Dynamics

Yesterday was interesting, almost entirely because our current, comfortable little group swelled by half. If you recall, I've spoken before about the fact that my colleagues in this clerkship really don't do many procedures, or see much of anything at all, and that several of them were supposed to be assigned to our doctor, but had yet to get in touch with him. There was that one Friday weeks ago when the cancer survivor showed up, but that was it - aside from that, nothing. Thus, this past Thursday at our weekly lecture (this time on gestational diabetes), those two students came up to Nicole and I, said something about how the doc they were assigned to (who no longer does any procedures, referring all complicated cases to our doc) thought that they weren't taking the initiative, and asked what our doc's schedule looked like. We told them about the few planned deliveries, and suggested that, since they were done for the day and we most certainly were not, they come back with us to meet him, rather than just barging into a delivery unannounced - like the cancer survivor did, all those weeks ago. Well, they didn't want to come back with us, nor, I think, did they want to call - and so they missed the emergency ectopic pregnancy surgery on which Nicole got to scrub in.

One of them did, however, show up the next morning - Friday. It was my understanding that they were supposed to do weekends, but (1) I don't make the rules and (2) every future doctor should be exposed to this stuff. I had a beautifully easy vaginal delivery - very little screaming, very little blood - it was fantastic. Afterwards, the doc said to me that I didn't even need him, but I couldn't help but think that they new mother didn't need me either, so smoothly did things go. That was when the other student showed up, and we all went in for another easy easy delivery - this one was Nicole's. As sad as it was that the poor girl was 16 and giving birth, she was a little trooper; the girl didn't get any epidural, and handled it like a champ. 2 smooth deliveries and 2 beautiful babies makes for a great Friday morning.

A short while later, I scrubbed in on a planned C-section. The woman was 400 pounds, prompting me to ask whether or not there was a correlation between BMI and C-sections (since we've seen quite a few obese women go get sections, while the slender ones deliver vaginally). The doc shook his head, and said that if it seemed like that, it was because I hadn't see enough. So we went back, and I helped the anesthesiologist tape this woman's stomach up out of the way of the surgical field. Anesthetizing these obese patients is difficult, and takes so long partly because their voluminous flesh obscures the surgical landmarks the docs use to precisely place their needles. This case was different, though - it seems like not matter how long we waited, this woman's sensation never went away. Usually, the doc places the needles, pushes the anesthetic, and we prep for surgery, stopping along the way to check their sensation by pinching them with forceps. Usually, they don't feel a thing, but this woman just about jumped off the table every time we pinched her - and so we waited, and waited, and still she could feel everything. Getting an epidural hurts, and the patients get a little bit anxious before they're sedated, but this woman got to the place where she was strapped down and absolutely terrified that we'd cut her open before she was numb. Finally the anesthesiologist had to use propofol to put her under.

We got the surgery under way, slipped down through her skin, fat, fascia, and got to her uterus. I helped retract and maintain the surgical field as we placed the ring retractor, and pulled her baby out. As we started to suture her, though, this woman bled a lot. I would have done some suturing, but it seemed like every time the surgical assistant finished a stitch, there was a little, bright red fountain somewhere. He had to stop several times to go back and place sutures, closing off the little arteries. Eventually they pulled her uterus out of her abdomen, to check all around for bleeds, and then pushed it back in to continue suturing (apparently, that's how most docs do it, but the ring retractor allows a level of access that makes pulling the uterus out unnecessary). We continued to stitch and tie off bleeders, and then, since this woman had made it very clear that she didn't want any more children, we did a bilateral tubal ligation, using the Parkland (modified Pomeroy) technique - in which a section of the Fallopian tubes are secured with forceps, and a length is tied off with sutures, making a loop, before the isolated sections are cauterized away. As we closed her up, she had several little varices (dilations of veins) that I got to cauterize, and then it was over.

Generally, the OB doc leaves after the fascial layer is closed, and I stay and help the nurses, surgical assistants, and scrub techs finish everything off, not leaving the patient's side until she's back in recovery. It was fortunate that I did so this time, because at nearly 400 lbs, this woman might have rolled off the table and crushed her tiny little nurse.

Also interestingly, that second medical student - the cancer survivor - showed up halfway through the C-section, and came right in to the OR. He'd only met this doc once, and he doesn't know the mother, or anyone of the staff, and I thought this move a little inappropriate. He'd done the same thing last time when, upon showing up halfway through a delivery - after I told him he should wait for the doc to come out - he went and poked his head into the patient's room. I'm the first person to laud aggression in learning, but there's a fine line with these thing; there's a difference between being enthusiastic and volunteering for everything, and barging into room where woman's giving birth, and no one knows your face - but that's just me.

Now the 6 of us (Nicole, PA girl, Sub-I girl, Student 1, Cancer survivor Student 2, and myself) followed the doc into the main OR, where he was supposed to perform a reversal of a tubal ligation. Once we got there, though, another doc (a woman) was screaming at a nurse (also a woman. Why it's important that they're both women, I don't know - it just seems to be) about surgeries getting switched around - our doc had been scheduled for 10 that morning, but had done the deliveries, and so said that the other doc could go before him, despite the fact that she was an add-on. For some reason, the screaming continued, only dying down a tad when another nurse asked them not to carry on so in front of the patients. So the six of us sat around, the other two listening in while the original four of us joked about our late Denny's run last night, and the piece of chocolate cake we picked up for the doc, which he didn't want (and which I gladly gobbled), when over the intercom came the alert for a code-blue (cardiac arrest) in one of the sections of the hospital where our doc had patients.

It wasn't one of his, but we all headed back over that way - it was on the same floor as mother/baby and L&D, and once we arrived, we ran headlong into all-out panic. Remember the anesthesiologist who'd had a stroke on that morning we got called out to the hospital at 5:45? He'd been in the hospital for a month and was preparing to be discharged when he hit the floor. His wife had been there, and was giving history to the nurses in charge, while docs flooded past us into the room, giving everything they had to work on their colleague. He'd been asystolic (no heartbeat) and apneic (no breathing) when he'd been found, and we listened as they ordered stat labs and pushed epinephrine. We watched through the curtains as docs did compressions, and someone called for defibrillator paddles. Other docs stopped to comfort the wife. Another thing I thought more than a little inappropriate was when cancer-survivor student 2 went and poked his head into the room. I don't think I'm wrong in saying it was bad form; this was a very sensitive time, and it's not like there was anything he could have done to help. They worked on him for an hour, and I don't know what his status is, but that when we left, he was still in the room.

Anyway, there was another planned C-section, and another delivery. That delivery was odd and a little frustrating - we all kept hoping that this woman wouldn't go back for a C-section, but it seemed that, perhaps due in part to the epidural, she just wasn't pushing. We all stood there around her, encouraging her and trying to get her to push. She had so many visitors that the morning nurses almost had to call security (no more than 2 per room), but by the time the delivery rolled around, it was just her mother and the baby's-father's-mother in the room with her, while everyone else hung around the hallway outside L&D. Finally, it got to the place where the doc had to use the Kiwi-suction assistance, and then things got moving - the baby was born healthy and screaming. During these deliveries, I try to be a good cheerleader; this is a physical effort, and I've gotten to be pretty good at cheering people on and encouraging them to push past the physical barriers set up in their own minds. I've learned that if the delivery is normal, there's no urgency - I continue the steady encouragement, and I think it helps a lot. I tell the moms that they're almost there, that the baby moves every time they push, and that they have to push, like they really mean it. During clean-up, I tell them how good they did, and congratulate them. I said the same things to this mother, and when I told her how good she did, the Doc jokingly said "You know he's only being nice to you, right?" We all got good laugh out of that, but even though she came close to being sectioned, it all ended very happily - the cluster of her family and friends lining the hallway to L&D cheered us as we left, like we were some victorious sports team. One enthusiastic woman gave us all high-fives - I loved it!

Oddly enough, that cancer survivor, though he apparently wanted to be an OB, left early to be with his family or something. Nicole and I both found it strange, especially since he and the other student only work 4 days a week, and regular hours at that. I'm sure he means well, but it just seems a bit inappropriate - to show up late (when at all -I'm including the other student in this), and leave early.

We headed from there to the main OR to attend to the woman who'd been waiting all day for her possible tubal ligation reversal. The plan was to start out laparoscopically - if they got in there with the cameras and saw that nothing could be done, they wouldn't have to make it much more invasive and open her up. That's exactly what happened; once the cameras were in, we all saw how little of her tubes were left, and there was nothing more that could be done. When the modified Pomeroy is used, as it was with this woman, more tissue dies than is immediately apparent upon cautery - it's the most successful technique, with the lowest risk (damn near none) of subsequent pregnancies, but it's also the hardest to reverse. There must be a certain amount of Fallopian tubes left, and this woman had nearly none. However, she did have two children already - but she was with a new man, so I guess his reproductive impetus nearly pushed her under the knife.

The four of us have a comfortable rotation that's somehow come into existence, for vaginal deliveries and for C-sections (PA girl, then Nicole, then me, and then Sub-I girl) - so yesterday, Sub-I girl and I got to do a vaginal delivery and a C-section apiece, and Nicole got to do the first vaginal delivery. This rotation is so comfortable - everyone knows their place; I was more than a little pleased that neither of the 2 medical students seemed to want to participate too much, opting instead to just hang back and watch. I'm sure that when they round with the doc today, they'll get their hands on some babies too.

And so we left sometime around 10 that night - giving us a nice, short, 12 hour day. Thursday had gone from 10 in the morning until 2 the next morning which is more the norm. We'd have gone in today, but there was some ceiling damage from the apartment upstairs....

OH! I completely forgot!

So the asshole upstairs likes to blast his techno music, which reverberates down here. I've complained to our landlord, causing the music to quiet for a while, and I've gone upstairs, pounding on their door until it shook in the frame (because he couldn't hear me over the noise) until he came and opened it up, and it quieted down. When we came home at 2am Friday morning, the music was blasting, and I went right upstairs and pounded on the door . A different guy opened the door, and was immediately profusely apologetic - apparently, I'm not the only neighbor who complains, and he's had to smooth things out between them and his roommate. He said something about their moving out in 10 days (which I took to mean that our landlord was telling the truth when he said they'd be asked to move out), and that the guy wasn't answering his bedroom door, but he promised to talk to him. Once I got back downstairs, there erupted an expletive filled shouting match between the two, sounding like it was mainly over someone owing someone else rent. I don't care about their domestic dispute; they just need to shut up, especially at 2 am. I consider myself a fairly even-tempered individual, but the only thing that makes me immediately, irrationally angry is when someone is making noise and I'm trying to sleep. It happened at Yale, it happened on the island and in Valencia during 5th semester, and it's happened here - I almost went back upstairs, but the more I thought about it (and the more Nicole tried to calm me), the more I thought about potential physical altercations snarling the progression of my medical career. And so they quieted down.

Anyway, their toilet hadn't been installed properly, and water had been leaking down, causing some water damage in our ceiling, and the maintenance folks came today to fix it, so we have the day off. I think I'll go in tomorrow, though; I've got a case presentation to give on Thursday, and I've yet to find a patient. I think I'll just pick some random post-partum woman, interview her, and let that be that - I'd rather spend my time getting ready for the shelf exam.