose the delivery to a C-section, however we don't have any medical students (aka human retractors) these last couple of days since they are also at the end of their rotation and are taking their final in OB-gyn tomorrow. At the beginning of today, I casually asked if I might scrub in just to assist on a C-section, and the attending and senior both said sure if it was ok with the intern since they have dibs on 1st time C-sections.
When my patient started to have issues and looked like she would need a stat C-section for failure to progress, 2 of the other intern's patients started pushing around the same time, and she had 2 consults in the E.D. So, when I asked about scrubbing in for the C-section, she said to go ahead and have fun. So I did.
The best feeling was pulling out the surgical scrub brush and washing my hands and forearms. I don't know that much can compare to that feeling of anticipation as you let the warm soapy water run over your arms and you scrub back and forth 20 times along the front, back, sides, and each finger, then up the arms on four sides. Then comes the rinse. The ritual was so ingrained in my head that I always used that time to run through the surgical procedure in my head while I scrubbed. In this case, I tried to think back to third year medical school and the handful of C-sections I participated in.
When we were dressed, and we prepped and draped the patient, I thought I would be just holding retractors, etc., but the senior and attending let me participate in the section. I didn't do any scalpel cutting, but I assisted in the dissection, then when the uterus was delivered I applied pressure to assist in the delivery of the baby (a boy). I cut the cord and assisted the senior in removing the placenta. They then started sewing the uterus closed from my end, and when the senior got halfway, he asked for another needle and suture. He then passed it to me!
I got to sew the uterus from his end toward my end to meet up with where he had ended. A few more sutures and the uterus was closed. It was then returned to the abdomen, and we closed the fascial layer in the same manner, and I got to sew again. The senior and attending were both happy with my sewing skills, and I was happy to see I hadn't lost my touch.
We cleaned and closed the skin, and all too quickly it was over. But then came the paperwork, writing orders, adding the patient to the list, planning for the post-op check. Flashbacks to a prior life.
We came out of the OR around 1630, and I was only working until 5. I saw an outpatient with abdominal pain and got her discharged just at 5. And, that was it for my day. Amazing how fast it passed by.
Of interest, today was almost labeled "Social Work Thursday." My patient that I operated on is a paranoid schizophrenic with developmental delay living in a group home. The FOB (father of the baby, or baby's daddy as is the colloquialism) is also developmentally delayed and living in the same group home. There was some question about her possibly giving the baby up for adoption. Also, as to whether or not she would be able to manage to care for her baby. She had given up her medication in order to protect the baby and seemed to be doing ok, but there are still a lot of issues for her to face.
Secondly, we had another patient who is a prison inmate with a history of drug use and five suicide attempts. She is HIV, Hep C and Herpes positive. I don't know how much longer her prison sentence is (we're legally not allowed to ask), but I did hear that the FOB was planning to take the child until she is released. Her previous 4 or 5 children were in foster care since she wasn't able to take care of them. I wonder if she actually will get to keep this recent one.
Tomorrow is my last day on L&D. We'll see if I can, officially, get that last one or two more births in.
(on the soapbox: the seal hunt starts tomorrow morning. 275,000 seals are in the quota. the pressure continues on the canadian government to put an end to the hunt. help support the HSUS' efforts by clicking on my link to the side.)
Wednesday, March 26, 2008
Random Thoughts I
Not much to write about today. It's Grand Rounds Wednesday so I spent my morning, after sleeping in to a glorious 6 a.m., in meetings. Then the "girls" and I went out to lunch. There are 12 residents in the first year, and 5 of us are female. Our schedules are so crazy that we rarely have time to meet together. It was nice to spend time socializing outside of the hospital and work environment.
Since I had no clinical duties, I thought I would post some random thoughts. You may or may not agree with me, but it's my blog and you can voice your opinions in the comments section. I do read them and will respond.
Here goes:
#1 (on the soapbox) - For the next several weeks I will be posting a photo of a baby harp seal as the hunting season begins. If you notice the link on the side of my page, it connects to the Humane Societies' website. It encourages you to not buy Canadian seafood and to support the many businesses (such as my favorite Legal Seafoods in Boston) who won't buy Canadian seafood. There's a great list of businesses (such as Publix) which continue to buy Canadian seafood so you can consciously, and financially, boycott these as well. Humane Society writer Rebecca Aldworth will be posting daily blogs during the hunt Live From the Ice and my pictures will be from that website. I know there's an international crowd on AOL journals, so spread the word. Create a link or Permalink to my blog. Stop the killing of animals in the name of fashion!
#2 - My last several posts have been somewhat depressing as the newness of delivering babies fades, and I get into some of the sadder cases that are also a part of life on L&D. Today while catching up on some of my websites and links, I came across an article at MSNBC.com related to prenatal hospice care. It describes a new trend in assisting families in dealing with the impending death of a baby when a prenatal ultrasound shows a fatal lesion. There was also a side video bar about photographers that take photos during the pregnancy and after the birth to help preserve those precious memories. Prenatal Death
#3 - I've been on a chocolate bender recently. My family has a predisposition to Diabetes, and since I was raised in my grandmother's house, we never had any sweets around (or salt, high blood pressure too). So I actually do not really have much of a sweet tooth. Every once in a while, though, I crave some chocolate. And, a bender for me is having more than a piece of chocolate a month. Over the last 3 days, since Easter Sunday, I've had, well, several. Chocolate & peanut butter combos are probably my favorites, followed by Lindt milk chocolate. The best chocolate I've ever had is a Swiss chocolate by Teuscher's. They have a Champagne Truffle that is awesome. If you're ever near Rockefeller Center, the store is on the right side of the promenade when you're facing the ice rink and main building. Or, as in most things, you can order online: Teuscher's
#4 - My "children" are turning five this month. The consensus is that they are in their "cat year equivalents" somewhere in their mid-30's. Both my kitties are lean and still frisky. I anticipate adopting #3 hopefully within the next year, so we'll keep them fresh and lively. I am in the process of working on their birthday scrapbook pages, so look for those on my other blog within the next couple of days. I have the photos, I just need to lay them out.
Here's a preview of their birthday portraits:
Two days left in OB. So far, I am tied with the most babies delivered at 15. We'll see what the next 2 days bring!
Tuesday, March 25, 2008
The Sounds of Silence
I think most people who know me know I like hearts. When I was a surgery resident, I seriously considered Cardiac Surgery, and I really enjoyed the time I spent as a junior fellow in Cardiac Surgery at Brigham and Women's Hospital in Boston. I have always been fascinated by echos, and I was most excited during my Ultrasound rotation this year when I got to practice my cardiac skills.
During this rotation, one of the procedures we perform is a sono (ultrasound) on the women when they first show up. We look to see if the fetal head is up or down, where the placenta is lying, and we calculate how much fluid surrounds the fetus. A change from the norm in any of these areas changes our plan for delivery. I always like to look for the heart and then show the expectant parents. It usually brings a smile to their face as they see their baby's heart beating along to the sound they hear on the fetal monitor.
Unfortunately, sometimes the ultrasound is used to confirm the worst - a fetal demise (IUFD). Today I went in with one of the seniors to confirm that it had occurred. This was their sono:
In the picture at the top, I enhanced where you would see blood flow using the doppler. You can also see a "pulse wave" at the bottom of the screen. As you can see in this sono, where the thick line is sitting along the thinner line is the location of the baby's heart. There was no flow color change. And, at the bottom, no flow waves. The baby had died.
What I was most impressed by was the eerie silence. Having done so many sonos and turning on the doppler to see flow and listening for the pulse wave, the absence of it was so apparent. Also, you keep expecting to see the cardiac contraction. But there was none. This was a young teen mother, and when I left today, they were planning on inducing her labor so she could deliver the fetus. They were also reviewing her records to see if somewhere they could find out what happened. That's always the biggest question... why?
This was one of three final days on the service. We were SO busy, and yet I had nothing to do. I admitted and delivered a patient throughout the course of the morning/early afternoon. Nothing unusual there, but the majority of the patients coming in today were not "normal" deliveries. Since the complicated patients go to the senior level OB residents, I could only stand back and watch the flurry of excitement around me (just for some background, a "term" baby is from 37 weeks on, a full term being 40 weeks, a preterm baby is 25 - 36 weeks, a non-viable meaning unlikely to survive outside the womb baby is less than 25 weeks. Just like a cake, babies needs to stay in the oven long enough to be fully cooked, er, developed.)
We had:
- the teen mother with fetal demise at 36 weeks
- the mother of twins at 26 weeks that went into labor and had to be taken for an emergency c-section, the twins are intubated in the NICU and it's uncertain if they will survive
- a 31 weeker with signs of pre-eclampsia that was being monitored
- a term baby thought to have multiple fetal anomalies, the mother only went to clinic once for a sono late in the pregnancy and never went back for prenatal care
- another 31 weeker whose mother smoked cocaine over the weekend and who was showing signs of pre-eclampsia and who might have to be rushed for an emergency c-section
- a 27 weeker whose water broke and was being monitored for pre-term labor
- a woman in labor with a term baby with gastroschesis which I described in a previous entry
- about 4 women in active labor that had been induced or had come in overnight
- and probably about 3 or 5 other patients that were in various stages of waiting to be seen, or admitted, etc.
- we had 3 patients on the board at sign-out and by 11 a.m. we had seen 10 patients in triage and 7 of those were diagnosed and admitted as being in labor
My poor senior starts to pull and twist his hair when he gets anxious. Usually I tease him that he's going to make himself bald. Today he put on a surgical hat, which is a good thing because he was starting to be like a cook with too many boiling pots on the stove and would have worried off a good chunk of his hair with the amount of complicated patients coming in.
Hmm.. that's a lot of kitchen recipes. I guess I will have to get a snack while I read up onLimps and motion abnormalities for reading group tomorrow. It's Grand Rounds Wednesday, so no clinical duties for me. Two more days on the service, and then I am done with L&D. I have to see how many deliveries my colleagues had... have to see if I can beat them!
Baby Counter:
Births witnessed: 9
Babies delivered: 15
C-sections witnessed: 3
Monday, March 24, 2008
Thank You, Easter Bunny, Bawk! Bawk!
So I was right. The waning moon meant a "waning" in the amount of patients that we saw last night. Given that it was also Easter Sunday, we figured most people would want to stay home. As predicted, we had the overnight patients (all of 3) to deal with in the morning, and then no more patients until after dinner. A, somewhat steady Easter Parade of sorts that kept us busy until around 1 in the morning.
My first delivery, and the only vaginal delivery of the day, was around 1600. I delivered her with one of the private attendings who then allowed me to repair her episiotomy. The first actual suturing I've done other than teaching the medical students on sponges all rotation. I was almost so excited my hands were shaking... not really, even on a caffeine, double shot expresso, I haven't slept all night and now I have to do one more surgery, morning while in residency my hands didn't shake. But, metaphorically, I really was that excited.
For the most part, we hung around and talked about some of the more bizarre and sad cases that had come in over the previous 24 hours. When we signed out the morning before, Saturday, we had 2 patients on the board that we knew were delivering terminal fetuses. One was a young mother that started to have contractions due to a premature rupture of membranes at 19 weeks. There was nothing to do but expect to deliver a dead or soon to be dead fetus. The second was a patient with a recent ultrasound showing a fetal anomaly called holoprosencephaly - essentially, the fetus had no brain development. I think I wrote once before about a patient that was a "brainstem with a body." In that case, the skull was developed, there was just nothing inside. In the case of this baby, there was a very small, misshapen head with the classical features. Picture
Of course, that didn't include the 20 year old who delivered a Trisomy 21 or "Down's Syndrome" baby. According to the attending, the baby was found to have some cardiac anomalies as well, and it's going to be a long hard road for that young family. We were left with a woman who had also had an IUFD (intrauterine fetal demise) from a rupture of the placenta. She came in bleeding profusely, and she was being prepared for the OR when we took sign-out at 8 in the morning. She and another patient at 31 weeks were the other 2 patients to deliver Sunday morning.
So the rest of the time... kinda boring. We had organized a pot-luck of sorts and spent a lot of time sneaking back to the staff lounge to eat ham, fruit salad, potato salad and all kinds of chocolate goodies throughout the day. Then, as I said, around dinner time, the next round of patients started to arrive.
We always have patients who are "past dates" meaning they didn't deliver by their due date who come in to be induced. So, there is almost always an admission or two in the evenings. They get their drug of choice depending on exam or fetal status and then labor through the night with the plan being they most likely will deliver the next morning. I admitted one patient like that. I then had another who came in that had broken her waters and had some cervical changes, so she was admitted.
We had an assortment of outpatients (pregnant patients not in labor but having some medical issue or other) ranging from an MVC (motor vehicle collision), to nausea and vomiting, to diarrhea from drinking someone's bowel prep without knowing. (A bowel prep is given to thoroughly clean the bowels prior to a colonoscopy or surgery. It induces massive watery diarrhea.) There were also several patients to be evaluated in the emergency department, but since I didn't have to do that, the other intern was busier than I was.
And, that's it. I went to bed around 1:30 and woke up to my alarm at 5:30. Rounds, home, a number of errands and then an appointment to do my taxes... finally. I work tomorrow, Thursday and Friday and that's it! Until then.... we'll see if I can add a few more to the total.
Baby Counter:
Births witnessed: 9
Babies delivered: 14
C-sections witnessed: 3
Saturday, March 22, 2008
Like Moths to a Flame
As I drove in to work yesterday morning, I saw the moon hanging over the horizon. The full moon. As it guided and directed the tides of the sea, it guided and directed the tides of women coming in to give birth throughout the next 24 hours... and they gave birth in waves.
After rounds, etc, we went to the L&D ward to find a quickly filling board. Many women had come in overnight either in labor or to be induced for delivery. So, in the morning, we had about 6 or 7 women who would be delivering at any time. No sooner had we started getting settled in than one woman began to deliver. The seniors covered that delivery because she delivered so fast that the rest of us never even got a chance to get in the room.
I admitted two patients early on who were progressing rapidly. Given the other women we already had in labor, the concern was that they would all give birth at the same time. Which mine almost did. I went in to check on my second admission who'd given birth before.
She said she was feeling uncomfortable and felt like pushing. I told her to go ahead and see how it felt. She did, and I could see the head working its way down the birth canal. I told the RN to call my senior to come in the room as my patient was ready for delivery. However, my patient decided that she wanted the baby out and started to push harder.
We told her to stop and wait! She said, "NO! It hurts too bad, and I want it over with!" I barely had time to grab some gloves and run back to the bed as the head popped out. We told her to stop pushing as I guided the umbilical cord over the baby's head. She barely stopped to inhale as I did and then pushed again and the rest of the baby was out!
My senior walked into the room to find me holding onto the baby and trying not to drop him. I had birth slime and blood on my uncovered arms, and I was trying to keep my shoes somewhat clean since she'd delivered on the bed and everything was dripping everywhere. I was barely able to get her placenta delivered and the paperwork and orders filled out before my second patient decided she was going to start pushing too.
I walked, luckily, into the next door room, and within about 20 minutes, my second patient delivered. This time a lot more controlled, and at least I had a gown and shoe protection on. After getting her settled, I went to change scrubs while I had a chance. During that time, the baby tunes sounded over the hospital system. Another one delivered.
I didn't have any more deliveries for a while, but that doesn't mean my colleagues weren't busy. Soon we were "log jammed" and wondering how we were going to coordinate patients between those in labor, those delivering and those who had delivered. I was told they'd had to put patients in the hallway, but we had so many coming in with labor that it wouldn't be practical. Part of the problem was getting patients discharged from the Mother - Infant ward upstairs and rooms cleaned so our delivered mothers could move upstairs. So there was a bit of stress until things started moving forward again and rooms were cleared on our unit.
Around 1900 I picked up a patient from the intern who was going home for the day. I wandered in with the senior to introduce myself as he checked her progress. He decided she was ready to start pushing and working toward delivery. She did. We breathed, she pushed and over about 10 minutes she was able to get the baby into position. My senior walked out of the room to get the chief resident, and I turned around to grab my gloves and gown to get ready.
I heard the nurse say, "Stop pushing" while at the same time saying "Get those gloves on quick!" And barely turned while the nurse pushed the staff button to call in the delivery team. I quickly grabbed my gloves and rushed back to the bed in time to get a hand on the baby's head to guide him in a more controlled fashion into the world. The chief walked in the door as I was guiding the shoulders and quickly pulled on gloves to help me with the rest of the delivery. Another bed delivery. And, off I was again to change scrubs.
And the women kept coming.
Around midnight, I was in the middle of admitting two patients that I had rechecked after 2 hours and found to be in labor when another 3 patients showed up. So the other intern and I scrambled to try to get everyone checked and admitted. I was doing the paperwork for my second admission when the RN for the first admission called that the patient was uncomfortable. The senior and I went to check her and broke her bag of waters since she was close to being completely dilated (10cm).
We stayed with her for a while while she learned to breath and push. She was first time delivery, so I walked out of the room to finish my other admission's paperwork, but had to rush back in when the nurse called to say the patient was actively pushing. Again, my senior checked her and said that it would be soon since the baby had moved down well, and he said the now ill-fated words that he was "leaving to get the chief."
I had my gloves and gown ready, and the nurse was getting things in order to break down the bed (take out the center cushion and put up the foot rests for delivery) when suddenly the patient said, "I really have to push" and did. Again, barely got gloves on in time to catch yet another baby on the bed. My fourth of the shift. Afterward I was teased that I was supposed to be getting some experience since I was an Emergency Medicine resident but that didn't mean more than the OB interns! It was all in good fun.
I finally was able to sneak in a nap between 4 in the morning and rounds at 0630. My second admission of the night delivered with the other resident around 0700, which I missed, but somehow didn't really care. I'd seen more than enough during the shift.
On my way off the Mother - Infant unit, I stopped to look in the "Baby Aquarium" (my own special name for the large picture window where you can look into the nursery.) I counted 15 babies. That didn't include the ones still downstairs, or the ones in their mother's rooms.
I wonder if the waning moon will lead to waning deliveries as I take my final 24 hour shift tomorrow. We'll soon see.
Baby Counter:
Births witnessed: 9
Babies delivered: 13
C-sections witnessed: 3
Thursday, March 20, 2008
It's All Harasho...
It's a little like working at the United Nations.
My chief resident - Syrian
My 3rd year resident - Ukrainian
My 2nd year resident - Nigerian
My OB intern - Indian
And the patient I delivered today - from Belarus. Oh yeah, Harasho means "good!"
Yesterday was Grand Rounds Wednesday, so nothing very exciting other than shooting the pic I entered for the Community photo challenge while I was out running errands in the afternoon. http://journals.aol.com/mariebm56/aol-community-photo-challenge/#Entry646
and http://journals.aol.com/vbonalesmd/MyPaperCuts/entries/2008/03/19/community-photo-challenge---wearing-of-the-green/1073
to see my entry
Anyway...
Today was a short day. We only had two deliveries during the day, my Russian lady and another. I had one admission that came late in the afternoon, and another patient I evaluated that fell. I sent her to the E.D. to get x-rays of her hands after we checked her baby out (it was fine.)
I don't know what was in the air today, but all of the residents were surly. And, like I said, given the multinational personalities making up the service, sometimes a simple comment can be taken the wrong way due to cultural differences. Next thing you know it's WW III L&D style.
I can think of about 3 or 4 arguments that erupted throughout the course of the day. Mostly, I think, because everyone is feeling stressed and overworked and in desperate need of a vacation, which, luckily, this particular set of residents is headed for next week. I mostly try to stay out of the thick of things, although I did step in briefly to defend the OB intern when she was blamed for something that happened on a patient I admitted. The flare-up was quickly dampened, and no one brought it up for the rest of the day.
I was trying to explain to both the intern and one of my medical students, that if there's something I've learned at this point in my life, it's that sometimes you just have to be, um, diplomatic about certain things. Be the bigger man, let the other person have their rant, and in the end you'll be the one respected and admired for not losing your cool and getting emotional. Venting is for the gym... or the local bar. We all have our ways of letting off steam.
As for me, tomorrow starts the final Weekend of Hell. I will be on 24 hour call Friday and Sunday. Then it's one more week, and I am done... downstairs to the Pediatric Emergency Room at WCHOB. But, that's in the future... there's still this weekend to get through.
Tuesday, March 18, 2008
A Parade for Your Birthday
When last we counted:Baby Counter:
Births witnessed: 5
Babies delivered: 5
C-sections witnessed: 1
After yesterday's Call night:Baby Counter:
Births witnessed: 9
Babies delivered: 8
C-sections witnessed: 3
Ok, so in one day I made up for about a week of no deliveries. After morning rounds, I presented to the L&D ward and was just getting settled in when suddenly a patient started pushing and the Family Medicine resident was no where to be found. Normally, they deliver their own patients, but when he failed to show even after being paged and told his patient was pushing I wandered into the OR after a shout out from the nurses for a doctor.
I barely got gloves on as the woman pushed and suddenly the head was visible. I barely had time to get a grip when she gave another push and the baby was out! Luckily, I got another hand up and on the legs in time to catch the baby. No time to think about "control the head, pull up, pull down and deliver." It was more like, "DON'T DROP IT!" I was passing off the baby to the nursery RN when the FM resident plus my senior resident walked in.
I left them to sew up the laceration the woman sustained during the birth and walked out the door to wash my arms and assess the cleanliness of my scrubs since I hadn't even had time to gown or put on shoe covers. I decided I was ok and was contemplating my solo delivery when I was called into another room because another patient was pushing.
This time, I was able to gown and glove. The chief resident walked me through this delivery and within less than an hour I had two deliveries. We repaired the laceration on this patient, and I was finally able to go back to the desk and catch my breath. We had about another 4 patients on the board, some of which had been induced overnight and were now in various stages of labor.
The rest of the morning was uneventful: at least for me. My medical student was in surgery almost all day with a total of 6 C-sections which were performed during our 24 hours on. We had a planned C-section at 8 in the morning, and another set of triplets in which the mother was starting to show signs of pre-eclampsia, so the decision was made to deliver. In between, 3 patients suddenly became more critical and needed to be rushed to surgery (one was pre-eclamptic: moreso than the triplets' mom, one was not progressing well in labor and the baby was showing signs of distress, and the third was a non-progression of labor.)
I think the triplets were finally taken to surgery around 2100, and I went in to see the delivery. It was amazing. The first birth sac contained two babies, and once the first one was delivered, the second came like almost immediately. They then opened the second sac which contained one baby. When he came into the world, he immediately started crying loudly which suddenly sparked the other two which joined in. A semi-quiet OR suddenly came alive with the crying of three healthy babies. These babies were at 33 weeks, so they had an excellent chance for survival having made it that far. It was known they were all boys, so these parents are going to have a handful.
I am amazed at how organized and coordinated the teams are with these multiple deliveries. Each baby had an NICU RN, the neonatologist, and another nursery RN. Including myself, the other intern, a nursing student, the circulating RN, two anesthesiologists (resident and attending), not to mention our attending, senior, second year and medical student, the room was quite full.
I saw a number of patients for flu-like symptoms and assessment of labor, all of which I discharged home. I assisted the Nurse Midwife with a delivery. This was interesting in that the parents had very explicit instructions about when the cord was cut, when the baby would receive its first medications, how much fluid would be given. The woman received no drugs, her in-laws hovered over her during the birth. Everything was calm and peaceful. She delivered on the bed and was so stoic throughout the entire process.
Contrast that to literally the last delivery of the day. While I was with the stoic patient, you could hear my last patient crying through the wall. This was around 1400. I went in every several hours with my senior as he checked her progress. Finally, around 2300, she started crying that she didn't want to push anymore, she was too tired, her epidural was not working as well as she hoped.
Her husband encouraged her, brought her cool cloths and ice chips while the labor RN reminded her that the patient had wanted a St. Patrick's Day baby and that she had only an hour in which to do it. Around 2320, the patient decided that this baby was going to be born and pushed harder and got the baby further down the birth canal. Within 20 minutes, she was actively pushing for delivery.
We got gowned and gloved and helped her deliver a 9 pound 7 oz baby boy at 2347 (she is 6'3" and her husband 6'10", they already have NBA plans, or so they joked). She was so excited, and as the father held his son, he told him that every year on his birthday there would be a parade, just for him. I don't know that I've witnessed two more pure expressions of love than the looks between these two couples just after the birth of their children. I can only hope and romanticize that these are families that will have wonderful lives.
**Note, if you want to stop reading here with wonderful thoughts of beautiful newborn babies and happy families, I don't mind, but I have to get on my soapbox and write about the not-so-happy endings we sometimes see. Fair warning.**
I think I've talked about patients leaving AMA (against medical advice) in prior entries. Sometimes, we don't mind when a patient signs out, mostly because their reason for coming to the E.D. was not emergent, but sometimes we worry, if only for a little while, about the patient's well-being (like the man having a massive heart attack while I was on the CCU service who signed himself out AMA, we suspect to smoke, but still, is he still alive?)
During my first overnight call on the 3rd, one of the patients being evaluated was a young woman in her early 20's with a history of diabetes. She was non-compliant with her medications and was being evaluated for DKA which is a dangerous metabolic condition related to super high blood sugars. Add to that her pregnancy. It's well-known that high maternal blood sugars can be dangerous, even deadly, to the developing embryo and fetus. That's why mothers are routinely tested for any sign of gestational diabetes during pregnancy and are managed on the High Risk service if they are known diabetics.
When this woman came into the High Risk clinic, her blood sugar level was in the high 300's. They quickly evaluated her and one of the tests they do is an amniocentesis. Essentially, they stick a needle into the uterus and get some fluid to assess the baby's development. Most often, you have heard it associated with searching for genetic defects, but in MFM (maternal-fetal medicine) it's almost routinely done to assess the baby's ability to survive outside the womb.
On that date, she was 36 weeks, and the amnio revealed meconium which is the first BM a baby has. It is always a sign of fetal distress when it is noted prior to birth, and since the baby is essentially "breathing in" the amniotic fluid, meconium will go into the lungs and causes damage. So, you have a High Risk baby because of the diabetes. It's pre-term. Now you have meconium. The mother was sent down to L&D for observation and to start planning for delivery.
However...
The reason I initially heard about this patient is that she didn't want to stay. She didn't want to be delivered. She wanted to go home. The attending went to her room and talked to her at length about all of the possible complication the baby might have including death. She asked the patient to consider the implications of her actions. And, the attending documented her conversation with the patient. About an hour later, the patient signed out AMA.
Yesterday afternoon the patient returned to the clinic, having missed the prior weeks' scheduled clinic appointment. She told them that she hadn't felt the baby move in several hours. They laid a doppler on her and didn't hear a heartbeat. She was sent down to L&D for a sono evaluation. Yes, you guessed it, the baby was dead. I walked out of another patient's room to hear the wails in the unit and saw the second year who had just done the evaluation.
When she began to describe the patient, I immediately remembered her from 2 weeks before. The resident said that the attending had been worried about her and wondering what had happened. The resident was now going to have to call the attending and let her know about the fetal demise.
When I left this morning, the patient had been induced and, at this point, may have already expelled the fetus. Fetus, not baby. This little one never got the chance to take a breath.
Off the soapbox, except to say, again, "If you're going to lie back on the bed and tell me that you're in 10/10 abdominal pain, that you've been so for the last two weeks, you're vomiting constantly, and that you decided at 0100 to call an ambulance to bring you to one of the only hospitals in the city where your primary care provider doesn't work, I am not really going to be very sympathetic. Really.
One, you're pregnant and should have seen a doctor earlier if you're vomiting 10 x a day. Two, why didn't you go to the hospital where you normally get your care and where all of your records are? Three, let me show you some video of the "I'm delivering before midnight" patient I just had. SHE was a 10/10, and in between pushes, she showed her true inner strength.
House would get to say these things. I just politely smile, fill out the chart, order the labs I know will be normal and wonder how much sleep I'll be getting that night. 4 hours? Ok.
Births witnessed: 5
Babies delivered: 5
C-sections witnessed: 1
After yesterday's Call night:Baby Counter:
Births witnessed: 9
Babies delivered: 8
C-sections witnessed: 3
Ok, so in one day I made up for about a week of no deliveries. After morning rounds, I presented to the L&D ward and was just getting settled in when suddenly a patient started pushing and the Family Medicine resident was no where to be found. Normally, they deliver their own patients, but when he failed to show even after being paged and told his patient was pushing I wandered into the OR after a shout out from the nurses for a doctor.
I barely got gloves on as the woman pushed and suddenly the head was visible. I barely had time to get a grip when she gave another push and the baby was out! Luckily, I got another hand up and on the legs in time to catch the baby. No time to think about "control the head, pull up, pull down and deliver." It was more like, "DON'T DROP IT!" I was passing off the baby to the nursery RN when the FM resident plus my senior resident walked in.
I left them to sew up the laceration the woman sustained during the birth and walked out the door to wash my arms and assess the cleanliness of my scrubs since I hadn't even had time to gown or put on shoe covers. I decided I was ok and was contemplating my solo delivery when I was called into another room because another patient was pushing.
This time, I was able to gown and glove. The chief resident walked me through this delivery and within less than an hour I had two deliveries. We repaired the laceration on this patient, and I was finally able to go back to the desk and catch my breath. We had about another 4 patients on the board, some of which had been induced overnight and were now in various stages of labor.
The rest of the morning was uneventful: at least for me. My medical student was in surgery almost all day with a total of 6 C-sections which were performed during our 24 hours on. We had a planned C-section at 8 in the morning, and another set of triplets in which the mother was starting to show signs of pre-eclampsia, so the decision was made to deliver. In between, 3 patients suddenly became more critical and needed to be rushed to surgery (one was pre-eclamptic: moreso than the triplets' mom, one was not progressing well in labor and the baby was showing signs of distress, and the third was a non-progression of labor.)
I think the triplets were finally taken to surgery around 2100, and I went in to see the delivery. It was amazing. The first birth sac contained two babies, and once the first one was delivered, the second came like almost immediately. They then opened the second sac which contained one baby. When he came into the world, he immediately started crying loudly which suddenly sparked the other two which joined in. A semi-quiet OR suddenly came alive with the crying of three healthy babies. These babies were at 33 weeks, so they had an excellent chance for survival having made it that far. It was known they were all boys, so these parents are going to have a handful.
I am amazed at how organized and coordinated the teams are with these multiple deliveries. Each baby had an NICU RN, the neonatologist, and another nursery RN. Including myself, the other intern, a nursing student, the circulating RN, two anesthesiologists (resident and attending), not to mention our attending, senior, second year and medical student, the room was quite full.
I saw a number of patients for flu-like symptoms and assessment of labor, all of which I discharged home. I assisted the Nurse Midwife with a delivery. This was interesting in that the parents had very explicit instructions about when the cord was cut, when the baby would receive its first medications, how much fluid would be given. The woman received no drugs, her in-laws hovered over her during the birth. Everything was calm and peaceful. She delivered on the bed and was so stoic throughout the entire process.
Contrast that to literally the last delivery of the day. While I was with the stoic patient, you could hear my last patient crying through the wall. This was around 1400. I went in every several hours with my senior as he checked her progress. Finally, around 2300, she started crying that she didn't want to push anymore, she was too tired, her epidural was not working as well as she hoped.
Her husband encouraged her, brought her cool cloths and ice chips while the labor RN reminded her that the patient had wanted a St. Patrick's Day baby and that she had only an hour in which to do it. Around 2320, the patient decided that this baby was going to be born and pushed harder and got the baby further down the birth canal. Within 20 minutes, she was actively pushing for delivery.
We got gowned and gloved and helped her deliver a 9 pound 7 oz baby boy at 2347 (she is 6'3" and her husband 6'10", they already have NBA plans, or so they joked). She was so excited, and as the father held his son, he told him that every year on his birthday there would be a parade, just for him. I don't know that I've witnessed two more pure expressions of love than the looks between these two couples just after the birth of their children. I can only hope and romanticize that these are families that will have wonderful lives.
**Note, if you want to stop reading here with wonderful thoughts of beautiful newborn babies and happy families, I don't mind, but I have to get on my soapbox and write about the not-so-happy endings we sometimes see. Fair warning.**
I think I've talked about patients leaving AMA (against medical advice) in prior entries. Sometimes, we don't mind when a patient signs out, mostly because their reason for coming to the E.D. was not emergent, but sometimes we worry, if only for a little while, about the patient's well-being (like the man having a massive heart attack while I was on the CCU service who signed himself out AMA, we suspect to smoke, but still, is he still alive?)
During my first overnight call on the 3rd, one of the patients being evaluated was a young woman in her early 20's with a history of diabetes. She was non-compliant with her medications and was being evaluated for DKA which is a dangerous metabolic condition related to super high blood sugars. Add to that her pregnancy. It's well-known that high maternal blood sugars can be dangerous, even deadly, to the developing embryo and fetus. That's why mothers are routinely tested for any sign of gestational diabetes during pregnancy and are managed on the High Risk service if they are known diabetics.
When this woman came into the High Risk clinic, her blood sugar level was in the high 300's. They quickly evaluated her and one of the tests they do is an amniocentesis. Essentially, they stick a needle into the uterus and get some fluid to assess the baby's development. Most often, you have heard it associated with searching for genetic defects, but in MFM (maternal-fetal medicine) it's almost routinely done to assess the baby's ability to survive outside the womb.
On that date, she was 36 weeks, and the amnio revealed meconium which is the first BM a baby has. It is always a sign of fetal distress when it is noted prior to birth, and since the baby is essentially "breathing in" the amniotic fluid, meconium will go into the lungs and causes damage. So, you have a High Risk baby because of the diabetes. It's pre-term. Now you have meconium. The mother was sent down to L&D for observation and to start planning for delivery.
However...
The reason I initially heard about this patient is that she didn't want to stay. She didn't want to be delivered. She wanted to go home. The attending went to her room and talked to her at length about all of the possible complication the baby might have including death. She asked the patient to consider the implications of her actions. And, the attending documented her conversation with the patient. About an hour later, the patient signed out AMA.
Yesterday afternoon the patient returned to the clinic, having missed the prior weeks' scheduled clinic appointment. She told them that she hadn't felt the baby move in several hours. They laid a doppler on her and didn't hear a heartbeat. She was sent down to L&D for a sono evaluation. Yes, you guessed it, the baby was dead. I walked out of another patient's room to hear the wails in the unit and saw the second year who had just done the evaluation.
When she began to describe the patient, I immediately remembered her from 2 weeks before. The resident said that the attending had been worried about her and wondering what had happened. The resident was now going to have to call the attending and let her know about the fetal demise.
When I left this morning, the patient had been induced and, at this point, may have already expelled the fetus. Fetus, not baby. This little one never got the chance to take a breath.
Off the soapbox, except to say, again, "If you're going to lie back on the bed and tell me that you're in 10/10 abdominal pain, that you've been so for the last two weeks, you're vomiting constantly, and that you decided at 0100 to call an ambulance to bring you to one of the only hospitals in the city where your primary care provider doesn't work, I am not really going to be very sympathetic. Really.
One, you're pregnant and should have seen a doctor earlier if you're vomiting 10 x a day. Two, why didn't you go to the hospital where you normally get your care and where all of your records are? Three, let me show you some video of the "I'm delivering before midnight" patient I just had. SHE was a 10/10, and in between pushes, she showed her true inner strength.
House would get to say these things. I just politely smile, fill out the chart, order the labs I know will be normal and wonder how much sleep I'll be getting that night. 4 hours? Ok.
Sunday, March 16, 2008
Spring Cleaning, Part I
I say Part I because I just got the downstairs sort of organized, and I know that in a couple of weeks, I will open all the windows, dust everything from top to bottom and really give the place a good scrubbing. I did open the window in my bedroom even though it's 40 degrees, but it was a nice 40 degrees. It should help to blow some of the dander and dust that's collected over the last several weeks.
I really didn't do much this weekend. Good for me. I watched the entire 7th season of CSI, which I love. It's gotten so I don't really have a lot of time to watch TV, and I have a number of shows I've followed for years. I bought the DVD's when the set came out, and this is the first time in a long time I've had a dedicated 2 days to watch all of the episodes. Since I hadn't seen any of them, they were new to me, and so addictive I went to bed late last night.
Tomorrow, it's back to the grind. Two more weeks. Funny, I really enjoyed L&D my first week. It started to become a chore the second week, along with no deliveries by my count. Now, I am looking at the end with relief. I need to move on. This however will be my hell weekend as I will be on 24 hour call Friday and Sunday, so essentially on all weekend. Not looking forward to this. I am on 24 hour call tomorrow, so we'll see what Monday brings.
Until then...
worked on a new Scrapbook page which you can see on my other blog:
http://journals.aol.com/vbonalesmd/MyPaperCuts
I really didn't do much this weekend. Good for me. I watched the entire 7th season of CSI, which I love. It's gotten so I don't really have a lot of time to watch TV, and I have a number of shows I've followed for years. I bought the DVD's when the set came out, and this is the first time in a long time I've had a dedicated 2 days to watch all of the episodes. Since I hadn't seen any of them, they were new to me, and so addictive I went to bed late last night.
Tomorrow, it's back to the grind. Two more weeks. Funny, I really enjoyed L&D my first week. It started to become a chore the second week, along with no deliveries by my count. Now, I am looking at the end with relief. I need to move on. This however will be my hell weekend as I will be on 24 hour call Friday and Sunday, so essentially on all weekend. Not looking forward to this. I am on 24 hour call tomorrow, so we'll see what Monday brings.
Until then...
worked on a new Scrapbook page which you can see on my other blog:
http://journals.aol.com/vbonalesmd/MyPaperCuts
Friday, March 14, 2008
Do All the Work, Reap None of the Rewards
So, no babies delivered last night. Did I even deliver a baby this week? I don't remember, but I don't think so. I did get to see a C-section with the delivery of twins. That was pretty cool. The twins were teeny, and they both needed to be intubated almost immediately after birth because they were so small.
Yesterday, I took a patient who should have delivered, she didn't. I saw a patient I sent home because she wasn't in labor. And, I admitted a patient around midnight that I thought might go fast, she didn't. That was the extent of my 24 hour call. Very boring.
So, now I have the weekend free. I have a stack of mail to go through. I need to make sure I paid all of my bills. I also need to get a driver's license and register my car in New York, and I am digging through boxes and envelopes looking for all of the necessary papers. My grand plan is to get my apartment cleaned and organized this weekend. We'll see how much I actually accomplish. Not to mention I'd like to keep working on my scrapbook and wedding photos.
As for the children, they will be so happy to have me home for a full 48 hours. They're about to turn 5 years old this month. I can't believe it. I talked to my husband about adopting our next. I had always planned to do it around this time. I am keeping an eye out on Petfinder.com to see if I see one I want.
I have been trying to find a cat similar to the one he had when we first met. It was his daughter's cat, a Persian mix colored blue and cream. She unfortunately was killed by a dog just before he moved to join me in Wisconsin, or else we would have her as well. So, we'll see. I know we're heading into "kitten season" so I know they'll start showing up in the postings.
As for now, it's me and the kitties, all warm and bundled up for the night... waiting to see what tomorrow will bring.
Yesterday, I took a patient who should have delivered, she didn't. I saw a patient I sent home because she wasn't in labor. And, I admitted a patient around midnight that I thought might go fast, she didn't. That was the extent of my 24 hour call. Very boring.
So, now I have the weekend free. I have a stack of mail to go through. I need to make sure I paid all of my bills. I also need to get a driver's license and register my car in New York, and I am digging through boxes and envelopes looking for all of the necessary papers. My grand plan is to get my apartment cleaned and organized this weekend. We'll see how much I actually accomplish. Not to mention I'd like to keep working on my scrapbook and wedding photos.
As for the children, they will be so happy to have me home for a full 48 hours. They're about to turn 5 years old this month. I can't believe it. I talked to my husband about adopting our next. I had always planned to do it around this time. I am keeping an eye out on Petfinder.com to see if I see one I want.
I have been trying to find a cat similar to the one he had when we first met. It was his daughter's cat, a Persian mix colored blue and cream. She unfortunately was killed by a dog just before he moved to join me in Wisconsin, or else we would have her as well. So, we'll see. I know we're heading into "kitten season" so I know they'll start showing up in the postings.
As for now, it's me and the kitties, all warm and bundled up for the night... waiting to see what tomorrow will bring.
Wednesday, March 12, 2008
Slippery Slopes
Today we had the traditional "Ski Rounds" where all of the residents meet at Kissing Bridge Ski Resort for morning lectures and then an afternoon of fun. Several of the faculty are members of the local Ski Patrol, and many are skiing, especially back country, enthusiasts. So, they take the time to teach us a little about wilderness medicine, and we have some fun too.
The topic of discussion was Avalanches and how to survive and rescue people from them. We learned all about snow and how to be safe when going out into the back country. We learned that a person caught in an avalanche is most likely to die from suffocation and that 80% of people who are found within 15 minutes survive while only 50% of those found after 30 do. It takes 90 minutes to develop fatal hypothermia, so if the person is able to create an oxygen window, they have a bit of time.
We practiced learning how to find people in 15 minutes.
Here my colleagues have formed a line to try to find someone buried under the snow.
Here they are using a beacon which many back country enthusiasts use in case of avalanche. They are trying to hone in on the signal from another beacon that is buried below the snow presumably on our victim.
After the lectures and practice sessions, we had some lunch and then hit the slopes. I seriously need to start going to the gym again. I only lasted for a short while and then had to stop, but I did get one decent run in, and it was so much fun being outdoors with colleagues and doing something non-medical.
Back to 24 hour call tomorrow on the OB unit and then a free weekend! What will I do with myself?? :)
From the drive up:
The topic of discussion was Avalanches and how to survive and rescue people from them. We learned all about snow and how to be safe when going out into the back country. We learned that a person caught in an avalanche is most likely to die from suffocation and that 80% of people who are found within 15 minutes survive while only 50% of those found after 30 do. It takes 90 minutes to develop fatal hypothermia, so if the person is able to create an oxygen window, they have a bit of time.
We practiced learning how to find people in 15 minutes.
Here my colleagues have formed a line to try to find someone buried under the snow.
Here they are using a beacon which many back country enthusiasts use in case of avalanche. They are trying to hone in on the signal from another beacon that is buried below the snow presumably on our victim.
After the lectures and practice sessions, we had some lunch and then hit the slopes. I seriously need to start going to the gym again. I only lasted for a short while and then had to stop, but I did get one decent run in, and it was so much fun being outdoors with colleagues and doing something non-medical.
Back to 24 hour call tomorrow on the OB unit and then a free weekend! What will I do with myself?? :)
From the drive up:
Tuesday, March 11, 2008
A Plethora of Problem Pregnancies
All I can say today is that it was both interesting and frustrating. Interesting because we had an abundance of case studies in obstetrical medicine. Frustrating because I wasn't allowed to do much about any of them.
I love the time I spent in surgery, but at times I wish I didn't have the experience because I sometimes long to be back in the O.R. We had a number of cases today that I have done in the past, but now, I can only watch from the sidelines, and at times it gets so that I wish I was back in surgery, taking the patients to the O.R. Not being stopped from seeing my patients all the way through because of my current position. I hate being on the sidelines.
This is how I greeted the morning:
It made me think of San Francisco - of course if SF suddenly flattened out, lost about 3/4 of its inhabitants, and dropped 20 degrees below it's norm for this time of year. Still.
But, let's focus on the positive... there really were a lot of interesting cases. I can't explain all of the different medical conditions so I added a hyperlink to a website explaining them:
Hydrops fetalis in an Amish woman who was on her 9th pregnancy. She has Rh negative blood and had 4 previous Rh positive pregnancies. She is only in her 28th week, so tomorrow they plan to try an intra-uterine blood transfusion to see if she can at least carry the baby a little longer and to give it the best chance for survival. (http://www.healthsystem.virginia.edu/uvahealth/peds_hrnewborn/hydrops.cfm)
Gastroschisis in a 37 weeker who ended up getting a C-section when the baby started having problems. Surgery was there to replace the bowel contents. I had a couple of these during my peds surgery rotation, and I help put a silo in one of them. They usually do better once everything is back inside.
(http://www.chw.org/display/PPF/DocID/34307/Nav/1/router.asp )
Psuedocyesis in a patient that has been to the L&D ward multiple times. I talked about this while I was working in the ED at ECMC ( http://journals.aol.com/vbonalesmd/emresident/entries/2007/10/11/three-nights-three-tales/858 ). Apparently this patient is bipolar, and when she doesn't take her medication she has bizarre delusions. She got a laugh out of the other intern who, unknowingly, placed an ultrasound on the patient and found an empty uterus. Although convincing oneself that they are pregnant to the extent of gaining weight, producing milk and even "going through labor" is a documented psychiatric condition, there's another called Munchausen's where a patient fakes a condition for some gain, mostly attention. My patient at ECMC gained attention during her "pregnancy" including all the extra perks that pregnant women get. Also, once she told everyone that she had lost her baby, she gained the sympathy from everyone for her "dead baby." I am still not convinced that her first pregnancy wasn't a lie as well.
PPROM (Preterm Premature Rupture of Membranes) in a woman with twins. The twins are 31 wks old so they are "preterm." PROM happens when one's water breaks long before labor starts. Usually labor will eventually follow, however the risk of infection is very high in these women because their uterus is now essentially exposed to the open. The treatment is usually antibiotics and to watch for signs of labor. In this case, the mother was transported from a Canadian hospital to Fort Erie by helicopter and then met by an ambulance that brought her across the border. Supposedly, helicopters can't cross international borders with patients. She's being watched and hopefully will give the twins a couple more days. (http://www.healthsystem.virginia.edu/uvahealth/peds_hrpregnant/prm.cfm)
There was also a whole host of high risk patients, several sets of twins including the mother having a boy and a girl after IVF. She was interesting because they had tried to fertilize 12 eggs. Of the 12, only two developed, and one was considered "small and weak." She was told that of the two to be placed in her uterus, more than likely only one would "stick." So, she tells everyone "what was meant to be happened."
I had a teen pregnancy where the mother was found to have active herpes and had to be taken back for a C-section which I, of course, don't get to have anything to do with even though we diagnosed the lesions and I worked up the patient.
I had two other women that came in to rule out labor. One I sent home just before the end of my shift, and the other was going to be re-evaluated by the overnight resident.
We had a mom with a baby with a bad congenital heart defect. When I left, they were planning to induce her, and if the infant survived, they would stabilize it and transfer it to Rochester for either pediatric cardiac surgery or to await a transplant that might be its only hope.
Also, I complain a lot about having to do pelvics. I think I've mentioned how there are certain parts of the body I really don't want to have anything to do with. However, being on this service, I've now set myself a goal of being able to accurately measure cervical width. Today, I finally was able to feel a cervix or two and confidently say whether it was a 2 or a 4. Now I just need to add effacement, and I'll be golden. Setting the challenge distracts me from what I am doing... and at times, we could all use a little distraction, n'est pas?
"Ski Rounds" tomorrow. I will explain then. Back to L&D for 24 hour call on Thursday.
I love the time I spent in surgery, but at times I wish I didn't have the experience because I sometimes long to be back in the O.R. We had a number of cases today that I have done in the past, but now, I can only watch from the sidelines, and at times it gets so that I wish I was back in surgery, taking the patients to the O.R. Not being stopped from seeing my patients all the way through because of my current position. I hate being on the sidelines.
This is how I greeted the morning:
It made me think of San Francisco - of course if SF suddenly flattened out, lost about 3/4 of its inhabitants, and dropped 20 degrees below it's norm for this time of year. Still.
But, let's focus on the positive... there really were a lot of interesting cases. I can't explain all of the different medical conditions so I added a hyperlink to a website explaining them:
Hydrops fetalis in an Amish woman who was on her 9th pregnancy. She has Rh negative blood and had 4 previous Rh positive pregnancies. She is only in her 28th week, so tomorrow they plan to try an intra-uterine blood transfusion to see if she can at least carry the baby a little longer and to give it the best chance for survival. (http://www.healthsystem.virginia.edu/uvahealth/peds_hrnewborn/hydrops.cfm)
Gastroschisis in a 37 weeker who ended up getting a C-section when the baby started having problems. Surgery was there to replace the bowel contents. I had a couple of these during my peds surgery rotation, and I help put a silo in one of them. They usually do better once everything is back inside.
(http://www.chw.org/display/PPF/DocID/34307/Nav/1/router.asp )
Psuedocyesis in a patient that has been to the L&D ward multiple times. I talked about this while I was working in the ED at ECMC ( http://journals.aol.com/vbonalesmd/emresident/entries/2007/10/11/three-nights-three-tales/858 ). Apparently this patient is bipolar, and when she doesn't take her medication she has bizarre delusions. She got a laugh out of the other intern who, unknowingly, placed an ultrasound on the patient and found an empty uterus. Although convincing oneself that they are pregnant to the extent of gaining weight, producing milk and even "going through labor" is a documented psychiatric condition, there's another called Munchausen's where a patient fakes a condition for some gain, mostly attention. My patient at ECMC gained attention during her "pregnancy" including all the extra perks that pregnant women get. Also, once she told everyone that she had lost her baby, she gained the sympathy from everyone for her "dead baby." I am still not convinced that her first pregnancy wasn't a lie as well.
PPROM (Preterm Premature Rupture of Membranes) in a woman with twins. The twins are 31 wks old so they are "preterm." PROM happens when one's water breaks long before labor starts. Usually labor will eventually follow, however the risk of infection is very high in these women because their uterus is now essentially exposed to the open. The treatment is usually antibiotics and to watch for signs of labor. In this case, the mother was transported from a Canadian hospital to Fort Erie by helicopter and then met by an ambulance that brought her across the border. Supposedly, helicopters can't cross international borders with patients. She's being watched and hopefully will give the twins a couple more days. (http://www.healthsystem.virginia.edu/uvahealth/peds_hrpregnant/prm.cfm)
There was also a whole host of high risk patients, several sets of twins including the mother having a boy and a girl after IVF. She was interesting because they had tried to fertilize 12 eggs. Of the 12, only two developed, and one was considered "small and weak." She was told that of the two to be placed in her uterus, more than likely only one would "stick." So, she tells everyone "what was meant to be happened."
I had a teen pregnancy where the mother was found to have active herpes and had to be taken back for a C-section which I, of course, don't get to have anything to do with even though we diagnosed the lesions and I worked up the patient.
I had two other women that came in to rule out labor. One I sent home just before the end of my shift, and the other was going to be re-evaluated by the overnight resident.
We had a mom with a baby with a bad congenital heart defect. When I left, they were planning to induce her, and if the infant survived, they would stabilize it and transfer it to Rochester for either pediatric cardiac surgery or to await a transplant that might be its only hope.
Also, I complain a lot about having to do pelvics. I think I've mentioned how there are certain parts of the body I really don't want to have anything to do with. However, being on this service, I've now set myself a goal of being able to accurately measure cervical width. Today, I finally was able to feel a cervix or two and confidently say whether it was a 2 or a 4. Now I just need to add effacement, and I'll be golden. Setting the challenge distracts me from what I am doing... and at times, we could all use a little distraction, n'est pas?
"Ski Rounds" tomorrow. I will explain then. Back to L&D for 24 hour call on Thursday.
Monday, March 10, 2008
A Monday of Mothers
Getting up at 4:15 in the morning is no fun at all. Drive to the hospital, round on patients, morning report and a double shot cafe mocha, then report to the L&D floor. I was very tired.
The medical students changed during the weekend, so this morning's flock of new students was a bit disorganized starting out. They seem like a good group, though, and I am sure they will settle out over the next week. It's fun having medical students again. One of the things I miss most about surgery is that I always had medical students during most of my rotations, and especially as a second year, I actually knew something and had the time to teach. I really miss that.
So, we came onto the unit with NO PATIENTS ON THE BOARD!!!! None. So we went and had breakfast. Came back. The senior went to breakfast. Came back. I spent 30 minutes teaching knot tying to the medical students. And then the first trio of patients came in: chief complaint - fell on the ice. They get observed for a total of six hours from the time they fell. So now three rooms were occupied. Then the next trio of patients came: chief complaint - high blood pressure, possible pre-eclampsia. Six rooms occupied. Then the rush started.
I think the next time I checked the clock it was after 1 p.m., and we were hopping... with outpatients - patients that are being triaged for this or that complaint, but not actually in labor so they're not staying unless a medical issue arises where they have to stay. We got our first L&D - I'm having a baby soon around 2 or so, and she delivered pretty fast with the Family Medicine resident around 4 p.m.
I was in the middle of seeing another patient who felt like she was having contractions. I think I'll probably go back tomorrow to find she was sent home. What was interesting is that this patient and I were born on the same day. I noted on her chart that this was her first baby. She replied yes, and at her age. Well, her age & 6 months. I asked when she was born, and she said July. I asked the date and it was the same as mine. She joked that she was going to call her mother and ask what time to see if we were close. I told her I'd been born around 1 in the afternoon. She thought she might have been born in the morning but wasn't sure.
And, that was about the excitement for the day. On weekdays when I am not on overnight call, I get to leave at 5 p.m. Which I did, and thoroughly enjoyed being out in the evening sunshine made possible by Daylight Saving Time.
So what did I do? Well, just a note here: (on the soapbox) if you noticed my sidebar my one political cause at this time is to protest the annual seal hunt planned to start on March 28th. There are several websites offering information, but I have posted the link to Human Society's website. Please sign the petition, if you're so inclined, and there's even a place to send an email to the Canadian Prime Minister in support of stopping the hunt. (off the soapbox)
The only reason I point out the above is that just below that is the link for my wedding photos, which I just got the link for. Enjoy! I will be posting some of my PSP Photo X2 creations from these on my other blog and will provide a link when I do....
Back to L&D in the a.m.
Baby Counter:
Births witnessed: 5
Babies delivered: 5
C-sections witnessed: 1
The medical students changed during the weekend, so this morning's flock of new students was a bit disorganized starting out. They seem like a good group, though, and I am sure they will settle out over the next week. It's fun having medical students again. One of the things I miss most about surgery is that I always had medical students during most of my rotations, and especially as a second year, I actually knew something and had the time to teach. I really miss that.
So, we came onto the unit with NO PATIENTS ON THE BOARD!!!! None. So we went and had breakfast. Came back. The senior went to breakfast. Came back. I spent 30 minutes teaching knot tying to the medical students. And then the first trio of patients came in: chief complaint - fell on the ice. They get observed for a total of six hours from the time they fell. So now three rooms were occupied. Then the next trio of patients came: chief complaint - high blood pressure, possible pre-eclampsia. Six rooms occupied. Then the rush started.
I think the next time I checked the clock it was after 1 p.m., and we were hopping... with outpatients - patients that are being triaged for this or that complaint, but not actually in labor so they're not staying unless a medical issue arises where they have to stay. We got our first L&D - I'm having a baby soon around 2 or so, and she delivered pretty fast with the Family Medicine resident around 4 p.m.
I was in the middle of seeing another patient who felt like she was having contractions. I think I'll probably go back tomorrow to find she was sent home. What was interesting is that this patient and I were born on the same day. I noted on her chart that this was her first baby. She replied yes, and at her age. Well, her age & 6 months. I asked when she was born, and she said July. I asked the date and it was the same as mine. She joked that she was going to call her mother and ask what time to see if we were close. I told her I'd been born around 1 in the afternoon. She thought she might have been born in the morning but wasn't sure.
And, that was about the excitement for the day. On weekdays when I am not on overnight call, I get to leave at 5 p.m. Which I did, and thoroughly enjoyed being out in the evening sunshine made possible by Daylight Saving Time.
So what did I do? Well, just a note here: (on the soapbox) if you noticed my sidebar my one political cause at this time is to protest the annual seal hunt planned to start on March 28th. There are several websites offering information, but I have posted the link to Human Society's website. Please sign the petition, if you're so inclined, and there's even a place to send an email to the Canadian Prime Minister in support of stopping the hunt. (off the soapbox)
The only reason I point out the above is that just below that is the link for my wedding photos, which I just got the link for. Enjoy! I will be posting some of my PSP Photo X2 creations from these on my other blog and will provide a link when I do....
Back to L&D in the a.m.
Baby Counter:
Births witnessed: 5
Babies delivered: 5
C-sections witnessed: 1
Sunday, March 9, 2008
Blame It on the Weather
This is what is looked like on my way to work yesterday morning... This is what it looked like mid afternoon from one of the hospital windows... And, this is what it looked like coming home this morning....
It was a, gasp, quiet 24 hour call yesterday. I got up a little earlier because it had started snowing pretty much from the time I got home on Friday morning. By that evening, the plows were rolling in full force. When I got up Saturday morning, I just put the Jeep in 4-wheel drive and drove over the piles of snow in our driveway. None of the streets were plowed, but my colleagues and I were amazed at the number of people driving at 6 in the morning.
After seeing my patients, including the two new moms I delivered yesterday, we presented ourselves down to L&D at just past 8 in the morning.... and proceeded to wait. There were six patients on the board at that time. Three were actually inductions from the night before, and the three others were "pre-termers" (gestational age less than 36 weeks) who had been evaluated for various things and were waiting for a bed upstairs. (I should explain that L&D is on the 3rd floor and the Mother - Infant ward is on the 6th floor. High risk is on the 5th.)
The first year intern offered me my choice of patients, and I randomly picked the one in 307. She picked up the other 2, and I offered to take the next admission. And, so we waited...
And waited...
And waited...
Around noon, a patient I had seen on Thursday night who was already 41 weeks came in. I had sent her home because she wasn't in labor, and she had been very upset that I was sending her home. She just wanted to have the baby and get it over with. But, now she was happy, well, as happy as she could be having contractions every 10 minutes.
We put her in a room, and I checked her out with the first year (I am still not confident in my cervical exam), and when I went to check the patient, she was prattling on about how she was going to get her epidural, and have the baby, etc. The OB intern later told me she saw the look on my face as I examined the patient and internally went, "Oh Crap."
I didn't feel anything that felt like cervix, and what I did feel was bony and firm... kinda like a baby's head. I stepped back and said, "I think she's fully dilated and engaged in the birth canal." The OB intern felt and quickly stepped back and said, "We've got to get her to a room, like now." We called for the nurse, got the patient packed in a wheelchair and rolled her into a room.
The patient was excited about having the baby. However, this soon changed when we told her that because she was so far dilated, she could no longer have an epidural. Then the patient's personality underwent a Dr. Jeckell/Hyde transformation. I won't go into the details of the birth, but let me just say that by the end of the ordeal (about an hour later) everyone in the room had been cursed out in two languages.
She had a lovely baby boy, and once the delivery was over and some IV pain relief was able to be given, the personality switched again, and she was in love with life, her husband (who 30 minutes earlier had been denounced to the nth degree), and especially her new son. Wild.
Anyway, I had delivered one, my other patient from the morning was moved to another room and had begun to have stronger contractions, and the interns other three patients were trudging along. So we waited. I missed lunch and it was around 3 in the afternoon, so we gave the medical students a mission to find anyone who was delivering despite the weather and get a menu and collect orders.
About an hour later, my other patient began to have stronger contractions and it was time to deliver her. I got a chance to work with one of the private attendings,and she helped me deliver the baby right on the bed. No stirrups, no worrying about dropping the baby, everything happened right on the bed. This time it was a beautiful baby girl. Her older sister ran out of the room at about the time we set up for the delivery, but she soon came back to see her new little sister.
One of the best parts of the process, while we were repairing a slight tear from the birth, was the father walking around the room talking to his new daughter, LM. He was telling her that she couldn't have anything pierced until the age of 12, that she couldn't have a cell phone until she was in high school, no television in the bedroom, and as for dating, well, they would cross that bridge when they came to it. It seemed like a very nice family, and they were going to take the placenta home and plant it in the back yard with a tree. Interesting.
I came out of that room to find the nurses clamoring for dinner. I didn't know why they seemed so agitated, but soon found out it was because everyone was waiting for me to finish the delivery. I quickly made my choices, and we ordered dinner. And, so we waited.
During my two deliveries, one of the intern's patients was sent home to see if she would begin to have contractions at some point, and her other patient continued to sit and wait. So she sat and waited too. Dinner came just after 6, we all ate, and then we waited some more.
You might wonder what medical staff does during that down time... or maybe not, but I am still going to tell you... everyone saw my wedding photos, we looked at one of the nurse's photos from her trip to Africa, we teased the senior resident about his relationship with a nurse from another hospital, we talked about the EM residents, we talked about the OB residents, we exchanged horror stories and war stories about the stupid consults we're sometimes called to see. We learned how to curse in Russian and taught the Russian resident a few choice phrases in English.
Somewhere around 9 p.m., the intern's patient started attempting to push, and there was a small burst of excitement. Half an hour later there was little progress, but some other excitement as a patient was being transferred from BGH ED "broken waters and fully dilated." She was only 31 weeks, so about 2 months premature.
Suddenly everyone mobilized. The OR team was called,the Neonatologist service was called, anesthesia was called, and the attending was called up to the floor. When the patient arrived, she was met by about 12 eager people who examined her from every angle, obtained her history, filled out the forms, and after a second exam showed she wasn't as dilated as previously thought, heart rates slowed down, and we prepared to go to the OR. I didn't scrub in, but I did get a chance to come in and watch the C-section. She'd had 3 prior C-sections, so there was no question that she'd be getting another one.
A small, but very healthy baby boy was delivered. He cried continuously until he was wrapped burrito-style and handed off to his father. They checked on him every 5 minutes or so and kept him in the OR until just about the end of the C-section.
We got out of the OR around 11 p.m., and it seemed like the C-section brought the patients in with her from the cold as suddenly there were 3 patients waiting to be seen and evaluated, there was a consult in the Emergency Room, and one of patients who was still waiting for a bed upstairs suddenly developed a fever and abdominal pain.
And, the intern's original patient from the morning...? She was still pushing. The patients that arrived were all less than 35 weeks, so I couldn't evaluate them. I don't see consults in the E.D. So, I went to bed. It was around 11:30 p.m. but I ended up staying up until around 1 a.m. talking to a friend on the phone.
We lost an hour off our 24 hour call with the time change, but it was no fun waking up at old 5:30 in the morning which was now 6:30 in the morning.
I rounded on my two patients from yesterday. I heard that the other intern's patient had delivered finally at a minute before midnight, and that it had not been a good delivery, but missed the details. We had new medical students as they were transitioning over from the first half of their rotation. It was a quick rush to have all patients seen by 8 in the morning, then sign-out and back out into the real world.
It was such a glorious morning. Quiet except for the sound of early morning snowblowers. The streets weren't plowed, and there were few cars on the road. I don't know if I've mentioned that morning is my favorite time of day. Full of hope, full of promise, full of possibilities... A great day to be born and livein.
Baby Counter:
Births witnessed: 5
Babies delivered: 5
C-sections witnessed: 1
It was a, gasp, quiet 24 hour call yesterday. I got up a little earlier because it had started snowing pretty much from the time I got home on Friday morning. By that evening, the plows were rolling in full force. When I got up Saturday morning, I just put the Jeep in 4-wheel drive and drove over the piles of snow in our driveway. None of the streets were plowed, but my colleagues and I were amazed at the number of people driving at 6 in the morning.
After seeing my patients, including the two new moms I delivered yesterday, we presented ourselves down to L&D at just past 8 in the morning.... and proceeded to wait. There were six patients on the board at that time. Three were actually inductions from the night before, and the three others were "pre-termers" (gestational age less than 36 weeks) who had been evaluated for various things and were waiting for a bed upstairs. (I should explain that L&D is on the 3rd floor and the Mother - Infant ward is on the 6th floor. High risk is on the 5th.)
The first year intern offered me my choice of patients, and I randomly picked the one in 307. She picked up the other 2, and I offered to take the next admission. And, so we waited...
And waited...
And waited...
Around noon, a patient I had seen on Thursday night who was already 41 weeks came in. I had sent her home because she wasn't in labor, and she had been very upset that I was sending her home. She just wanted to have the baby and get it over with. But, now she was happy, well, as happy as she could be having contractions every 10 minutes.
We put her in a room, and I checked her out with the first year (I am still not confident in my cervical exam), and when I went to check the patient, she was prattling on about how she was going to get her epidural, and have the baby, etc. The OB intern later told me she saw the look on my face as I examined the patient and internally went, "Oh Crap."
I didn't feel anything that felt like cervix, and what I did feel was bony and firm... kinda like a baby's head. I stepped back and said, "I think she's fully dilated and engaged in the birth canal." The OB intern felt and quickly stepped back and said, "We've got to get her to a room, like now." We called for the nurse, got the patient packed in a wheelchair and rolled her into a room.
The patient was excited about having the baby. However, this soon changed when we told her that because she was so far dilated, she could no longer have an epidural. Then the patient's personality underwent a Dr. Jeckell/Hyde transformation. I won't go into the details of the birth, but let me just say that by the end of the ordeal (about an hour later) everyone in the room had been cursed out in two languages.
She had a lovely baby boy, and once the delivery was over and some IV pain relief was able to be given, the personality switched again, and she was in love with life, her husband (who 30 minutes earlier had been denounced to the nth degree), and especially her new son. Wild.
Anyway, I had delivered one, my other patient from the morning was moved to another room and had begun to have stronger contractions, and the interns other three patients were trudging along. So we waited. I missed lunch and it was around 3 in the afternoon, so we gave the medical students a mission to find anyone who was delivering despite the weather and get a menu and collect orders.
About an hour later, my other patient began to have stronger contractions and it was time to deliver her. I got a chance to work with one of the private attendings,and she helped me deliver the baby right on the bed. No stirrups, no worrying about dropping the baby, everything happened right on the bed. This time it was a beautiful baby girl. Her older sister ran out of the room at about the time we set up for the delivery, but she soon came back to see her new little sister.
One of the best parts of the process, while we were repairing a slight tear from the birth, was the father walking around the room talking to his new daughter, LM. He was telling her that she couldn't have anything pierced until the age of 12, that she couldn't have a cell phone until she was in high school, no television in the bedroom, and as for dating, well, they would cross that bridge when they came to it. It seemed like a very nice family, and they were going to take the placenta home and plant it in the back yard with a tree. Interesting.
I came out of that room to find the nurses clamoring for dinner. I didn't know why they seemed so agitated, but soon found out it was because everyone was waiting for me to finish the delivery. I quickly made my choices, and we ordered dinner. And, so we waited.
During my two deliveries, one of the intern's patients was sent home to see if she would begin to have contractions at some point, and her other patient continued to sit and wait. So she sat and waited too. Dinner came just after 6, we all ate, and then we waited some more.
You might wonder what medical staff does during that down time... or maybe not, but I am still going to tell you... everyone saw my wedding photos, we looked at one of the nurse's photos from her trip to Africa, we teased the senior resident about his relationship with a nurse from another hospital, we talked about the EM residents, we talked about the OB residents, we exchanged horror stories and war stories about the stupid consults we're sometimes called to see. We learned how to curse in Russian and taught the Russian resident a few choice phrases in English.
Somewhere around 9 p.m., the intern's patient started attempting to push, and there was a small burst of excitement. Half an hour later there was little progress, but some other excitement as a patient was being transferred from BGH ED "broken waters and fully dilated." She was only 31 weeks, so about 2 months premature.
Suddenly everyone mobilized. The OR team was called,the Neonatologist service was called, anesthesia was called, and the attending was called up to the floor. When the patient arrived, she was met by about 12 eager people who examined her from every angle, obtained her history, filled out the forms, and after a second exam showed she wasn't as dilated as previously thought, heart rates slowed down, and we prepared to go to the OR. I didn't scrub in, but I did get a chance to come in and watch the C-section. She'd had 3 prior C-sections, so there was no question that she'd be getting another one.
A small, but very healthy baby boy was delivered. He cried continuously until he was wrapped burrito-style and handed off to his father. They checked on him every 5 minutes or so and kept him in the OR until just about the end of the C-section.
We got out of the OR around 11 p.m., and it seemed like the C-section brought the patients in with her from the cold as suddenly there were 3 patients waiting to be seen and evaluated, there was a consult in the Emergency Room, and one of patients who was still waiting for a bed upstairs suddenly developed a fever and abdominal pain.
And, the intern's original patient from the morning...? She was still pushing. The patients that arrived were all less than 35 weeks, so I couldn't evaluate them. I don't see consults in the E.D. So, I went to bed. It was around 11:30 p.m. but I ended up staying up until around 1 a.m. talking to a friend on the phone.
We lost an hour off our 24 hour call with the time change, but it was no fun waking up at old 5:30 in the morning which was now 6:30 in the morning.
I rounded on my two patients from yesterday. I heard that the other intern's patient had delivered finally at a minute before midnight, and that it had not been a good delivery, but missed the details. We had new medical students as they were transitioning over from the first half of their rotation. It was a quick rush to have all patients seen by 8 in the morning, then sign-out and back out into the real world.
It was such a glorious morning. Quiet except for the sound of early morning snowblowers. The streets weren't plowed, and there were few cars on the road. I don't know if I've mentioned that morning is my favorite time of day. Full of hope, full of promise, full of possibilities... A great day to be born and livein.
Baby Counter:
Births witnessed: 5
Babies delivered: 5
C-sections witnessed: 1
Friday, March 7, 2008
Hurry Up & Stand Around
Some medical conditions lead to what is called "expectant management." You're expecting that something is eventually going to happen. In our case, it's a birth. And, while you "expect" for something to happen, you wait....
We get to the hospital relatively early, at 0530, to round on all the patients. We then have the morning meeting at 0700 where all the patients are presented and discussed. Maybe a student presentation on a pertinent topic. We then end about 0800 and report for our various duties. In my case, I present to L&D (Labor and Delivery Unit), where I wait for something to happen. Yesterday morning, I didn't have to wait long.
My first delivery of the day happened at 0820. We had been signed out about 4 or 5 patients from the night before, three of which were still waiting to give birth. I got the first one. Again, push, push, out comes the head, turn, lift up, pull down and catch the baby! A little girl in this case. DH. Her mother let me take her first photos since she was alone and family hadn't yet arrived.
Then it was back to waiting...
There are many reasons people come to Women & Children's Hospital of Buffalo, and one of them is the expertise of the Maternal & Fetal Medicine (MFM) team. They handle all of the complications and high risk pregnancies that present to the hospital. As an intern, and especially an Emergency Medicine intern, I'm expected to see non-emergent pregnant patients, like the one I had with an upper respiratory infection, pregnant patients that we "rule out" as being not in or in labor, and to help where I can. Any high risk or possible premature birth is handled by the 2nd year OB/Gyn resident and yesterday she had her hands full as she is also expected to attend all of the C-sections.
So, much of my day was spent watching her run around admitting patient after patient with various textbook complications of pregnancy such as placenta previa, where the placenta lies across the cervical opening or close to the opening. Most often they will have bleeding and spotting throughout the pregnancy and have to be delivered by C-section. We had three of them come yesterday for admission.
We had two women with pre-eclampsia which is a combination of high blood pressures, protein loss in the urine and to some extent edema. If not treated, the condition can lead to seizures and possible coma. The only real treatment is delivery of the baby. Usually it occurs in the last trimester which is good in terms of fetal development and in this case every week or sometimes day can make a difference.
Both of our patients were in their early 30th week. One was able to be controlled, the other, unfortunately was not and was taken for a C-section where she was found to have another complication of pregnancy, placenta accreta, which is an abnormal attachment of the placenta into the uterine wall. She, unfortunately, ended up with a hysterectomy since the placenta had invaded into the musculature of the uterus. These are just some of the reasons to have an MFM team on site. You just never know what might happen.
As you can see, I wasn't very busy yesterday in terms of my duties. All of the less than 36 weekers had to be seen by the second year. So I just helped out where I could. I finally got my own admission around 8 p.m., but she was coming to be induced so she wouldn't be delivering for another 12 hours. But, I admitted her, got her comfortable and waited. Luckily, the other intern had been managing a few other laboring patients, so I saw another delivery with her - this baby literally flew out of the birth canal before my colleague could even get a towel around him. She managed to catch the baby and hang on long enough for the pass to the waiting nurse. And, my colleague let me deliver one of her other patients who delivered very rapidly as well. So I got in a second delivery yesterday.
We did have an emergency on the floor I was sent to see since the seniors were tied up with all the complicated pregnancies that seemed to be coming in. A 15 year old pregnant with her second child suddenly became hypoxic (dropped her O2 saturations) and tachycardic (had an increased HR > 100). In most cases, you have to think about a blood clot to the lungs as pregnant women are at higher risk for developing them. She turned out, in the end, to have pneumonia, but we spent about an hour getting her tests and labs coordinated so that occupied a part of my evening.
Things seemed to slow down in general even more close to midnight, and I got about 4 hours' sleep before getting up for rounds this morning. After rounds home, a nap, a few odd and ends things in my office watching the skies open and snow fall like crazy. Close to two feet is supposed to fall over the next 48 hours, and it will be no fun digging out in the morning. I have a garage, my Jeep and 4 wheel drive. Give me heated seats and I can go anywhere.
Back to the hospital in the morning for another 24 hours on-call. Well, maybe 23 since it's changing to Daylight Saving Time (no 's') on Saturday night. We'll see how much we can pack into this shift.
Baby Counter:
Births witnessed: 4
Babies delivered: 3
We get to the hospital relatively early, at 0530, to round on all the patients. We then have the morning meeting at 0700 where all the patients are presented and discussed. Maybe a student presentation on a pertinent topic. We then end about 0800 and report for our various duties. In my case, I present to L&D (Labor and Delivery Unit), where I wait for something to happen. Yesterday morning, I didn't have to wait long.
My first delivery of the day happened at 0820. We had been signed out about 4 or 5 patients from the night before, three of which were still waiting to give birth. I got the first one. Again, push, push, out comes the head, turn, lift up, pull down and catch the baby! A little girl in this case. DH. Her mother let me take her first photos since she was alone and family hadn't yet arrived.
Then it was back to waiting...
There are many reasons people come to Women & Children's Hospital of Buffalo, and one of them is the expertise of the Maternal & Fetal Medicine (MFM) team. They handle all of the complications and high risk pregnancies that present to the hospital. As an intern, and especially an Emergency Medicine intern, I'm expected to see non-emergent pregnant patients, like the one I had with an upper respiratory infection, pregnant patients that we "rule out" as being not in or in labor, and to help where I can. Any high risk or possible premature birth is handled by the 2nd year OB/Gyn resident and yesterday she had her hands full as she is also expected to attend all of the C-sections.
So, much of my day was spent watching her run around admitting patient after patient with various textbook complications of pregnancy such as placenta previa, where the placenta lies across the cervical opening or close to the opening. Most often they will have bleeding and spotting throughout the pregnancy and have to be delivered by C-section. We had three of them come yesterday for admission.
We had two women with pre-eclampsia which is a combination of high blood pressures, protein loss in the urine and to some extent edema. If not treated, the condition can lead to seizures and possible coma. The only real treatment is delivery of the baby. Usually it occurs in the last trimester which is good in terms of fetal development and in this case every week or sometimes day can make a difference.
Both of our patients were in their early 30th week. One was able to be controlled, the other, unfortunately was not and was taken for a C-section where she was found to have another complication of pregnancy, placenta accreta, which is an abnormal attachment of the placenta into the uterine wall. She, unfortunately, ended up with a hysterectomy since the placenta had invaded into the musculature of the uterus. These are just some of the reasons to have an MFM team on site. You just never know what might happen.
As you can see, I wasn't very busy yesterday in terms of my duties. All of the less than 36 weekers had to be seen by the second year. So I just helped out where I could. I finally got my own admission around 8 p.m., but she was coming to be induced so she wouldn't be delivering for another 12 hours. But, I admitted her, got her comfortable and waited. Luckily, the other intern had been managing a few other laboring patients, so I saw another delivery with her - this baby literally flew out of the birth canal before my colleague could even get a towel around him. She managed to catch the baby and hang on long enough for the pass to the waiting nurse. And, my colleague let me deliver one of her other patients who delivered very rapidly as well. So I got in a second delivery yesterday.
We did have an emergency on the floor I was sent to see since the seniors were tied up with all the complicated pregnancies that seemed to be coming in. A 15 year old pregnant with her second child suddenly became hypoxic (dropped her O2 saturations) and tachycardic (had an increased HR > 100). In most cases, you have to think about a blood clot to the lungs as pregnant women are at higher risk for developing them. She turned out, in the end, to have pneumonia, but we spent about an hour getting her tests and labs coordinated so that occupied a part of my evening.
Things seemed to slow down in general even more close to midnight, and I got about 4 hours' sleep before getting up for rounds this morning. After rounds home, a nap, a few odd and ends things in my office watching the skies open and snow fall like crazy. Close to two feet is supposed to fall over the next 48 hours, and it will be no fun digging out in the morning. I have a garage, my Jeep and 4 wheel drive. Give me heated seats and I can go anywhere.
Back to the hospital in the morning for another 24 hours on-call. Well, maybe 23 since it's changing to Daylight Saving Time (no 's') on Saturday night. We'll see how much we can pack into this shift.
Baby Counter:
Births witnessed: 4
Babies delivered: 3
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