Fun on OB

Just finished my first week on OB rotation, and I love it! So far, I've done two C-sections, delivered seven babies and done two circumcisions. Of course, all of that is with supervision. I'm becoming a bit more comfortable with the deliveries - at least the straight-forward ones. On Saturday, I was helping to deliver a baby that was really big. After the head was delivered, the mom had a lot of trouble pushing the rest of the baby out. We call that shoulder dystocia - when the shoulder gets hung up on the pubic bone. There are a number of manouvers we can try to get baby out. In this case, we were able to deliver the baby, but it was pretty scary. Fortunately, the baby is doing really well now, with no injuries, and so is mom. In fact, I got to do the baby's circumcision today, so that was fun.

The circumcisions are also a little scary, if you think about what you're doing and what could go wrong. However, the equipment we use is designed to minimize the risk of harm to the baby's anatomy. One of the senior faculty walked me through the first circumcision - showing me step by step how to do it and then letting me actually do the procedure. He was a great teacher, and I really enjoyed working with him. The second circ was a lot more familiar. But I still have a long way to go before I feel completely comfortable with it.

On Saturday, I had my first 24-hour call - 7 AM to 7AM on Sunday. It was a LONG day, but thankfully not too hectic. During our call, I had to keep tabs on all the women in labor (there were only a two at the beginning), checking how their progress every hour or so. That involves reading the fetal monitoring strips for the baby's heart rate and mother's contraction rate, checking cervical dilation and baby's position, and making sure mom's vital signs are stable and mom is comfortable. Then I have to update the patient's OB doctor to let them know what's going on and see what else they want to do. In the meantime, there are always patients coming into the PSU - Perinatal Support Unit. That's where all the pregnant women with problems come for care - like the pregnancy ER. They come in with contractions, bleeding, rupture of membranes (when their water breaks), and lots of other symptoms. Some are full-term; others are in early pregnancy. Some get to go home once we establish that the baby is okay and mom isn't in labor. Others are admitted from the PSU to the labor and delivery unit because they are in labor. My job is to figure out what is going on and if they need to stay. Also, on call, I get to solve any problems from the post-partum floor - fevers, pain, nausea/vomiting, itching, etc., including problems with newborns. Between all these responsibilities, there isn't a lot of free time. Although, I did have some down time between 3 and 6 AM. That gave me time to update my log of clinical procedures and to some practice board questions just to keep me awake.

The hardest part of the job is communicating with attendings. I have to be sure I know exactly what is going on with each patient and have a plan for what I'd like to do. Obviously, I'm no expert yet. You would think the attendings would understand that I'm just beginning my training, but they aren't always that gracious. I guess I wouldn't be either if I was getting called in the middle of the night. And they have huge liability issues on OB. So I try to make sure I check everything out with the upper level resident on call before I call the attendings. I've already been chewed out a couple of times for not having all the right information and not being concise enough. Guess I'll develop some thick skin by the end of the rotation. I'm trying to learn to anticipate the questions and think like the attendings so I can be helpful, thorough and efficient.

Fortunately, I only have one other 24-hour call. The rest are just overnight. I can handle 12-14 hours if it's not to busy. There is always an upper level on call with me, so that is good. But if it's really crazy, he or she may be in a delivery or emergency c-section, and I am on my own on the floor. So far, there hasn't been anything I can't handle. But there are still 3 weeks left!

Despite the challenges and quirky personalities of the attendings, it is a happy, upbeat rotation. I love my teammates and enjoy working with the moms and babies. Please pray I will continue to gain experience, wisdom, and the skills I need to be good at this!

First day of OB

Monday, I hit the ground running on my obstetrics rotation. It was crazy!!!!! We start with rounds at 6AM - dividing up all the post-partum patients on the floor between those on duty. I only had to see three patients, but it took me a good hour just learning how the charts are organized, how to write up the discharge orders and prescriptions, etc. After rounds, we had morning board rounds, where the folks on duty overnight check out the patients they were following to the new folks coming on the floor (i.e., me). I got three ladies to follow at the start, all in the early stages of labor. My job was to check on them every hour or so and see how they were progressing, how the baby was doing (looking at fetal heart rate monitoring) and update the attending physician. I also got assigned to assist on a c-section right off the bat.

Now, I've seen several c-sections, but I've never done much assisting before. Normally, the attending allows the first-year residents to actually DO the c-section with supervision and teaching. But I must have looked pretty green, so in this case I was only allowed to assist. As it turns out, I wasn't even a very good assistant, so the nurse had to do most of what I should have done. I felt more in the way than anything. But, hey, there will be plenty more opportunities and I can only get better (can't get much worse, I don't think). Overall, it was a good experience to be back in the OR, and next time I will be able to better anticipate my role as assistant (I'd like to assista a couple more times before being the primary surgeon).

Once I was done with the c-section, I checked on all my laboring patients. In medical school, I didn't get the chance to do the cervical exam on many of the patients, so I am still quite inexperienced at assessing the degree of dilation and baby's position. If only you could SEE what you're feeling! The first few times, I couldn't tell WHAT I was feeling, but eventually it got a little easier and I was guessing the level of dilation pretty close to what the nurse or upper level resident was getting. I will still have an experienced nurse or resident check after me for the rest of this month I think to make sure I don't miss anything important. I mean, it's pretty obvious when the baby is crowning, but in between, there a lot of room for error.

After checking in with the two attending physicians for my patients, one wanted me to artificially rupture the membranes (break her water) to help get labor going a little faster. The supervising resident ended up doing that, since I was not sure exactly how to do it and wasn't sure I could even find the cervix, much less the amniotic sac! Later, I did get to place an intrauterine pressure catheter in that same patient (successfully, I might add!). This is a device that goes into the uterus, beside baby, that measures the pressure generated by each contraction. It allows us to assess the quality and sufficiency of contractions to see if we need more pitocyn (a hormone used to enhance labor contractions). A few hours after that, the same patient's baby was having lots of sharp decelerations in heart rate, which usually are caused by the umbilical cord being compressed by baby during contractions. When we ruptured this patient's membranes, she had very little amniotic fluid, so there wasn't a lot of fluid for the cord to float around in, probably explaining the frequent cord compressions. The intrauterine pressure catheter can be used to infuse sterile saline solution into the uterus to provide more "cushioning" for baby. Once we started infusing fluid into this patient's uterus, the baby's heart rate leveled out and did not show those sharp decelerations for the rest of labor. The patient's labor progressed throughout the day. By the time I left, she was almost ready to push, but I didn't get to attend her delivery.

Meanwhile, my other two patients did complete labor and deliver healthy babies. I got to help with both of those deliveries. The attending was present and did a lot of the work, but I was definitely a significant participant in both cases, getting to help baby out, clamp the cord, deliver the placenta, and sew up lacerations. What a wonderful experience! Although I felt a little unsure about my role and not always certain of what to do, the attendings walked me through things. Next time I will be a little more confident and step in to do more and ask more questions. My supervising resident, who was with me all day, was amazing! She was so encouraging and managed to keep a calm and cool attitude despite having a LOT of work to do with two new interns on the floor and a lot of patients.

In the midst of all these deliveries, I also had to check in two patients from the PSU (prenatal triage area). One was in active labor, so she was admitted, and I followed her all day until I left. She was actually ready to deliver when I left, but the night-duty resident got to deliver that one. The other patient was not in labor, but was having some lower pelvic pain (probably muscular). However, she had been having high blood pressure over the preceding few weeks and came in with elevated blood pressure, so she needed to get some labs to rule out preeclampsia. If she did have preeclampsia (I wasn't there when the labs came back, so I don't know what happened), she probably would have been induced, since she was already term (39 weeks). There is so much to learn about what to questions to ask, what to look for on exam and in the prenatal records, what to tell the attending, what forms to fill out, what labs to get... It was definitely an overwhelming first day!

And tonight I will be on duty from 5 PM to 7 AM. There will be one other resident (a second year I think) on duty with me, but I am expected to manage most of the cases I think, and he is simply there for back-up in case I get swamped or need help and to do any emergency c-sections. Whew!!

Yesterday I spent the morning in a non-profit clinic called Choices. They offer free ultrasounds and counseling for patients who are not sure they want to keep their babies. They also provide prenatal/perinatal hospice services - counseling and guidance for patients whose babies have been diagnosed with any sort of severe or fatal problem. Incidentally, Choices is located next door to a late-term abortion clinic - they have a very interesting history. But more on that later. Time to go get a nap before my night shift!

Oh, by the way, when I got home yesterday, my weather guage was showing an outside temperature of 112 degrees!!! But only 20% humidity, so that's good, right? I was going to go for a run but decided against it. By 9PM, the temp was down in the low 90s. It's supposed to be cooling off to the high 90s for the rest of the week.

Old Cowtown

Old Cowtown Museum Wichita

My sister and her family drove through Wichita this weekend on their way home from Minnesota. It was great to have some time with family and see a little more of Wichita. We visited the Old Cowtown Museum (click on photo above to view album), a replica of Wichita in the 1870s when it was, literally, a cowtown. Although it was hot (over 100 degrees), we enjoyed wandering the street (only one, really), seeing the old fashioned grain elevator, blacksmith shop, and general store before finally hitting the saloon for a cold sarsaparilla (basically, rootbeer). My niece and nephew spent most of the rest of the time on their iTouch or laptop playing games, texting or whatever.

Tomorrow I start my OB rotation. I'm very excited to start delivering babies! I'll keep you posted how it goes!

Botanical Gardens

One of the tricks of surviving residency is knowing how to make use of days off. Last Sunday I visited Wichita's Botanica (botanical gardens). Even in the heat of summer (105 degrees some days), one can enjoy a feast of colors, shapes, fragrances, and beauty. It's refreshing to the soul.

Here are a few photos to add some sparkle to your day.

From Wichita Botanical Gardens

From Wichita Botanical Gardens

From Wichita Botanical Gardens

From Wichita Botanical Gardens

Settling In

My first month of residency is almost over - three more ER shifts and I will be done! It has been a long month, but I think I have actually made some progress in figuring out how to be a doctor. The variety of cases and conditions I've seen is incredible. Even if two patients have the same condition, the presentation can be completely different, and thus the treatment will also be different.

For example a few nights ago I saw a middle-aged woman with acute chest pain radiating to her neck and jaw with nausea and sweating relieved by a nitroglycerin tablet under her tongue - the typical description of a heart attack. However, she had had a full cardiac work-up recently revealing no atherosclerosis or blockage of her coronary arteries. She likely has a condition called Prinzmetal angina, where there is spasming of the arteries leading to ischemia (decreased blood flow and oxygen) to the heart. A cardiac catheterization or bypass surgery won't fix her problem since it is not an issue of stopped up plumbing. Last night, a 50-year-old man came in with the same presentation. Although he had no past medical history suggesting heart disease, he did have a strong family history. After following his cardiac enzymes for a couple of hours, he did turn out to be having a heart attack. So he gets to go for a catheterization to look for and hopefully correct blocked arteries. So how do you know if someone's chest pain is caused by a heart attack? Fortunately, there is a standard set of labs and tests that get done on any patient with suspected myocardial infarction. So that takes some of the guesswork out of it.

In the past week, I have been able to do a lot of small procedures - particularly, draining abscesses and suturing lacerations. I've sewn up faces, fingers, arms, scalps, even an eyelid. I must admit that last one made me really nervous. It wasn't right over the eyeball, but pretty close. But I managed to do a pretty good job - hope it heals well without a bad scar! Generally suturing is not too bad - I'm always a little nervous about getting the wound to come together properly, but at least you can numb people up well enough that they don't feel anything. Abscesses are different. No matter how much lidocaine you use, the patient always feels some pain. They are just so tender and tense under the pressure of the abscess, and the lidocaine just doesn't penetrate into the underlying tissue well enough to make the entire operation painless. I'm still not entirely comfortable cutting people open with a scalpel. But that's not the worst part. You have to go into the abscess and break up the pockets so all the fluid can drain out. That is almost always very uncomfortable for the patient. It always makes me feel so bad to hurt them, even though I know in the long run it is for their good and will facilitate healing of the infection. Anyway, with all the practice I've had this past week, I'm beginning to at least feel more confident about my skills and more at home with a needle and scalpel in my hand.

More than anything, I love interacting with my patients. It is so gratifying to feel like I am able to help patients when they are most scared and vulnerable - reassuring them when appropriate and explaining what tests we're doing and what the results mean, educating them about how to take care of themselves when they go home, answering their questions...I think there are many patients who come to the ER just to have someone listen to their problems and "take care" of them. We have a lot of "frequent flyers" who come for every little ache and pain. Maybe some of them come because they want refills of their pain medications (narcotics). But I think some are just lonely and depressed, and perhaps their problems are more psychosocial with the pain being either a secondary issue that exacerbates or is exacerbated by their emotional issues, or a direct result of psychological problems (somatization). I admire how some of the ER docs handle these cases with compassion and patience, without doing unnecessary tests or giving out unwarranted narcotic pain medicine.

Bottom line: I have a lot to learn about doctoring - the medical part and the interpersonal part. I'm sure you will get tired of hearing that, but I think it will be a major theme for me in the next year or two. Keep praying for me and stay in touch.

Day Ten on the Job

I am now into my second full week of being a doctor, and it's beginning to feel a little more like I really belong here. The first week was really challenging - constant feelings of inadequacy, uncertainty, and overwhelming fear. For every patient I saw in the ER, I forgot parts of the history and exam, bumbled through the assessment, missed key elements of the differential diagnosis, guessed (usually wrong) what tests to run, and was completely clueless about dosing and how to write orders for medications. After three days, I was seriously struggling with doubts about my ability to ever be a good doctor.

Now, though, I think I'm beginning to turn a corner. I'm still on my emergency room rotation and still as "green" as ever - not sure how to work up and manage most of the cases I see. But I'm getting to know most of the ER doctors and what they expect. They have been very encouraging, reminding me that I am only just beginning my training, and I WILL learn with time. So, I have been trying to focus on what I can learn from each case and patient. Amazingly, I really am learning a ton. Not that I feel at all ready to take care of patients on my own, but it feels a little more comfortable.

This past weekend, I worked a couple of night shifts in the ER. Night time brings a lot of drug and alcohol related cases, as well as some trauma (accidents, injuries). One of the coolest things I got to do this week was put in a chest tube. A young guy came into the ER complaining of shortness of breath and chest pain. He didn't have any risk factors for a heart attack. He turned out to have a pneumothorax - complete collapse of one of his lungs! The chest x-ray was pretty impressive. Even I couldn't miss the diagnosis! In a pneumothorax, air collects in the pleural space between the lung and the chest wall, making it impossible to inflate the lung. To fix it, you need to get the air out, which you do by inserting a tube and connecting it to suction. I've seen chest tubes placed before, but I've never put one in myself. The ER attending allowed me to do most of the procedure. It's weird and sort of awesome to stick a scalpel into someone's chest wall, to basically cut a hole between the ribs into the inside of the chest. But now that I've done one, I can't wait to do more. I've also gotten to do a lumbar puncture (spinal tap), an arthrocentesis (where you stick a needle into someone's joint - in this case a knee - and aspirate fluid to send for analysis, then inject steroids and numbing medicine to relieve pain), incision and drainage of abscesses and suturing of lacerations. I'm not that good at these things, but I know I can learn the skills and be proficient and confident eventually.

Once again, I am reminded of God's goodness and faithfulness. He is with me and is able to provide all it takes for me to be a good doctor so I can serve him. The process may be painful at time, as I learn humility and dependence on God. So I have renewed hope and joy that I am in fact growing and learning, and it will all be worth it in the long-run.

Well, that's all for now. I am yawning and can barely keep my eyes open. Tomorrow is clinic day - instead of being in the ER, I'll be seeing patients in the office. Keep me in your prayers - for a good attitude, humility, patience and joy!

My First Day as a Doctor

July 1 - the first day of residency for most new medical school graduates. I've been looking forward to this day with a mixture of excitement and apprehension. What if I don't have a clue what to do for a patient? What if I make a mistake? What if I miss something important?

Well, the first day has come and gone. I'm still alive, and so are my patients. I am on ER this month - emergency medicine rotation. Arriving in the ER this morning at 7:30 AM, I introduced myself as a brand new doctor. One of the attending docs showed me the ropes, explained the paperwork, answered my questions, gave me some suggestions for managing my patients and was generally very supportive, encouraging and helpful. It was an awesome day!! I may not have done everything independently or in perfect order, but I felt like I sort of new what I was doing - or at least that I could have done it on my own. I only saw five patients today, but each one was completely different, so I got to think through a variety of conditions (extreme hypertension, pancreatitis, a sprained thumb, diabetes/kidney failure, and seizures) and how to diagnose and treat them. At the end of the day, I got to call one of my colleagues, who happened to be on pediatrics, and tell her about a patient we were admitting to her team. That was pretty cool. I know some day I will look back on this post and laugh at how ridiculously naive and it is. But for now, I am loving my job! Of course, tomorrow may be different. I know I shouldn't base my contentment on the circumstances - how people treat me or how much I think I know - those are very transient and extremely changeable factors. Still, I am thankful for a good first day. Thank you Lord!