Cat Trouble and other Tidbits

Mr. Thumbs (a Hemingway, 6 toed kitty) and FattyMcGee (Mr. Whoo's once-upon-a-time slender kitty, who now tops 20lbs) are a part of our dysfunctional little family. Nevermind that I am pretty well violently allergic to cat dander, I love them, and the cats are here to stay. In our pre-child days, Mr. Whoo was as fond of the kitties as I. Lately, it's been a different story. We've moved several times in Fatty McGee's lifetime, she's older and really pretty well adjusted. Mr. Thumbs, however, has been having potty issues ever since we moved to our new house a little over a year ago. More specifically, Mr. Thumbs' potty problem seemed to arise from a holiday visit from my family. My brothers chose to sleep down in our basement (aka Cat Heaven) during their stay. Ever since that time, even though no one else has deigned to sleep down there, Mr. Thumbs has been leaving solid presents all over the carpet in the basement. The problem became so annoying that we have been enclosing the cats in one of our partially finished basement rooms (it has a lot of space, all of their food, water, litter boxes, and piles of carpet remnants, tons of toys, and it is heated/air conditioned) during the day while we are at work. When we get home, the cats have the run of the basement and first floor. The upstairs bedrooms are off limits by way of the baby gate, which also keeps CindyLou from attempting to end her short life by jumping on the stairs. Mr. Thumbs has taken to using the carpet remnants upon which his food bowl rests as his own private litter box. What kind of animal poops right in front of where it eats?? It doesn't seem to matter if the litter boxes are clean or dirty, he uses the floor just the same. So far, since we've relocated them, it has been confined to the unfinished room, but it is so frustrating! Any cat psychologists out there? What can we do to remedy this problem?

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!

Why I Love My Nurse(s)

When I left you last, I gave you the somewhat faulty impression that I had, indeed, become SuperMom, curing sore throats and doing household chores at the speed of sound. In reality, my sick baby took a 3 hour nap, I sorted and did exactly 2 loads of laundry, passed on cleaning the kitchen in favor of reading blogs, and, instead of cooking, my husband brought home take-out for dinner. Domestic goddess, I am not. Fortunately, CindyLou awakened from her power nap afebrile and happy as a clam. I expect she will make a full recovery, and she is back to requesting chocolate for dinner (she is totally my daughter). I went back to being a physician, and had a relatively good Wednesday.

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.

Home Sick

CindyLou is sick. You have to love day care for all of the ways it, um, strengthens your child's immune system. If I had been a better, more "in-tune" mother, I probably would have realized that her (most unusual) grumpiness on Monday morning was a sign of impending illness. Unfortunately, I just chalked it up to the fact that we had altered her schedule by me dropping her at day care instead of her Daddy. Mondays are supposed to be a "half day" in the office for me, but, as you may have read previously, this is seldom the case. Yesterday, I was finished with seeing patients by 2pm, but then I had the ever-present paperwork and dictations to complete. I left the office by 4 in hopes to pick up CindyLou early to go Halloween costume shopping. When I arrived in her room, I found her lying down, with a fever of over 102 degrees. Her teachers had not yet phoned my husband or myself, which made me a little upset, but I think that they had just taken her temp a few minutes before I arrived. The teachers said that she hadn't been acting herself all day long. I felt terrible that she had to be in school all day, feeling as badly as I knew she must.

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.

OPP (Other People's Patients)

If you recognized the title of this post as the title of a rather questionable rap song, you are old (just like me). I have mentioned in previous posts that OtherDoc has finally agreed to share weekend call with me. The inordinate luxury of having 2 whole weekends free of the pager is well worth the 2 weekends of double the patient responsibility. I have come to realize, however, that OtherDoc's patient management is a bit different from my own. This leads to occasional patient care dilemmas.

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!

How To End a Fight

Let's face it, married people fight. No matter how blissfully happy you are, no matter how much you have in common, no matter how good your life is in the bedroom, you are still individual people, and are apt to disagree. In our marriage, we have adopted the mantra of never going to bed angry, and, to tell the truth, we don't have terribly major fights. More often than not, we just irritate one another and nib at each other from time to time. Often, after spending a lot of time with one another, you start to develop your very own secret language. You have special looks, inside jokes, and phrases, while non-sensical to others, that hold a great amount of meaning to you as a couple. Most of our general bickering is halted by a few catch phrases, that, more often than not, make us laugh and forget about the squabbling.

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?"

Post Operative Complications

Prior to any scheduled surgery, I usually have a pre-op appointment with the patient to review the surgery, do a quick exam to check for any brewing acute illness, and cover the risks of the surgery. I can do this spiel in my sleep. "With any surgery there are risks: bleeding, infection, damage to internal organs such as bowel or bladder, risk of hemorrhage requiring transfusion, risk of anesthesia, or even risk of death." I also will cover additional risks specific to the surgery the patient is having. There is an adage in medicine that the surgeon that has never had any complications has not done enough surgery. While frightening, it is true. Eventually, if you operate enough, you are going to have surgical and post operative complications. Like it or not. Last night, between every 3 hour pages (all night long) for normal blood sugars (!) and worrying about my post-operative patients, I got very little sleep.

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!

Accountability

Way back in prehistoric times, when dinosaurs roamed the earth and I was studying Psychology, I learned a concept called "Locus of Control." Essentially, the polar opposite traits are described as "internal locus of control" and "external locus of control." People with an internal locus of control feel that it is within their power to affect change in their lives, be it positive or negative; whereas people with an external locus of control tend to blame (or thank) external forces such as fate, luck, or authoritative will for what happens in their lives. Of course, as with all personality characteristics, there is a continuum. I think that is a rare person that is 100% in either direction. It is theorized that locus of control is a learned behavior, cultivated in the home and effected by multiple variables including socio-economic status. My own childhood home is an interesting contrast. I, the first child and the only child for 6 years, have always been a responsible person. I have always had what I felt was an internal locus of control. I was internally motivated to study, to be involved, and to set goals and achieve them for myself. If I bombed a test, I didn't curse the horoscope for a bad day, I accepted that it was because I did not study correctly. Don't get me wrong, I do have some great "good luck" rituals, and I love to dabble in Tarot cards and horoscopes, but ultimately, I know that I am accountable for my actions and for my fate. My younger brothers, on the other had, are completely different than I. Until very recently, both lived at home ( they are in their mid-20s), neither have completed college, one has never held a job, and everything in their lives happened "to" them. It has always boggled my mind how we could be so different, being raised by the same parents in the very same environment. I know that I have difficulty relating to people on the opposite end of the spectrum, and get easily frustrated with those that do not take responsibility for their own actions. I encounter this daily with my patient population. The victim mentality is alive and well, and it is a personal pet peeve of mine.

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!

Old School

Last weekend, when Mr. Whoo and I went to the concert in nearby University City, we got a painful reminder of our advancing age. The concert was held on the campus of the local University, therefore there were lots of college students in attendance. We usually scan the crowd in hopes that we are not "those old people" at every concert we attend. (We have this secret fear that the younger set is whispering "Look at those old married people! How do they know about CoolBand? Maybe their kids listen to the band." We also have a secret hope that we, at least, look like cool older people, attending such concerts!) Luckily for us, there was an eclectic mix of bands at this showcase, so we were not even close to the oldest people at the venue. As I mentioned previously, we were right in the third row, center. We had arrived super early (a leftover compulsion from my groupie days) and the show was general seating, so getting there early paid off in fantastic seats. Since we were seated nearly an hour before the concert was scheduled to begin, we settled in for a favorite past time, people watching. The thing that impressed me immediately was how the college age crowd is consistently "plugged in." All around us, kids were texting on phones, playing games on PDAs, hell, maybe even blogging! In the row directly in front of us, there was a group of 4 friends, and one guy was showing his friends pics and videos of a recent football game on his phone. This is just so crazy to me! Then, a bit later, the same guy was playing Tetris on the self same phone. His buddy leaned over and said, "Oh, yeah, I haven't played that game since I had a GameBoy. You know, one of the original ones, with the *huge* game cards, before they were in color. Totally old school." My husband and I looked at each other and suppressed howls of laughter. Talking about handheld video games being Old School! It made us go (way) back to what we consider "old school" video games, like Intellivision, Pong, and Atari. Funnier still, we remember when the majority of kids had no access to video games at home, and played "old school" games outside like Freeze Tag! As a kid, I remember thinking that the idea of a "video phone," one where you could see someone on a screen and speak to them at the same time, was so far in the future, I couldn't fathom it. I can't believe how much technology has advanced in the 30-some years of my life. It is amazing how our perspective changes from generation to generation. So what is "old school" to you?

Freaky Friday

Forgive me bloggers, for I have sinned...it has been nearly a week since my last blog entry. I promise to publish all comments, add new links, and will foster an attempt to be generally entertaining. Am I forgiven? In the last installment of "(Not So) General Hospital," our fearless protagonist had a serious case of the PMS monster, she was whiny, self-absorbed, worn out, and sleep deprived. Lather, rinse, repeat for the next 5 days. I did get to go to the concert, which was awesome. We arrived early and got to sit in the third row, center. The bands were truly amazing, and I got a cool new long sleeve t-shirt. It takes so very little sometimes.

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!

Blue

Warning! Whiny post ahead! I'm in a terrible funk, and I just can't seem to shake it loose. It is my favorite time of year. The colors are bright, and the air is cool. It is beautiful here in the mountains. Hormonally, I'm still waiting for the PMS monster to go away (no, alas, I'm not pregnant). My football team is in the cellar of a mediocre conference, and I've been working really hard, but feeling like I'm getting nowhere. I was also sad to hear of a fellow OB/GYN blogger and her unexpected death. I really loved her blogging voice, and could relate so closely to the things she was enduring as an intern. She had a brilliant light, and it saddens me that it has been extinguished, I feel, too soon. It's funny, because we really don't know one another out here in the blogging world, but I find myself emotionally invested in the blogs that I read. I asked my husband to update my blog, should anything ever happen to me. I feel as though our whole lives are working toward something...the next weekend, the next vacation, the next pregnancy. We so often forget to appreciate the now. I have been trying to stop my forward thinking, just to sit back and enjoy all with which my life has been blessed.

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.

Tagged

I can't say that I have ever thought about this before, but, thanks to At Your Cervix, I am dreaming up the lyrical background for my funeral. This is odd for me, as I really haven't given this all that much thought. I would like to think that those I leave behind would be the ones to narrate my lyrical legacy. Maybe that is naive. The three immediate songs that come to mind are the ones that are listed. I would also encourage those who may mourn me to add to the list. Suggestions welcome below!

Only the Good Die Young - Billy Joel

Come out Virginia, don't let me wait
You Catholic girls start much too late, aw
But sooner or later it comes down to fate
I might as well be the one.
Well they showed you a statue, told you to pray
They built you a temple and locked you away, aw
But they never told you the price that you pay
For things that you might have done
Well only the good die young, that's what I said
Only the good die young, only the good die young.
You might'a heard I run with a dangerous crowd
We ain't too pretty, we ain't too proud
We might be laughing a bit too loud, aw
But that never hurt no one.
So come on Virginia, show me a sign
Send up a signal, I'll throw you the line
The stained-glass curtain you're hiding behind
Never lets in the sunDarlin' only the good die young, woah woah woah woah woah woah
I tell you only the good die young, only the good die young
You got a nice white dress and a party on your confirmation
You got a brand new soul, mmm and a cross of gold
Well Virginia they didn't give you quite enough information
You didn't count on me, when you were counting on your rosary
Oh woah woah, and they say there's a heaven for those who'll wait
And some say it's better, but I say it ain'tI'd rather laugh with the sinners than cry with the saints
The sinners are much more fun
You know that only the good die young, woah baby
I tell you only the good die young, only the good die young
Said your mother told you all that I could give you was a reputation, aw
She never cared for me, but did she ever say a prayer for me?
Woah woah woah, come out, come out, Virginia don't let me wait
You Catholic girls start much too late
But sooner or later it comes down to fate
I might as well be the one
You know that only the good die young
Tell ya babyYou know that only the good die young, only the good die young
Only the good, only the good die young
Woo, woo, woo, wooWoo, woo, woo, woo
Only the good die young, only the good die young.


Jesters, Dreamers, and Thieves - Edwin McCain

Looking back on younger days the view stretched on for miles
We charged into our futures with laughter and smiles
As we traveled blindly the road became so thick
No chance to change direction and we've laughed until we're sick

Now I keep company with wicked evil men
My generosity's brimming but I'm still inclined to sin
My friends think I am crazy and I know that may be so
But I'm as happy with a penny as coffers full of gold

Chorus:And so for all of you I say, don't miss the forest for all the trees
And don't ever question Honor Among Thieves
The undergrowth has parted now the path is easily read
It's lined with all the doubters regretting all they've said
God bless all the dreamers and those who lead with soul
For how can you know virtue 'less you fought out of a hole

Chorus Trickle of a chuckle as laughter starts to pour
Bells begin to jingle the trickles now a roar
Pan floutist, cloven dancerThe mischief has begun
Laugh with me if it's funny, laugh at me if it's fun
And I don't know St. Peter but I know he believes
There's a place in heaven for Jesters, Dreamers & Thieves

Daylight Fading - Counting Crows

Waiting for the moon to come and light me up inside
And I am waiting for the telephone to tell me I'm alive
Well I heard you let somebody get their fingers into you
It's getting cold in California
I guess I'll be leaving soon
Daylight fading
Come and waste another year
All the the anger and the eloquence are bleeding into fear
Moonlight creeping around the corners of our lawn
When we see the early signs that daylight's fading
We leave just before it's gone

She said "everybody loves you,"she says, "everybody cares"
But all the things I keep inside myselfthey vanish in the air
If you tell me that you'll wait for me
I'll say I won't be hereI want to say goodbye to you
Goodbye to all my friends
Goodbye to everyone I know
Daylight fading
Come and waste another year
All the the anger and the eloquence are bleeding into fear
Moonlight creeping around the corners of our lawn
When we see the early signs that daylight's fading
We leave just before it's gone

P.S. I officially am disowning Florida State. We suck ass. Did I mention? I effing hate Jeff Bowden. 1-2 in the ACC. Un-freakin-believable.

Busy Week

I see a full moon a'risin'...whew, what a week! I had two babies on Friday, one on Monday, one on Tuesday, one today and one more on the way (hopefully sometime today) and an induction for Friday. When it rains, it pours, and I am always the one being followed by a little black cloud. I am totally whipped, and it is only mid-week. I am grouchy, sleep-deprived, out of sorts, and, I fear, in the grips of the PMS monster. I have been living on L&D these last few days. I had to physically extricate myself from the nurses' station on labor and delivery, because I'm staring at the strips way too much.

I've had a really worrisome week with respect to my patients. On Monday morning I received a call from labor and delivery at 9 am. One of my post due patients had broken her water the evening before and was in early labor, about 1-2 cm. Immediately alarm bells started sounding in my brain, because I knew that Ms. PostDue was GBS positive. It turns out that she had likely ruptured membranes at about 10 pm the evening prior. She was started immediately on prophylactic antibiotics, but little danger signs were dancing through my head. I finished the rest of my clinic day as expeditiously as I could. When I arrived on labor and delivery in the late afternoon, the patient was 7 cm, and had just gotten her epidural 2 hours prior. The baby was reactive, the patient was resting, and her contractions were 3-4 minutes apart. I settled in for a rather short wait (or so I believed). Three hours after I arrived the nurse approached me, stating that Ms. PostDue had a low grade temperature (99.7), the fetal baseline had shifted upwards by ten beats per minute. The baby was still reactive, though mildly tachycardic at this time. Her cervical exam was only 8 cm, just 1 cm of change in three hours. Uh oh. There had been very little descent, and the cervix was starting to swell. The patient seemed to have an adequate pelvis, but she was petite, and the baby was measuring at just over 9 pounds. We sat her up, hoping gravity would work with us. I really thought that she could deliver vaginally, so, I sat and watched the strip creep from mildly tachycardic to moderately tachycardic. Just an hour or so later, the patient had a temp of 100.4, the baby was tachycardic, and her cervical exam remained unchanged. Off we went to the OR, whereupon delivery, the (almost exactly 9 pound) baby appeared slightly acidotic. "Good call, Dr. Whoo," the pediatrician, "(The Baby) couldn't have taken much more labor." The Apgars were 6 and 9, we finished the surgery, and I fell into bed shortly after arriving home around 11pm.

The next day, the baby was having trouble breathing outside of an oxygen rich environment. The white count was elevated, and IV antibiotics were started. Sometime during the day, the baby's pulse started hovering around the 80-90s (low for a newborn babe). After 24 hours of IV antibiotics, a clear chest x-ray, no obvious signs of sepsis, and failure to wean from oxygen, the pediatricians were starting to suspect a heart condition or pulmonary hypertension. Today the baby was transported to University Medical Center. I keep going over and over in my mind the progression of events, wondering if there was anything I could do differently. Maybe I could have called the section earlier, when the temp and tachycardia first appeared? I find myself going back and forth between trying to advocate for a vaginal delivery versus jumping at a section on the first sign of trouble. I have got to find a happy medium with which I can live. With this patient, I beat myself up for having to do a c-section, and then I beat myself up for not doing it sooner! For those anons that would criticize my delivery stats, this woman never had pitocin or AROM or internal monitors. She was 41 weeks, and she went into labor all on her own. She was not induced or augmented in any way. She did choose to have an epidural, but it was placed after she was in active labor (her choice, by the way, I wasn't even in the building when she asked for one) and her contraction pattern never changed or spaced. For whatever reason, she arrested descent and dilation at 8 centimeters. Maybe the baby was malpositioned, maybe there was CPD, maybe, maybe, maybe. The bottom line is, I am worried sick for that little baby and her family tonight, and I hope that waiting around a little longer for a try at a vaginal delivery has not harmed her in any way, great or small.

The same evening that I delivered Ms. PostDue, I also admitted Ms. PTL (pre-term labor). This patient had been contracting off and on ever since she was 32 weeks gestation. She had been in and out of the hospital, and she had received both mag sulfate and brethine tocolysis. I stopped all tocolytics at 35 weeks and waited for her to labor. She made frequent trips to triage in the intervening weeks, but she never changed her cervix...until Monday evening. She had been in both my office and then triage earlier in the day, and she arrived back in triage around 8 in the evening. She was 3 cm and ballotable earlier in the day. One of our most seasoned nurses was running triage that evening, and I begged her to tell me that Ms. PTL was not in labor. She said, "Dr. Whoo, she's a definite 4 cm, and I think she *is* in labor." I never doubt a seasoned L&D nurse, so we admitted Ms. PTL for overnight observation. I arrived back on the L&D floor around 7 am on Tuedsay morning, and I found that Ms. PTL had slept all night long. Hmmm. Her fetal tracing looked a little flat, but she had pain medicine overnight, so I attributed the lack of variability to the meds. On exam she was already 5 cm and the head was well engaged. Since the nurses were having difficulty monitoring contractions, I broke her water and placed internal monitors. At the moment of AROM, a torrent of muddy brownish-green amniotic fluid flooded the bed and trickled onto the floor. Meconium. Ms. PTL has a history of rapid deliveries, so I cancelled clinic for the morning, thinking her delivery was imminent. I was wrong. I waited for nearly 6 hours before she delivered, and even though DeLee suction was used at delivery, the infant had some trouble transitioning from mom to the outside world. Luckily, the little one only needed oxygen for a short while before being back with mom and dad. Despite being pre-term, they will likely get to go home together.

In other fun news, I have one patient whose endometrial biopsy pathology came back as adenocarcinoma, and I admitted a second lady from the ER on whom I performed a D&C for post-menopausal bleeding. Based on the copious amount of suspiciously fluffy tissue yielded by the D&C, I presume it to be endometrial cancer, as well. It isn't always perfect deliveries, healthy patients, and healthy babies. This field can be as devastatingly bad as it can be unbelievably good. Tonight, I am just hoping for a good delivery outcome for both the baby and the mom...hopefully in time for me to catch the season premier of Lost (if not, Tivo, I heart you).