Weeks 2 and 3, Halfway in/out of the forest

Week 2: High Risk OB / Maternal-Fetal Medicine

So I was told by slim shady (one my goodest friends in medical school) that I would rather enjoy High Risk OB as it involves treating moms with babies that are risk for things like macrosomia, Trisomies, etc. As such, I made sure I'd get a full week on this service.

She was totally on spot. Maternal-Fetal Medicine totally works for the pediatrician in me. Basically, using ultrasounds and other diagnostics, the high risk doc evaluates moms to be and counsels them on his findings. This doc that I worked with was awesome. He'd have the ultrasound techs do the ultrasounds, then he'd review the findings in his office. He'd correlate with any kind of other tests/screens that he might have. Then he'd go and talk to the patient. This is where I would tag along.

One of the more interesting cases was a finding of ventriculomegaly. Basically, the baby's ventricles were a touch bigger than expected. We ran through all the possibilities with mom and dad. While certainly not exhaustive, we split it into infectious, congenital (genetic), structural. We ruled out congenital as it is unlikely that a trisomy or genetic illness would have ventriculomegaly as the sole finding. You'd expect skeletal abnormalities or other defects. The US Techs were super helpful in explaining what they would look for to rule out Down's syndrome, etc. This sums up some of the findings that they look for:

I suppose this takes the whole nastiness of OB (GYN Exams, Diseases, Etc. ) and introduces a more cerebral aspect of it. Here, you use technology to help diagnose a developing baby. This particular day at the office as full of "your baby is normal, everything is okay."

Other than that, I spent my afternoons helping out on the floor. We also had two days at the County Health Department. It's really a student/resident run clinic and we get to do a good bit. Let me highlight my classic of classic moments at the Health Department:

At the conference table where we sign out to the residents, basically suggesting our treatment plan, etc.

Resident : So did you do a wet prep

Me: Yeah

Resident: and the results?

Me: Oh, the nurse hasn't told me them yet

Resident: What?

Me: Yeah, she took it.. isn't she gonna review it?

Resident: You're supposed to look at the slide

Me:......

Me:... yeah...

Resident: Go check if she still has it, if you did the prep, she ought not to have thrown it away

Me: Okay

Me (to nurse) : Hey, do you still have the slide I did

Nurse: uhhh, you didn't seem to want it.. so I threw it away

-FAIL-

Week 3: OB FLOOR

Floor is basically the heart of OB. Everything happens on one half the third floor. You basically enter via the card access door and your day begins and ends behind this door. There are four areas of activity :

3 South/ 3 Main - Postpartum peepz. This is where the moms go after they deliver. These are the patients that we round on at 6am. Most of the time.. it's a rapid fire question asking consisting of breast/bottle, circumcision?, nauseavomitingdiarrhea (I do sometimes say this as one word), birth control, pain, walking any?, tolerating food? any questions

3N - Other stable OB patients

L and D - laboring patients, patients that need close nursing. These ones are rearing up to pop em out. This is also where the OB OR Rooms are. C-sections, D and Cs and that kind of stuff goes down here. All the L and D rooms are built for delivery. There's a bed for baby, scrub gear to suit up, and the bottom of the bed comes out for maximum baby delivering optimization.

OB Assessment - As Mikey T. would say. OB Assessment is more like OB Ass. This is where preggos (I know this is a horrible word to use for mothers to be but it sounds funny and adds some edginess to my blog) who have any sort of complaint or are past a certain week time period go. So if they have a cough/fever/ SOB.. they get turfed here. As such, we have to evaluate them which means : H and P, Ultrasound (more than likely), Cervical Exam , Labs of some variety, waiting until we can safely send them home.

Call Night #2 - So this was my most tiring and exciting call night of 3rd year. I think I stayed up all night once on surgery but I can't remember.

So call began around 5p, now I'm the floor student so really call is no different than being on the floor so I basically signed up to be on the floor from 6a Monday to whenever they let me go after 8a Tuesday. Really, the fun didn't start till 730p. I had gotten my dinner of subway and was praying for a super quiet night but then I went upstairs and Mikey was there. Now Mikey is a bastardization of my resident's real name .. but we'll use it for blog anonymity purposes. Mikey tells me there's people in OB Assessment. We got stuck in OB assessment and floor stuff from 730p-1230a . We admitted a lady that was gonna deliver soon. At this point the following transpired over two hours

1230a

Mikey: So, that's pretty much it. There's labor notes that need to be written q2h on this laboring lady

Me:...

Mikey: But I'll take care of em

Me: [thank God]

Mikey: What's the number to your call room

Me: I'll text you when I find out, when do you think she'll deliver?

Mikey: I'd guess 5a/6a

Me: That's good, can get a fair number of hours (a fair number of hours on call = 4-5 hrs sleep, anything above that means someone was extra nice to you)

Mikey: call you if anything happens

Me: see ya [4-5 hrs sleep.. awesome.. ]

zzzzzzz

zzzzzzz

zzzzzzz

2: something am

[phone rings in call room, I wake up super confused and thrown off.. I reach for phone]

Me: Hello?

Mikey: She's laboring and ready

Me:.... okay

So then proceeds the craziest 1.5 hrs of my life. We get upstairs, Mikey confirms that I want to deliver this one. She's multigravida so it should go all right. I put my booties on, put on a face shield, ask for size 8 triflex, and it's go time. They didn't get the epidural in so she's in pain. She starts to contract. I have my hands in position, V to protect the bajingo with my right hand and other hand ready to protect baby's head. Baby starts to crown. Baby's head is delivered, reposition hands , right hand on top, left hand on bottom. Time to deliver the anterior shoulder... AND

holy crap, the baby has stalled... stuck.. beneath the pubic symphasis

residents take over

mcrobert's position is assumed : mom's legs are pushed back

pubic pressure is applied

baby is turning blueish

everyone is anxious at this point

in what seemed like an enternity, a decision is made to do an episiotomy, basically cutting the bajingo (at first I thought this was to give the baby some room, but later it was explained that this is really to give the person delivering more hand space to manipulate the baby so they can deliver; if you think about it, the pelvic anatomy dictates how the delivery goes, only anatomical manipulation will change the outcome, so a surgical cut doesn't do that)

baby is delivered

baby cries

I get a little teary eyed beneath my face mask , realizing that cry means that baby is alive

Mikey T: okay, let's get the cord blood and deliver the placenta

Me:....

I then proceed to get the cord blood and deliver the placenta which is really a bloody mess

----and finish --- , 1st deliver OVER

around 400a, after dictating, etc

Nurse: so did you see that roach

Me: what??

Nurse: it was on one of your gloves.. .. actually your glove, you started the delivery right

Me: yeah

Nurse : there was this roach.. that came from somewhere

Me: gross

Mikey T: yeah.. maybe I did see a roach

Me: [rolls eyes]

So that remained the running joke/urban legend the rest of the week .. that in the midst of this chaos.. a roach came from "somewhere" and ran across my glove and disappeared like a fart in the wind. So after that , Mikey T tells me to peace out and get some rest. I couldn't sleep of course and I probably netted around 2-2.5 hrs of sleep that night.

The baby turned out to have Erb-Duchenne's palsy (injury to C5, C6 nerve roots) from the shoulder dystocia. We definitely took the baby to the nursery to check her moro reflex and she had the classic waiter's tip. Per my OB attending, 90% resolve on their own with rehab.

So that was really the highlight to my week. Otherwise I'd been able to do a good bit besides take Histories and do physicals. I assisted on

I've done abdominal ultrasounds, vaginal ultrasounds, removed a cerclage, congratulated a bunch of new moms with my "your baby is beautiful". Thank God, I haven't seen a non-beautiful baby yet.

Lastly, here's some tidbits/definitions:

Cave of nastiness - One of my fellow students/friends made an reference to the cave of wonders in Aladdin. I told her that we're dealing with the cave of nastiness.

Wanting to palpate the fundus - I feel a strange desire to check every female's fundus after being on the floor.... Weird, I know.

Blending into the background, not getting introduced - Two things are tantamount to being a medical school. One is blending into the background and not being noticed. The other is walking in to a room with an attending and not getting introduced resulting in a very awkward encounter where you realize that they realize.. that they have no idea why you're there and who you are.

Over the top, getting in nice with people - Being nice to the point of demeaning yourself works.. and it works well. As long as you believe in yourself.. you can pull this off with good results. Nurses love my comments like "I'm no expert like them.. or these wonderful nurses... "

Bovie - I finally got to use the bovie electrocautery tool. It was the greatest surgical moment of my life when my resident hands me it and says.. cauterize that over there... AWESOMENESS It's almost like a miniature light saber for surgeons...

First Week of OB/GYN

So I've got less than 5 weeks left of third year and my last rotation OB/GYN.

I've been told this is the hardest rotation: long hours, lots of work, busy call, etc, etc.

I'll say this much to begin: It's not the worst thing in the world, haha.

OB is really unique in every regards. They deal with women's health, women's anatomy. Nobody else really deals with this aspect of health care. I mean if someone has a baby or they have issues with their baby making anatomy, it's OB/GYN's turf. Let's run through my days on Gynecology Surgery:

Preround at 6am - This puts me at waking up around 420a so I can have oatmeal and such and get to the hospital. I hate waking up early.

Presentations at 7am - Present to residents in conference room. We present on postpartum patients only so there's usually only 3-4 patients. This takes 30minutes or so , usually time to get a drink/coffee/quick breakfast before attending rounds

Attending sit down rounds around 8am - Attendings show up and we sit in a particular formation. Attendings sit in the comfy chairs at the table. The senior residents sit closest to the table. Other residents flank around and the students sit in a corner on the less comfy chairs , huddled together for support. Residents are the only ones that really talk during these rounds and mostly the senior resident.

OB is all about specifics. Presentations consist of mostly Gs, Ps, postive or negative, immune, bottle or breast fed, boy/girl , birth control, circs. I find it really strange not to talk about age or race which is vital in (internal) medicine.

Once this is done, we all flank out to whatever service you're on. There's High Risk OB, regular OB, Gynecology (Surgery), Reproductive Endocrinology, Oncology and Urogynecology. I was on Gynecology so really I just find surgeries I'd like to observe/take part in. So during this relatively short week, I saw two surgeries : I saw a cystectomy/ex-lap that went for 5.5 hours. We had to call in a general surgeon and resident because of extensive adhesions and bowel issues. They basically ran the show, mobilizing bowel to get to the cyst. The bowel has to be resected because of adhesions and whatnot. Ordinarily, such a long procedure would bore the bejeezus out of me but I was able to help as the unofficial circulating nurse, grabbing supplies and making calls while the real circulating nurse was doing stuff. Oh, I also had some precious duties which I'll enumerate:

Alcohol washer - The general surgeon perforated one of his gloves so I had to grab some alcohol and pour it over his hand over the dirty bucket without breaking sterile field.. as I was not scrubbed

Beeper retriever - The GYN surgeon needed me to retrieve her beeper, underneath her gown without breaking her scrub. That was precious.

Glass pusher upper - The surgery resident who I knew pretty well having worked with him on general surgery would occasionally and nicely ask for me to push up his glasses on his face. On one occasion he nodded to me to say "sup" as the surgery went on forever and I mistakenly took that for a cue to nudge his glasses up, that was a little awkward.

Gown untier - When scrubbing out, it's customary to help the attendings/residents get out of their gowns

Beeper caller backer - Occasionally when others are busy, I have to call back pages and say Did you page so and so? And then find out what they wanted and relay that to the attending/resident.

1 hour left and the general surgeon and resident dipped out, the GYN surgeon says: well Dr. Abdullah, go ahead and scrub in, I'm going to need some help. Now, I like scrubbing. Not the idea of suturing or doing surgical things, the actual hand washing. I don't know why this is but something is fun about washing your hands in this giant sink , not being allowed to touch anything. It's almost like hot lava except the lava is everything else besides the air above your waist.

After that, you have to hold your hands above your waist and use your glutes to open doors. There are two main ways to hold your hands above your waist.

There's the t-rex and the methodical evil genius finger positions.

T-rex hands: Hold hands above waist but not together avoiding touching ANYTHING

Evil genius/pensive pose: My variation is slightly different, I don't hold my arms so close to my body and I don't collapse my fingers inward , leaving them up like a tepee but I do have the evil genius look especially behind a mask and sexy scrub cap.

Anyway, I assisted with closure. I suctioned using the Yonker and kept tension on the sutures to close the midline incision. Then I totally placed some kick ass staples.

The next surgery I observed was the next day; it was a robotic hysterectomy. This was kind of neat because there's several monitors that show what's going on. Basically, one doc sits at a terminal and operates the robotic arms and the other assists by directly placing sutures into the trochars or manipulating certain things. Two things stood out about this particular surgery.

A. The robotic hands that are the DaVinci robot. It's like they made a miniature version of Doc Oc's arms and let them run the surgery:

and B. The pulling out of the uterus via the interoitus is like watching that dude rip out the heart in Indiana Jones. Especially when the dialogue went like this:

Second doctor: So I guess we'll have to cut the uterus in half to pull it out.

First doctor: No, I'll just pull it out

[everyone takes a few steps back]

First doctor : grabs the uterine manipulator and tugs , tugs some more and

WHOOSH .. it's out

I also learned that the porn industry borrowed the pelvic muscle trainer from work done by one of our attendings. Apparently, Kegel exercises are not only good for stress incontinence but for sexual performance as well.

Lastly, my first night of call was amazing. Not much happened at night, there was a fourth year student rotating with us and this particular resident doesn't page students. Too bad my other 5 are with the hardest working intern, ever.

5 weeks and counting.