Nearly 1/12 through my residency - 3 out of 36 months! This month I am on sports medicine - a rather laid-back rotation compared to some. My days are spent in clinic, at university athletic training rooms and sports events. I've seen some pretty cool stuff and learned how to examine most joints in the body.
Today I saw a high school kid with a football injury - got hit from the side and busted his knee. The x-ray showed a fracture through one side of the growth plate in the femur and into the joint - a Salter Harris Type III fracture. I know that doesn't mean much to most of you, but it was pretty cool to see it on the x-ray, CT and MRI. Very interesting case!
Last week I saw another pretty interesting case - a girl with an osteochondritis dissecans lesion. This is where a portion of the bone near the joint, just under the cartilage, is damaged from lack of adequate blood supply. The bone gets fragmented and the overlying cartilage can break off and travel into the joint space and cause pain. In this case, the fragment was 2.5 x 1.5 cm and had traveled from inside the knee up to the lateral thigh just above the knee. I could feel the cartilage piece under the skin! Okay, so not cool for the patient, but a great learning case.
Our sports medicine faculty serve as team physicians for several of the local high school and university teams. I am required to attend at least 4 sports events this month. My first was a Wichita State University volleyball game. The WSU team (the Shockers) are in the top ten ladies volleyball teams in the country supposedly. Of course, the night I saw them they lost - oh well. The game was great, but no inuries - except wounded pride, I suspect. Last week I attended a high school football game that was much more eventful. We had a shoulder dislocation, an ankle sprain/fracture, a hypoglycemic episode (one of the flag carriers in the marching band) and a case of cervical cord neuropraxia (CCN). CCN happens when a player gets hit with his neck extended, putting pressure on the spinal cord. Usually, there is some underlying cervical stenosis - narrowing of the spinal canal in the neck, predisposing the person to compression of the cord when the neck is over-extended. This results in temporary numbness, tingling and sometimes weakness/paralysis of the upper and/or lower extremities. Most players recover in a few minutes, and I don't think there are any cases of permanent paralysis. However, in the case of a narrow cervical spinal canal, the patient is at risk of recurrent injuries, and that is not a good thing. Anyway, the kid who got hurt at the football game had already had several similar episodes, so he needs to get an MRI before he will be allowed to play again. Unfortunately, this game ended with a score of 59 to 0 (the team we represented lost dismally - they were definitely at a disadvantage compared to the well-equipped private school team they were playing).
Last week I got to inject a patient's sacroiliac joint. The patient was having a lot of pain in his hip/back just where the sacral spine meets the pelvic girdle. It's a fairly big joint, but not always that easy to palpate depending on how much soft tissue the patient has on his/her backside. I got it on the first try though, which is good since I was using a 1-1/2 inch long needle!
I love this program! I get to do so many hands-on things. Last week I got to play around with the ultrasound machine with one of my pregnant patients. I'm still learning how to navigate around - it's so much fun seeing baby's face, hands, feet, heart...! What a great job I have!
Monday, September 13, 2010
Saturday, September 4, 2010
Clinic Day
As a first-year resident, I get approximately two half-days of clinic each week where I see my own patients on an outpatient basis. The actual amount of time in clinic depends on what rotation I'm on. I just started sports medicine, so my clinic time is all day on Friday. This is the first time I've had a full day of clinic, and it was a bit challenging. Every month, the administration adds to the number of patients we are expected to see in a half day. I started with just two patients in four hours and am now expected to see four to five patients in four hours. The idea is to allow the residents to get used to the electronic medical record and to give time to check out each patient to the faculty preceptors. And believe me, I need all the time I can get!
So, Friday I had my first full day with 4-5 patients in each half dayn (ended up seeing 9 patients total). Sounds pretty easy, right? And actually, I did manage to finish on time. But I still had to finish up my notes at the end of the day, so I was at the office till about 7:30 PM. I find it hard to actually write my note while I'm with the patient. The program loans us a laptop to use in clinic, so I take it into the exam room, but I feel bad if I'm trying to listen to the patient while searching around on the computer for where I'm supposed to enter information or orders. So generally, I talk to the patient and then leave the room to enter orders for labs, imaging or medications. Those have to be done before the patient leaves, so it's important to at least finish that much. I also try to fill in my assessment and plan before the patient leaves. This is like a "to do" list. I list the problems I'm addressing that day and what I did or am going to do about them. I'm getting better at it, but it's still really slow. Sometimes my patients have to wait while I figure out how to refill their medications or how to order a specific referral. They don't seem to mind too much, but I feel bad taking up their time.
Some patients are really straightforward - pregnant or post-partum patients, for example. For these patients, there is a checklist of things to do and standard labs to order. So they get in and out pretty quickly. Pediatric visits are also fast in general. The ones that take the longest are the patients with several major chronic conditions (diabetes, high blood pressure, heart disease, COPD, etc.) on 15 to 20 different medications. Of course, I can't expect to address all their problems every time, but when a patient is new to me, I want to know how they are doing with all their conditions, especially since these problems are all interrelated and any new complaint or symptom could be linked to poor management or progression of any or all of the chronic problems. It's really hard for me to sort through all that in a short time and focus on only one or two things. I guess I have to get more efficient, and I am sure I will learn as I go. Plus, as I get to know each patient, I will have a better grasp of what their underlying issues are and what things are most important to address. Right now, most of my patients are new - to me at least. Except for the pregnant patients, there aren't many that I have seen more than once.
Yesterday I did see one of my "regular" patients. I've seen her about four times already in the two short months I've been in residency. She has chronic abdominal pain, likely caused by adhesions from several prior abdominal surgeries. She's tried a number of different medications for pain, none of them completely effective. When I first saw her she had had a seizure, and after getting her history I felt that it was likely due to the large amounts of a specific pain medication she was taking at the time. She also had elevated liver function tests, probably related to some of the medications she was taking. So we had to stop that several of her medications and essentially start over in figuring out how to manage her pain. I am not comfortable giving a patient, especially a young person like this patient, narcotics for long-term pain control. Narcotics do have their role, but they also have high abuse and dependency potential. Anyway, I was trying to find a way to keep this patient from depending on increasing levels of percocet or lortab for her pain. Chronic pain can be very debilitating, and over time can lead to depression and worsening of the pain in a vicious cycle - pain leading to depression and depression making the pain even less tolerable.
Every time I have seen this particular patient, she looks depressed, fatigued and totally demoralized by being unable to enjoy her usual life activities because of pain, even though she denies feeling depressed. Yesterday when I walked in the room I could tell she was not doing well. Her face, posture and voice all looked depressed. However, after we talked about what was going on and I made some suggestions about steps we could take to improve her pain, her face brightened and she actually left smiling! Amazing! It felt so good to develop some trust and rapport with my patient! This is the way I imagine myself as a family doctor - seeing my patients regularly and becoming familiar with their lives, their medical conditions, what things they've tried, what's worked and what hasn't worked, what stressors in their lives make their conditions worse, how their major relationships are going. Being a doctor is an awesome privilige and joy.
So, Friday I had my first full day with 4-5 patients in each half dayn (ended up seeing 9 patients total). Sounds pretty easy, right? And actually, I did manage to finish on time. But I still had to finish up my notes at the end of the day, so I was at the office till about 7:30 PM. I find it hard to actually write my note while I'm with the patient. The program loans us a laptop to use in clinic, so I take it into the exam room, but I feel bad if I'm trying to listen to the patient while searching around on the computer for where I'm supposed to enter information or orders. So generally, I talk to the patient and then leave the room to enter orders for labs, imaging or medications. Those have to be done before the patient leaves, so it's important to at least finish that much. I also try to fill in my assessment and plan before the patient leaves. This is like a "to do" list. I list the problems I'm addressing that day and what I did or am going to do about them. I'm getting better at it, but it's still really slow. Sometimes my patients have to wait while I figure out how to refill their medications or how to order a specific referral. They don't seem to mind too much, but I feel bad taking up their time.
Some patients are really straightforward - pregnant or post-partum patients, for example. For these patients, there is a checklist of things to do and standard labs to order. So they get in and out pretty quickly. Pediatric visits are also fast in general. The ones that take the longest are the patients with several major chronic conditions (diabetes, high blood pressure, heart disease, COPD, etc.) on 15 to 20 different medications. Of course, I can't expect to address all their problems every time, but when a patient is new to me, I want to know how they are doing with all their conditions, especially since these problems are all interrelated and any new complaint or symptom could be linked to poor management or progression of any or all of the chronic problems. It's really hard for me to sort through all that in a short time and focus on only one or two things. I guess I have to get more efficient, and I am sure I will learn as I go. Plus, as I get to know each patient, I will have a better grasp of what their underlying issues are and what things are most important to address. Right now, most of my patients are new - to me at least. Except for the pregnant patients, there aren't many that I have seen more than once.
Yesterday I did see one of my "regular" patients. I've seen her about four times already in the two short months I've been in residency. She has chronic abdominal pain, likely caused by adhesions from several prior abdominal surgeries. She's tried a number of different medications for pain, none of them completely effective. When I first saw her she had had a seizure, and after getting her history I felt that it was likely due to the large amounts of a specific pain medication she was taking at the time. She also had elevated liver function tests, probably related to some of the medications she was taking. So we had to stop that several of her medications and essentially start over in figuring out how to manage her pain. I am not comfortable giving a patient, especially a young person like this patient, narcotics for long-term pain control. Narcotics do have their role, but they also have high abuse and dependency potential. Anyway, I was trying to find a way to keep this patient from depending on increasing levels of percocet or lortab for her pain. Chronic pain can be very debilitating, and over time can lead to depression and worsening of the pain in a vicious cycle - pain leading to depression and depression making the pain even less tolerable.
Every time I have seen this particular patient, she looks depressed, fatigued and totally demoralized by being unable to enjoy her usual life activities because of pain, even though she denies feeling depressed. Yesterday when I walked in the room I could tell she was not doing well. Her face, posture and voice all looked depressed. However, after we talked about what was going on and I made some suggestions about steps we could take to improve her pain, her face brightened and she actually left smiling! Amazing! It felt so good to develop some trust and rapport with my patient! This is the way I imagine myself as a family doctor - seeing my patients regularly and becoming familiar with their lives, their medical conditions, what things they've tried, what's worked and what hasn't worked, what stressors in their lives make their conditions worse, how their major relationships are going. Being a doctor is an awesome privilige and joy.
Monday, August 30, 2010
Last OB Call Night
Another rotation done and another month of residency under my belt. I just finished my last duty shift on my OB rotation this morning. This past week was particularly busy. I was on the "floor" on Monday and Thursday, meaning I spent the day caring for women in labor and delivering babies. On Friday, I got to see an interesting surgery. And I was on call Tuesday night, Friday night and all day and night Sunday. Total hours for the week: 90. Those 24-hour shifts are killer. At least things stayed relatively busy - not insanely busy thankfully, but steady. I have had the most wonderful upper level residents to work with, too, and I really appreciate their wisdom, advice, and willingness to answer my questions, even at 3 AM!
So after a month of OB, here are my "numbers":
So after a month of OB, here are my "numbers":
- 16 vaginal deliveries (1 forceps, 3 vacuum)
- 6 c-sections (4 as the actual primary surgeon)
- 5 circumcisions
I'm definitely feeling much more confident in my skills and ability to manage various labor and post-partum problems. Last night I delivered two babies and all went smoothly. One of my patients only spoke Spanish. She was so thankful that her doctora spoke Spanish too and didn't stop thanking me all day!
Although OB was a busy and intense rotation in many ways, I am sad to see it end. I get another month of OB in the spring and will likely cover OB call nights throughout the year, as well as delivering my own clinic patients when they're due. But I will miss being there at one of the most significant and happy moments of life.
On to new things though - next month, Sports Medicine. It's a good month for this rotation since all the fall sports are well underway now. I should see some "good" injuries. Of course, I don't wish for anyone to get injured. But since young athletes do get injured in football, volleyball, hockey, etc., I'm glad I have the chance to be part of their care and learn how to diagnose and manage various types of joint and muscle injuries. During September, I'll also take call for the adult medicine service. I'm a little nervous about that - we get some very critically ill patients and have the responsibility of running codes for patients in cardiovascular or pulmonary arrest. I've never run a code before - we took a two-day course in advanced cardiac life support, so I technically know how to do it. Please pray that I will be able to stay calm and clear-headed!
Thanks for your prayers!
Saturday, August 21, 2010
C-Sections, Suturing and Circumcisions, Oh My!
One of the strengths of my residency program is the training in obstetrics, including regular deliveries and c-sections. I was told that I would get the chance to be the primary surgeon on c-sections from the get-go, and now I can say that is true. Thursday I got to do two c-sections - and I mean really DO them. Up to now, I have only assisted on c-sections, scrubbing in, but standing on the left side and helping to hold retractors, cut sutures, etc. So this week when it was my turn on the "floor" I was determined to overcome my fear and dive in. I watched the step-by-step video on c-section techniques, and I asked my upper level residents to walk me through the process. I wasn't sure the OB attendings would let me take the leading role, but I've learned that showing confidence and being assertive goes a long way.
When the time came I was SO nervous. I was afraid I would completely screw things up. But I have determined not to be ruled by fear. And in learning procedures, the best and only way to learn is to do - hands-on, down and dirty, physical learning. On my first case of the day, I told the OB attending that I would really love to have the chance to do the c-section myself with her guidance. Her response was, "we'll see." But once we were scrubbed in, she pointed to the patient's right side and nodded. The right side is where the main surgeon stands (not sure why, but I suppose it assumes the surgeon is right handed and it is easier to do most of the procedure from that side). Anyway, there I was. The scrub nurse handed me the scalpel and after a moment of panic and a strong desire to flee (oh my gosh, what the heck am I doing here?!!), I made the incision and off we went. Everything went smoothly. The attending guided me through each step, the baby came out just fine, we got mom sewn up, and all lived happily ever after!
Later that day I had the chance to do another c-section. It meant staying 3 hours late on my shift. But I knew the attending was really nice, liked to teach and was very patient with residents. I figured a second c-section the same day would reinforce my learning and solidify it, as well as boost my confidence level. It was great. The second doctor did things a little differently, but he was so good about explaining each step and encouraging me. What a wonderful and amazing experience! I have now actually cut into someone's uterus and extracted a baby! Wow!
I still have a long way to go before I'm proficient in doing c-sections. Suturing is one of the toughest skills to learn. Holding the needle right, manipulating the needle driver and instruments, tying knots - all of these require manual dexterity and practice. I will eventually be able to do this in my sleep, but right now it's awkward and I am slow at it. That's why it's so good to get the chance to practice whenever possible.
Friday I also got to do another circumcision. That makes #5. After I've done 10 with supervision, I will be able to do them by myself without an attending present. That's a little scary, but no, I will not let fear get the best of me. Circumcisions are actually pretty simple, short, and fun to do. And the babies are so cute! Don't worry, I'm not being sadistic or cruel. The babies get local anesthetic and sugar water and most of them don't even cry that much. Mostly I think they cry because they're just mad at being handled.
So my job is really cool. I can't believe I get to do all this stuff! Plus, as I get more confident, I have much better interaction with my patients. A little more experience and wisdom helps me to put them at ease, answer their questions and connect with them personally. Although they have their own OB doctor, I'm the one they see most throughout their labor, so I feel like their doctor for a while, which is nice.
Well, all for now. Have a great week.
When the time came I was SO nervous. I was afraid I would completely screw things up. But I have determined not to be ruled by fear. And in learning procedures, the best and only way to learn is to do - hands-on, down and dirty, physical learning. On my first case of the day, I told the OB attending that I would really love to have the chance to do the c-section myself with her guidance. Her response was, "we'll see." But once we were scrubbed in, she pointed to the patient's right side and nodded. The right side is where the main surgeon stands (not sure why, but I suppose it assumes the surgeon is right handed and it is easier to do most of the procedure from that side). Anyway, there I was. The scrub nurse handed me the scalpel and after a moment of panic and a strong desire to flee (oh my gosh, what the heck am I doing here?!!), I made the incision and off we went. Everything went smoothly. The attending guided me through each step, the baby came out just fine, we got mom sewn up, and all lived happily ever after!
Later that day I had the chance to do another c-section. It meant staying 3 hours late on my shift. But I knew the attending was really nice, liked to teach and was very patient with residents. I figured a second c-section the same day would reinforce my learning and solidify it, as well as boost my confidence level. It was great. The second doctor did things a little differently, but he was so good about explaining each step and encouraging me. What a wonderful and amazing experience! I have now actually cut into someone's uterus and extracted a baby! Wow!
I still have a long way to go before I'm proficient in doing c-sections. Suturing is one of the toughest skills to learn. Holding the needle right, manipulating the needle driver and instruments, tying knots - all of these require manual dexterity and practice. I will eventually be able to do this in my sleep, but right now it's awkward and I am slow at it. That's why it's so good to get the chance to practice whenever possible.
Friday I also got to do another circumcision. That makes #5. After I've done 10 with supervision, I will be able to do them by myself without an attending present. That's a little scary, but no, I will not let fear get the best of me. Circumcisions are actually pretty simple, short, and fun to do. And the babies are so cute! Don't worry, I'm not being sadistic or cruel. The babies get local anesthetic and sugar water and most of them don't even cry that much. Mostly I think they cry because they're just mad at being handled.
So my job is really cool. I can't believe I get to do all this stuff! Plus, as I get more confident, I have much better interaction with my patients. A little more experience and wisdom helps me to put them at ease, answer their questions and connect with them personally. Although they have their own OB doctor, I'm the one they see most throughout their labor, so I feel like their doctor for a while, which is nice.
Well, all for now. Have a great week.
Monday, August 16, 2010
A Night on OB Call
After my third OB call, I'm beginning to get the rhythm of things. Here's a glimpse of my most recent night call:
Arrive 5 PM. Get check-out from resident going off duty. 2 patients laboring. Two patients in the PSU (perinatal support unit - where all pregnant ladies over 20 weeks come for urgent care and labor check-in).
5:15. Check on laboring patients. Call OB attendings to update.
5:30. Go to PSU. Do history and exam on new patient. Complains of contractions that are irregular but sharp at 40 weeks, first pregnancy. Check cervix - still closed. Plan to recheck in an hour to see if any change and still contracting. Patient to walk around for a while.
5:45. Call from post-partum ward - post-partum patient with high blood pressure. Go see patient. Patient asymptomatic. Discuss with upper level resident. Write orders for blood pressure medications.
5:55. Call from PSU to check second patient with nausea/vomiting/abdominal pain who has just finished getting IV fluids and nausea medications. Do I want to come see her? Sure. She's feeling a little better but not entirely.
6:00. Call from labor room. Patient feels like pushing. Can I come check her again? Check patient. She is nearly completely dilated and feels pressure/pushy with pain in back. Baby doing fine. Write note. Ask nurse to call anesthesia to give more medicine through epidural. Call attending and update her. Attending says to let her continue laboring for a while before trying to push.
6:10. Call from post-partum floor. One of the newborns had a high bilirubin level. Okay, thanks. Not an emergency, but I'll check on him in a bit.
6:15. Call from PSU. What do I want to do with the patient with nausea? Talk to upper level resident and discuss what to tell attending. Call attending and recommend discharge home with nausea meds. Attending says patient has tried various nausea meds to no effect but she can go home and see him in the office tomorrow. Discharge patient and explain that we can't do much for her. She should take her nausea meds prior to eating and try to keep fluids down as much as possible.
7:20. Call from floor. Another high bilirubin. Thanks. I'll follow up. Talk to upper level resident about high bilirubins. Look up information on when to start bilirubin lights. Look up patient's risk factors - not preterm, no infection, no mismatch between mother and fetal blood types. Baby not feeding that well yet but pooping and peeing okay, so probably just physiological. Write orders to recheck bilirubin in AM.
7:30. Check on pushing patient. Not making a lot of progress, but it's her first baby so no surprise. Encourage her to keep pushing.
7:45. Back to induction room. Interpreter available and Cervidil (prostaglandin agent) in room. Explain to patient, through interpreter, how the prostaglandin is used. She will have to stay lying down in bed for 2 hours after placement. Place cervidil near cervix. Write note in chart. Text page attending to let her know induction started.
9:45. Enter previous delivery in my procedure log. Check email.
10:00. Upper level done with c-section. Check in regarding preterm patient in PSU. Review her lab results (equivocal). Recheck cervical exam - no change. No contractions on monitor. Call attending to recommend discharge and treatment of infection. Explain results and treatment plan to patient. Encourage her to drink lots of fluids and take medications. Discharge patient.
10:30. Call from PSU. First patient seen earlier in evening is back with stronger contractions, this time 3 to 5 minutes apart. Redo history and exam. Check cervix - more dilated than previously. Patient admitted to labor and delivery. Call attending and let him know.
10:50. Call from labor and delivery room on patient I delivered a few hours ago. She passed out in the bathroom. Go see patient. Her vital signs are stable. She's not bleeding. I order a bolus of IV fluids. Discuss with upper level resident. Call attending to notify her of the event. Patient doing better.
11:05. Another patient in PSU in labor. Do history and exam. Review prenatal records. Patient is definitely contracting. Cervix dilated to 4 cm. Plan to recheck in one hour.
11:30. Check on laboring patient. In the process of getting epidural.
12:00. Check on PSU patient. Dilated to 5 cm. Admit to labor and delivery. Call attending to get orders.
12:15. Patient now has epidural and is comfortable. Recheck and still progressing. Call attending to notify. Write note.
12:30. Back to induction patient. Place second prostaglandin tablet for cervical "ripening." Write note.
12:45. Check on fainting patient. Doing fine now.
For the rest of the night, I alternate on checking the laboring patients (room to room), with PSU patients to be seen and examined in between. At some point during the night, I rupture membranes (break the water) of both patients. That speeds things up. One patient begins to push at 5 AM and delivers around 6. She has some extensive lacerations that take a while to repair. The upper level has to cover PSU calls and check on my induction patient during this time. My other patient's nurse calls several times with updates (patient wants to push, please come examine...). The upper level takes care of all of this and updates the other attending. When I'm through with the first patient (about 6:30), I head to the next room, thinking she will already have delivered. But she is just barely complete and beginning to try pushing. Turns out she is also occiput posterior, which takes a lot longer. She pushes for 3 hours and finally delivers with vacuum assistance. I stay till 10:00 AM for her delivery and repairs. I've now been up for 28 hours straight. But it was a great night!
Arrive 5 PM. Get check-out from resident going off duty. 2 patients laboring. Two patients in the PSU (perinatal support unit - where all pregnant ladies over 20 weeks come for urgent care and labor check-in).
5:15. Check on laboring patients. Call OB attendings to update.
5:30. Go to PSU. Do history and exam on new patient. Complains of contractions that are irregular but sharp at 40 weeks, first pregnancy. Check cervix - still closed. Plan to recheck in an hour to see if any change and still contracting. Patient to walk around for a while.
5:45. Call from post-partum ward - post-partum patient with high blood pressure. Go see patient. Patient asymptomatic. Discuss with upper level resident. Write orders for blood pressure medications.
5:55. Call from PSU to check second patient with nausea/vomiting/abdominal pain who has just finished getting IV fluids and nausea medications. Do I want to come see her? Sure. She's feeling a little better but not entirely.
6:00. Call from labor room. Patient feels like pushing. Can I come check her again? Check patient. She is nearly completely dilated and feels pressure/pushy with pain in back. Baby doing fine. Write note. Ask nurse to call anesthesia to give more medicine through epidural. Call attending and update her. Attending says to let her continue laboring for a while before trying to push.
6:10. Call from post-partum floor. One of the newborns had a high bilirubin level. Okay, thanks. Not an emergency, but I'll check on him in a bit.
6:15. Call from PSU. What do I want to do with the patient with nausea? Talk to upper level resident and discuss what to tell attending. Call attending and recommend discharge home with nausea meds. Attending says patient has tried various nausea meds to no effect but she can go home and see him in the office tomorrow. Discharge patient and explain that we can't do much for her. She should take her nausea meds prior to eating and try to keep fluids down as much as possible.
6:30. Recheck PSU patient. Still contracting but not as much. Cervix unchanged. Call attending and discuss options. He says to send her home. It could be a while before she's in active labor and she will be more comfortable at home for now. Explain this to patient and discharge her.
6:45. Call from labor and delivery room on a lady who has come in for induction of labor. They start the night before with a prostaglandin that helps to "ripen" the cervix - make it start to dilate and soften. Then we start pitocin (the hormone that stimulates uterine contractions) in the morning. I've never done an induction before. Discuss orders and procedure with upper level. Nurse states the patient speaks Vietnamese and they are waiting on an interpreter but husband is present and speaks some English. Do history and physical exam, review prenatal records. Do quick bedside ultrasound to verify baby is head down. Call attending and verify what she would like to have done. Write orders and give to nurse to get prostaglandins for the first step of induction.
7:05. Check on laboring patient. Now completely dilated. Patient feels like pushing -uncomfortable. Call attending and update. Attending gives okay to have patient start pushing. She's on her way.7:20. Call from floor. Another high bilirubin. Thanks. I'll follow up. Talk to upper level resident about high bilirubins. Look up information on when to start bilirubin lights. Look up patient's risk factors - not preterm, no infection, no mismatch between mother and fetal blood types. Baby not feeding that well yet but pooping and peeing okay, so probably just physiological. Write orders to recheck bilirubin in AM.
7:30. Check on pushing patient. Not making a lot of progress, but it's her first baby so no surprise. Encourage her to keep pushing.
7:45. Back to induction room. Interpreter available and Cervidil (prostaglandin agent) in room. Explain to patient, through interpreter, how the prostaglandin is used. She will have to stay lying down in bed for 2 hours after placement. Place cervidil near cervix. Write note in chart. Text page attending to let her know induction started.
8:00. Back to pushing patient. Attending now present. I stay in the room to help with delivery. Baby is occiput posterior. This means he is facing up instead of down (or front instead of back), which is harder for mom to deliver. The head has to be molded more into a cone to get baby through the birth canal, and this takes time and effort pushing. After another 30 minutes (seems like longer), the attending decides to assist with vacuum delivery (applies suction to baby's head to help mom get baby out). Baby out and okay. Mom has some pretty ugly looking lacerations that take some time to sew up.
8:55. Check in with upper level resident. The other lady who was in labor at the start of the shift is going for c-section. This means the upper level will be out of commission for an hour doing the c-section.
9:00. Time for a quick dinner and bathroom break - while I can. Check in with nurse on post-partum floor to see if that patient's blood pressure is back to normal.
9:10. Call from PSU. Another patient presenting with "contractions" and dizziness at 35 weeks. Likely dehydration (it was 110 degrees today!). Do history and exam. Check monitor. Fetal heart tones are fine. No real contractions showing on monitor. Review mother's records in computer - frequent visitor to ER. Suspect desire for pain medications or mom just tired of being pregnant. Order urinalysis to check for infection (common cause of preterm contractions) and dehydration. Do pelvic exam with cultures for other types of infections that can also cause contractions. Also check for cervical dilation - no significant dilation noted. Plan to recheck in one hour and follow up labs.
9:30. Visit to post-partum floor to check on hypertensive patient. Blood pressure in normal range now, patient still asymptomatic. Write note on chart and orders to increase dose of blood pressure meds for next day.
9:45. Enter previous delivery in my procedure log. Check email.
10:00. Upper level done with c-section. Check in regarding preterm patient in PSU. Review her lab results (equivocal). Recheck cervical exam - no change. No contractions on monitor. Call attending to recommend discharge and treatment of infection. Explain results and treatment plan to patient. Encourage her to drink lots of fluids and take medications. Discharge patient.
10:30. Call from PSU. First patient seen earlier in evening is back with stronger contractions, this time 3 to 5 minutes apart. Redo history and exam. Check cervix - more dilated than previously. Patient admitted to labor and delivery. Call attending and let him know.
10:50. Call from labor and delivery room on patient I delivered a few hours ago. She passed out in the bathroom. Go see patient. Her vital signs are stable. She's not bleeding. I order a bolus of IV fluids. Discuss with upper level resident. Call attending to notify her of the event. Patient doing better.
11:05. Another patient in PSU in labor. Do history and exam. Review prenatal records. Patient is definitely contracting. Cervix dilated to 4 cm. Plan to recheck in one hour.
11:30. Check on laboring patient. In the process of getting epidural.
12:00. Check on PSU patient. Dilated to 5 cm. Admit to labor and delivery. Call attending to get orders.
12:15. Patient now has epidural and is comfortable. Recheck and still progressing. Call attending to notify. Write note.
12:30. Back to induction patient. Place second prostaglandin tablet for cervical "ripening." Write note.
12:45. Check on fainting patient. Doing fine now.
For the rest of the night, I alternate on checking the laboring patients (room to room), with PSU patients to be seen and examined in between. At some point during the night, I rupture membranes (break the water) of both patients. That speeds things up. One patient begins to push at 5 AM and delivers around 6. She has some extensive lacerations that take a while to repair. The upper level has to cover PSU calls and check on my induction patient during this time. My other patient's nurse calls several times with updates (patient wants to push, please come examine...). The upper level takes care of all of this and updates the other attending. When I'm through with the first patient (about 6:30), I head to the next room, thinking she will already have delivered. But she is just barely complete and beginning to try pushing. Turns out she is also occiput posterior, which takes a lot longer. She pushes for 3 hours and finally delivers with vacuum assistance. I stay till 10:00 AM for her delivery and repairs. I've now been up for 28 hours straight. But it was a great night!
Monday, August 9, 2010
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!
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!
Wednesday, August 4, 2010
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.
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.
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