Saturday, December 23, 2006
Wednesday I had 4 scheduled surgeries and two inductions. The first surgery was a 400 pound repeat C-section. Her initial incision was, for some reason, made high on her abdomen, transverse, through the thickest part of her pannus. (We are talking about one foot of fat here, at least.) Due to the increased risk of infection making an incision in a low position under the pannus, we decided to use the same site. To add to the fun, the baby's presentation was transverse back down. We had to rotate kiddo to vertex, then I used a vacuum to gain the proper traction to deliver the baby. Fortunately, I had a seasoned OB as a first assist, and we both struggled with this case. Comparatively, the remaining surgeries progressed in a fairly straightforward manner.
One induction was for post-dates, one was for pre-ecclampsia. In true pre-ecclamptic style, my first induction zipped from 3 cm to pushing in about an hour, max. My second induction never made it past 4 cm and -2 station, as the baby decided it was against this whole labor business and decided to have huge, ugly late decelerations. To the OR we went, and thus I had my 5th surgery of the day.
My parents are in town, and CindyLou is just beside herself with all of the attention being lavished upon her. My mother baked (love you, mom!) and my dad fixed up the Grinch-y Christmas tree so that all of the lights are lit and the star is straight! I addressed all of the Christmas cards this morning (better late than never). Now I have to get myself together, get to the hospital to round and to tell my 39 weeker with gastroenteritis why this is *not* the ideal time for induction (what she wants), what with her puking her guts out and all. Then it's off to brave the last minute crowds to finish up the shopping! I will likely be incommunicado for a bit, with all of the family and holiday and work obligations, but I want to wish all of you a very Merry Christmas and the happiest of New Years!
Monday, December 18, 2006
I also got a really nice compliment today from the OB that I went to see in University City. I refer high-risk patients to this clinic, and the doc today said that they always welcomed my referrals as they were always appropriate. He said "If you call us after-hours about a patient, we know that she needs to be here." So very nice of him!
I am feeling all warm and fuzzy and happy now. We celebrated by taking CindyLou out for Mexican; she even ate salsa! I just wanted to give you a quick update and to thank all of you for all of your wonderful comments and support through all of my angst-ing. Your kindness has meant so much to me. Y'all are the best! More later, must. dictate. charts. :)
Saturday, December 16, 2006
~people whose job resides within the confines of 8 to 5
~people that don't have to work at all
~one of my colleagues that is working in a large group and only has call one weekday each week and one weekend each month
~every person that has their holiday shopping/decorating/baking done
~anyone whose Christmas tree has not fallen over (twice) this season, thus destroying countless ornaments and hence appearing as though the Grinch has attempted to stuff said tree up the chimbley
~my patients that lounge upon my exam table (in their pajamas, no less) and proclaim how the hour of 10 am is "sooooooo early" to be at an appointment
~my patients with the unmitigated gall to start asking for medical maternity leave at 8 weeks gestation because they are just "way too tired" to work
~anyone whose job perks include having every single holiday off...Thanksgiving, Christmas, New Year's, etc. Not to mention everyone whose job guarantees every single weekend without work obligation
~organized people (like those crazy people from whom I received Christmas cards in freaking November!)
~people with time in their life to sleep, to exercise, and to prepare healthy meals for their families
~Fat Doctor, who has spent the last few weeks making the conference rounds at fun locations (so jealous!)
~people that aren't so whiny and complain-y as I
~people that can brush their teeth without fear of yakking
~people that know how their pregnancy is progressing without fear or worry
All right, enough pity party for now. Lest the strident objections about how I "chose" this lifestyle and "knew what I was getting into" when I became a physician arise, let me say that there really is no way to anticipate how difficult this kind of life can truly be until you are actually living it and unable to turn around and choose again without serious repercussions. I would say that 90% of the time I love my life, and wouldn't change a thing. Sometimes, that 10% that I would like to change gets a little vocal. I have so many blessings in my life for which to be grateful, so maybe I should start listing them when I start feeling my green-eyed monster stirring about.
Now I must do some serious internet Christmas shopping. I don't think anyone in my life would be getting any presents at all if not for the wondrous internet. I heart shopping online. Happy weekend to all!
Saturday, December 09, 2006
First, from Dr. K at That Mirror belongs to Frank - My 5 favorite Christmas Songs.
1. God Rest Ye Merry Gentlemen - My current favorite is performed by the Barenaked Ladies and Sarah McLaughlin, and it is such a cool version, how can you not love it?
2. O Holy Night - This song never ceases to make me tear up, pregnant or not.
3. Carol of the Bells - I identify with the frenetic pacing of this Carol. Makes me feel right at home!
4. Tie! Simply Having a Wonderful Christmas Time - Paul McCartney This is a song that is really happy and cheery, and it reminds me of my parents. (P.S. Ew, while looking for a clip online I found out that Hilary Duff ruins, I mean, covers this song. My ears! Ick.)
Rudolph the Red-Nosed Reindeer - My childhood favorite, now CindyLou's very favorite, as well.
5. Adeste Fideles (O Come All Ye Faithful) - Only because I took Latin once upon a time, and I can actually sing this entire song in Latin. Yes, I am a dork.
Honorable Mention - Just about any song from John Denver and The Muppets - A Christmas Together. This just really takes me back to my childhood and Christmas with my parents. Also guaranteed to make me bawl like a little girl.
The second meme comes from At Your Cervix, and is titled "6 Weird Things." Only 6? Hmm.
1. I think that I have mentioned before that I have a real social phobia. I know this is weird because I interact with multiple people, strangers, in my every day work and life, and do quite well at it. However, in residency, I developed a true reluctance to answer the phone at home...ever. I think it stems from having such a demanding job, and I am wanting my time at home to have no other demands placed upon it. I am a real call screener. Sometimes I can make exceptions for my mother, but most of the time, I have to talk myself into answering the phone. Also, I hate to call in orders (like for pizza, etc.) or speak to people I don't know on the phone. Email can also go unanswered (and sometimes even unread) by me for weeks because I can't handle the pressure of a reply. Weird, right? I should be on medication for this.
2. I dig the paranormal. Ghosts, hauntings, astrology, tarot cards, divination, you name it, it is fascinating to me. I know my rising sign and where my moon is and have analyzed my and Mr. Whoo's astrological charts. I can also be very superstitious. This is weird because most of me is very rational/scientific, but I'm a sucker for anything extraordinary. Must be the Pisces in me. ;)
3. I eat spaghetti with ketchup on it. Yes, you read that correctly. Spaghetti with ketchup and parmesan cheese, and sometimes butter. This evolved from childhood, when my mother used to add a little ketchup to her spaghetti sauce on my serving, because it took the spice and bite out of the sauce for my young, delicate palate. It has since mutated. This habit really grosses Mr. Whoo out, but he eats tuna in mac and cheese, which I find equally disgusting. (How can you defile mac and cheese in this way?)
4. I am somewhat claustrophobic. While I don't dig small places, the true underlying fear is being unable to breathe. If I am in a small place, but can feel cool air blowing past my face, I am usually ok. I once had a total meltdown whilst "caving" in Tennessee on a youth group trip, because in one portion of the cave you had to get down and *roll* to pass through the cavern. Huge rocks on the top of you, mud and dirt beneath you. Freak out city. I also have to sleep on the right side of the bed, because I sleep on my right side, facing right, and have to have air in front of my face.
5. I was a Navy brat. I grew up moving about every 2 years, which sucked. My dad retired from the Navy when I was 12 or 13 and we moved to Florida where I completed high school, college, and med school before moving northward for residency. Mr. Whoo and I hope to stay put so that CindyLou can have the experience of growing up in one spot.
6. As a child, I was obsessed with Unicorns. Loved them to pieces. Think of Kate from Dodgeball, except that the obsession did not follow me into adulthood. I wanted to believe they were real, and I had a book extolling all of the possibilities of the existence of unicorns. I had a blue million "My Little Ponies." (Which, I am happy to report, CindyLou now adores.) I have an obscene collection of unicorns packed away in my basement, just waiting for CindyLou to be ripe for a passion of her own. Evil Mommy.
I know that I am now supposed to tag other people to do this, but I think that everyone I read has already done these memes weeks ago! If you haven't yet, consider yourself tagged. Lazy = me.
P. S. S. As for the bean, no news, thus far, is good news, right? So far everything is status quo, gagginess, fatigue, et. al. No bleeding or cramping, so I assume the bean is hanging in there. My appointment isn't until the 18th, so I am trying not to obsess too much until then.
Saturday, December 02, 2006
~ show up to round at least half an hour after the physician is already there, and a full hour after the time that s/he told you to be there
~ after being late to said rounds, ask "Well, you don't want me to write notes on the patients *now*, do you?"
~ when your precepting physician asks you to pull up a newish drug on your fancy new PDA to check for interactions, do not say "Don't *you* have one of these to look things up?"
~ wander over and play with the newborn kiddo while your precepting physician is repairing a second degree, and trying to show you how to do it.
~ make up a lie about an ailing, possibly dying, relative, in order to get the full week around Thanksgiving off, rather than just being upfront, honest and asking for the time outright.
~ ask your precepting physician for the dosages of medications when writing prescriptions (after s/he has told you several different times, nevermind that you have a fancy PDA to look them up) because "It's easier to ask you than to look it up."
~ near the end of the rotation, when you are well versed in discharge instructions and discharge meds, when the precepting physician asks you to get a patient's discharge ready, do not ignore her/his request, and instead, play with one of the newborn kiddos in the nursery because "She was crying."
~ decline to watch a circ because you've "seen enough of those, already."
This is just a sampling of the smorgasbord of med student miscues during a recent rotation. It really blows my mind (long winded tirade ahead) because when *I* was a student in a large teaching institution, my butt was rounding on patients at 4 in the morning, frantically getting notes written, vitals, and labs pulled before the intern came in to round between 5 and 5 :30 am. You wouldn't dream of getting to the hospital after the intern much less the attending! All discharge orders were skeletonized (along with prescriptions) and tucked in a pocket in the front of the chart in order for more efficient discharges. If (and I do mean if) the attending ever spoke to you directly outside of lecture and asked you to do something, you better have it done before the request was cold in the air! You certainly didn't smart back. Declining to watch *any* procedure? That just didn't happen. Because of the atmosphere in the hospital in which I trained, you functioned as a Sub-I when you were a third year, and really, as a fourth year, you functioned as an intern. I realize that a small community based hospital is going to be cushier, and definitely not as much work as a large inner city hospital. The respect and interest in learning should be the same across the board though. *Sigh*
Okay, you can start reading again. I'm done ranting for now.
In other news, Mr. Whoo is sitting out in the freezing cold woods looking to shoot some poor defenseless animal, CindyLou is watching her 3rd episode of Mickey Mouse Club-house, and I am getting really good at holding my breath when opening the fridge, lest the smell of the food in there make me gag. I really don't think there is anything rotten in the fridge. Mr. Whoo can't seem to smell anything offensive, but I'm gagging just the same. I'd like to know what is going on with this pregnancy, because I'm really not digging the gagginess, but I would gladly take it if it meant that the bean was going to be ok. I have made the decision not to order any further testing on myself, and I will wait until I see a physician in University City and let them diagnose me...hopefully sometime next week. Thank you all again for your kind thoughts, wishes and prayers. You are the best, and I will keep you updated. :)
Tuesday, November 28, 2006
As for the little July bean, it is still only a bean. The USG shows a 5w2d gestational sac with yolk sac. (EDC July 29) It seems to look ok (good decidual reaction, etc.), but I'm concerned because I figured my dates to be about 6 weeks. It is definitely feasible (TMI) that conception happened on Nov. 4th, but I figure that's a little late for ovulation. HcG is about 10,000 (ok, but really should see a heartbeat around this level) and progesterone is a little lower than I am happy with at 14.5. So, I may be dealing with an SAB, which sucks, but it happens. I'm waffling on supplementation, since there really is no evidence that it helps (it just may make me feel like I am doing *something*!)
Nothing to do but wait and see. I firmly believe that everything happens for a reason. I'll repeat the USG next week and pray a lot between now and then. The good news is that I conceived within 2 months of trying, so I still have decent fertility. This may be the universe's way of telling me to get into better shape before I start a pregnancy. Thank all of you for your wonderful comments and concerns. I promise to write more this weekend when I am finally free of laboring women for a full 2 days. (Yippee!) You guys are awesome, I mean it.
Sunday, November 26, 2006
The multiple hits kept on coming through Thursday evening, between the ER and OB triage, I think I was paged every 1-2 hours. Not very conducive to rest, I might add! Earlier in the week, I had gotten the early morning (5 am) bathroom report two mornings in a row from one of OtherDoc's patients, QuestionWoman. I was treated to a fantastical description of the appearance of QW's mucus when she wiped (clear with a few brown spots if you must know). I was thrilled beyond belief to tell this woman (not a first time mother, either) how normal she was, both mornings. Fast forward to 1 am on Friday morning when I got the ruptured water report, followed by the question of what to do? (Hmmm, I wonder?) I pushed back my jaded cynicism and tried to be a pleasant and understanding sleep-deprived physician. I put my very best phone voice on and urged her to get up to OB triage, and then silently prayed that she had peed. No such luck, the call came in from triage at 2:30 am, she was definitely ruptured.
CindyLou's daycare was closed on Friday, and in an unprecedented show of optimism, I had figured that I would be able to bring her to round at the hospital, then spend the majority of the day at home, having mother-daughter time. Well, that all went out the window with a labor patient, so I asked Mr. Whoo to take CindyLou to his office during my rounds, where I would pick her up in between rounding and delivering QW. I discharged the one patient that had the miscarriage, and got QW tucked in with her epidural right around 10 am. I was about to fly to Mr. Whoo's office to pick up the munchkin and get her home for lunch when I received the wonderful news that another of OtherDoc's patients was in triage with ruptured membranes. "That's funny!" I told the triage nurse, "Great joke." Only she wasn't joking. Ok, make that two labor patients. I called Mr. Whoo back and broke the news that it was he that got to keep CindyLou for the work day, and I felt terrible. He was his ever-gracious self, though. I love that man.
Long story, short, between the two labor patients and multiple triage visitors and admissions(some of whom were actually *my* patients), I was at the hospital until about 6:30 Friday evening. I got to see CindyLou for about an hour before she was ready for bed. I stayed up until around 10:30 or so, more just to decompress from the day than anything, and I then became as dead to the world. I was awakened by tiny fingers on my arm at 1:45 in the morning. In my sleep fogged brain, I didn't question the rarity of a middle of the night venture into our bedroom, I simply began to lift CindyLou into the bed...and then I touched something damp on her PJs. That smelled like vomit. (Mental note to self, do quick puke check on darling child *prior* to lifting her into your own bed and fouling your own sheets.) The poor thing had vomit all over the front of her PJ's. The smell was just a little too much for my super-sensitive nostrils, and it triggered my extra-sensitive gag reflex. Before I made my own mess, I handed her off to Mr. Whoo, composed myself, and set about cleaning the bed.
Vomit was *everywhere;* on her pillow, on the side of the bed, and piled on the floor. I couldn't believe that we didn't hear her puking on the monitor. I felt like a really bad mommy. Between the two of us, with Mr. Whoo dealing with most of the vomit clean up due to my constant gagging, we got CindyLou cleaned up, clothes changed, hair washed, her bed remade, and tucked her back into bed. Then we changed our own bed and puke tainted clothes, and were back in bed by 2:30. Cue the pager at 3:16 am. ( I am not kidding.) One of my patients (1 of the the remaining 2 due this month) was in triage, a mere 8 cm dilated. I was out of the bed, dressed, and back at the hospital by 3:45 am. The patient delivered her baby in about 15 minutes, and sustained a partial 4th degree tear in the process, despite my best efforts. Ah, there's just nothing like fixing a 4th degree on a woman without an epidural at 4 am. Fun times.
I finished the delivery, and dragged myself to the nurses' station to write orders, where I was greeted with more wonderful news that OtherDoc had yet another term patient in triage, who had (you guessed it!) ruptured membranes. I considered dissolving into a raving, sputtering heap at that very instant, but somehow kept it together enough to find out her stats and determine that I could, at least, go back home and sleep in my own bed for a few hours. I drove, zombie-like, back home, narrowly missed hitting a deer, and fell into my bed at about 5:15 am. At this point, sleep was fitful and disjointed, and punctuated with pages at 7 and 9 am. OtherDoc's patient was requesting an epidural, so I dragged myself out of bed and back to the hospital by 10:30 am. I rounded on a gazillion patients, admitted yet another one of OtherDoc's patients with ruptured membranes (are you seeing the pattern, here?) for a repeat C-Section, did the C-section, caught a baby, and made my way back home in time to watch my Seminoles blow opportunity after opportunity to beat the hated Gates. I don't think I did much more than stare blankly at the TV for the remainder of Saturday. I was too tired to even nap. Mr. Whoo is amazing, and he had the whole kitchen cleaned up, and even did laundry all day yesterday. He is Superman.
I had a few more pages for wanna-be labor contenders last night, but no further admissions, thank you, lord. I still have 7 or 8 patients to round on today, and 5 o'clock (when OtherDoc starts taking his own patients again) cannot get here fast enough. Unfortunately, I'll not have much of a reprieve this week. I have a few inductions, a few surgeries, and full clinic days looming ahead. Thank goodness for a weekend off in the not too distant future. I can't keep this frantic pace; I am getting too old for this!
Thursday, November 23, 2006
Mr. Whoo and I have the Thanksgiving dinner down to a science. I'm almost positive that we have had Thanksgiving at home for the five years that we have been married. I cook the stuffing, he preps the bird, I peel potatoes, he mashes them, I set the table, and he carves the turkey. We are a well-oiled, Thanksiving dinner making machine. I baked my pumpkin pie last night, and had CindyLou help me mix it all together. It was so much fun to "cook" with her. She is growing up so fast. I only had to make a quick run to the hospital this morning to round on one patient (that I released this morning to go to her own Thanksgiving Dinner). I figure that this Thanksgiving will play out much like Thanksgivings that I have worked in the past, very peaceful, until, that is, after everyone has finished their dinner! Then, either they figure "Hey, the family is all together! What better time than now to head to the hospital en masse to see if Sally Jo happens to be in labor?" or the pregnant moms start mistaking their indigestion for labor pain. It never fails. It goes the same for Christmas, as well.
I have so very much for which to be thankful this year. My wonderful husband and daughter, my family and extended family, our wonderful friends, a lovely home, a job that I love (most days), good health, and the promise of new little miracle, due sometime in July. God has truly blessed our lives, and I am so thankful, today and every day. God bless and Happy Thanksgiving!
Sunday, November 19, 2006
Mr. Whoo was a bit more productive (as always), and he even took it upon himself to groom our fatty-bobolatty cats. You see, once a kitty reaches such gargantuan proportion, it is damn near impossible for them to clean their backsides. Therefore, it is up to us to brush and groom the hapless creatures. Our girl kitty bears the brunt of having "bad hair." She has tons of kitty dandruff, and her fur gets really oily. Mr. Whoo brushed the equivalent of a whole cat's worth of hair from her back, and then remarked how nice it would be if someone would just invent a handy-dandy spray in order to spruce the cats up with minimal effort. "They could even call it Ca-breze," he quipped. Hilarious. Everyone knows how fun it is to give a cat a bath, so Cabreze sounds like a phenomenal idea to me!
We also had our Body for Life "free day" yesterday, in honor of college football. We ordered Chinese delivery at 11:00 in the morning, y'all. We are pathetic. It was sooooo good! So far this week I am down 4.2 pounds, and I haven't even been getting all of the meals into the day, so I am pumped. It is a good start, at any rate. I used to live every day like it was a "free day" so eating on track this week was a true eye-opener. This week I need to try a little harder with the weight lifting. I am such a puss, and I know I'm not pushing myself as hard as I should be. I am really proud of Mr. Whoo, as well. He's lost over 6 pounds! (He has been much better about sticking to plan and really utilizing the workouts. I think it is because he made the mistake of telling one of his buddies about BFL and now said buddy is starting the program, too. Ever the competitor!)
Today we went to church and I cried through a really nice service about giving thanks and counting blessings. It was really very touching. Then we braved the masses and hit Sam's club and the grocery store to stock up for our Thanksgiving feast. Now CindyLou is napping, Mr. Whoo is out scouting hunting sites (insert eye roll here), and I am blogging, procrastinating dictating my delinquent charts, and watching a herd of deer in the backyard. It's been a good weekend; let's hope this trend continues throughout the week!
Saturday, November 18, 2006
Labor patient number one had been plagued by pre-term contractions since her 32nd week of pregnancy, but finally came into labor on her own at 39 weeks. I checked on her before my 7:30 surgery and found that she was 4 cm and getting comfortable with her epidural. The nurse requested an internal monitor, because her contractions weren't tracing well, so I broke her water and placed an intrauterine pressure catheter. Her contractions were just one minute apart! I predicted she would be the first to deliver, but I was very surprised to be called out of my second surgery (a hysterectomy) at 10:00 because the patient was ready to push! Fortunately, I had another physician assisting me with the hysterectomy, and he stayed with the surgery patient (we had half of her uterus dissected already) while I ran upstairs to deliver the super speedy baby! I was in such a rush to get back to the surgery patient that I ended up sticking myself with a needle whilst repairing LP#1's perineal laceration.
Stupid, stupid, stupid. I berated myself all the way back to the OR. Most of our OB patients are very well screened for communicable diseases, but it is always scary to get a needle stick. I hadn't had one in over 3 years (back when I was a resident, on night float, and pregnant to boot). I re-scrubbed and finished up the surgery with my colleague. It went very smoothly, as it always does with another physician assisting. I wish I had this luxury all the time! After the hyst was finished, my surgery day was over, and I went to the depths of the hospital basement to complete the necessary forms and get the requisite blood drawn for the needlestick panel. Ouch. Everything came back fine, with the patient's bloodwork and my own, thank goodness.
My second delivery of the day was an induction for mild pre-ecclampsia at 38 weeks. I had used m.isoprostol overnight for cervical ripening, and the patient was already 5 cm on her first cervical exam. It wasn't surprising when she delivered the baby shortly after noon. The delivery itself was quite smooth and very touching. I just love it when the Daddy cries. It really tugs at the heartstrings. Even better, the patient's blood pressures stabilized almost immediately after delivery.
My third (and most unexpected) delivery of the day was an induction of labor for an LGA baby at 37 weeks. The baby was macrosomic (measuring just over 9 pounds by ultrasound) and the mother was a primigravida with an unproven pelvis. The patient is employed by the hospital in a health care capacity, so that usually means some kind of complication. I know it sounds paranoid, but physicians, nurses, physician's wives, and health care professionals in general have some of the most complicated and bizarre labor and delivery outcomes of any other group. I have no idea why. At any rate, upon her initial exam, her cervix was so closed and so thick and high that my stubby little fingers could barely reach it. I psyched her up for a 2 day induction, reviewed c-section risks, and placed misop.rostol the evening prior. Overnight she had gotten a total of 3 doses of mi.soprostol. The night shift nurses told me that they never could find her cervix overnight, so imagine my delight to find her 2 cm dilated and 90% effaced when I checked her!
I immediately broke her water to place internal monitors because the patient was a little, well, "fluffy" and the externals were not even registering contractions and the fetal tracing was spotty at best. The patient had been asking for an epidural for a few hours, so she finally got her wish, and I got on with my surgeries and other deliveries of the day.
I still fully expected the labor to last well into the evening. I walked out of my second delivery to find that my third patient was complete and pushing! Crazy. In true primigravida form, it took her a little time to get the hang of pushing, and after a little over an hour, the labor nurse came to me, expressing concern about the patient's pushing progress. She had also started bleeding a little more briskly than usual. The epidural was turned off, and I stayed in the room for the next 45 minutes and helped push with the patient. When I checked, I could feel a posterior vaginal laceration, and I worried about a posterior fourth degree. She did very well with just a little encouragement, and she was able to push the baby out without forcep or vacuum assistance. The laceration was a cell membrane away from a fourth degree, but did not go completely through. However, it did extend along the left vaginal sidewall all the way up to the posterior fornix, and due to her habitus, was more than a little difficult to repair. I put two layers of suture in, and the repair took nearly 40 minutes. I guess she didn't completely escape the health care provider curse, after all. The baby weighed over 8.5 pounds, and I am certain that her mother did not have even one more millimeter of room to push her out, so I was very glad that we induced labor when we did!
Thursday was more clinic, more paperwork, and a stat c-section for fetal bradycardia. (Mom and baby both came through ok.) Friday was a half day of clinic and a half day of charting. I didn't leave the office until nearly 6 pm, but I finished every last one of this week's clinic charts. I can actually see my desk! Now I have to tackle my delinquent dictations this weekend (alas, my weekend off is not even a *true* weekend off) and I may finally be caught up...until Monday starts the process all over again. I am also covering for OtherDoc for the whole of next week, so I am hoping that he delivers all of his November patients this weekend! Geez, I am tired just writing about this week, and I am sure you are all snoozing at your computer by now. Happy Saturday!
Tuesday, November 14, 2006
I bolted out of bed and told the mother that I would meet her at the hospital. I notified the OR about the possible surgery and headed in. While I was waiting for the patient to arrive, I checked on my admitted patients. One patient had been admitted the day prior for pre-term contractions at 32 weeks. I had placed her on magnesium sulfate for tocolysis and initiated betamethasone therapy for the fetal lungs. Upon admission she was 2 cm dilated. Overnight she had contracted irregularly on the magnesium, but the contractions had appeared to slow down. She had started complaining of increased pelvic pressure about 15 minutes before I arrived, so I re-checked her cervix and found her to be 4 cm dilated with bulging membranes. I made a few phone calls and arranged her transfer to UniversityHospital, about 30 miles north. Our nursery is not equipped for infant care less than 36 weeks, so off she went. Last I heard, she's still pregnant.
Next was my labor induction for post-dates. Her previous labor had lasted for over 24 hours, and she was convinced that she would labor all day long. About 7 am she was 3 cm and 90 percent effaced, and the head was at 0 station. I broke her water, told her she would have a baby before noon, and told her if she wanted an epidural, she'd better ask for one sooner than later. She laughed it off, as did the nurse. While I was admitting my ovarian torsion patient, the nurse paged me and told me that the patient had just gotten her epidural and was feeling pressure to push. I ran upstairs while they prepped the torsion patient for surgery and caught a baby; less than 2 hours from the time I had first checked her cervix.
Then it was back to the OR for the surgery. All of the imaging studies had suggested that the ovarian cyst was originating on the right ovary, so imagine my surprise when the patient's torsion was actually in her left adnexa! The right tube and ovary were perfectly normal. The adnexa was not twisted once or twice; it was twisted on the pedicle no less than 4 times. The Fallopian tube was a hematosalpinx and it was irreparably damaged and filled with clot. It measured 12 cm by 10 cm. The ovary appeared dusky, but I made an attempt to salvage the tissue. There was bleeding in the uterine cornu that was difficult to control, but it was all hemostatic by the end of the case. The real kicker is that there was no ovarian cyst at all! The ovary, while edematous from lack of venous drainage, had no cystic lesion. So where was the pelvic cyst? I'm not certain. I am awaiting pathology, but I guess it is possible that the cystic lesion in the pelvis was arising from the Fallopian tube, perhaps in the form of a hydrosalpinx. That is pretty rare in young patients, and even more rare in a women that is not sexually active, but until I have the pathology, I guess I'll just have to speculate. Today, the young girl, even after major abdominal surgery, says that she feels a million times better! I feel badly that she has lost her tube, but hopefully the ovary can regain some function.
Needless to say, I never made it to the office on Monday. This means more double-booked clinic appointments and hellish clinic days for me. Bleargh. It also means that I got a late evening phone call by a patient I have yet to see (her appointment was cancelled because I was dealing with emergencies). She was really very nasty, demanding that I order her another h.cg level, since she hadn't had one in 2 whole weeks and she was having some cramping. She was having no bleeding or spotting. I tried to explain that another single level would not tell me anything about the status of her pregnancy, and if she was concerned about the pain to go to the ER. Otherwise, I told her I would order an ultrasound in the morning (US department goes home around 9 pm, and suffice it to say her call was later than this.) She was still supremely pissed off when she hung up the phone because I had the unmitigated gall to cancel her first OB appointment due to other people's emergencies. Frigging shame on me. One day, I shall manage to be in all areas simultaneously, so as not to upset such delicate sensibilities.
(Before I get flamed, yes, I know she is worried. I understand this. Cramping can be scary, but it is also a normal early pregnancy symptom. She has already had 4 normally doubling betas and an ultrasound that shows a viable intrauterine gestation. I am not without compassion, but I recognize obsession when I see it. She is only 7 weeks, and it is going to be a looooonnnggg pregnancy at this rate. Maybe I'll transfer her to high risk? Tempting.)
As for Body for Life? This is day two. I'm doing pretty well with staying with the eating plan...except for getting all of those meals into a day. (Seriously, I barely have time to pee, much less eat every 2 hours). Right now I am procrastinating my upper body workout in favor of writing this blog, and dreaming about what I am going to eat on my "free day." Somehow, I don't think that this is the way it is supposed to go. Ah well. Enough rambling for the day, I've got surgery charts to dictate for tomorrow.
Saturday, November 11, 2006
Also, I'm not quite sure if I should be insulted or not, but today the nurses on L&D were asking me how old I was; I told them that I was 31, and they seemed, well, disappointed! They thought that I was a lot older than they (alas, I was not!) I guess that I don't look as young as I think I do, but the nurses were sure that I was 35+ years old. That freaks me out, because I have always looked younger than my age. I think a lot of the problem is the extra weight that I am carrying. It definitely adds age to my face. I am also pretty sure that I am about to start another period, and while we haven't been *trying* to get pregnant, per se, we have not been preventing pregnancy, either. I know that I am not in the best physical shape for a pregnancy, so maybe God and the universe are trying to tell me something.
In other news, Mr. Whoo and I are starting Body For Life this week. I am going to try to post updates, in order to motivate myself and also to keep me in line! This is the program that worked so well for us, prior to our first pregnancy. I abruptly had to stop the BFL secondary to severe nausea and vomiting. I couldn't even look at chicken for the entire pregnancy. Crazy. Since there is no pregancy holding us back, we are getting back with the program. Maybe now I won't have to feel like such a hypocrite when I counsel my patients on weight loss. It is grey and dreary and rainy here, I hope that the weekend is brighter wherever you may be.
Thursday, November 09, 2006
Right now I am Hating....
....being on staff call.
....working for the last 12 days straight.
....not having a day off until next Friday evening.
....getting a combined 10 hours of sleep in the last 72 hours.
....jumping as though shocked every time I hear a beeping noise, even if it is only the gas pump and not my pager.
....missing CindyLou's bedtime on Sunday, Tuesday, and Wednesday.
....the fact that CindyLou's daycare is closed tomorrow.
....that I can't just cancel my patients for tomorrow.
....that my house is a wreck.
....the fact that OtherDoc is going out of town for the *entire week* of Thanksgiving, leaving me to cover his umpteen-million patients (that, most likely, will collectively go into labor on Thanksgiving Day and ruin my dinner plans.)
....not having clean laundry.
....politics - local, national, and global.
....the 642 charts littering my desk, waiting for me to document exams that happened days ago.
....having major schedule issues, and no office manager available to correct them.
....that the office manager is OtherDoc's wife, and thus not easily fired.
....not having another vacation planned until the very end of December.
....feeling like a hypocrite when I am counseling other people on how to lose weight.
....having to argue with a nurse about Methergine injection location semantics, whilst my post-partum patient (another nurse!) was hemorrhaging.
....being so used to living in the hospital, that I actually dialed a "9" (to get an outside line, you see) on my HOME phone.
...."dropped bladders" and incontinence.
....the PMS monster.
....being a crappy friend.
....feeling guilty about being a crappy friend.
....that none of my close girlfriends are within a weekend's driving distance.
....dreading seeing my office schedule every day, and thus, dreading work.
....wishing my life away, just to get to the next break from being on call.
Whew, I think that is enough for now. Just can't wait to see the Google hits I get from that post! It is really strange how I feel so much better after writing it all out. Thanks for cyber-listening, and I promise to return you to your regularly scheduled snarking as soon as possible.
Monday, November 06, 2006
I recently saw a patient in the office as a new OB patient. I noted from her chart that she was in her 40s, which, while quite common in more urban areas, is practically unheard of in this rural area of the country. I also noted, based on her stated last menstrual period, that she was nearly into her third trimester! Unsure of what to expect, I entered the room to find a very pleasant, very anxious couple. Ms.X had a long history of irregular periods, and it was not unusual for her to skip several months at a time. She stated that she had been very tired for several months, as well. Over the last week, she went to an urgent care center to be treated for symptoms of a URI. She also complained of nausea and vomiting, and, because of her remote LMP, the PA ordered a urine pregnancy test. It was positive. Unfortunately, the center did not do a pelvic exam, order an ultrasound, or a serum beta.HCG (!) So, this poor patient and her husband had no idea exactly how far she was into the pregnancy, and they had been agonizing for the past week, awaiting her appointment with me.
Ms. X has had 2 previous cesarean deliveries, and both of her children are in their 20s. One of her children is currently fighting in the war overseas. She is shell-shocked, and cannot believe that she is pregnant. Over the last week, the flutters she once attributed to gas pains, she now recognizes as fetal movements. On exam, her fundal height was greater than 34 weeks, and her cervix was 1 cm dilated. The fetal heart tones were nice and strong in the 140s. I don't have an ultrasound in the office, so I set up an appointment for a full ultrasound. It may feel like the shortest pregnancy on record, if she ends up actually being as far along as I believe her to be. Limited or no prenatal care can be problematic, especially in a patient that would be considered somewhat high-risk, based on age alone. I am anxiously awaiting the dating from the ultrasound to proceed with proper testing. The kicker of the story, though, is that her child that is overseas is coming home for a surprise visit, right around the time that the baby would be due to deliver. Her husband took me aside, told me of the surprise visit, and his eyes teared up as he asked if it would be possible to deliver the baby during the homecoming. I told him that I would do what I could, but given such little information at present, I could make no guarantees.
As they left, it struck me how this child is going to rock their proverbial world. Imagine, thinking you were done with child-rearing, looking forward to menopause and retirement, only to be faced with starting all over again! I've probably mentioned before that "the best laid plans of mice and men often go awry" is kind of like my own personal mantra. It just goes to show that sometimes you just don't know what life has in store for you. It is definitely a wild ride!
Saturday, November 04, 2006
My husband's redneck trait? His penchant for hunting and killing poor defenseless animals. My redneck trait? I'm a packrat, and I like to drink just a wee bit more than your average citizen. My mother's redneck legacy? She is a Christmas freak. She has every sort of Christmas decoration known to man, and keeps buying more every year. My friend, ChurchMom, loves shopping at Nordstrom. Her whole house is decorated in Pottery Barn, and she is a bit of a label junkie. Her favorite pastimes? Watching Nascar, baseball, and drinking beer. I can think of a redneck trait in every single one of my (usually refined, and quite well-educated) friends. We all buy more than we need at Wal Mart. We secretly enjoy Jerry Springer, even if we would never admit it to our seemingly "classy" friends. Maybe this is bourgeoise rhetoric. Perhaps the truly aristocratic of our society wouldn't dream of collecting snow globes or decorating the front lawn with huge, blow-up characters; nor would they be caught dead at a Nascar rally. Perhaps you can breed the redneck traits right out of your lineage, but I like to think otherwise.
I have patients that could write the book on being a redneck; yet they are the most genuine, passionate, and generous people that I have ever had the good fortune to know. Being a redneck, in many ways, can be a positive personality trait. It all hinges on your perception. How do you embrace your inner redneck?
Wednesday, November 01, 2006
I've always liked Halloween, even though I am the world's worst costume idea originator. Seriously, I suck. I don't think I have ever had an original costume idea. In Halloweens past, when I was younger and more lithe, it was an excuse to dress in a risque fashion (once I was a black cat in a one piece bodysuit, once I was a sexy devil, you get the picture) Ah, to have that body once again! This year, we asked CindyLou what she wanted to be for her first trick-or-treat. (Yes, she *is* two-and-a-half. Yes, she has been alive for 3 total Halloweens. Yes, we have dressed her up. No, we have not taken her trick-or-treating. Color us lazy.) She decided to be a "purple firefly," or purple butterfly in toddler-ese. Deciding what to be was the easy part, piecing together an actual purple butterfly costume, however, was an entirely different endeavor. My first bright idea was to order a pair of purple butterfly wings online, thinking that I would be able to find a toddler sized purple leotard and tights at the local dance shop. Maybe I could have, if only I had gone to the store 6 weeks in advance to order a leotard in her teensy size. And size 2 purple tights without a print? The single hardest clothing article to locate....ever. I had to settle for a long sleeved purple onesie (it is chilly here) with a slightly different shade of flower print purple tights. The two shades of purple looked funny to me, so I decided to get a different colored tutu to minimize the difference between the two. Part of the original costume idea was to buy a headband with sparkly antennae. Great in theory, but my child's head is still too small and her hair too fine to hold such a headband in place. Her final costume ended up looking like some kind of deranged pink and purple fairy ballerina, but she was happy as a clam. That's all that counts, right?
We live in a very hilly neighborhood, so we decided to just take CindyLou to the immediate neighbors' houses. She was appropriately adorable, and got way more candy than she (or we) needed. Our next door neighbors even prepared her a little Halloween gift bag, complete with toys, candy, and a PEZ dispenser! The people in our neighborhood are so awesome, and they give out great candy, but we have very few trick-or-treaters. (I believe it is due to the HILLS, we were dying just going to 6 houses!) Last year we had 4 total, this year we had 2 kids. Mr. Whoo and I decided that next year we are going to reward the trick-or-treaters that make the climb to our house with King sized candy bars. We had made the rounds by 6:30 pm, and made our way home for a dubious dinner of pizza and candy. It was fun, and CindyLou really enjoyed her sugar high. After we put our purple butterfly to bed, we snuggled on the couch and watched some exorcism show on the History Channel, that should have been scary, but must not have been since we both fell asleep 10 minutes into the show! Exciting times in the Whoo household, folks. When did I get old? Anyway, Happy Belated Halloween!
Saturday, October 28, 2006
In other excitement, it is a blustery, windy, and rainy day. I am awaiting the FSU/Maryland game with the appropriate amount of dread and gloomy thoughts. We are currently in the process of disposing of the 13, 547 magazines and paper clutter which grace our end tables and kitchen countertops, and I may just get my laundry done this weekend. Woot! Oh, and I got a new car. It is badass. It's the kind of car that talks back to you and will respond to certain voice commands...like Kit from Night Rider. We would not have gotten it, but we got a really sweet deal, way less than sticker, since the dealerships are trying to move their 2006 stock. Mr. Whoo was actually next in line for a new vehicle, but he is enjoying the search too much to settle on one just yet. I am off to have a glass of wine and read 7 back issues of Parenting magazine (how's that for being the model wife and mother?) Hope your weekend is relaxing!
Thursday, October 26, 2006
I fully expected to have a crappy day today. I had 14 new patients on the schedule, and I had 45 total patients on my list. I also was continuing an induction from yesterday, a primip that was post-dates with pre-ecclampsia. She never dilated more than 1 cm all day long yesterday, so I was worried about her progression, and I was really hoping to avoid a C-section, if possible. I don't know what is up with my schedule, but I started the day in a foul mood. My clinic nurse, SuperNurse, listened to my venting and told me that it would all be alright.
Let me expound, for a minute, on why I love her so very much. She takes care of me like I am one of her own children, she trusts me enough to let me care for her daughter (her daughter is 20 weeks pregnant), she loves my daughter like a grandchild (and CindyLou loves her!), she has been CindyLou's babysitter by choice, she answers my phone messages, deals with difficult patients, triages my patients, and assists me with exams and procedures, she gave me my flu shot and it didn't even hurt, and today, since she was worried that I wouldn't have time to eat, she brought me a salad and pepperoni roll from her own house so that I would have lunch. I love her to pieces, and she is never allowed to leave me. I had my own private hissy fit about my schedule for the day, she listened patiently, and then I got to work.
By the grace of God, I had numerous cancellations today, lightening the schedule significantly. As I trudged through clinic, I was in touch with my patient's labor nurse often throughout the day. Yesterday this patient had received Multiple doses of cytotec, yielding many contractions, but very little cervical change. When I rounded in the morning, she was 2cm/70% effaced/ and -2 station. I was hopeful for a vaginal delivery, but whenever you encounter such an unfavorable cervix, it is always a concern that the induction will fail. I was surprised (and pleased) to learn that she had dilated to 5 cm in just under 3 hours. The labor nurse, a seasoned professional with 20 years of experience under her belt, stated that the patient was having a few decelerations, but the baby was responding to scalp stimulation, and the labor was progressing well. I trusted her clinical judgment, and proceeded through my clinic day. Imagine my surprise when she paged me at 2:30 pm, stating that the patient was completely dilated! I quickly completed my remaining office visits, cancelled the remainder of the afternoon, and dashed to the hospital.
My patient delivered her long-awaited baby in a mere 4 pushes, and the baby was perfect, with Apgars of 9 and 9. After the delivery was completed and I sat at the nurses' station, completing paperwork, I asked the labor nurse to pull the strip from earlier, when the baby was having decelerations. Ladies and gents, the strip was U.G.L.Y. (you ain't got no alibi you ugly, hey, hey, you ugly...um, sorry, latent cheerleader tendencies emerging, here...nothing to see) It showed repetitive late decelerations and minimal beat to beat variability, for a good 20 minutes. Any other, less experienced, nurse likely would have pulled the plug on this patient due to the non-reassuring strip. This nurse, however, repositioned, started oxygen, gave positive scalp stim, and did not panic. It was fortutitous that this seasoned nurse held steady with the patient and worked steadfastly to improve the fetal status. Because of her expertise and confidence in the face of a non-reassuring strip, not only did she save my patient's peace of mind, she preserved her ability to proceed with a vaginal delivery.
Nurses save my butt every single day, and while I do my best to thank them, I fear it just isn't sufficient. So, to all you nurses out there, regardless of your specialty, thank you a million times over for everything that you do. Nursing can be such a thankless job, and you deserve so much more. Hug your nurses today, folks, they are the heart and the soul of good medical care, without them, we physicians would be lost.
Tuesday, October 24, 2006
Luckily, I was able to take her straight to the pediatrician, and they diagnosed her with tonsillitis. Since she's considered contagious for at least 24 hours after initiation of antibiotics, that meant no day care for her today, and a mad scramble for Mr. Whoo and myself to get things in order. We did some juggling, and decided that he would take the "morning shift," and I would see the patients scheduled in the morning, and cancel my afternoon patients in favor of staying home. Mr. Whoo could then head to the office and take care of some appointments and prep for an early morning meeting on Wednesday. I felt bad canceling the 19 patients that I had scheduled between 1 and 4:30, but I really didn't think that bringing CindyLou to an OB office, where she could spread her germs to pregnant people, was the best idea, and Mr. Whoo, while his job is far more flexible than my own, still has plenty of responsibilities. I don't think it is fair to always ask him to make sacrifices at work when problems arise at home.
So, here I am, home in the early afternoon, feeling as though I am playing hooky! Little CindyLou is taking a much needed nap. Her temp was still up to 101 this morning, so we've been alternating Tylenol with Motrin, and she's taking lots of fluids. Most of the day has been spent on the couch watching Disney movies and cuddling. Just what a sick day should be! For me, staying home sick with my mom meant Sprite, soup and saltines, Phil Donahue, and Days of Our Lives. I always felt cared for and safe, and I want CindyLou to feel that way. Even if my job is demanding, I want her to know that she comes first. Now I am going to do laundry, clean the kitchen, and cook a real dinner for tonight. (Color me domestic!) For today, I get to be a normal Mom, tomorrow, I'll get back to being a physician.
Sunday, October 22, 2006
OtherDoc has been practicing for nearly 15 years, and sees probably quadruple the patients that I see, he is board certified, and sticks to the standard of care in most cases. Sometimes, I think, he gets just a little too busy, and can neglect certain duties essential for transfer of care like writing notes in the chart. I come from an era in training where the threat of lawsuits lurk at every turn, and documentation is your very best friend. We were taught that the chart should be able to stand on its own. After being in solo practice for so long, I can see where you could let note writing fall by the wayside, since *you* know what you are going to do/what you have done/what you are concerned about, etc. I, on the other hand, cannot divine the true purpose for hospitalization/plan of care without some documentation. I'm also finding that OtherDoc doesn't get a chance to do a lot of patient education (as evidenced by multiple pages over simple questions this weekend), nor does he share his plan of care with his patients all that often. Such was the case with one of his pregnant patients in the hospital this weekend. As per usual, we did a quick sign out at the office on Friday, where he basically stated the patient was a "chronic hypertensive in for rule out pre-ecclampsia, oh, and her sugars are a little out of whack, too." I left check out with the impression that the patient was to have a 24 hour urine protein, and if her BP was controlled on her new medication regimen, she was to be discharged. Imagine my surprise when I pulled the patient's blood sugars for the last 2 days, 90% of which were over 200 (!) OtherDoc had written for low dose insulin the day prior, but did not tell the patient his reasoning, and therefore she was refusing the meds. I also found, after a little digging, that her 1 hour glucola value (taken last month!) was well over 200 and the baby was macrosomic with polyhydramnios. Woo hoo. Her blood pressure, ironically, was just fine on the meds she was taking.
I sat and had a long talk with the patient, who was (more than a little) in denial about her condition, about uncontrolled blood sugars and the effects on the baby. She still refused insulin, so we compromised and settled on a trial of Glyburide, with the caveat that if Glyburide did not control her glucose, we needed to proceed to insulin. I also had the dietician come in to teach the patient about carb counting and diet control. Her 24 hour urine protein was consistent with mild pre-ecclampsia, but she had not had a baseline 24 hour urine, and I have the feeling that she may have had some proteinuria prior to the pregnancy. In the end, it all got straightened out, but I feel as though I may have taken a different direction than OtherDoc was intending to take. I surely don't mean to question or undermine his management, because there are several correct ways to approach clinical problems. I'm just trying to do the best for the patient under the circumstances. I'm sure, if he desires, he can tweak the adjustments I made when he sees her next. If anything, this weekend has just reinforced how very important it is to document your plan of care, and to share that plan of care with your patients. The good news is that this weekend is nearly over, and I will then have the next two whole weekends off! O frabjous day!
Saturday, October 21, 2006
In the early years of our relationship, Mr. Whoo and I seemed to only fight when we were around his buddies. Invariably, early on, this was because one of us was more intoxicated than the other, and that divide between states of consciousness was just not easily bridged. One of our more major fights occured over a Thanksgiving weekend, when 2 of his buddies and their wives came to our house to celebrate Thanksgiving, as we were all too far from our respective families to travel for the weekend. The day after Thanksgiving, all of the boys went outside to throw the football around, leaving us girls to our own devices. It was nearly 11:30 in the morning, so we did the most logical thing; we started drinking wine. We drank and giggled and watched, I think, some dog show on TV for a couple of hours before the guys came back in from playing in the yard. I think they were surprised (and maybe a little miffed) to find us absolutely blitzed in the living room, but whatever. Strike one. We decided to go see one of the Harry Potter movies, and since we were still riding the wave of intoxication, we decided to try to sneak wine into the theater in sport bottles, concealed in bulky coats and purses. We arrived in the theater where I promptly fell asleep (ie. passed out) for the duration of the movie. Strike two. When the movie was over, Mr. Whoo had to jostle me to wake me up, and I decided it was a good idea just to stay in the theater and sleep it off. Strike three. "I'm not going without my Richmond!" my drunken-self proclaimed. What I meant was that I had forgotten my still full sports bottle in the theater. Mr. Whoo, clearly at the end of his rope at this point, refused to let me go back to retrieve the "Richmond." We loaded into the car, where I spat across 2 rows of seats that I was "Sooooo, effing-sorry!" Except I didn't say "efffing," I said the "Queen Mother of all Curse Words." Since it was obvious that I wasn't sorry at all, things went from bad to worse. Our friends, of course, thought that this was hilarious. We finally worked it out, no harm done, but to this day, all sports bottles in our house are "Richmonds" and one way to end a fight and get a good laugh is saying "I'm so efff-ing sorry!"
Other choice phrases in our house to end a fight include the circa-4th grade retort, "You are." (Variations on which include, "You're the one," or "You're the one that is.") "You don't even know." (Thanks to a comic that we both watched once upon a time.) and the very versatile "Suck it," or "You can suck it." The wonderful phrase, "Suck it" was perpetuated by my good friend YogaGirl and her husband, and let me tell you, it is a most amusing way to agree to disagree. When any of the above phrases are uttered, we know to drop the subject, and we can end the conversation with a smile.
Here is a sample Whoo household squabble:
The complaint, "You forgot to put a new roll of toilet paper on the roll (do the dishes, bathe the child, etc.)"
The initial reply, "You're the one that did."
The insistence, "I mean really, how hard is it?"
The volley, "You don't even know!"
The resolution, "You can suck it."
"I'm soooo effing soooorry."
End of fight.
Do any of you have special "fighting words?"
Thursday, October 19, 2006
I've sailed through several weeks without any surgical complications, and that lucky streak came to an end yesterday. It started off as a diagnostic laparoscopy for pelvic pain. The patient was taking narcotic pain meds like tic tacs, without relief. She was convinced that it was her uterus, so we took her to surgery to find a cause of her pain. Her uterus, tubes, and ovaries looked as normal as they could be, but she had pelvic adhesions from her intestines, criss-crossing her abdomen from top to bottom. I was able to dissect the majority of the bowel adhesions without complication, but one area, upon inspection, appeared as though I may have dissected too close to the bowel mucosa. I called a general surgeon in to take a peek, and he blustered and cursed, and finally agreed that he thought it was a little too close, too. I extended her umbilical incision by just a couple of cm, and we were able to bring the bowel up to the incision and oversew the questionable defect. I kept her overnight, just in case, but she did well and went home this morning.
My next worry was a patient with pelvic prolapse and urinary incontinence. Every Ob/Gyn has an area of surgery they love to do, and, more often than not, an area of surgery that they dislike. I. Hate. Urogynecology. I don't like anterior repairs ( I don't think they work). I hate vault suspensions. I hate mesh. I'm not particularly fond of Burches. TVTs are pretty cool, but the urologists in this hospital have domain over that procedure and get a little pissy (heh) if you step on their toes. No skin off my nose, since I really would rather not mess with Urogyn. Since there are no urogynecologists in my hospital, I had to co-schedule her surgery with a urologist so that he could do a sling. She had quite a bit of prolapse, and she really wanted a vaginal hysterectomy. No problem, right? She is also post-menopausal, so she wanted her ovaries out, no matter what (risk of cancer and all). Vaginal hysterectomies, as a general rule, are really cool surgeries, but the flow of the surgery is completely dependent upon the skill of your assistants. The name of the game is visualization, so your assistants need to know what you need to see. Skilled assistants are difficult to come by, and between my med student (that had never even scrubbed a case before this rotation) and the scrub tech that never does GYN, I was screwed in the assistant department. The uterus came down and out without too much of a struggle, but the ovaries were plastered to the pelvic sidewall. This means, for my non-medical readers, it is more difficult to completely remove the ovary and tubes, and more risky for not completely securing the big bad blood vessel leading to the ovary, thereby increasing risk for post op hemorrhage. I struggled with the stubborn ovaries for a solid hour, and finally coaxed them from their happy homes, there was a little oozing on both sides from the dissection, but I was fairly certain there was no active arterial bleeding at the end of the case. I did the obligatory anterior repair, and then the urologist did the sling. We had very little blood loss, and even though the entire surgery ended up taking over 2.5 hours, I felt satisfied that it had been successful. There is always that niggling doubt in the back of my mind about post-op complications, and for her, I knew, it would be bleeding.
After the surgery, I spoke with her family, and they were so happy that we were able to do the entire surgery vaginally. Fast forward to this morning, when I found that her hematocrit had dropped 10 points. That's a lot of blood, folks. Her vitals were stable and she had good urine output overnight, and her abdominal exam was normal for post-op day #1. She had very little vaginal bleeding, but I know that she bled somewhere. I didn't go rushing back to the OR, like my panicked little brain wanted to do. Instead, I checked another blood level, 6 hours after the morning level, and held her diet in anticipation in heading back for re-exploration. Then I prayed. God must love me, or, more pointedly, this woman, because her level at 12 noon was exactly the same as it was at 6 am. So, she bled somewhere overnight, but she is no longer bleeding. Yee haw. Most of the time, a source of the bleed is never found. It is usually venous oozing, and it could have been from my ovary dissection, but suburethral slings can cause some serious hematomas, too, so we may never know. For now, she is doing well, and maybe I can get some decent sleep tonight. Here's hoping!
Monday, October 16, 2006
So, imagine my deep chagrin when I noticed the one area in my life in which I have not employed my internal locus of control, my weight and my health. I look at my eating and exercise habits, and the excuses just keep rolling on. It's too hard, it takes too much time, I'm too tired, I have too much to do, I only slept 6 hours in the last 3 days, the stars aren't correctly aligned, it's too hot, too cold, not cold enough, too windy, it's just one bowl of pasta, one glass of wine, one serving of french fries, I'll start tomorrow, after the next football weekend, when we get new workout equipment etc. etc. etc. I have started over again more times than I care to admit. My father has a saying that is simple and true, and I have probably mentioned it before, "There's nothing to it, but to do it." I can make excuses and caveats until I am blue in the face, but in the end, my health, weight, and diet are no other person's responsibility but my own. I know that I will not do this weight loss thing perfectly, and I have to accept that. I think that my perfectionism leads me to an all or nothing mentality. Once I fall off the wagon, so to speak, I don't just fall, I roll around on the ground and wallow in the mud. I am not going to become that which I dislike, just because the going is rough. I've persevered through tougher obstacles than this. It's time to go tackle just 30 minutes of cardio. I can and will do this.
P.S. I would like to offer a sincere apology to the person that landed here by Google searching "FSU Babes." You poor, unfortunate soul. I hope that you have adequately Cloroxed your eyes!
Saturday, October 14, 2006
Friday, October 13, 2006
Unfortunately, I had to turn my pager back on that evening. I got a page in the wee hours of the morning from an ER doc that had been haunting me all weekend long. This attending is the King of Pointless Admissions. He is just incapable of treating and streeting pregnant women with problems unrelated to pregnancy (GI viruses, toothaches, viral upper respiratory infections, etc.) I had already admitted 2 patients over the weekend, and I groaned (inwardly) when I heard his voice on the phone. One of my patients, 23 weeks pregnant, had presented with symptoms of a URI and likely subsequent costochondritis. She also happens to weigh 320 pounds, and had bilateral lower extremity edema. The freaking ER attending ordered a CT chest (during which they screwed up the progression of dye, therefore rendering it useless) and when it failed to show any problem, he then decided she had a possible pulmonary embolus. Her O2 saturations, you ask? 98-100% on room air. Her pulse? 80s-90s. Respiratory distress? No. She did have chest pain...that was reproducible with palpation over the sternum. PE, my ass. I was too tired to argue with the ER doc at 4 in the morning, although I'm sure that I was less than polite about the whole thing. The next morning, her work-up for DVT and PE was, surprise, negative. I was unremittingly bitter for the remainder of the day over the thousands of wasted dollars on unnecessary testing, and for the fear that my patient suffered, as she really believed that she, indeed, was dying. The poor girl is anxious enough as it is. Fortunately, I was able to reassure her before I sent her home from the hospital.
The rest of the week was a blur. There were lots of clinic patients. One late night vacuum delivery, four surgeries, an emergent vacuum delivery, a tubal, and a circ. I have a new medical student with me, and I feel sorry for her quality of learning as she follows me, rushing around, trying to teach in fits and starts. She says that she really loves OB, and that it is her favorite rotation, so far. I really like her, so I'm trying to get her as much hands-on experience as I can, while trying to show her how rough the quality of life can be. You have to go into this profession with eyes wide open. I had her do a hands on hands delivery with me, and she first-assisted on my tubal this afternoon. I miss that starry-eyed optimisim. That used to be me, young, fresh, and not yet cynical. *sigh*
Today is Friday the 13th, which is kinda creepy in itself, but for some reason, it seems even creepier because it is an October Friday the 13th. I know it sounds weird, but as a kid, I used to comfort myself on the various and sundry Friday the 13ths because at least they weren't in October. I don't really know why this is, except for maybe the fact that Halloween was also in October, and that was scary? Who knows? I fully expected this day to be really rough. In reality it was fan-freaking-tastic. It was a gorgeous fall day, clear, cold, bright, and sunny. I only had 15 clinic patients scheduled this morning, so it was the first true "half day" I've had in the office in ages. I even had a colpo and I was still done by 11:45 am! I sweet-talked the OR staff into letting me do my post-partum tubal at one this afternoon, instead of waiting until after 3 pm, and I am officially off -call for the entire weekend. I got to pick up CindyLou early from daycare, and we are chilling out on the couch watching the Curious George movie and snacking on cheese and crackers. My wonderful husband brought home a bottle of champagne, and has promised to pamper me all weekend. What a difference a week can make! Should I be concerned that Friday the 13th has been such a great day for me? What does that say about my inherent goodness? Ah, well, I'll take a good day when I can get one. I hope you all have a wonderful, not scary, Friday the 13th!
Saturday, October 07, 2006
I'm taking call this weekend for the hospital, for myself, and for OtherDoc, but tomorrow night my husband and I are going to a concert. I miss getting out amongst the living in a social setting (sans pager!) Next weekend will be the first weekend that I am not on call and not on vacation. I can't wait. I think we are going to visit some of the surrounding parks/recreation areas. The fall colors should be at their peak, and we will get to enjoy some beautiful scenery with our nature-loving daughter.
It has been a very busy week, and I've been at the hospital late a couple of nights. I've had good deliveries and not so great deliveries. One of the best deliveries was one of my post-dates patients (one I had to talk out of an elective induction) that came in naturally laboring. She walked until she was 7 centimeters, rested a bit, and then asked for an epidural. At that point it was too late because she was anterior lip and nearly ready to deliver! She delivered an 8-and-a-half pound baby without any meds. She was so thrilled. I love labors like these! My second labor patient of the day (the one that caused me to miss the live Lost premiere ) was also post-dates with oligohydramnios. She had a very large (and quite overbearing) family, and she had rotating groups of people migrating between her room and the waiting room throughout the day. She and her husband are quite pleasant, but you would not believe the way she was coddled by her family. It was if she were some kind of fragile doll. I chalked my snarkiness up to PMS, and tried to hold my tongue when person after person pressed me for a time of delivery. Her mother sidelined me and asked weather or not I thought she would be able to have a vaginal delivery, since she was "so small." I explained that she at least deserved a chance, and encouraged her mother to continue supporting her. The patient did have the rather unreasonable expectation of having no discomfort whatsoever in labor. That was unfortunate, and after she had been pushing for just a little under an hour, she begged me to "just pull it out!" I reassured her, and encouraged her to rest a while and resume pushing. The baby's presentation was right occiput posterior, but still a little too high for a vacuum or forceps. She pushed for yet another hour, and was able to bring the head down to +2 station. I applied a vacuum and rotated the baby to OA and delivered in one push. That was the good news. The bad news was that, upon delivery, the posterior shoulder tore into the perineum, and she sustained a partial fourth degree laceration. (No, she did not have an episiotomy.) Even more exciting, the spotlight chose that moment to expire, necessitating an impromptu call to maintenance. My patient rested, her legs up in the stirrups, draped strategically with blue towels, while the poor maintenance man did the fastest light bulb change on record. Talk about awkward! The repair itself actually went very well, but I feel for the discomfort she will endure in the coming weeks. Ouch!
Today I did a c-section on a woman with severe pre-eclampsia. She had been laboring for 2 days, and despite adequate contractions and every trick in the book, she never dilated past 2 centimeters. Stranger still, neither her mother nor her grandmother ever progressed in labor further than 2 centimeters! We jokingly dubbed the phenomenon the "2 centimeter curse." Luckily, she had a man-child, so he shall dodge the hereditary misfortune. Tonight I am praying for good company, some good sleep, and the return of a good mood. Perhaps I will awake tomorrow with the remnants of my funk evaporating like the mist over the mountains. I certainly hope so.