The Almighty Call Gods

Any one in medicine, or with a loved one in medicine already knows that we tend to be a superstitious bunch. Funny, since you would think that people, who are, in general, so scientifically minded, would scoff at silly ritual and the whims of fate. *Everybody* knows that you should never, ever say that you are having a "quiet" day or an "easy" case. And, what ever you do, you should not piss off the forces that are better known as the "call gods." When you are on call, especially in L&D, you never know what kind of call you are going to have. Some days and nights are smooth and easy, and some are absolute hell on earth. You can be certain, if you you are having the latter kind of call, that you have transgressioned against the call gods, and they are exacting their wrath upon you.

How exactly do you anger the call gods? I'm not entirely certain of all the ways one can anger them. One way is to plan to do something, anything at all, on the day/night/weekend on which you are on call. If you make plans other than sitting at the hospital on your call day, it tends to blow up in your face. Another way is to get too comfortable, especially at home. Woe betide the on-call physician who dares to try to change out of scrubs into pajamas, take a long bath, or, heaven forbid, take a nap, for the call gods will smite thee mightily. I think another thing that rouses the wrath of the call gods is becoming anything less than vigilant about scouting potential customers coming in through labor and delivery or the emergency room. Your radar must always be roving for potential impending disaster.

For whatever the reason, or, perhaps because they felt bad for destroying me over my last holiday call, a Labor Day weekend 13 delivery-palooza, the call gods were incredibly kind to me this past weekend. I started with a full census, delivered one baby at 3 pm on Friday, discharged every single patient from the census by Sunday, did one consult on Sunday, and delivered another baby at 2 am this morning. I slept in my own bed for 2.5 out of 3 total nights on call. It was the strangest, most unsettling feeling. I kept checking my pager and the computer. I kept waiting for the other shoe to drop, but truly, it never did. That is, of course, until this morning, feeling safe from the call gods' collective hearing, I happened to post to fac.eboo.k that I had an eerily slow call weekend. Oh how my hubris was heard and met with a swift and mighty justice. Not 30 minutes later, I received a call from a sick colleague, requesting that I cover call tomorrow night in exchange for them covering my week-day call next week. Of course, I agreed. I am not looking forward to the kind of payback that the call gods have in mind for me.

Heeyyy Iiiiiii, ooohhh, I'm still alive...

Still alive, still snarky, still slacking on the blog. I miss you guys! The time just keeps passing and passing, and I keep meaning to blog, and, before I know it, it is bedtime and I am too tired to post. Bad bloggger. No cookie!

Speaking of no cookies, I am starting a physician-directed weight loss program for the next three months. I am in desperate need of someone else to kick my ass. I had all of my fasting bloodwork drawn this week. I am hoping that the raw numbers will jolt me from my post-Halloween candy daze. Mmmmm, Kit Kats......

We are having too much fun as a family, now that I am not on call. We've been to the circus, and the pool, and the beach and to the store. We are having friends over and sleep overs and lots of good family time. I love hearing my kids shout "Mommy!" with joy when I come home (nearly every night...at a decent time!) from work. Life is good.

On the work-front, I have had some good deliveries. My favorite was one where the baby was really. not. happy. with labor. Lots of decels, angsting at the nurses station. The patient was a multip, so I was hanging on by my toenails to try to get her a vaginal delivery, while trying to keep from having angina, myself. The cool part came when I went to check her cervix to make the final C-section call. I felt her cervix change from 4 to 6 to 8 to complete in the span of about 20 minutes. She delivered a fit and fiesty baby boy (OP) with about 30 minutes between thinking I was going to have to call a section and delivery. Too awesome.

I have more eloquent posts swirling about the cortex, but the bottom line is, I am well, the family is well, and I love my job. I will be back soon. Happy November!

Overheard in a Beauty Salon

Who knew that having more free time would be counter-productive to blogging? The hardest thing for me is being able to let enough time elapse between bloggable events and actually writing about them, so as not to violate privacy issues. This post, however, happened somewhere that my profession should very rarely come into play, a hair salon. I'm not the first to bemoan the loss of a hairdresser when moving, and, while I held out as long as I could, the root situation was becoming very serious. I got a recommendation from my good friend who lives here in Newville. She's usually brutally honest, and her hair always looks fabulous, so I trusted her opinion. The hairdresser, herself, was fine. Despite trying to sell me on some "organic, sulfate free" shampoo (to a Suave-type girl) at twelve bucks a bottle, she was professional and did a nice job. The fun started when she set me aside for my highlights to process.

As many stylists do, she had stagger-scheduled a client to come in during the time that my highlights were processing. The second client, SC, breezed in and perched in an adjacent seat, waiting for her turn in the chair. "You aren't *pregnant* any more!" exclaimed the stylist to SC. "Nope, delivered 8 weeks early!" SC countered brightly. Needless to say, my interest was piqued, and while I don't make it a habit to eavesdrop, we were the only 3 people in the shop, and they were not discussing things quietly. It wasn't SC's story that surprised me, it was her incredibly flippant tone. I discovered, through their conversation, that SC had developed pre-eclampsia during each of her pregnancies, and this pregnancy was no exception She was admitted to the hospital, where those "incompetent doctors" had the gall to check her blood work every 6 hours and put her on this "vile medication" just in case she had seizures. SC didn't understand while they just didn't "take the baby, already." Finally, she says, after 2 days, her platelets *finally* started to drop, and the decision was made to deliver. She was angry, actually angry, that the baby was delivered after midnight so she couldn't have the "cool birthday date" that she had wanted. Oh, and where was the baby might you ask? He was still in the NICU (no big deal) because he was still apneic, of course. She had just delivered the week prior, by C-section, was obviously in HELLP a very short time ago, and she had driven herself to her hair appointment because she "couldn't stand" the way she looked. She was *glad* she delivered early, because she had only gained 20 pounds, and she was also glad she had "tan lines" so the doctor could see where her bathing suit hit so as not to go above it.

As she went on and on, you could have knocked me over with a feather. I was just shocked and appalled at this woman, so nonchalant about her premature baby, apneic in the NICU, and so unconcerned about her own health, that she was out driving to the hair salon a week after a c-section and HELLP syndrome so she could *look better.* I was blown away at the priorities here. The rest of the hair appointment passed without incident, but I was left to ponder how very differently patients can view their medical situations from their physicians. I am sure that her physician agonized over the decision to deliver her son so early, yet SC had wanted it all done even earlier. I also found it amusing that I cannot escape my profession, even in a place where most go to relax. Have you ever been appalled by an overheard conversation? Maybe next time, I'll bring my i.Pod.

Cool....and not so cool.

Every day in the office is a day to hear something new. In OB/Gyn, the work is pretty much the same, wherever you go (at least in the US). Annual exams are annual exams. Prenatal visits are pretty standard. Common problems are approached in much the same way in one office as another. The patients are the ones that make it different, interesting, and even, sometimes, really fun.

I am still getting acclimated to the new group setting. It is a little strange to work within a group dynamic when you are used to essentially a solo practice. You have to give up some control (difficult for a control freak). It is much harder to know the patients well and remember every detail about their history, and it is also challenging to work within the boundaries of other physicians' comfort levels. Before, any call that I made...testing, induction, observation, only had direct bearing on the patient and on me. Now, I have to consider group gestalt. I am getting there, and the time off is well worth the trade-offs thus far.

I am seeing quite a different patient population in Newville, a bit more urban and sophisticated. Ways in which this is cool...

~The patients are well educated, they are aware of their bodies and have done a lot of research into pregnancy and what is happening in each trimester. I rarely am telling them things they did not already know. Makes my job a bit easier.

~The happiness! I got to see a woman, coming in for a regular annual exam with an incidental finding of a positive pregnancy test. She was ecstatic. Her husband feigned needing a glass of water and hyperventilating. The cuteness was killing me. (I am used to tears and hysterics over an unplanned pregnancy!)

~The responsibility. These patients are amazingly compliant, and hold their and their baby's health in high regard. There are very few smokers, and I have yet to see Mountain Dew in a toddler's bottle. Unbelievable.

Ways in which this is not cool...

~The, um, "sophistication." I have met several young women for their first exams (17-21 years old), who qualify their number of partners as "really low." However, when pressed further for ballpark numbers, they toss out a number like, oh, 10-12. (!!!) Whoa.

~The bossiness. Never have I been instructed on how to treat a patient for a certain condition so often. Sheaves of information printed from the internet. "Drive-through" attempts at obtaining treatment. Sorry, honey, this isn't Bur.ger K.ing and you cannot "have it your way!" Yikes.

~The nonchalance. I kid you not, I had a woman that texted on her phone throughout her entire annual exam. Breast exam, pap, and pelvic. Holy cow! I wanted to know what she was texting..."now my breasts are being checked. Now the speculum is going in?" "Pap smears suck?" WTF?

All in all, I am settling in nicely here in Newville, and I am so happy to be back to loving my job once again. That being said, I am gearing up for my first full weekend of call (and a full moon to boot). Since I've not had a weekend call since July, we'll see how sunny I am come Monday. I wish you all the happiest of Labor Day weekends! Thanks for not giving up on this blog!

Stuck, stuck....STUCK!

As my time in Whooville was drawing to a close, I found myself in a very harrowing situation. As per usual, I was extremely busy delivering all of OtherDoc's patients, as well as my own patients during his vacation. (I never understood why he wouldn't limit the number of OB patients he would take when he knew he would be gone for half the month...oh, right, all about the dolla bills, y'all.)

There was a young patient (YP) that I had seen in the office earlier that day, she had been contracting, and while she was not yet dilated, she was beginning to soften and efface. I wasn't too surprised to see her later that evening at L&D. She was extremely uncomfortable, contracting every 2-3 minutes, and had dilated to 2 cm/90% effaced. It had been a long day, so I assumed that we would get her comfortable (she was requesting an epidural) and then she could labor through the night. The day shift left and the night shift came, and sometime in the middle of her bolus for her epidural, YP began to get a little out of control....like "I'm in transition" out of control. If you've never seen it, it is kind of like that seen from the Exorcist, minus the rotating head. I checked her, and surely enough, she was 8 cm. She had gone from 2 cm to 8 cm in the space of about an hour and a half. So much for the game plan.

The patient progressed quickly from 8 cm to complete, and that, dear friends, is when the fun began. As the patient began to push, the baby began to get unhappy. The more she pushed, the more unhappy the baby became. There were persistent and prolonged, deep variable and late decelerations. After tolerating the strip as long as I could, I talked to the patient and talked to the OR. preparing for a C-section. One problem, the anesthesiologist was not in house. Just at that moment, the baby decided to express her extreme displeasure with the proceedings by dropping her heart rate. To the 60s...one minute, two minutes, reposition, oxygen, scalp stim...no response. Three minutes, four minutes, more maneuvers, still no response. The patient was pushing with all of her might, her family was a step a way from hysterical, the baby was in trouble, and there was no anesthesiologist. The vertex was just barely at +2 station, so I attempted an emergency vacuum delivery. I pulled once...no descent...I pulled twice...small descent...I cut an episiotomy and pulled one final time to no avail. We had to go to the OR, and we had to go right then, anesthesiologist or not. At that point the baby had been in the 60s for about 10 minutes. "Please don't let my baby die." were the last words I heard before we left the floor.

We ran to the OR, and I told the CRNA to put the patient to sleep, anesthesiologist or no. I remember that the staff was moving as slow as molasses, even though I had relayed the urgency of the situation. We splashed the belly with betadine, draped her, the CRNA put the patient to sleep, and I went from skin to baby in under a minute. The nurse had to push up from below, and it was difficult to elevate the head out of the incision, but, thankfully we finally got her unstuck. All 9 pounds 8 ounces of her. She was a little pale and a little floppy, but pinked up almost immediately to get Apgars of 6 and 9. She was ok. Mom was ok. The nurses and I were puddles of goo. The adrenaline surge was so strong I was shaking.

I think the anesthesiologist finally got there as I was replacing the uterus. Thank God we didn't wait for him. After the C-section was over, I repaired her episiotomy. It didn't seem quite fair to be sore both places, but she had a happy, healthy baby. I kept turning the situation over and over in my mind. How could I have changed it? What could I have done to avoid the outcome? I felt like I had failed her in so many ways. It seemed incongruous when the nurses told me how "awesome" I was, and how the family cried and hugged me after the surgery. Afterwards, both mom and baby did wonderfully well. It was better than I could have ever hoped for, and an experience that I never, ever want to repeat.

In transition....

New posts shortly, as soon as I get my head above these boxes!!

I guess that's why they call it "The Blues."

So here I sit...alone, in a very empty, lonely house. Mr. Whoo, CindyLou, and the Bean are moved out and already in our new home city, while I sit here on my air mattress, waiting for my sentence to end. As a part of the agreement I reached with my current employer, I am being forced to serve one more term as indentured servant while OtherDoc takes his annual 2 week vacation. It has been a very rough week. The day that the house was finally packed, and Mr. Whoo and the kids had left for new city, my old, fat, girl kitty died. I have half a mind to think that she realized that we were moving again, and was going to be damned certain that she didn't have to go through it again, but it doesn't make it any easier. I found her curled up in her bed, as though she were sleeping, but when I touched her back, she was cold and stiff. She was old, and fat, but I just wasn't prepared to lose her just yet. The fact that I found her dead the same day that the rest of my family had left me alone in the house did not help matters one little bit. Poor Kitty. Poor me.

True to form, I have been inordinately busy, so I haven't much time to contemplate staying in our house all alone. I can't help but wandering through the empty rooms when I finally do get home, remembering all of the times when the rooms were full of us, our stuff, and our memories. Now, all that remains are those memories and faint impressions of furniture upon the carpet. I am alone, with my sole surviving kitty, an air mattress, a laptop, and a new set of books (The Sookie Stackhouse series). I thank God for the interwebs, facebook, and hulu. I have been watching reruns of "Dead Like Me" on hulu. If you haven't seen the series, I highly recommend it. It is a very cute show (despite the fact that it is about Grim Reapers and Death and the like.) I miss my babies, and tear up every time I hear their sweet baby voices on the phone. I miss my family so much that it hurts, and I can't wait to start the next chapter.

I have some hair-raising work stories percolating at the moment, and will post them within the next few days. It appears as though I will be going out of this job with a bang rather than a whimper. I have but a week left in my current position, a new horizon looms ever more brightly in front of me. I can't wait to share my newest adventures with all of you.

More Advice you Never Wanted to Hear: Residency

Holy shit, new residents are starting on Wednesday! Residency, for me, was such a far cry from medical school. When I started residency, it was back in the "dark ages" of medicine. Read: prior to the (oh so benevolent) 80 hour work week. That's right. I worked 120 hour weeks in my first 2 years. Uh huh. I'm the monsta. But seriously...I did have weeks when I was on call Monday, Wednesday, Friday, and Sunday. 36-48 hours on, 6-8 hours off. It was unbelievable. Surreal. I often fell asleep in my bed after a (much needed) shower with a Smirno.ff Ice or Be.er in my hand. I remember holding a retractor for a vag hyst, in an oncology case, at 9 pm, when I was post-call. I had tears streaming silently under my surgical mask. I thought I was going to die. But, guess what? I did not die. Not physically, anyway.

Residency isn't as hard as it used to be, but the principles remain the same. Work. Your. Ass. Off. I mean that. In order to be a good intern/resident, you'd better work (now turn it to the left). Pay attention in morning rounds. Make check boxes and lists. Make sure the labor and post-partum floors are taken care of when you are the OB resident. Be sure that all Gyn cases are covered, pre-opped, and post-opped when you are the Gyn resident. Be everywhere at every time. Seriously. I mean this.

A good resident knows his/her patients. Labs are checked often. Notes are written. Labor progress is always recorded. Gyn patients are rounded on 4 hours post op, AM, and PM. Know your patients better than the attendings know them. Be able to regurgitate labs, post-op blood loss, and diet orders. Help your fellow residents and interns. Don't throw people under the bus. Work as the team. If someone isn't sleeping, then *no one* is sleeping. Divide and conquer. Be nice to the nurses. Round on the floors and give universal "Wal-Mart orders" to the floors before you try to lay down (IE. if they can buy it at Wal-Mart ~heating pad, Tylenol, Tums, fan~ they can have it!)

Help your junior residents, and teach them how to run the board. There is no such thing as a "little" case. Scrub in on as many surgeries as humanly possible. I don't care if you have seen a million c-sections, scrub in on the next one....it may be a C-hyst. You need as much surgical exposure as humanly possible. Especially now in the restricted 80 hour work week.

If you have to do research for your residency graduation...do it NOW. Do not wait until your Senior year when you are trying to interview for jobs, study for written boards, and get licensed. Do the research early. Just suck it up and do it. Be good to your nurses, and they will be good to you. Don't whine. Don't ever let them see you cry. Stick up for yourself. Enjoy your time off. If you are considering a family, residency is a decent time to have a kiddo. Just be ready for the way your fellow residents will treat you. Especially if you are in a small program. No one wants to work more than they have to work, but you may never have so many people to cover your absence again. Don't delay your personal and family life for residency. Take care of yourself. Don't eat those fries with a grilled cheese at 2 am because you "deserve it." Exercise. Leave your job at work. Stay in touch with family and friends.

Learn as much as you can. When you go out into the "real world" you will wish that you did more surgery and paid more attention in clinic. Even when it sucks, you can do it. Even when you think you won't make it, you will. One day you will look back and 4 years of residency will be over...seemingly instantaneously. You can do it. One foot in front of the other. Life on the other side is good. Keep moving.

The Letter

Yes. This.

Glenn Beck - Current Events & Politics - Glenn Beck: The Letter

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Ass-vice: The Med School Years

Oh yes, so where were we? Medical School. Everyone finds their path to medical school a bit differently, but once you are there? It is a completely new "ball game." Once upon a time, you were the best of the best. You worked the hardest. You got the best grades. You were the smartest person that your friends knew. Guess what? Once you get to medical school...everyone is the same as you. You are all the smartest, the most rigorous, the most dedicated, and, no, you cannot all be the best in the class. Perhaps, for the first time in your young life, you will be an "average student." Please don't let that kill your self esteem. You know what they call the person to graduate last in his/her medical school class? That's right...Doctor.

For me, I felt like once I got to medical school I could actually *breathe.* I had, for all intents and purposes, made it to the "end game." I did not go into med school with a super clear idea of the field in which I wanted to specialize. (Aside: I thought Dermatology would be way cool with awesome hours/lifestyle, but, much to my dismay, I came home disgusted every day from Derm clinic (and also with a case of ringworm before the rotation was over).

However, first things first. The first two years of medical school? They suck. Hardcore suck. It is massive amounts of information, crammed into your brain in ways you never thought possible. You thought you studied hard in undergrad? Freaking forget it. I remember that I would sit....cross legged on my futon in my apartment, hunched over my books and notes for 8-10 hours (after going to class all day), pausing only for bathroom breaks and meals. I would do this, and then I would make a B or a C, because I was in the middle of the (incredibly intelligent) class. So. Frustrating. Studying in medical school surpassed anything that I ever dreamed of in undergrad, but so did the parties after the tests. Crayzee. I made my first D in medical school. I failed my first class (Endocrinology) in med school. I felt lower than I ever had felt....until 3rd year. Once we got into the wards, it all changed. I was taking care of patients. I liked it!!! All of the angst of the first 2 years felt redeemed.

For those of you going into medical school knowing that you want to specialize in Ob/Gyn...you have a leg up. I had no idea who I wanted to be when I "grew up." I blindly stumbled through the blocks until I found something that I really loved to do. For me, it was Women's Health. I loved reading about it. I enjoyed the clinics. I was intrigued with the GYN surgeries, and, of course, delivering babies was the biggest rush in the world. I remember vehemently wishing that I didn't love it. I looked at the lifestyle and was scared to death. But, I knew, just knew, that being an Ob/Gyn was what I was meant to do. I wished it was different, but I couldn't fight how I felt.

If you do know that you are passionate about Ob/Gyn in medical school, get involved early. Look for research (ugh) projects with residents. Bust your butt on your rotations, make yourself invaluable to your team, and impress your attendings. You will need good letters of recommendation from at least a couple attending physicians, so do as many rotations and electives as you can do. Be highly visible. Scrub every surgery that you can manage to do, get your hands in on as many deliveries as you can, and offer (often) to run scut for your interns. Learn the lifestyle before you take the final plunge.

The good news for you is that Ob/Gyn, because of the lifestyle, isn't super-competitive like Radiology or Dermatology. You don't need AOA to get into a good program. If you are a good student, with good references, you will likely go where you want to go. I graduated in the top 25% of my class, and I got my first pick from the Match. So, again with the bullet points:

~ If you know what you want to do, get involved early.
~ Don't despair, the first two years suck for everyone.
~ Go above and beyond on your Ob/Gyn (and, really, every) rotation. Make yourself invaluable to your team (without being a PITA).
~ Find research opportunities through the residents and interns. Everyone needs someone who can research charts and compile data.
~ Be thinking about your letters of recommendation early.
~ Work hard, and the rest will follow.
~ DO NOT be a know-it-all, or do anything listed here.

Up next, how to survive your residency...with your sanity somewhat intact! :)

"I give myself very good advice..."

"...but I very seldom follow it." I've been getting a few requests in comments and emails about advice for people in various stages of pre-medical and medical life. I think I have spilled a few kernels of (snicker) wisdom here and there within the blog, but I'm feeling froggy enough to try to organize my thoughts for your collective benefit. Since there are a million ways from point A to point B, what I will do is to describe what worked for me, and, if you are in a hurry, will bullet point the highlights at the end of the paragraph.

Elementary School

Joking! Joking! Ok? You people are way too serious.

High School

I wish that I could say that I was consciously preparing for a medical career even in high school, but in truth, I really wasn't. I liked science, hated math, and loved to read and write. For a brief time, I thought I wanted to be a lawyer...that lasted until I took a class in Law. I did make good grades, participated in a lot of activities, and took as many Advance Placement courses as my high school offered, so the better not to have to take them in college. Let me clarify that my parents had already prepaid for a state school, so I had no lofty aspirations of Ivy League schools. My fascination with my Anatomy and Physiology class led me to choose to be a Biology major in college.

~Make good grades
~Take as many AP courses as you can handle
~Have FUN (it may be the last time you are able...Hahahaha. Just Kidding)
~Get involved (volunteer, sports, music, student council, doesn't matter what, just do something else besides study!)


College

So, once I went to college, and chose to be a Biology major. I had to seriously consider my options for a career. I could be a research scientist, go for the PhD track, maybe teaching, or I could pursue the medical field. Once I had an inkling that I wanted to declare myself for "pre-med," I began to actively seek opportunities to volunteer. I worked at a hospital rehab center a few evenings a week, shadowed an (family friend) anesthesiologist during the summer months during surgeries. I also sought out other "extracurricular" activities, many of which involved leadership positions in my junior and senior years. When I was applying for medical school (back in the dark ages, though I imagine it is much the same now), the main goal for many schools was to find the "well-rounded" student. (read, *not* the person buried up to their eyeballs in books day and night).


Don't get me wrong, I did *plenty* of studying. I studied harder than I ever had before, and was fortunate enough to make Phi Beta Kappa, Golden Key, and Mortar Board. These things look good on a CV. Bio majors' classes were always Monday, Wednesday, and Fridays (so no four-day weekends) and usually started at 8 am. Oh, how my college self suffered, only being able to go out 3 nights a week instead of 5. I still managed to make great memories and go to football games, even if I didn't get to go out on as many Thursday nights as I would have liked.


I also did not take a class for the MCAT prep, and I totally wished that I had. I did my own prep, and did just fine (obviously), but I hate to think of how much better I could have been. I didn't even automatically release my scores until I saw them, I thought they were that bad. Luckily, it all worked out.


One thing that I always loved was being able to take some "non-major" coursework in the subjects which interested me, like Astronomy and Philosophy. My Biology major afforded me the flexibility to take a few classes "just for fun." I know that you can still go to medical school without a science undergraduate major, but it is more difficult to do. I couldn't imagine trying to get in all the pre-requisites for a completely different college *and* fulfill medical school requirements. I know people who did it, but I was far too lazy for that!


~Choose a science major (unless you are not lazy).
~Volunteer and expose yourself (not like *that*) to the medical profession in any capacity possible.
~Again, get involved! Leadership positions are a plus, as well, and you are going to need good people skills. (Trust me on this one.)
~Don't be a martyr. Yes, you are working hard, and no, your final exam isn't going to be as easy as making a giant cardboard Apple poster (no shit), but you ain't seen nothing yet.
~Study harder than you did in high school.
~Take non-major classes that interest you. This is your last opportunity to learn about something "for fun."
~Take an MCAT prep course.
~Again....HAVE FUN! I had a great time in college, and it was because my studies and social life were fairly well balanced.


Ok, I think I will stop here for tonight. Up in the next installment....ass-vice, I mean, advice for Medical School, Residency, and beyond!

Run, run, run

I'm coming off of another 18 day stretch of call, and has it been a wild ride. Most of the time, even with the unpredictable schedule I've come to expect, it isn't very often that I have a true, chaotic dash to the hospital to tend to an emergency. I know about most labors when they are early in the process, and can mentally prepare to leave for the hospital at the appropriate time. By the same token, most surgeries are planned well in advance. Of course, babies have a way of surprising even the most prepared, and they seem to have conspired against me in the past few weeks.

Emergency Dash #1 - Sunday afternoon, approximately 4 pm. I was out with CindyLou, Bean, and Mr. Whoo at the park, enjoying the weather. I answered an outside page from a husband, worrying that his term pregnant wife (OtherDoc's patient) had been in pain for 8 hours, and was now spotting. Of course, they were told to head straight to the hospital, and I pondered, loudly, why anyone would ever need wait 8 whole hours to make that call??? Just go, already!

As we rounded up the kids and were preparing to head out for ice cream, I received a "911" page from Labor and Delivery. Sure enough, the woman from the phone call had just arrived to triage...completely dilated. No time to change out of my sweaty workout clothes or to drop the family at home, we sped directly to the hospital. I dashed into the room, introducing myself, and promising that I was not some random person off the street in workout gear. Luckily, they believed me (or were so desperate that they just didn't care *who* caught the baby at this point), I made it just in time to catch the crowning baby boy, a mere 45 minutes after I had first received the page from the woman's husband. After all was finished, I joined my patient family in the parking lot, and we all went for some much deserved ice cream.



Emergency Dash #2 - Wednesday morning, 3 am. Awakened from a dead sleep, my groggy, sleepy brain was immediately doused with the equivalent of ice cold water as I saw the "911" page from labor and delivery. I dropped my glasses and the phone before being able to return the page. When I did get in touch with labor and delivery, I found that one of my patients had arrived in triage. She claimed that her water had been leaking since about noon the day before, but she came in because she was having pain. She was completely dilated, oh, and the baby was frank breech....and back down.

If ever there was an "Oh Shit!" moment, this was it. I think I got to the hospital in about 10 minutes flat (it usually takes 15), and the whole time I was on the phone with labor and delivery, checking fetal status, talking to the OR, and arranging for the patient to be in the operating room as soon as I arrived. The poor family medicine resident that had been up on L and D "just in case" she delivered before I got there (truly a nightmare, as a back down breech delivery in an inexperienced operator's hands would almost certainly lead to a head entrapment) offered to scrub with me. We did a true, stat cesarean section, complete with the nurses pushing the breech up from below. Luckily, the baby perked up nicely, despite a very bruised posterior. We got into the uterine arteries on both sides, due to the low position of the breech and extremely thin lower uterine segment, but were able to control the bleeding. Mother and baby boy ended up doing just fine, but I think I may have aged 5 years that night.

Emergency Dash #3 and #4 - I'm including these stories because they were eerily similar to one another. Both women were inductions, both in the same labor and delivery room, both on the same day, one week apart. Patient number #3 was an induction for post-dates. She had a very rough delivery with her last baby, and was leery of hospitals and interventions, but she had gone to 42 weeks, our agreed upon "exit point." She provided me and the hospital with her very simple birth plan, and everything progressed very nicely. She was 4 cm dilated at 11 am, and she decided on an epidural for pain control, as the narcotics she received at her first delivery made her have unpleasant hallucinations. I was at the office, seeing patients, when I got the call from labor and delivery. Her nurse had just come back from lunch, and as she went to check the patient. When she parted the labia, she saw the baby's head! Patient #3 was feeling *nothing!* She was fast asleep! I navigated lunch rush traffic as best I could, and, thanks to her excellent epidural, made it in time to deliver the baby boy at precisely 1:03 pm. She pushed exactly twice. Once for the head, once for the body. No tears, no pain, no long hours of contractions. She and her husband were thrilled, as was I.

Imagine the eerie sense of dejavu, when I had another induction, exactly one week later, in the same room. This time the induction was for IUGR, and the patient was a first time mom. Her induction progressed very smoothly, as well. At 11:30 am, I called to check in on her progress. Her labor nurse had just checked her, found her to be 4 cm, and medicated her with IV pain medication. Imagine my surprise, when a mere hour later, I got a call from the same nurse...she had just returned from lunch and was preparing the patient for an epidural. She checked the patient, as she was feeling pressure, and surprise! She was 9 cm and feeling very "push-y." It was yet another zig zagging race through town, at the lunch hour, where I seemed to catch every single light and get behind the *slowest* drivers on the planet. It is time like these that I wish I could have some kind of special "Ob/Gyn" flashing light to put up on my car to get people to move the heck out of the way!! I made it to the room, where she was trying with all her might not to push. I checked, found her to be completely dilated, and she proceeded to push. She delivered a healthy, if small, baby girl at precisely 1:03 pm. Weird, right?? Kind of cool, though.

Emergency Dash #5 - Yet another Sunday, about 6 pm. I had just arrived home after taking CindyLou over to the neighbor's for a playdate. We were just sitting down to the dinner that Mr. Whoo had prepared, when, you guessed it, I got the "911" page from L and D. This time, one of OtherDoc's patients, a G13P11 (that means 13 pregnancies, 11 babies) who had been wanting homebirth, arrived at the hospital. She stated her water had been broken for a week, she was 34 weeks pregnant, and "the baby just wasn't coming out." She was 9 cm when she arrived on labor and delivery. Fortunately, Sunday traffic isn't nearly as bad as lunch traffic, and I was there in time to help the resident deliver the little 34 weeker. The delivery was the easy part. The hard part came in the way of a retained placenta and post-partum hemorrhage (a risk in those grand multips). Thanks to cyto.tec and a banjo curette, we saved her a trip to the OR. Both mom and baby needed antibiotics post-delivery, probably due to her being ruptured for so long, but both went home a mere 4 days after delivery.

So, that's what I've been up to for the last few weeks. Freaking out, growing gray hair, and aging myself by leaps and bounds. Luckily though, all these moms and babies did well, so it was worth it. To say nothing of the other things swirling about, old job, new job, selling the house, looking for rentals, etc. I feel like I've been running a marathon, minus health benefits and sense of accomplishment. So, what have you been doing these days?

Dear OMFH

I'm writing you this letter because I know I'll never get to say any of these things in real life. You are a major contributing factor to why I am leaving this practice. This, I am certain, is no surprise to you. You are the *worst* office manager I have ever had the good fortune to know. From the beginning, you have viewed me as a threat to your husband (and to you) and have treated me as such. Your sabotage is blatant. From telling patients that they were not *allowed* to transfer to me, to conveniently *not billing* for procedures that I have done, to blatantly attributing payments meant for me to your husband...trust me, I know what you have done.

You don't know shit about running an office. You couldn't manage personnel if your life depended on it, and you let the inmates run the asylum. You say it is "inconsiderate" of me to make patients reschedule an appointment when they arrive 30 minutes late (without calling), yet is perfectly considerate (in your opinion) to let patients wait 3 hours to see your husband's nurse, as he is off at the hospital for another delivery. Oh yes, and it is also very *considerate* of patients to tell them they need to transfer to another office if they want to see me as their physician. Totally ethical. It is abundantly clear that the *only* thing you care about is money (really, $6000 window treatments and a new Mer.cedes every 6 months??) It is no wonder that your husband works like he does: 1) he needs to support your inordinate spending, and 2) I am sure he'd prefer to steer as clear of you as possible. You think that you are my boss, and can tell me who I have to see, but let me assure you, you have no power over me. I'm sure it gives you great pleasure that you are the one that makes the call schedule, and you relish not putting out the new schedule until half of the month is already over.

You treat my nurse, who is the best freaking employee in that office, like she is dirt beneath your feet, all the while claiming to be a "good Christian." You kiss the ass of the employees that sleep on the desk, shop online during office hours, and shirk their responsibilities. Your hypocrisy sickens me. Your faux concern is laughable, and I cannot *wait* to be rid of your fake, bitch ass. Every physician that interviews here, I am telling to steer the eff clear of you and your "office management." If the hospital had any idea how much money you were costing them, perhaps it would motivate them to grow a pair and fire your ass.

So, yes, mission accomplished, you have run me out of town, but you won't have another physician in my place to screw over and to split your overhead. As for your humanitarian shortcomings, "Judgement is mine, sayeth the Lord." I'd be making atonement, if I were you. Here's hoping that you get *everything* that you deserve.

Most Sincerely,
Dr. Whoo

To Get to the Other Side

There are times in life when everything seems to fall right in to place, and then, there are times like now. I can see the shimmering oasis of a new life, just on the horizon. A better call schedule, closer to family and friends, a chance to work in a collegial (not competitive) environment, more time with my precious kids and husband, and a chance to grow as a physician. Between the oasis and where I stand, however, is a treacherous, rock-filled, rapid river, swirling and threatening my ability to ever reach the opposite shore.

Obstacle #1 - Our house is on the market, and we have shown it at least a dozen times. Yet, despite positive overall feedback, not a single offer. I don't mean to boast, but our house is a beautiful house. I love it. I was ready to buy it the second I walked through the front door, and I can't believe that everyone else that sees it doesn't feel the same way. We never thought we would have to sell this house. Maybe we should have thought about selling it before we bought it. If we don't sell before we move, we'll have a hefty house payment, along with any rent payment we need to pay in Newville. This alone will be a financial strain.

Obstacle #2 - Mr. Whoo has yet to find a job, nor procure an interview in Newville. Granted, he has only starting looking in earnest recently. However, he is looking for work in the finance world, which isn't the best place to be seeking employment given the current state of our economy. We have been fortunate that he was able to quit his job last fall when our family really needed it, but now we worry that the employment gap may cause an impetus with new employers. Plus, without an additional income after the move, there will be more financial strain on our family. (See Obstacle #1)

Obstacle #3 - My current place of employment is not letting me go without a fight. There have been veiled and outright threats of lawsuits and damages and liabilities for me leaving earlier than my contract had mandated. There is also the matter of giving back a portion of student loans paid by the hospital. The fact that we would have to pay back was not unexpected, however, the amount that we calculated is about half of what the hospital estimates. We are procuring the services of a contract negotiator and a lawyer, who seem to believe we have a case for inducement, but I'm having angina just thinking of it. Not to mention the fact that, if the hospital's calculations are correct, they want us to pay up in less than 2 months. Add more financial liability to the swirly, cold, and fast water.

Obstacle #4 - Emotionally, I am wrung out. I am completely exhausted, and barely hanging on by my fingernails to make it to the date I indicated I was leaving. Being on call, continuously, with only 4 days off per month (plus vacation time), has left me completely burnt out. I find it hard to drag myself to work and muster compassion for my patients. They deserve better than the doctor I am right now. My health, mental and physical, is suffering. The remainder of my contract is a mere six months, and by finishing it out, I can alleviate much of the financial burden of the above obstacles...for the price of my very sanity. I want to cry just thinking of it.

So, I sit here on the bank, pining for the oasis, and unsure how to navigate the obstacles that lie before me. Oddly, I am reminded of the "old school" computer game, "The Oregon Trail." When faced with a river, you can try to ford the river, float the river, or hire someone else to help you across. Right now, I am pining desperately for someone to throw me a life line, or at the very least, a strategy for surviving these treacherous waters. The best advice I can relate to our readers is to know what you are getting in to before you sign a contract. There is no such thing as a perfect job, and if it seems too good to be true, it, in all likelihood, *is* too good to be true. Caveat emptor...and pass the caulk.

*cross posted at Mothers in Medicine

Revenge of the Pregnant Women

Oooooweeeeeeooooo. Scary, huh? Well, to a poor, unsuspecting, newly-recovered from the flu Ob/Gyn, it is the scariest prospect around. You see, for the first time (and I do mean, the very first time) in 4 years, I was oh-so-fortunate to have an entire 3 weekends off...in a ROW! The audacity! The outrage! Ohhhhh, and the payback. You see, 2 of those weekends were included on my vacation, which was less vacation, and more "how much activity can you cram into 10 days?" This was spent in the southerly regions and in Newville, the site of our pending relocation. The third weekend was Easter weekend, by some stroke of luck, I was able to convince OMFH to grant me the holiday off, to visit with Mr. Whoo's family in the Great White North. Easter weekend marked the beginning of the the Whoo Family's dalliance with "The Flu." It started with Bean, quickly moved to me, and took out CindyLou later on in the week. Mr. Whoo is the only one left standing, and he's starting to get that characteristic hacking cough. Surely, I thought in my fever-fogged brain, out of all that glorious time off, some of my patients would deliver in my absence. Much to their delight (and my relative dismay), they did not. Other Doc, throughout the whole of my vacation and time off, did not deliver a single patient of mine.


Instead, they all waited for me. So this week, between popping Day.Quil, Ny.Quil, and Mot.rin, I have been exceedingly busy. The day that I returned from vacation, I had an induction for post-dates (41 weeks and 6 days). She had received cervical ripening overnight and actually was really contracting well. About 5 minutes after I hit the floor, she SROM'd the thickest meconium fluid I had ever seen, this was followed by a 10 minute trip to the 60s for the fetal heart rate. I checked for a cord, couldn't find one, tried everything possible to get the kiddo to recover, and eventually went down for an emergent cesarean. The baby was out in less than a minute, and needed a little transition time, but ended up doing very well. Not the best way to start the morning. After finishing up the paper work and talking to the family, I saw a familiar patient roll up to the nurse's station...in obvious distress. She was supposed to have a repeat C-section later that week, but, she was in labor today. Back we went to the OR, where I delivered a 9.5 pound baby boy. I finally made it to the office that day around 3 o'clock.

The rest of the week continued in a similar fashion. There was a severe IUGR baby, born to a couple that struggled with fertility for a very long time. She was only 37 weeks, but the baby was measuring 32 weeks. We had watched the growth for the last few weeks, and it had steadily plateaued. The patient received only cerv.idil, but quickly labored and delivered a healthy, 5 pound baby girl. The placenta was incredibly calcified and quite small, so I felt confident the correct decision to deliver had been made. Unfortunately, there were a few inductions, one for preeclampsia and one for post dates that ended in late night cesarean sections. Both moms and babies did well, but I hate to have failed inductions. It makes me feel as if I have failed those patients.

Oh, and then the "weekend" came. My first weekend back since vacation, and, let's face it, I was already dragging from a busy week and a lingering illness, and OtherDoc had a similarly bad week. There were a million patients to round on, and about half a million circs (my favorite! Not.) I got the first call a little after midnight about patient at term with SROM. I had a little hope, as she did not want an epidural (score 1) and was only 2 cm when she was admitted (score 2!) Between my sick kids and being paged every hour from patients and from labor and delivery, very little rest was had between her admission and the call telling me that she was 8 cm at 4:00am. I arrived at the hospital right as she was beginning to push. Blessedly, it was a very nice, smooth delivery. No tears and a healthy baby. I'm sure my patients didn't appreciate being rounded on at 5 am, but I certainly wasn't coming back later! I did my umpteen circs, rounds, discharges, and spent the rest of the day trying, unsuccessfully to catch up on rest.

In the late afternoon, another "rule out labor" came in to triage. She had not changed her cervix, but she was post dates, and I decided to keep her for observation. I communicated several times with the nursing staff before I went to bed, and was assured she was "doing nothing." I took a Ny.Quil and was in bed no later than 10:30. Imagine my surprise when I received a page at 3:30 am telling me she was completely dilated. It was an all-too-familiar dash to the hospital in the middle of the night. I arrived, broke the bag of water, and she pushed out a beautiful 8.5 pound boy over an intact perineum. Once again, it was circs at 4:30 am, and rounds at 5 am. I have spent the rest of the day trying to recover. I am just now starting to feel human again. I really can't keep up this pace. I hope that I have done sufficient penance for my time off, and that the pregnant ladies are merciful tonight!

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Whoa! I just blinked and a whole month was gone! Sorry to be MIA for so long. You have heard it all before. Get the house ready to sell, try (yes, I said try) to leave the old job, try to arrange things for the new job, take the family to the extremes of the North and South for back to back vacations, oh, and you know, work a full-time, 4 days off/month job. Makes it difficult to blog, ya know?

It isn't for lack of material, that is certain. I have a million ideas rattling around my skull, but no ability to focus in and write. Shall I write about how my current job in Whooville is giving me hell about trying to leave my contract early? Or shall I write about how difficult it is to tell my patients that I am leaving...especially the pregnant ones, due after I am supposed to leave? How about writing on how I managed to not eat pasta for the entire of season of Lent, and still managed not to lose a single pound? (Oink!) Or how we still haven't sold the house and I am freaking out? Maybe I should write about how big my kids are getting, almost 5 and almost 2, and how I feel like I've missed out on so much. It isn't anything you haven't heard me bitch/moan/whine or complain about before. I know I have to get back in the blogging "saddle" again, but I am unsure of how to start. What do *you* want to hear about?

Oh, and happy Tax day. Heh.

Cleanin' Out My Closet

With all due respect to Em.in.em (who I strangely love), it is not as interesting as he makes it sound. We are T-minus 3.5 months and counting from the big move from Whooville to NewCity. Mr. Whoo has been a packing machine (watch him get down), and we are getting ready to pack the first of our P.O.D.S. in anticipation of the move. Unfortunately, the closet has been begging and pleading for our mutual attention. We have been fortunate enough to be blessed with a home with a large master closet. Well, I guess I mean blessed and cursed, because every damn thing that does not have a home ends up in our spacious closet. Oh, shit! Company coming? Shove it in the closet. Stacks of paper with no where to put it? The closet sounds like a good idea! No time to deal with it now? Put it in the closet. And so on, and so forth for 3+ years and counting. Except now? We need to show the house, awesome closet and all. Not to mention the fact that we need to pack, and, my lord! Do we really need all of this *stuff*?

So, for the last few days, we have been working on the closet. I have been forced to go through all of my clothing, hanging on hangers in the closet since 1991. I am not kidding. There were clothes in my closet that I wore in high school, and I have the yearbook pictures to prove it. To me, this begs the question...why in the *hell* am I holding on to these clothes? For one, there is no hope in hell of me fitting into my old high school clothes...ever. And, even if I managed to get back down to 110 pounds soaking wet, would I really be wearing a flowered shirt from The Limited? Really? (Does that store even exist anymore?) I took the plunge, made some hard (ahem) choices, and managed to purge more than half of my closet in favor of donations to Good.will. Going through the clothes was kind of therapeutic and fun, in a way. I finally parted with the cute gray skirt I would wear out on chilly nights in college with tights, and the sundry "dressy" skirts I would wear to my sorority chapter meetings. There were a lot of good memories in that closet, and, hopefully, the clothes that I donated will go on to a new owner (someone that can actually fit into them) and be a part of their memories. I feel a bit anthropomorphic, thinking of my clothes this way, but hey, I am the girl who cried about packing away stuffed animals because I thought they would miss me (damn you Veleveteen Rabbit book!)

I am finding that the more of the clutter that we pack away, the clearer my mind becomes. I have loved visiting the past by sorting through old clothes and sundry items stashed in the closet, but I have also felt comfortable leaving them behind and moving on to better things. I feel good about moving forward, and I am happy to be getting closer to a new life...one closet at a time. I hope you all are well...Happy Friday the 13th!

Why I Do This

Lately, for me, all you have been hearing is bitch, bitch, bitch about how this or that sucks big hairy balls (can't wait to get the misguided google searches on that one). So why, you collectively ask me, either outright or in your minds, do you put up with all that you do? Why not quit and become a garbage collector or something? This list, my friends and frenemies, is why:

~ Bringing babies into the world is, quite simply, awe-inspiring. I love it. It is so special and intimate, that moment when a family is born (and re-born), and I feel privileged to be a part of it.

~ I love helping women. Women are way too busy taking care of every one else to worry about taking care of themselves. It is good to have 15-20 minutes to sit and listen to women, and make suggestions on how they can better care for their own needs.

~ I like to *fix* things. I am, at heart, a fixer. I want to change things for the better, and being an Ob/Gyn allows me to do this more often than not. I find this infinitely satisfying when I can make things better through surgery or medical treatment.

~ I enjoy the continuity of care that being an Ob/Gyn affords. I love being able to deliver multiple babies for the same patient, and then be able to take care of their Gyn needs once childbearing is over. I like the lasting relationships the field can foster.

~ I like to do Gyn surgery. General surgery, to me, was overwhelming, but Gyn surgery affords me the ability to do a variety of cases in a limited area of the anatomy. The perfectionist in me enjoys the focus on one organ system, but there is always good enough variety to keep it interesting.

~ Procedures are fun. Not just surgeries, but colposcopies, LEEPs, IUD insertions, polyp removals, and endometrial biopsies are all very enjoyable, and the results are often immediately evident. Highly satisfactory.

~ There is a limited amount of pharmacology. For me, it is pretty much antibiotics, hormone replacement or suppression, birth control, anti-inflammatory meds, the occasional hypertension or diabetes med, and some anti-depressants. I loathe polypharmacy, so I enjoy the clean and simple pharmaceutical profiles that Ob/Gyn provides.

~ The patients. That's right, for all that they do to drive me crazy, it's the patients that keep me coming back for more. Be it the infertile woman that I helped to conceive, or the anemic, miserable woman whose ills were cured by a simple procedure or surgery, or even the chronic pain patient who got the correct diagnosis, treatment, and subsequent improved quality of life. I do this for the patients, plain and simple.

~ At the end of an exhausting day, I feel that I am making a difference and an impact for good in people's lives. That fact makes the unbearable actually bearable.

So, look, I love my job. I love it. For all of my whining, I wouldn't do anything else. I hope this answers the questions out there. Thank you for listening.

**cross posted at Mothers In Medicine

"Blah"ging

Wow, I just went fifteen days without even thinking about blogging! Maybe that is because I have delivered 12 babies in the last 2 weeks, including my second set of twins for the month. I am very happy to have attended 2 twin births this month, both vaginal deliveries, one without an epidural (go mom, woo!). February has been filled with post-dates patients and big babies (though none coming close to my recent 11 pounder!) It has also been filled with more C-sections than I would like to have, but I guess my good run of vaginal deliveries had to end somewhere.

The word is out that I am leaving the hospital. The feedback that I have gotten overall has been really positive. By that I mean, people seem sad to be seeing me go, but they aren't being jerky about it. Most people are very understanding of my family and call situation, as well as the reason why I am leaving. It's nice to know that I will be missed by the staff and the patients, for I will surely miss (most of) them. We have been showing the house sporadically. Let me tell you, getting the house "show ready" with two messy kids and (let's face it) two fairly messy adults is a serious challenge. After every showing I get this huge surge of hope that we will finally sell the house. And then? Nothing. I know it is a bum market right now, but the thought of carrying this house payment with us after we leave is daunting. So much hinges on whether or not we sell the house. Will we buy or rent in NewCity? Are we looking for temporary or more permanent? CindyLou will be starting Kindergarten (!!!) in the fall, so we are trying to find the area in which we want to settle in the "right" school district. So much uncertainty is fairly uncomfortable.

The licensing process is dragging on and on, but I think I have it all pulled together. Now I just have to get it all submitted. I don't know how anyone could fake being a physician and get a medical license. I can barely get all the bases covered, and I am totally legit! I just can't believe how much I am being nickeled and dimed to death on all of the various and sundry fees. I've decided that New State will be our final destination for the duration of my medical practice. I cannot fathom going through the licensure process yet again.

Mr. Whoo, CindyLou, and the Bean are all doing great. The Bean is 18 months old. (Can you believe it?) He is such a little sweetheart. His language has really taken off since he got his tubes put in last summer. He loves books, and will sit in your lap, snuggle, and read books for hours! He idolizes his big sister, and while he cannot say her name yet, he calls her "sissy" in the most adorable way. CindyLou is a stellar big sister, and, at times, is very much a little mommy to the Bean. She is so smart and curious. She drives crazy with her constant jabber sometimes, but I suppose this comes naturally. Both Mr. Whoo and I often got the admonishment of "Talks too much!" on our progress reports and report cards! Mr. Whoo continues to be the best husband on earth. I don't know where our family would be without him. I feel so lucky to have such a wonderful partner.

As for me? I'm getting through one day at a time. I am still 2 steps forward and 2 steps back (Paula Abdul reference completely unintended, sorry!) with respect to weight loss. I still find myself turning to food for comfort at the end of a long, hard day. I keep seeing everyone with whom I went to high school and college (via facebook, mostly) all looking so fit and well rested, I veritably seethe with envy at times. I look ten years older than I actually am, not to mention 50 lbs heavier than I should be. I know better times are on the horizon; I just need to quit making excuses. Any way, I just wanted to check in and let you know that I am still alive and kicking! Now I just have to figure out 2 snazzy posts for MIM before next Friday. Hmmm....

Is Mercury in Retrograde or Something?

Hello all, what a crappy week it has been. Is anyone else having "issues" this week? My week actually started out on a pretty good note. One of my patients, pregnant with twins, began to develop preeclampsia. We made the decision to augment labor (she was already contracting and 3 cm), and late in the evening I got to do my first vaginal twin delivery since residency. I was nervous because I am used to doing twin deliveries in the OR as a "double set up," just in case there is a need to emergently deliver the second twin by C-section. In Whoo Hospital, there are no ORs on the L&D floor, so the deliveries are done in the room, and, should an emergency arise, you have to go down several stories to the OR. In a situation where minutes and seconds are precious, this is a daunting thing, especially as the night wore on and I realized that she would deliver in the dead middle of the night (aka skeleton crew time). Luckily, it was the smoothest twin delivery I'd had or seen in a long time. The first baby had no complications on delivery, the second baby stayed vertex, we broke the second bag of water, and baby number two was born about 5 contractions and 2 pushes later. Both babies and mom did wonderfully well. It was truly an amazing experience, and I was happy to be a part of that.

After that, though, it all went downhill fast. Of course, due to the middle of the night delivery, I got very little sleep. Therefore I overslept, and was later than I wanted to be getting to the hospital. Waiting for me there was a consult for the ever dreaded "pelvic pain." Before I get roasted about pelvic pain, let me emphasize that yes, it exists. Yes, there are gynecologic causes. Yes, it is not always supratentorial (all in the patient's head). But this patient definitely had supratentorial pelvic pain. She was already on a cocktail of narcotics and benzodiazepenes, and she spoke of severe excruciating pain in the calmest of voices, her pulse at 60, blood pressure at 90/60. Her exam was completely normal, as were her labs and imaging studies. She blithely asked me to "go ahead and do a hysterectomy while she was "here" (IE admitted to the hospital for pneumonia)." I blithely declined, set a follow up appointment in the office, offered medical suppression for her cycles (got denied), and asked her to sign a medical record release to obtain information from her prior ("out of state") physician.

Already in a *fantastic* mood by this point, I proceeded to the office. Where my right hand woman, SuperNurse, had slipped on the ice in the parking lot and (unknown at the time)broken her leg. For a while she tried to walk on it, but we all finally convinced her to go get xrays. So then, I was stuck with NotSoSuper medical assistant, who may well be the laziest person on the face of the earth. Any one who has worked in an office knows that the nurse who assists you can make or break the flow of your day. This day was definitely broken. The afternoon dragged on with the most draining kinds of patients around including such hits as "every organ system bothers me, can't you just wave a wand and fix it?" and, after a "routine" annual, a 20 minute nervous breakdown over the (unfounded) perception that her female anatomy was somehow horribly disfigured, and she wanted vaginal reconstructive surgery, not one but two Op.rah inspired "natural hormones" consults, and, last, but certainly not least, a patient with known cancer, sent to me by her radiation oncologist for a "skin tag" removal, that I am almost 100% certain is a vulvar carcinoma. Good times, good times.

Then, after a long, hard day already at 5pm, I log on to the internet to learn that one of my friends that I knew from middle school, high school, and college had taken their own life, and leaves behind a small child. I was shocked, then dismayed, and am still very sad over the whole thing. Just terrible news. Mr. Whoo had his community service club meeting, so I kid wrangled alone for bedtime and bath time. Exhausting. To top all of the rest of the day off, after being unnecessarily snarky when I had meant to be funny, I had a misunderstanding with one of my friends, feelings were hurt (I believe on both sides), and now I am getting the technologic freeze out which isn't very pleasant, either.

I am still struggling with the license application for obtaining my medical license in New State. So far I am out almost $1000 in various fees and I haven't even submitted the application proper (which will be $5000 +). We haven't sold our house yet, we haven't begun packing, I'm still over weight and not losing, despite my best efforts, and for extra fun, I have decided to cut all alcohol consumption for the month of February. Oh yes, and I am on call this week and all weekend long. So yeah, my week has pretty much sucked! How about you all? Am I the only one?

So, Anyway

Where were we? Oh yes, my gigantor baby story. VM has been my patient since I started practicing here in Whooville. I delivered her first baby shortly before the Bean, so imagine my surprise (and hers) when she came to me last spring, pregnant with her second child. VM had gestational diabetes with her last pregnancy, but it was very well controlled with diet. This pregnancy was a different story. We tested early, and began the diabetic diet and teaching very quickly, but her sugars waged out of control for a good 2 weeks. There were some ups and downs with her insulin control, but we finally struck a good balance. She remained well controlled for the remainder of the pregnancy...on paper, any way. Long about 36 weeks, VM's fundal height began to measure larger than her dates by more than 2 cm. (2 cm above gestational age or 2 cm below are considered in the "normal range.") The ultrasound revealed a fetal weight extending into the 90th percentile.

Due to her early gestational age, we decided to observe the fetal growth and aim for induction of labor at 39 weeks (the week after Christmas). All progressed merrily, with an ultrasound at 38 weeks predicting an estimated fetal weight of 10 pounds 7 ounces. "Ha ha!" we laughed. How *funny* that would be if it were *true*? In the back of my mind visions of shoulder dystocias danced in my head, but I kept repeating the mantra that "Macrosomia is not an indication for induction." over and over until the voices were quashed. VM presented for induction of labor for insulin dependent gestational diabetes at 39 weeks and 2 days. She received ce.rvi.dil overnight, and pit.ocin was initiated in the morning. Her previous pregnancy had been a spontaneous labor at 38 weeks, and had lasted a little over 4 hours. By 10 AM, VM was comfortable, with a good epidural, and she was *frustrated* that the baby had not been born already! I reassured her that induced labors were different, and that this baby was probably just a wee bit bigger than her last (8 pound 3 oz) baby. Right about noon, she began to feel the telltale "pressure." Sure enough, she was complete and at +1 station. She had no discomfort at all, and not much urge to push, so we turned back the epidural and let her "labor down." Nearly 30 minutes later, VM was ready to push. I remember that she was laughing, because she couldn't feel what she was doing. What she was doing was pushing like a champ. She laughed/pushed for about 4 contractions.

Then, the head completely crowned....and I just about died. It was a very, very, large head. The delivery was very well controlled, but the head just kept coming and coming and coming. I made eye contact with the nurse, and, mirrored in her eyes, I saw my own concern. She maneuvered the patient into McRobert's and prepared for suprapubic pressure. We wouldn't need it. The anterior shoulder slid under the pubic bone with only the slightest pressure. I think I actually breathed again once I felt that shoulder deliver. I lifted the small toddler, erm, baby into the waiting arms of her mother, and she cried and the baby cried with her. There was a very small second degree laceration that was easily repaired. The head circumference as 16", and the weight was 10 pounds 15.7 ounces. VM asked if she could "get credit" for having an 11 pound baby. "Without a doubt!" I said. So that is my eleven pound baby story; the largest baby I have delivered vaginally. (The largest by C-section was 13 pounds, ack!)

SO, what is the moral of this story? Well, I think there are a few things. For one, sometimes, despite all of the talk of ultrasounds being incredibly inaccurate in the third trimester, your baby *is* as big as the ultrasound says it is. But second! Even if your baby is ginormous, and you have to undergo a god-forsaken medical induction, you can still have a smooth, successful delivery. And third, as a physician, it reinforces to me that it is always best to prepare for the absolute worst, while trusting the process, and hoping for the best.

Thank you all...

...for your support. You guys make me want to cry! Don't worry, I'm not going to stop blogging, nor will I change the way that I blog. I value this space, and I certainly value all of you, whether you agree with me or not! So, thanks again for all of the kind words. I was beginning to feel a little persecuted! Coming up...Dr. Whoo gets her first day off in 18 days, relocation woes, and an 11 pound baby (!). Thanks for reading!

Commentary

There were a couple of comments from sarai on my last post that were rather lengthy, so rather than leave them in the comment section, I am posting them both here, in their entirety, along with my response. Italics are sarai's words, and the regular text words are mine

It can be very hard for the patient however, after having the doctor be wrong numerous times over the years with drastic consequences to your life. I don't watch Oprah, and the articles you mentioned irritate me, but yes, I do look for reputable internet sites, and before the internet was available, I researched.

sarai, I realize that your postings are coming from a place where you have been burned by the medical profession, but I certainly do not believe that physicians are anything more than fallible human beings who will make mistakes. That was not the point of the post.

That doesn't mean that I approach the doctor like I know more, and like I expect them to act as my puppet. But if I go to an OB appointment and say my baby isn't moving as much, and I am concerned about placental insufficiency, for example, I DONT want to hear "you're baby is moving just as much, it just doesn't feel the same because he has less room". Excuse me, doctor, YOU are not the one that's actually pregnant here, DON'T tell me how much my baby is or is not moving. YOU are not the one that will have to live with a dead child if there is a stillbirth (which the medical world is completely unable to understand how to prevent) I and MY HUSBAND ARE.

I think you are misunderstanding me. I *do* appreciate an informed patient. As I stated before, I practice collaborative medicine, not paternalistic care. I take my appointment time with patient to educate them and talk about treatment options. I even have a list of reputable internet sites on which to research information. That is completely different than someone coming in (or better yet, just calling the nurse line) and telling me that they have already diagnosed themselves, and now would like me to prescribe this medicine or order this test for them.

Again, I know that you've been hurt, but I am not the doctor that didn't listen well enough to you when you knew something was wrong, so please don't cyber yell at me. Just because I may vent my spleen on anonymous blog about things that irritate me about patients does not mean that I quickly dismiss them or am rude to them, quite the opposite actually. I take my patient's complaints seriously and act quickly on alarming symptoms. The dismissive attitude you are attributing to me does not apply in real life. You only see the seedy underbelly of my brain here.

You doctors don't always know how many times in person's life a previous doctor missed something important and the patient paid a heavy price. The doctor may have done nothing wrong, they may have met the standard of care, but to the person living with the consequences, it just doesn't matter, and they will do anything they can (watch Oprah, read really stupid Reader's Digest, surf the net) to try to make sure they get more observant care next time around.

Yes, as I said, "we doctors" are not omniscient. I did already know the patient about whom I posted, and have been doing her GYN care for 3 years now ( and each time I did her pap, her small speculum was warmed and lubed). She is not new to me or my practice. My care of her has been as observant as can be. Doctors are human, we do our best, and sometimes, despite our best efforts, it just isn't good enough. It sucks, and we try hard so it won't happen, and it bothers us perhaps more than you will ever know.

As a nurse, I've seen term babies stillborn, (decreased fetal movement, doctor ignored, or minimized), diarrhea was actually Ecoli, which turned into HUS, by the time treated (after being sent home 3 times) kid had stroke and ended up needing kidney transplant, a "viral upper resp infection" was actually a bacterial pneumonia, doc wouldnt believe patient couldn't breathe well 'cause sat was OK, vomiting and increasingly decreased LOC was actually juvenile onset diabetes (also sent home a few time before ER doc figured it out -- kid almost died.) This may be why some people are reading articles and trying to advocated more vigorously for their own care. I know I am. Even as I feel sincere empathy for you as I see the look on your face when you see my internet sheets........

See above, and there are even term stillborn babies where there were *no* warning signs. No decreased movement, no pain, no bleeding, sometimes babies just die. We do everything we can to prevent it, but despite our best efforts, babies still die. Yes, there are physicians that dismiss patient concerns, or miss pertinent signs, but we are not all the same person. Advocating for your own care (what you are talking about) and telling the doctor what to do and how to do it (what my post was about) are two different things entirely.

And here's something that just kind of bothers me about your blog, which, BTW, I otherwise enjoy reading.........it's judgement both from you and commenters, about women's birth choices.

Well, I can't speak for my commenters, but part of my job is to regard "women's birth choices" with my own clinical judgement. That's my job. If women come to me for care, they are, in fact, asking me to use my clinical judgement in their care.

If I'm reading your blog right (and correct me if I'm not), the "ideal" expectant mother in your practice wants to go into labor naturally, not mind being past due date, and not object if you feel at the last minute she needs a crash c-section. Moms who want to be induced (God forbid a week or two early) prefer a c-section straight off, or "insist" on a "happy vaginal midwife birth" even if things don't go according to plan are subjected to the eye roll.... Kind of a tall order, Dr. Whoo.....

I don't know if there is a "right" way to read my blog, so who am I to say who is "reading it right" or "reading it wrong?" I do think that you may perceive my words in a more malicious way than they are intended, and this is probably only highlighted by your bad experiences. I vent on this blog when things get tough to take, a safety valve, if you will, so that I do not blow up in the presence of an actual patient. There is no actual eye rolling going on in the presence of my patients. No matter their circumstances, personality quirks, or clinical needs, they are treated fairly and equally.

Loosely speaking, my "ideal" patient (as you put it) doesn't exist. My guidelines for delivery, elective or otherwise, are dictated both by the standard of obstetrical care, my clinical judgement, and the individual aspects of each patient. What I expect of my patient is a relationship of mutual respect and trust. Those are things that must be earned...by both parties. There is no "laying down the law." There is a give and take that is natural in these kinds of professional relationships, and quite honestly it doesn't merit many blogging entries because it is so routine. I don't think that you understand, you only see so much of me here.

One thing I did NOT NOT want with my first child was a crash c section. Either a vaginal birth, or a planned section, didn't care which. Of course, doc wouldn't do a c-section just because I wanted one, so we had a crash vag delivery with vacuum, (baby crashed too late to get c-section) where I got to experience watching my firstborn be revived, separated for her for hours after birth while she stabilized, and was so sore and torn up that I didn't want to have sex for months and months, and still deal with stress incontinence since that delivery well over a decade ago.....but because I didn't go to med school I didn't get to decide what would be better for me. I would like to argue, both as a nurse and as a mom which was physically better for me -- ugly vag birth or planned c-section. Yep, I'd choose c-section. Sorry.

I'm sorry that you had such a traumatic experience, and that it still haunts you. There is no way to predict when something like that is going to happen. Crash deliveries of any kind are heart stopping, but it *is* the physician's decision, in that moment, what will lead to the best outcome for mother *and* baby. If there is a terminal deceleration, and the baby is on the perineum, it is much more likely you will get a better fetal (and maternal) outcome with an assisted vaginal delivery.

I'm sorry that your bottom got torn up, and you had to undergo the trauma of seeing your daughter (successfully?) resuscitated. But, if I'm reading correctly, your baby survived. If your physician did what you wanted them to do, what you *perceived* to be "physically" better for you, and did a c-section, your baby's brain could have been deprived of several additional minutes of oxygen, with possible disastrous consequences. Whose fault would it be then? Yours? No, it wouldn't, it would be the physician's fault, who let the clouded judgement of an overly involved party (read, you) make the call. Instead of a torn up bottom, you could have hemorrhaged and required an emergent hysterectomy, precluding any future deliveries. Would you take the responsibility of zero future fertility, just because you *wanted* a surgery? Or is that the physician's responsibility? So yes, when you put your medical care into the hands of your physician...in that critical moment...you may not get to make that final call on what you *think* may be best for you. That is what a physician is there to do.

The recovery from next delivery was even worse, crash section, nobody's fault, but if I had it to do over again, possibility of crash section or planned section, well, I'd choose planned every single time. The crash carries psychological scars --- many of them. If you are lucky, you get to go to sleep and miss your baby being born. If you are unlucky, you have to stay awake, with no one talking to you, while your baby gets CPR. and your husband is God knows where. Physically, its a lot harder, too, and wound healing is not nearly as good than it is when the surgeon has time to take his time.

Agreed, but the point is the same, you cannot always predict these things. You said yourself, nobody's fault. Precisely. Planned surgeries are often more controlled than emergent surgeries...but not always. There are exceptions to every single "rule." Again, I sympathize that you have had such traumatic experiences, but the neither medical profession at large (in general) nor I (in particular) are to blame for this. I didn't have the perfect, ideal, rainbows and orgasms births that I would have loved to have, either, but I was fortunate and had 2 viable, healthy babies. I wouldn't trade that for any "experience."

The reason that patients want to run the show is because THEY have to live with the outcome!!!!!!! Tell yourself over and over and over again, its not about me, its not about me, its not about me!!!! especially in your profession where the stakes are so so high.......

But in order to be safe, objective, and effective the patients cannot feasibly run the show! They can (and should) be involved in the decision making process and development of a treatment plan, and they can consent or not consent, but they *cannot* "run the show." That is what a physician is supposed to do. Run the health care show.

This blog *is* about me! How I feel about the things that I do and that I see. Here, in this little corner of the internet, it *is* all about me. That doesn't mean that I disregard what my patients want. It also doesn't mean that I haven't had to make a decision that a patient was not capable of making on their own.

Maybe they really want to be induced when they know YOU, whom I'm sure they all really like, will be there. Maybe they are tired. Maybe afraid of late 3rd trimester stillbirth. Maybe they are struggling financially and need tax break. Maybe already not able to work anymore and trying to maximize maternity leave. Wanting to be induced at 38 1/2 weeks is not a sin.

Perhaps it isn't a "sin," per se, but it isn't valid medically. There is a lot of research to read about elective inductions, especially prior to 39 weeks. Often the outcomes are less than stellar, both maternal and fetal. Wanting your own physician, or "being tired," or "being afraid," or "needing a *tax* break (!)" are not viable indications for medical procedures that can have lasting impact on fetal and maternal health and well being. Elective induction of labor is associated with higher rates of cesarean deliveries, fetal distress (and dreaded "crash deliveries"), and fetal hospitalization for various immaturity issues.

Take a page from your midwives book. Listen to your patient. Ask questions. Try to figure out what the patient is afraid of. What she values. Try "why is this so important to you?" instead thinking "I can't believe she wants to have her baby by Christmas!" Find out what other experiences she has had with other health care providers. Maybe the last doc that did a pelvic jammed a large cold speculum where the sun does not shine, and she thinks you respect Oprah more than her. And remember, if she wanted a midwife, she'd probably be seeing one, so try to tactfully ask what she wants from your expertise, if you feel like she is treating you like her puppet.

Not to beat a dead horse, because I'm already feeling nuts for defending myself for talking about the way I feel on my own freaking blog, but how do you know that I *don't* listen? You don't know. You don't know me. You don't know how I treat my patients. The last doc that patient had for a pelvic exam was *me*, and I did not jam a cold, extra large speculum into her.

I've found that being a patient and having really horrible medical experiences makes me a lot less offended by my patients. Because if a patient asks me "will the doctor use a small, warmed speculum like it says to in Oprah's magizine?" my first thought is not to roll my eyes, it is to ask, "what has your past experiences with pelvic exams been like...."

Unfortunately, having really horrible medical experiences makes you a lot *more* offended by the things that I say, anonymously, on this blog, and causes you to extrapolate and frame my commentary in a less than favorable light. I hope my response has given you some insight. And truly, for all the snarking on the blog, I never forget that my patients are just people, just like me, with a different frame of reference. Even if it doesn't translate in text, I'm certain it translates well in person. I wish you healing as you attempt to move forward from your painful past experiences.

Really?

It's a new year, it's raining outside, I'm cranky from dieting, and OtherDoc has been out of town for a week. Do I need to provide anymore preface than that? That's right, time to vent!

It's weeks like this that I truly wonder why any sane person would ever consider being in the medical field. Money? Small potatoes compared to other professions. Autonomy? Hardly. Respect? A resounding "Ha! I don't freaking think so!!" I don't know about anyone else, but I am getting sick of hearing about what Op.rah thinks about my profession. This week a patient advised me (and I quote), "Well, Op.rah said to be sure you use the very smallest, um, sepulchre things, and warm it up, too!" Um, did you *really* just say that to me? Really?? Gee, I would have never thought of that without Op.rah's help. Thank you so much for enlightening me, O great one, in how to better practice medicine for my patients. News flash, I know, but I *already* use small *speculums* and I always warm them, too thankyouverymuch. I am already cringing about next week when all the people that watched her s.ex show on Friday call in for urgent, stat libido check appointments. Thanks a heap, O.

It's not just her jumping on the bash physicians bandwagon, though. I see magazine articles and news stories every day instructing people how to "Find out if you have a *good* doctor," or "Things your doctor isn't telling you," or "Medical horror stories, part 374." It makes me physically ill. Like we don't have enough on our proverbial plates, now we have to dispel the media panic surrounding our profession, as well. Why is it that you never see articles about "Accountants gone bad!" or "What your plumber isn't telling you (but should)"? It certainly doesn't help me out when patients come in with printed sheaves of website information instructing me on how to treat their perceived ailment, before I have a chance to take a history, do an exam, or any baseline lab work. It seems that physicians are being reduced to being the "gatekeeper" of health care, instead of the director. "Just shut up and give me what ever test, drug, diagnosis, etc. that I want." What is worse is that we get this from both patients and insurance companies, further restricting our ability to practice our profession the way we are meant to practice. Don't get me wrong, I'm certainly not of the mindset that physicians are omniscient. I practice collaborative medicine, not paternalistic care, but I see the shift even away from collaboration to patient demanded care, and it just isn't right.

This attitude is reflected in the patients each time they call to demand a Di.flucan prescription without coming in for an appointment, over the phone, even if they haven't been seen in the office for 2 years. Or women who delight in paging the physician at 2 in the morning to ask for the list of cold medicines to take in pregnancy because they "lost" the sheet given them in the office, because that's my *job*, you know? It is also rampant in the lay and medical blogospheres. The fear and mistrust of the medical profession is almost painful to read. Sometimes I have to sit on my hands to keep from commenting, lest I perpetuate the "doctors are assholes" perception. Especially in the birthing blogs, where the common thought is that Ob/Gyns are out to fillet every pregnant woman that comes through the door, just because they are evil, scum sucking doctors and not loving, caring midwives. Practicing medicine isn't what it used to be, and I find myself disheartened at the direction our role in medical care is taking. I see my colleagues (and myself) yearning for a job where we can turn off our brains after plugging in our allotted hours of time, instead of taking our work home with us and worrying about people who only see us as drug dispensing/test ordering automatons.

I still have the flashes of what medicine is supposed to be. I'll have a really great pregnancy/delivery with a patient, or I'll do a surgery that improves some one's quality of life, or I'll make a diagnosis that has the potential to alleviate suffering or even save some one's life. It is those few moments that keep me moving forward, doing what I've spent 12 years of my life training to do. Medicine used to be about helping people, but if the changes I see now continue on, medicine will soon be just another "punching the clock" kind of job. If that happens, my friends, then we all lose. Every single one of us.