Not So Infrequent

I was just reading through the day's "Odd News" and found an article that raised my interest, possibly because it relates directly to my current situation. The story talks about a woman who was 36 weeks pregnant and started having labor pains. She went to the hospital, was told that it was false labor, and went home. Waiting for the false labor to pass, she rested at home until she just couldn't bear the false labor pains anymore. So she tried to get to the hospital again. Except she didn't make it very far. Only to her driveway, in fact.

The thing that struck me about this article is that it isn't exactly a rare event for a woman to go to the hospital and be told it's false labor and get sent home only deliver shortly thereafter. I remember a few such cases in the 3 weeks of inpatient OB that I did last year. That's 1 a week. Late in the residency calendar year. At the end of the residency calendar year, in fact. One woman came in and the resident checked her. He told her that she was only 2 cm dilated and her contractions weren't regular enough. So after protesting that she had a history of short labor she left. And then nearly had her baby at IHOP over pancakes. She made it back to the hospital and was crowning within 5 minutes of getting to triage.

I'm glad I'm not going into OB. It's becoming more and more of a regimented profession in a process that is highly variable. But that's a whole different story for another post....

Hugest Baby Ever

So I'm in the middle of studying for my Step 2 right now. Not nearly as hugely important in deciding the course of the rest of your life quite like Step 1, but it's still pretty important. So, I wasn't intending on blogging until after the test, which begins in 35 hours from now, but when I saw this I couldn't resist. A 17 pound 1 ounce baby. That's a really big baby.

Surprsingly, this little bundle of joy was born via C-section. I've seen my fair share of those and it's usually a pretty tight fit for a regular size baby to come out. I would have to guess they didn't go with a fanninsteil on this one.

Anyway, on further reading of the article lots of read flags went up. That's how they train us, you know. This was baby #12. Cheaper by the dozen, right? Apparently none of the other 11 babies came in under 10 pounds. And mom couldn't afford any fancy diet, so she just went with potatos (carbs), noodles (carbs), and tomatos (not-carbs). I thought pregnant women were supposed to get unsatiable odd cravings. The point is that this sounds like classic gestational diabetes. Insulin is an anabolic substance. Anabolic kinda like anabolic steroids, but not quite. That means it helps build tissue up. Mom's with diabetes are resistant to insulin's effects, which is why they start making too much. Babies, however, are not insulin resistant. So babies become overtly huge if gestational diabetes goes untreated. There can be other complications, but this is classic "macrosomia" (litterally translates to "ginormous body" in latin) that really is a red flag to look for Friday on my test. So this really was studying.

Whiff Test

So today was my last glorious day of OB/Gyn, and more importantly, of my 3rd year. And I had an extra special way of rounding out my 3rd year experience.

Today I got the opportunity of going to the county jail OB clinic to treat all the incarcerated women. They should really change the name of the clinic though. I suggest they rename it, BV clinic, because everyone who came in (with one exception) had really florid BV.

So, for all my non-medical fans, BV stands for bacterial vaginosis. It is essentially an infection caused by overgrowth of certain types of normal vaginal flora, much like a yeast infection except with bacteria and not yeast. What is extra special about BV is that the discharge has these cells in it (see picture) called "Clue Cells". I have yet to figure out why they call them clue cells. Mostly because the first clue you get that someone has BV is not the clue cell, but by the very distinct odor that wafts your way as you get up close and personal with an infected person's nether region. Who needs yet another clue as to what's going on? There's actually a test called the "whiff test" where one adds potassium hydroxide to the already foul smelling substance to see if you can make your sample smell even worse than it already does. While clue cells are rather inappropriately named, the whiff test (much like dumping syndrome) is quite an accurate description of the test.

BV is also associated with a discharge. Usually its white and somewhat thick. Sometimes its a little different. My favorite was asking the patients about it. "It's like boogers coming out my hoochie," was my personal favorite description. At least it painted a vivid image.

Strange Day

Today was perhaps one of the strangest day I've ever had on this rotation. It all started nice and early at 5 AM. I got to the hospital and rounded until 6 without ever seeing a resident. "That's weird," I thought.

At 630 at board checkout finally the residents showed up, a whole new set just because it was Thursday. Apparently the regularly scheduled residents all have clinic on Thursday and so the clinic residents come and take their place. We ran around the whole day with crosscover residents and a cross cover attending, on what was actually a pretty slow day, but somehow managed to not actually round on the patients at all. But back to my morning...

Then I went upstairs to see a baby born earlier. They told me I needed to see it for my education. So I get up there and the nurse says, "Oh, you want to see his malformations. Look here." And she takes off the diaper. I've seen ambigious genitalia before, but this was not ambiguous..definitely a boy. After trying to figure out what his problem was called, I found one single case report at pub med here. If the link is too medical mumbo jumbo for you, what it says is that this particular problem is where the scrotum is actually ABOVE the shaft. I didn't know what to think, and then the nurse says to look at his bottom. At which point I noticed his anus was way too high. It was posterior, just not low enough. The attending said he would never sit down to poo. Poor kid.

And then I met the mail-order bride. She was pregnant and not really having a problem but her husband was a complete nervous wreck. With way too much coffee. He kept checking the empty mug he brought in with himself in case magical coffee appeared in it again. And he never let her answer for herself. And asked a million and one irrelevant questions. "Why are you asking about that? Is something wrong? Is it bad that she is hurting like that? What should I do? Should she be taking her medicine more often? Is the baby a boy or girl? Is the cord wrapped around the neck? Is the baby too low? Where's her uterus?" 1) I can only answer 1 question at a time 2) I don't know the sex of a baby by asking about contraction pain 3) I don't have xray vision 4) I really wanted to find this guy some xanax just to shut him up so we could talk to his wife who actually knew what symptoms she was having.

At least it was interesting today.

Omega Beta Gamma Pt. 2

I guess now I can give a more fair assessment of OB/Gyn rotation now that I've done almost a week of OB. OB isn't bad in and of itself. It's actually pretty easy considering most of the patients are generally pretty healthy.

My general day consists of doing morning rounds on post partum patients, going to checkout (worthless for students to be there), and then trying to stay on top of all the new patients coming in through triage and those who are delivering for the next 12 hours until evening board checkout (equally worthless for students to be there). After that I can go home. Lather, Rinse, Repeat x 10. It actually seems a lot like working in an ER with a very focused patient population.

There also is a lot of procedures to do. On gynecology, it was all procedures. On OB, it's less so, but still everyday there is stuff in the OR, deliveries, tubal ligations, etc. It keeps you on your toes and is active medicine. I hate passive management. For example, today was my first delivery. Probably because everyone in Houston delivered today and so we were a little shorthanded. I can't take all the credit though. The resident delivered the head (i.e. yelled "PUSH PUSH PUSH" at the patient until the head was out) and then had me jump in to pull out the rest. I probably would've delivered the head too, but the baby was DOP (direct occiput posterior). That means the baby came out looking up. It sounds good, but it's not because of the diameters involved. So this kid came out looking like a conehead (like most vaginal deliveries), but the cone was on his forehead.

Then, of course, I did the obligate medical student delivery of the placenta. They finally actually taught me what exactly I was doing, so now it makes more sense why you push on mom's belly while you pull it out.

Anyway, so that part hasn't been bad. What's been bad is that a lot of the female residents in this program are mean. They just don't like medical students. I thought that one I had on gyn was bad, but almost all of them on OB this month are that way.

For example, today when I got there at 0500 and began rounding on the patients I worked backwards from the direction the resident usually goes. Once I got to the resident, she got upset and told me "Work the other direction so we aren't just fighting over charts." She just assumed I had ignored what I'd been told the other day and had come late to rounds. I guess she figured out she had wrongfully yelled at me once she got to the other pods and saw notes on all the other patients.

Then after board checkout the residents (all girls on this OB team) just walked out of the room without saying a word to us. So we just went and tried to find stuff to do. I thought we were doing OK, but apparently one of the residents thought we weren't doing the right stuff and yelled at us. Usually the first step in getting people to do what you want is to ask them, not just assume they know and yell after it doesn't happen.

Then we have a bunch of stuff happen all at once with admitted patients. Cool stuff, like a velimentous implantation of the umbilical cord and stat c-sections. The problem was everytime something good happened, they would overhead page the other med student on the team (a girl) to come do them. The other problem was whenever something cool was about to happen suddenly there would be some kind of mind dumbing scut for me to suddenly have to do right then.

So, that's how the day goes almost all day long. I'm seeing all the patients in triage. I'm doing all the stupid paperwork. I'm spending all day trying to chase down the residents. The other (girl) medical student is spending all day doing procedures and scrubbing in cases (that I had been invited to scrub until they found out she wasn't doing anything). And then we get to board checkout at 5 pm. Finally the day was over. While doing checkout on a newly admited patient from triage (guess who the med student was who saw her) a question came up about her history. The attending asked and didn't get an answer, so finally I spoke up and answered the question. And got an evil eye death glare from one of the residents for having spoken during board checkout. Heaven forbid I attempt to make sure the patient gets good quality care instead of protecting the resident's ego. I mean it would be one thing if board checkout was 99% a ginormous gossip session about all the residents and attendings who are not currently present (note the sarcasm). So, once again put in my place for looking out for patient care. Like the time I mentioned chest pain and shortness of breath in a tachycardic women in triage, who had come with a different chief complaint, to the resident who went on to send the patient home at which point the patient called their clinic doctor who then had the patient direct admitted for chest pain. And then suddenly the residents threw a fit over how the patient had never complained of that to anyone and she shouldn't be being admitted.

I guess she didn't read very closely the MS3 note she copied almost verbatim.

Omega Beta Gamma

I was warned that when I started my OB/Gyn rotation that the residents were all gossipy and back biters. I heard that it was essentially like living through 6 weeks of some perverted sorority; the Omega Beta Gamma sorority, if you will.

I honestly can't say that's been my experience so far. I've worked with several residents, and while I have noticed that they are far more focused on their education than mine, I can't say it's been what I was expecting.

One resident, who is pregnant with twins, I have come to notice treats all encounters with medical students the same. She makes a few basic assumptions. 1) Each medical student encounter is the first time she has worked with that medical student. Today, after working with her sporadically over the past 2 weeks, she introduced herself to me and asked how long I'd been on the rotation. 2) All medical students are on their first rotation. Despite realizing that I had been to the OR with her before, I again got a lecture about how blue things are sterile and you sew in to out and then out to in. She also took my job everytime the chief resident asked me to do anything during the operation. I'm not helpless and can suture. The ones I did looked better than hers in the end anyway, despite her having to double check every aspect of how I had tied the knot. 3) Medical students do not understand medical theory. I may not know everything, especially about the eccentricites of gynecology, but I'm not stupid. If anything, my knowledge base is something that carries me through the other aspects of medical school.

The big down side is how little time we spend on each team. In order to get us out to clinic (which in my opinion is of little educational value) they pared down our time on gynecology and obstetrics to two weeks each. Now that I have the hang of the gynecology service and just what I need to do to stand out (in a good way of course), I am being shuffled off to the obstetrics team on Monday. Hopefully that one requires a little less scut, but I'm not keeping my hopes up too high.