Chew 'em up, spit 'em out.

Today, Nicole and I headed a few towns over (just another little Miami suburb, really) to one of the OB's other offices. This one is a little more comfortable than his primary office; these patients are a little more high risk, but it's nowhere near as packed - which makes for some great study time. I mentioned before how I don't like having my plans changed, and I don't like having new folks monkey-wrench themselves into the comfortable rotation between Nicole, PA girl, Sub-I girl, and myself. Today, we received another student - this time from the University of Miami (Miller) School of Medicine. The first thing that rubbed me the wrong way about this girl was that she was wearing a long coat - at first, I thought she was the new OB who was working in that office. You see, that long coat signifies that you're either an M.D., P.A., or lab tech - we as medical students wear short-coats (they're actually called "consultation coats"), because to do otherwise would be misleading. So she introduced herself, and Nicole and I shared a "what-the-hell-is-she-doing" glance.

The next thing that rubbed me the wrong way was her tone. Despite the mind-numbing advances in technology and our triumph over [some of] the pestilential killers of yester-year, medicine is still a conservative old-boy's club. There's a certain amount of implicit politeness, of deference, of respect that should go into every word that issues forth from the mouths of lowly med students [and nurses]. Thus, it pissed me off a little when her tone was less than deferential - actually, it bordered on accusatory. A patient came in today with some pain on urination and supra-pubic tenderness. He examined her and had her pee in a cup for culture. The UM med student said something along the lines of "Aren't you going to do a UA (urinalysis) to rule out pyelonephritis?" First of all, generally, as a third year med student, our thinking is a few giant leaps behind the doctor's - if they didn't do it, there tends to be a damn good reason. Secondly, I know that we can microscopically check for casts and all.....but this woman presented with symptoms of cystitis, and since she was just pregnant, he wouldn't get a clean-catch for a UA anyway.

Apparently, when I was interviewing the patient with the OB, this new med student got a phone call from one of her professors who'd called to check on her site placement. Nicole and PA girl tell me she answered the phone with a "Hey", or a simple "Hi", instead of the expected "Good afternoon Dr. So-and-so". I know....that sounds incredibly picky....but it's one of those things that rubs me the wrong way.

UM must have some weird philosophies on medical education (at least now they do). Apparently, this girl will only be here for three days - she's not following him around like we do, but is rather being placed here and there - she'll be getting a few weeks in L&D, maybe a few in gynecology. She only did an afternoon with a pediatric endocrinologist, and some other asinine amount of time in something else. The fact of the matter is that, apparently, the program would rather expose them to a lot of stuff on a really broad scale, rather than have them get to know anything really well. *I slap my forehead, rolling my eyes* So anyway, this girl had scheduled some dinner plans today, and thus couldn't be available all evening. When questioned further about it, since the doc had to run, she said something along the lines of "I mean, I'm not going to drive back out here..." followed by obnoxious laughter. All of this after remarking that hypertension and diabetes bore her, and that during internal medicine, she wanted to dig her eyes out. I don't like her.

The icing on the cake, though, was when she admitted that she "screwed the pooch" (an epithet I'd never heard until today) on step 1, and so was getting a jump on Step 2. So this unprofessionally impolite, semi-lazy, arrogant US med student didn't do so hot on her boards? Rich, double chocolate icing on my cake. It may sound as if I have a chip on my shoulder, being a Ross student, and that her shortcomings validate me somehow - but this is what that icing really tastes like: if that is my competition, I shall feast like a king......if those are my opponents, I shall glut myself on the hordes of them. If that's what I'm up against, I'll eat 'em for breakfast!

In MERP, one of our junior faculty told us that Ross students were more dedicated because they had something to prove; they came earlier, stayed later, and worked harder. I'll climb over a hundred US med students to get to where I'm supposed to be - I guess that starts tomorrow!

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.

Weak and Weary

I just spent 23 hours in the hospital - arriving sometime around 9:40 Monday morning, and leaving around 8:30 Tuesday morning. It wasn't supposed to pan out quite like this.

Nicole and I went in early to round - I know that doesn't count as "early" when talking about rounding in any other specialty, but this doc gets to sleep in since he damn near always has midnight/early morning deliveries. So we went and saw the patients who had delivered over the weekend (incidentally, none of the other med students who were supposed to show up actually did), and decided to grab an early lunch. Nicole and PA-girl went out for Pollo Tropical, but being of a mind to get some work done, I sat in North Shore's little gift shop/cafe and reviewed primary amenorrhea. The text came from Sub-I girl that the doc had been held up, and we went to L&D to wait for him, back to our little Nook. We'd checked the board earlier in the day, and knew that he didn't have any patients who were going to deliver soon. He arrived shortly, broke some patients' water to hasten delivery, and we all shuffled off to his office in the professional building.

I saw one patient who'd had some dysfunctional uterine bleeding, had been frighteningly anemic due to fibroids, and had undergone a pelvic ultrasound. Unfortunately, her results were at the hospital. After I interviewed her and while she went to get those results, I interviewed another patient who was going through perimenopause complicated by COPD, diabetes, and heart problems. Finally the first patient returned, but without her results; that department of the hospital was closed. So we repeated her pap smear and set another appointment for her. It may appear that we didn't do a whole lot, but the doc was running between 4 different rooms, seeing the patients interviewed and examined by Nicole, PA girl, Sub-I girl, and myself.

Once those patients had been seen, we headed back over to the hospital. The next vaginal delivery in the rotation was mine, and when we got there, I glanced in to see how she was doing. She was a young first-time mother, frustrated, tired, and afraid of the pain. Her labor was progressing, but too slowly; the baby's head wasn't descending properly - and so the doc decided on an operative delivery. In tears at the end of forceful contractions, the mother cried that she couldn't do it - I'd thought for sure that she'd be taken to the back for a C-section, but the doc delivered the baby's head using a vacuum suction device called the Kiwi (at first, I'd thought the nurse had said that the baby's crowning scalp looked like a kiwi.....which was true). Once the little boy's head had been delivered, a few more forceful pushes completed the joyous birth. The baby was hollering, the family was thrilled, and mom was incredibly relieved - but she'd suffered a pretty severe second degree perineal laceration. The doc guided me as I sewed her tissue back together - a surprisingly more difficult task than simply closing the uterus and fascia in surgery. Here I was working in an area no more than a few inches wide and had to not only attend to two different layers of tissue, I had to make nearly hairpin turns with the needle in order to align things properly. Her epidural started to wear off halfway through; she was feeling the needle, nd had to be kept from flailing by Sub-I girl. I told her she could squeeze my arm, but that, in the long run, she'd be much happier if she didn't hit my hand. And so we paused while a nurse ran for 1% lidocaine, which I injected into her skin, and then finished.

That must have been somewhere around 11:30 at night. We all went back to the nurse's station to check the board - he had three patients who seemed to be in a race to the finish, dilated 6-7cm, 8-9cm, and 9cm (with 10 being the maximum). And, as always seems to happen, everything started to go down at once. The first one to start seriously pushing was one VIP (Very Important Patient) from his other office - I don't know why exactly she was a VIP, but this woman had paid some $60k for in-vitro fertilization, and so was treated with kid gloves. Next door was another first time mother who'd lost several pregnancies. Nicole took Mrs. In Vitro, and Sub-I girl took her neighbor next door. Mrs. In Vitro was very calm and placid, pushing forcefully until finally her little girl popped out, and we called the father into the room (he hadn't wanted to watch the messiness). They were thrilled and relieved, and their little girl was screaming; all was well. I stepped next door for the first-timer (nullipara) who was so happy she cried when she saw her baby's head. The doctor moved back and forth between the two rooms, making sure everyone was alright and congratulating the families.

The third patient was dilated to 8-9cm by this point, though the nurse said that she thought it was more like 6-7cm. We'd seen her earlier in the day, and she'd had a bad reaction to some of the anesthesia - it wasn't quite an allergic reaction, but she'd become strangely lethargic, and so the anesthesiologist was treating her carefully and conservatively. This was PA-girl's delivery, and so she checked on the poor woman every once in a while. I say "poor", because she was in exquisite pain and discomfort; I sat in her room and one point and just held her hand (the baby's father was curled up asleep in a recliner in the room, oblivious). The doc had opened up to us the on-call room because, apparently, he knew it was going to be a long night, and so Nicole and PA girl went and grabbed some Zs. I stayed out at the nurse's station with Sub-I girl, periodically checking on the slowly progressing patient. Finally the anesthesiologist came and gave her something for the pain, which slowed her labor even more, and eventually, she slept.

And so I ran to the ER for cheap coffee and pretzels, sat watching fetal heart monitors and discussing various tracings with the nurses, and watched the hours creep past like the indifferent minions of some blind tyrant. Around 5:345 in the morning, EMS brought in a young lady on a stretcher. she was wrapped in a bubble-gum pink bedspread and seemed strangely perky despite what they were telling the nurses - that she was about 17 weeks pregnant, and had begun to deliver. I won't get into the gory details (which are disturbing), but that ended in miscarriage. It was difficult; Sub-I girl didn't want to look, but I don't think I'll ever forget the sight. I suppose I'd known that I'd seen something like this all along, and I guess one never really can be prepared.

The other patient still hadn't progressed, and so at 7:00 in the morning, we took her to the back for a C-section (with as much pain as she'd been in, I hadn't though she'd delivery vaginally anyway). PA-girl got to assist, mom and baby were fine, and we all left the hospital to jump into 8:30 am traffic.

Looking back, there was a lot of sitting around. I got to do some reading, but in those wee hours there really wasn't much point. I thought it was particularly interesting just how annoyed PA-girl was at simply being there, not doing anything. The rest of us - Nicole, Sub-I girl, and myself accepted it as par for the course; I guess it was what we expected. Long, physically and emotionally draining days are what we expected.

Must love Swindlers

I started reading Robert Greene's The 48 Laws of Power sometime in my sophomore year in college. It was incredibly enjoyable - perhaps 60% nonsense, 20% fluff, and 20% good stuff, all wrapped in a pleasantly pretentious package. Most importantly, Mr. Greene introduced me to Joseph "Yellow Kid" Weil, one of America's most famous con artists. I read his biography and learned how he only took advantage of those looking for a quick, dishonest buck, plying his trade most often at the horse races. Something about swindler's has always tickled me - I remember being a child and gasping inwardly the first time I heard someone described as the kind of person who could "sell ice to an Eskimo". Thus, I'm a little surprised that I've never delved more into the life of Frank Abnagale, author of Catch me if you Can, (which was turned into the movie with Leo DiCaprio and Tom Hanks). Nevertheless, that unconscious fascination continues - while in between patients at one of the OB doc's offices, I picked up a copy of Kevin Trudeau's The Weight Loss Cure. I first became acquainted with Mr. Trudeau through his late-night informercials for his other book Natural Cures They Don't Want You to Know About. My mother was given a copy, and so, since it was just lying around the house, I thumbed through. In it, he bashes the medical profession, big pharma, and goverments large and small, liberally sprinkling his scare-mongering with enough truth and fact to be plausible. I didn't finish it, but I did thumb through The Weight Loss Cure, just to see what he said. Once again, he's bashing medicine and the food industry (which, by the way, is fascinatingly evil - just check out Eric Schlosser's Fast food Nation). While his vilification of prescription drugs and medical doctors is laughable at the least and downright lethal at the most - when scared, sick, hypertensives, diabetics, and cancer patients are convinced to eschew proven, life-saving treatment in favor of St. John's wort - enough of it was pure and simple logic (eat more organic food, work out more, don't eat fast food), that I kept on reading. And then I found this:

I KNEW there was a reason I liked this guy - he's the most successful modern scam artist!

Hailing babies and stitching the womb

Today was absolutely crazy - not like a regular "whew that was crazy" kinda crazy...but a holy damn kinda crazy. Last night was late - we got home around 1 in the morning after a C-section. The poor scared woman didn't want to make any decisions without her mother, so we sat around the doc's office waiting and wondering what she was going to do. I thought that she was going to take the epidural, and the student doing her Sub-I (sub-internship) didn't think so. Finally, we got the call that the mother had arrived and that the patient wanted the epidural - and so I celebrated. However, 30 seconds later, the doc got another call - the woman had opted for the C-section. So we headed over and got ready. It was the Sub-I's turn, so I just observed, with a small amount of envy - she not only got to open with the electrocautery, but she also got to suture shut the fascial layer.

Anyway, that all ended around one in the morning, and after all was said and done, the doc said "Don't call me at 8 tomorrow. Don't call me at 9. Maybe 10...." So, Nicole and I rolled up to mother/baby to round right around 10:20. Most of this doc's patients were in L&D, so we rounded on the few new mothers - everyone was doing well, and then we got the text. Sub-I girl is living with the OBGYN doc and his family; she's kind of attached to his hip, and I get in touch with the doc through her. We headed over to L&D, where one of his patients was already in labor. This was a fairly young mother giving birth to her first baby ( a nullipara), and so, since it was her turn, Nicole gloved-up and assumed the position right next to the mother. I hung back a bit; the father looked a little nervous having so many people around (he eventually got nauseous and had to leave). The baby started crowning, and the mom started pushing, and this big head appeared, followed literally two seconds later by her whole little body - it was just about the fastest birth I'd ever seen! The nurse weighed her and did APGAR scores, and the dad finally came back in, overwhelmed with pride.

Back out in the hall, we met up with the PA student (henceforth to be known as PA girl) who had spent the morning interviewing at a dermatologist's office where she'd been offered a job. We've got a great little group; PAgirl is absolutely hilarious, and peppers our down time with laughter and sound effects, and Sub-I girl is just as hilarious with a plethora of stories about little kids. Nicole loves telling stories, and I slip in a few when I can - the point is that we've got a group of four students who get along surprisingly well, and that helps to pass the time....because we spend a lot of time waiting. Initially, Nicole and I had brought our books in, to study on the down-time. After her delivery, Nicole took the books out to the car, but once the down-time reappeared, I went and got mine. Bad idea...I should have known I wouldn't get the chance to study.

If our night was late, the doc's was certainly even later - so he retired to his office to catch a catnap. Since he said not to go too far, the four of us grabbed lunch in the cafeteria and went to eat in the intense sunlight of the hospital's little garden. With opera music piping through the speakers, I almost forgot where I was - but I guess that's the whole point of the little place. We headed back up to L&D, back to our little nook -the end of a hallway in L&D where they stored extra wheelchairs, overlooking the hospital and downtown Miami - and chillaxed for a while.

Gradually, it became apparent that things were very tense; the families of women in labor were poking their heads out of the rooms wondering why some of the nurses were running. We heard one of them frantically calling for our doc, and knew something was up. I went and got out his surgical gear to streamline the process, and within 2 minutes he'd rushed into L&D. I couldn't tell exactly what was going on, but one nurse said something about the baby's heart rate being in the 70's (it's supposed to be 110 to 160), and that the mother had just come in from the ER - and that no one knew anything about her except that she was 39.5 weeks. Since things seemed so hectic, the four of us decided to wait and not scrub in, lest we find ourselves underfoot. The last thing I heard before the doors shut to the surgical suite was one of the nurses saying "and I can't guarantee the baby's even alive". And all of us were going "ohshitohshitohshit....."

We stood around nervously, waiting with baited breath as we stared at the doors to the surgical suite. I said a silent prayer for the baby and mom, and Sub-I girl went off to pray alone. Minute after tense minute passed - and finally we saw the doc walking down the hall towards us. Those were the most tense moments; knowing that we were about to discover the fate of one, possibly two lives. Fortunately, the baby and mother were ok - it turned out that she'd had a placental abruption, in which the placenta begins so shear away from the uterus, and the space in between fills up with blood. This can be fatal for both - but they got to it in time. There was some down time, then, and we followed the doc to Mother/baby, where we told stories about Dominica, the cows and crabs, lizards and food poisoning, while the doc dictated.

Next thing I knew, another mother was getting ready to deliver, and it was Sub-I girl's turn again. I believe this mother had had a few children, and so was an old pro. That delivery went smoothly, and we waited some more. Another mother got ready to deliver, and this time it was PA girl's turn - for this one, I helped hold the mother's legs. She had a small perineal tear, and the doc walked her through the sutures. That delivery went well also - halfway through, though, after the baby had been delivered and before the placenta had been delivered, PA girl's clamp slipped on the umbilical cord, and as they were banking the cord blood, a jet of it shot across the table. Fortunately, it missed me - but she wasn't so lucky, and went to change scrubs after it was over.

There was a scheduled C-section, and this was my turn to scrub in. I helped arrange things, and set out my gown and gloves, and then hung around our Nook until they brought the mother back. I scrubbed in and gowned-up, watched the woman being anesthetized - and then every one except for the anesthesiologist, the scrub nurse, and I, disappeared. Minutes passed, and it got to be sweltering. 40 more minutes passed - I later learned that the doc had unexpectedly been called to another delivery that was hectic in it's own way; the umbilical cord was wrapped tightly around the baby's neck and couldn't be pulled over her head - and there wasn't a table prepared with scissors. So Nicole ran around until she found some, damn near livid at how slowly some of the nurses were moving, and finally found some scissors and saved the day.

Finally, everyone came back to the OR, and the C-section got underway - the sweat on my forehead and my headache forgotten. Apparently, if a woman has had a previous C-section, part of the standard of care is to remove that scar tissue, in effect giving the woman a mini tummy-tuck. Much like the woman from the C-section last night, this woman was obese, and had to have her stomach taped up and out of the way, to clear the surgical field. So the doc used electrocautery to slice through her voluminous flesh, delving down from skin, through fat, fascia, and muscle, to her uterus. With delicate scalpel slices he opened the uterus, and pulled out the baby. Someone told me to suction, and so I grabbed the bulb and suctioned amniotic fluid from her airways - and she started screaming in protest; always a good sign. The neonatologist whisked her away, and the doc prepared for the next step - delivery of the placenta. In C-sections, you can't just wait for the placenta to be delivered; it must be done manually. The doc essentially said "Get your hand in there" - and then I had my hand inside this woman's uterus. I've been wanting to say that I'd had my hands inside someone, but even though I'd assisted with a few C-sections, it just wasn't true. And then there I was - my hand inside her uterus, gently peeling away the placenta from the inside. Once that was complete, the doc asked for the sutures to close the uterus. He placed the anchoring stitches, and handed the instruments to me

This was something I'd been waiting for and looking forward to, but didn't think I was ready for. I figured that, like Nicole and Sub-I girl, I'd get to suture the fascial layer, or something not so quite so vascular - but the doc handed me the sutures, and I began sewing up this woman's uterus. There was perhaps a second in which I had to take a deep breath to still my trembling hands, but overall, it felt strangely normal. I'd expected it to be mind-blowingly exciting, but instead it felt natural, and right. The doc commented that either I'd been watching a lot of videos on youtube or just paying a lot of attention - I told him that youtube's videos weren't that great. I don't know what it was; of course I'd watched closely - this whole process is fascinating. Also, the instruments just felt right and proper in my hands, perhaps due to my extra time as an anatomy TA and the suture clinics on the island. My suturing wasn't perfect, but this was the first time I'd ever placed a stitch in living flesh.

It was awesome and fascinating, watching the bright-red blood well up and be suctioned away as I slipped a crescent moon needle through the bundles of muscle fibers and out the other side, slowly and surely sealing her womb. The amazing thing is that this is a completely commonplace procedure; this happens every day, and today was my day - my turn to sew up a person's insides. You know, I've noticed something - when I step up to the table, everything disappears except for the surgical site. It's like a hush falls over the room - everyone stops talking - and there's only the sound of the doc's voice, suction, and electrocautery. Once in a while, something will grab my attention, and I'll break through back into reality, catching snippets of conversation and songs on the radio (my favorite anesthesiologist loves Caribbean music) - only to quickly be pulled back under the concentration and complete focus on the person lying open before me. That sensation was magnified by a factor of ten when I actually had the instruments in my hands; there was nothing else.

We moved on to the fascia, and made sure that it was sewed up nice and tight - I did half of this layer as well. After that was done, the doc left - (apparently, he was very impressed with how comfortable I was with the tools...so Nicole says...). The surgical assistant and I closed up, and then the patient was wheeled into recovery.

So how was your day?

You can hate me now

Today - like every Thursday - Nicole and I broke from the awesome madness of our OBGYN rotation to go for our weekly lecture. It could have been all in my head, but I got the impression of an undercurrent of animosity from the other students. Perhaps it was because we showed up in our scrubs, when the class was expressly told to wear business-casual attire. Well, after last week's lecture, I spoke with the program director and explained to her our hours - and she gave the ok for scrubs. Perhaps it was that we showed up halfway through the lecture. This was due entirely to the fact that we were in a C-section, and left as soon as we could. Perhaps, though, the real reason for the animosity I felt - real or imagined - was because I'd been a tad boastful the previous week about how awesome our rotation is - and other folks don't seem to be doing a whole lot.

I've gotten to deliver babies! I've assisted in vaginal deliveries and c-sections, and I round on patients nearly every day. I find babies' heartbeats with doppler ultrasound. I've done endometrial biopsies, colopscopies, bi-manual pelvic exams, and swabs for STDs. Hell, the first time the doc handed me a speculum, I remember looking at the thing like I had no idea what it was. Today, it felt downright comfortable in my hands (hopefully it was just as comfortable for the patient). Nicole got to suture up some fascia post c-section today, and hopefully I'll get my day in the sun soon. My point is this: see all that cool stuff that I'm doing, all of the awesomeness that I'm learning? It doesn't sound like anyone in our rotation is having anywhere near as good a time. Sure, there's a lot of waiting, but while my colleagues are only doing vital signs (which I also do) and cursory exams, I'm deciphering fetal heart tracings, delving into the labyrinth of abnormal vaginal bleeding, and helping babies be born. You can hate me now.

Full Spectrum

Today was entirely too long, but it was awesome. It began by a lengthy drive out to Miami Lakes, where our OB has some office space. Since so much of yesterday involved sitting around, Nicole and I took our books today, intending to continue our studies. Surprisingly, the doc had arrived before we did, and so we left the books - only to listen to him talk to nurses for an hour and a half; none of the patients showed up.

So we drove back to North Shore and rounded on his patients. By chance, the first chart I picked up belonged to the woman whose C-section I attended yesterday. She was up and walking and was surrounded by her other three children; she was a little bloated, but in good spirits. I left to write up the progress note, but the mother/baby floor was surprisingly devoid of the other students (yet another one joined us today; she's a few weeks from graduating and has returned for what should be an obstetrics sub-internship). The others were attending a labor already in progress.

The OB was getting ready to go by the time I got there - we'd sort of decided that this was supposed to be my delivery, and so I scrubbed up and threw on some gloves. First of all, this woman refused an epidural, and so was screaming (everyone could hear her; we didn't need the door thrown wide open by the cantankerous nurse with the bad attitude). I assumed the position right next to the OB just as the baby was crowning, and gripped the sides of her little head to help her on out. In preparation for this moment, I'd been keeping up with my reading on labor and delivery, and there was nothing I was more nervous about than a possible shoulder dystocia (which occurs when one of the baby's shoulders gets trapped behind the mother's pubic bone, effectively ceasing labor) and the list of increasingly morbid things done to correct it. Much to my relief, a few moments after this little girl's face popped into the world and the OB suctioned her, one tiny shoulder appeared, followed by another - and then I was the first person in the wide world to hold her. The little sweetheart was hollering when she hit the table.

Cord clamped and cut, the nurses whisked her away for her APGAR scores while I began to work on delivering the placenta. I'd thought that epidurals made this part easier, and in some respect I was correct; the OB explained that when a woman has pain meds, one can more forcefully massage her abdomen and uterus, which speeds up placental delivery. This one took a while - nowhere near the 30 minute mark, but longer than the others. Cord blood was banked, and then the placenta came.

The whole thing was surprisingly peaceful and natural; my heart wasn't pounding from excitement like it was during the emergency C-section. It felt so calm; despite the mother's screaming (she only spoke Creole, by the way, so she didn't understand my comforting words), I was tranquil - although this is probably due entirely to the fact that it was expected to be a completely normal, completely safe delivery, and it was.

That was happy, and joyous, and we turned right around and entered the other end of the spectrum. One of the OB's patients had miscarried, and we went to the surgical suite for her dilation and curettage (D&C). This woman apparently suffers from bipolar disorder - which is why her procedure was completed in surgery, rather than in his office. Her loss was sad, but I don't think she was devastated; as feisty as she was, this woman was grateful for her other children.

We returned to the doctor's office to see a few patients, and then got lost looking for a Subway that was suppose to be "right down the road". It was a 50/50 shot; right or left - and I chose wrong. So, since the OB wanted us back over at his other clinic, we just headed back over there. Once lunch was over, we returned to his office from the morning and sat and waited. After a while, the patients started rolling in. Of particular note was the one crazy patient who was 5 weeks pregnant; I only say she was crazy because she was. There was some bizarre anxiety/depression thing going on; I almost got the impression that the OB was a little apprehensive to delve too deeply into this woman's bothersome thoughts. Apparently she'd kicked out the father of her baby - because she didn't like the smell of him. However, more interesting than this woman was the one who, upon asking if she could resume sex with her husband, volunteered that the aforementioned sex would involve a bunny suit.

Somewhere in the 10:00pm hour, we returned to North Shore to remove a woman's cerclage - a stitch placed to hold shut the cervix when it opens too early. This woman had lost a baby and was seeing an OB across town, but since she lived near North Shore, that's where the emergency responders brought her when she called and said that her membranes had ruptured. Her mother wanted her across town, and her baby's father wanted the baby born now - this poor woman was pulled in so many different directions, and was trying to please so many people, that I'm glad she did what I thought was best for her, and stayed where she was.

So that was the day. 9am to 11:30 am. My father said that, during his OB rotation, he delivered 27 babies - I'm only at 2 so far (counting both the vaginal delivery and the C-section). Time to get moving.

My First Emergency C-Section

Surprisingly, we didn't get called over the weekend; there were supposed to be deliveries on Saturday afternoon and Sunday evening (after folks got back from Easter services, according to our non-religious OB) - but we all got to relax and have a nice, quiet weekend. Thus, when we went in to round this morning, we were a little surprised that there had been deliveries. And so we waited - the girls began to wonder if perhaps the OB was pissed at us for some reason or other. I can't imagine what it might have been, but we were supposed to meet him at 10-11ish, and he still hadn't shown by lunchtime. Finally, we got in touch with him and found out that he'd gone in for an emergency dental appointment. The three of us (Nicole, the P.A. student, and I) wandered around between L&D, mother/baby, and the professional building, which houses the OB's office. Finally, we got the call and headed back to L&D. As soon as we stepped onto the floor, the mood was heavy.

The patient hadn't been doing well; the fetal heart tracings weren't reassuring at all (the baby's heart was beating frighteningly slowly), and it couldn't be explained away by any of the usual suspect - a slipped electrode, a strange position of the mom, etc. The nurse was agitated and restless, lacking the practiced composure of the doc who, though he calmly watched the fetal heart monitor for a few moments, was in a bad mood. My father is a doc, and so I've gotten to understand the difference between when a doc is pissed at me, and when he's just pissed. Our OB today fell into the latter category, and so the best course of action, as always, is to (1) stay out of their way, and (2) to do what they say right away. So when he said for us to go scrub in, the three of us ran back to the surgical suite.

We'd decided to take turns assisting, and today was my turn. As saffron flecks of iodine flew from my furious lathering, I sort of kicked myself; maybe this wasn't the best surgery to be my first time assisting. Nevertheless, as the risk of sounding crass, I figured it was time to show I had a pair. I finished and had assumed the position - fingers spread and dripping hands held above my shoulders - when one of the other surgeons came in and said not to scrub in yet. They hadn't figured out which OR they'd be using, and it'd be best to wait. So the three of us (the girls dressed for observation; they didn't scrub) headed back to L&D, and nearly ran into the patient's bed as they wheeled her back for her surgery. I checked with the other surgeon - a recent transplant from Cuba who had done some plastics (as evidenced by his beautiful sub-cuticular stitches), and he said to go ahead. So I went and re-scrubbed (cleanest hands in the whole hospital), and went into the other OR, hands up, and waited.......and waited....... I was going to go ahead and gown-up, but the Cuban doc told me just to wait - and then he and the neonatologist left the room.

Apparently, at that exact same time, there was another woman in labor, and her baby wasn't doing well either. I found this out later from Nicole and the P.A. student - the baby came out, and was silent. The placenta looked all wrong, and everyone held their breath until, by the time the neonatologists arrived, the little one started screaming.

The surgery was back on - the Cuban doc came back, scrubbed in, gowned-up, and helped me gown (there's a lot of twisting involved; it's like learning a new dance), the OB arrived and gowned-up, and the electrocauterization got underway. I was right up at the table for this one; last time I was observed from the side of the room, trying to stay out of people's way. The smell of burning flesh isn't that bad at all, and it the cautery keeps blood loss down. They sliced through the patient's lower abdominal skin, and then zipped through layers of fat. The surgeon pulled apart the layers of muscle and fascia using a surprising amount of force. C-sections aren't pretty at all; they look harsh and even violent - but the prettiness of incisions doesn't mean a damn thing if that baby isn't alright. After the barbarism of dividing the layers of sinew and muscle, there shone the bluish, almost nacreous membranes covering the uterus. Incidentally, there's this fascinating tool composed of two bendable plastic hoops connected by a tube of transparent plastic. One of the loops is encircled about the uterus, and the other end lines the surgical opening, providing a perfectly clear window into the site of interest.

the OB took a scaplel and incredibly delicately knicked the near-gossamer membranes layer, drawing a hair-thin line of bright-red blood. Another knick, and another crimson line, and the earlier roughness was completely forgotten.

And then we were through the walls of the uterus, and there was the baby's hair head. In one swift motion, the OB pulled the baby from the artificial opening in his mother's womb, through the plastic hoop. In a flash, the cord was clamped and snipped, and they baby whisked away for his apgar score. The placenta quickly followed, and then the real work began. The reason for the baby's low heartbeat was because the umbilical cord was wrapped around his neck (nuchal cord). Fortunately, the young fellow was alright.

So many layers were breached for this procedure, and just as many must be repaired. The Cuban surgeon first began by suturing up the walls of the uterus. Here I assisted by holding tension on the suture cord and maintaining the surgical field with retractors. Like I said yesterday, these surgeons' fingers flew - neat and precise when they slipped the curved needle through paper-thin layers of fascia or flesh, I couldn't follow what they were doing as they knotted and re-knotted the stitches. It was difficult for me at first - now knowing exactly what was required - but the suturing surgeon and I soon fell into a rhythm between applying tension and applying stitches. My heart was pounding through my chest during this whole thing, and as i watched them push suture and push around her organs, I realized that there is nothing more beautiful - more perfectly, magnificently exquisite, than loops of healthy, pink bowel. I was shocked at how wonderful it was; the intestines I'd studied in the lab were old, and dead, and slack - but this was the living, breathing, inside of a person; the way God made it. Man was never supposed to see such wondrous awesomeness.

We closed up layer by layer, until all that was left was the skin. After placing staples, the surgeon applied beautiful sub-cuticular stiches. Instead of interrupted stitches, these were buried within the layer of the skin, winding sideways from one side of the incision to the other and back again. when the suture cord was drawn taught, it was as if the wound was closed by an invisible zipper. I believe I blogged about these stitches the first time I did them back on the island, but watching the closure of pink and healthy flesh was significantly more impressive than zipping up the leathery skin of cadavers.

This is by far the most fun I've had in medicine. Thus far.

The rest of the day passed relatively quietly; we went back to the OB's office and saw some patients there. Then we returned to mother/baby, rounded on patients, and went back to L&D to wait. Earlier in the day, the doc had asked us three what we felt we needed from him to further our learning. Nicole blurted out that she wanted to deliver a baby - and she got her wish later on that day. The last case of the night was a woman who was ready to deliver. To prep her, the OB had given her some Pitocin (oxytocin) a few hours prior - thus, when we got there, it was game time. Nicole threw on some sterile gloves, and once the nurse said the baby was crowning, we called the doc to let him know. He showed up and guided Nicole through the whole process, and this lady - much like that first one - pushed out her little girl like a champ. I keep forgetting that childbirth is a natural process that's been going on for ages without docs - and the OB reminded us of that, teaching us as he guided Nicole to allow the baby's natural motions as she descended the birth canal.

Today was an awesome day.

Addendum

20 minutes after my last post, I received the call to once more cross town for OB. Luckily, I was ready this time - I'd eaten as fast as I could, and was reviewing some stuff when the doc called and said that there was a C-section scheduled. So Nicole and I hopped into our newly rented Chevy Malibu - and got snarled in the worst traffic I've ever seen. Maybe it wasn't that bad.....but it was really frustrating. I've had to rush because of being late to work or class, but this was entirely different - I told myself it was life and death, which probably wasn't the case. Sometimes I hate this city; I hate that people drive like they're on crack, and the fact that they all seem to want to go the same place at the same time. It's difficult to get to South Beach on a Friday afternoon, but today we actually had trouble getting to Miami proper. I wasn't quite swerving like a madman, but I used some words my mother wouldn't like.

So I get to the parking lot and am almost running towards the ER when I get a phone call - it's the P.A. student, letting me know that the doc isn't even there yet. So we casually stroll up to L&D to wait. Some of the other students in our rotation are assigned to docs who only practice gynecology, and so won't see any births. Since our doc is so heavily into obstetrics, these other students rotate with him for a few days. One such student was there waiting for us - incidentally, this kid is semi-famous; he'd had T-cell ALL (acute lymphoblastic leukemia), and had run up a ginormous hospital bill with experimental medications (Gleevec 2.0) - which our student insurance had declined to cover (it was all over student news back when I was on the island). Anyway, he beat his cancer and was joining us today. Coincidentally, he wants to go into OB-GYN, so he was really excited about this rotation. And so Nicole, the P.A. student, the cancer survivor and I hung around the same nurse's station where Nicole had earlier fainted, waiting for our doc.

While we waited, another doc performed a C-section, which the girls went to watch. I opted to stay and wait for the doc, since I figured he'd be there any time. Time came and went, and we were still waiting, and another one of our doc's patients was getting ready to deliver. So we waited. Finally, he arrived and delivered the baby (OBs like to do that, it seems - let the nurses do the checking and prepping, and then swoop in when the kid is crowning for their 10 minutes of day-saving glory). Then there was a bit more hanging around, and we all went to watch a C-section. I know it's still early in my rotation, but I know how I feel about this: though my father said that delivering babies was the fascinating and fun part of this whole rotation (and though I haven't actually done anything yet), I am not thrilled by vaginal deliveries. I thought to myself, as I watched my third one of the day, that I'd be unhappy if I had to do that for the rest of my life; it just wasn't exhilarating. The C-section/tubal ligation, however, was a completely different story - there's an electricity in the air, that just wasn't there for me during the deliveries. Since our cancer survivor was so into OB, the three of us stepped back and observed while he went to assist. I'm not complaining; this is the first official surgery I've ever seen. Nevertheless, I found it far more exciting than the other deliveries; the surgeons' dexterity was very impressive - the cauterizing as they descended through the layers of the abdominal wall was interesting in a technical way, but watching the doc's fingers as he sutured and knotted was like watching someone play an instrument I've never heard. Am I going to be a surgeon? Dunno, but the conviction remains - I have to do something with my hands.

Interestingly, that third vaginal delivery was the only of the four births of the day in which the father was present. It was Nicole's favorite, because the family was so excited, but my favorite of the day was that first girl; she was a champ.

And now all I want is a glass of wine. I'm hoping for no more calls.

Starting off OB-GYN

This is the first week of my OB-GYN rotation, and things are fascinating - as of now. We went for our orientation on Monday, and met the program director - she's a Ross grad awaiting her residency position. She's a sweetheart, but as the week has progressed, I've come to realize that her organizational skills leave much to be desired. She told us that, this week, we wouldn't have any lectures, and that everything would pretty much begin next week.

On Tuesday, Nicole and I drove to North Shore Hospital, where we'll be rotating with one of the obstetricians, to pick up ID badges. We arrived and waited while other students filtered in, passing the time reading through Blueprints OB, the required text and an astoundingly better book than the one we used for our family practice rotation (incidentally, we received our scores for the shelf, and I scored well above average. Nice). Anyway, eventually one of the hospital liaisons came to see us, and we were told that we'd have to wait until orientation to get our badges, and that there wouldn't be an orientation until next Friday, because the program director hadn't contacted him. Unfortunately, without those badges, none of the students are allowed in the hospital proper, though we are permitted in the doctor's private office. Unpleasant, but oh well - I figured that this would be an easy two weeks, during which time I could really sink my teeth into this novel and confusing culture of obstetrics and gynecology....but we all know how my plans turn out, especially those involving Ross. We called and spoke with the doctor, explained the predicament, and agreed to meet up with him when he was out of surgery. In the mean time, we took a quick trip to Costco - because Target stores everywhere were sold out of my protein powder - and Nicole got into it with one of cashiers over a change to some membership policy. Around the same time, I called and spoke with someone in the central office - the program director was unavailable - and tried to get something sorted out with the badges. They told me they were working on something. We sat and read at Starbucks until the appointed time.

Then we went to the doctor's office, which was absolutely packed, and waited some more, continuing the reading. He showed up an hour or two after he thought he would, which is understandable given the capricious nature of surgery. We finally met him and his cute Ecuadorian P.A. student, and figured out the particulars of the schedule. Fortunately, this is a young, energetic doc who loves to teach. The only serious drawback is that he performs abortions - we won't have to participate or even be present, but this is perhaps the sole issue that indelibly colors my view of this sub-speciality. There isn't anything else in medicine so polarizing. Regardless of the issue, we agreed to meet up with the doc on Thursday - he'd be in surgery all day. Importantly, he told us not to ever wear anything to OB that we'd have a hard time throwing away at the end of the day, so on the way home, Nicole and I detoured to uniform city and picked up a few sets of scrubs. As much as I love my ties, this was certainly the way to go.

Wednesday was nice and relaxing - I had time to read about the complications of delivery, work out, and go on a light jog with Nicole. Midway through the day, the program director sent out an e-mail, alerting us to the fact that (1) there would be an orientation Thursday morning so that we could get our badges (2) there would be a lecture on Thursday, despite her earlier comment, and (3) regardless of how the docs told us to dress, we were to present to the clinic where we'd receive our lectures in business casual attire. See what I mean about the plans? There goes the two weeks of study. A particularly frustrating point of contention was the "no-scrubs-in-the-clinic" rule - it's completely asinine to put on scrubs for the hospital, change into a shirt and tie for the lecture, and change back to return to the hospital. Asinine.

We showed up bright and early Thursday morning - I'd planned to have a heart-to-heart with our program director. This seemed like a good idea - our family practice rotation didn't allow carpooling or other schedule-change requests (because some idiot students had, upon deciding they didn't like a clinic, simply stopped going). I called and spoke with that program director, and very politely wove the conversation in such a way as to talk her into allowing Nicole and I to carpool. I also talked this current program director into the carpooling thing, and so I figured that it couldn't hurt to bring the scrubs issue to her attention. She never showed up. The orientation was supposed to begin at 8am - we also had to go to an orientation at Jackson North at 12 noon - but 8:45 came and went, and no one had arrived. Finally, someone showed up, and my frustration with her tardiness quickly dissipated once she'd told us that the person who'd called her to come do the orientation had never confirmed with her, and this dear sweet woman had come in on one of her vacation days. Bless her heart. So we drove back over to North Shore, picked up our badges, and made out way over to Jackson North.

Fortunately we showed up early, because there was not only paperwork to hand in, but the woman to whom we handed the paperwork screwed it up, and we had to run back and forth between physician services and human resources. Finally, we got things squared away and had ID badges for Jackson North and North Shore Hospitals, allowing us access to all the surgical suites. By that point, it was perhaps 2:00, and though we were supposed to meet up with the doc, we decided that it'd be better to cross town for the 4:30 lecture. I spoke with the P.A. student, and learned that she wasn't supposed to meet up with the doc before 3:30, so it was a done deal.

We returned to the clinic and sat down for our weekly lecture on uterine leiomyomata - the common fibroid. Perhaps they began with this topic because it's so overwhelmingly common - in fact it's the most common tumor in women. That being the case, though, it's something I've been reading about here and there since beginning medical school - so the lecture didn't really provide too much new information. Once that was over, I texted the PA student to see what was going on - and there was a C-section in 15 minutes! Nicole and I hastily put on our scrubs and burned rubber over to North Shore. Unfortunately, we were a few minutes too late - the surgery had started by the time we got there. So, Nicole and I sat out in the lobby.....waiting.....and waiting..... Finally they shut off most of the lights and announced that visiting offers were over....and then came the text. Nicole and I made our way up to labor and delivery (L&D) and met up with the doc and the P.A. student. We followed him around while he rounded on some patients, and around 10:00 that night, agreed that we'd met up on Friday. The doc told us that there were a few ladies who were getting close to delivery, but that it probably wouldn't be before 2 or 3pm; in fact, he told us not to call him before noon. That sounds like my ideal schedule!

So - my uneventful, slightly frustrating 14 hour day ended in a big bowl of lentil soup. Since we were supposed to have the next morning off, I planned out my reading - reviewing the complications and physiological changes of labor, exams of pregnant patients - and planned to take a morning jog, figuring I could relax a bit . What was that I said about my plans?

The call came at 5:45 in the morning - one of the patients was ready to deliver. I should have known that this was an inauspicious omen that would color the course of the rest of the day. I drove like a bat out of hell through the pre-dawn darkness of I-95, realizing that this was the very first experience of being ripped from a comfortable sleep by my chosen career - the first step on a long, long path. Once again, we arrived just too late, though the doc was impressed that we'd made such good time. And so Nicole and I hung around the L&D nurse's station, waiting for something to happen. An older anesthesiologist came by, looking for supplies. He didn't seem that old, but he looked very tired; he was trembling and told us it was because of the flu. So our doc made him promise to go home as soon as possible. He had to sit down to enter a security code to one of the supply closets, and finally one of the nurses had to go open the door for him. Then he placed an epidural, and went on his way.

There wasn't any time to get coffee or a meal, and so I felt as if I was swimming through cotton when the doc started giving us a lesson on fetal heart monitoring. Fortunately, I'd covered a lot of it in my reading. He was telling us about accelerations and decelerations when, out of the corner of my eye, I saw Nicole's head moving strangely. I wondered what she was looking at, and before I knew what was happening, she'd gone limp and was on her way down. I caught her and guided her to the floor, and we were immediately swarmed by nurses with orange juice and smelling salts. She stared at the ceiling with glass eyes while I patted her cheek, until she came around a few seconds later, terribly embarrassed. She said that she'd just gotten really hot all of a sudden, thinking that she should sit down - and then we were all around her. After one of the nurses made her some coffee and got her a donut, she was as good as new.

We stood around waiting for something else to happen after that, and finally they called the doc back because one of the patients was ready to deliver. It was my first time seeing anyone give birth, and after watching Nicole faint, I was wondering how I'd handle it. One the one hand, I was nervous that I'd be grossed out, but on the other hand, I'd been told how amazing it is, and that it makes one think of the miracle of life. The reality was somewhere in beteween - this particular mother was very calm and at-ease - she'd actually walked passed us in the lobby last night while we were waiting for the doc. She took a few deep breaths, gave a few good pushes, and her little boy popped out with a full head of hair. As I watched his entrance in the world, I couldn't help but recall all of the changes that happen when a baby takes their first breath of air, and their physiology switches over from womb to world. He was a perfect little guy - all of his fingers and toes, pink and healthy, and screaming like there was nothing else to do.

The second birth I watched today was far different - this mother had had 2 epidurals and was still in serious pain. She was dilated to 8cm hours before, but after checking on some patients in the mother and baby section, we got the call that she was ready to go. There was a lot more screaming to this one; it was more how I imagined it to be. The mother was in a lot of pain and was exhausted from her labor. Finally, she squeezed out her perfect little girl, also pink and hollerin'. The P.A. student had shown up by then - apparently, she only watched 3 deliveries before the doc really let her participate. For this birth, she jumped right in like an old pro - helping position the mother for the birth, and then delivering the placenta. I don't feel like I know anything about obstetrics yet, but I guess I've seen enough to be useful.

After checking on and discharging some other mothers, the doc told us that it was unlikely for anything else to happen before 3 or 4 this afternoon, so we were done for a while. We were headed down the stairwell to the parking lot when he turned around to us and said "Hey - you guys remember that anesthesiologist from this morning?"

"Yeah, "I said - "He told us he was shaking because of the flu".

"No," said the doc "He had a stroke."

"What? When?"

"This morning."

Wow. Luckily, there was no place better to have a stroke than in a hospital. Wow.