Tuesday, November 14, 2006

Manic Monday

Wow, if I didn't know any better, I would have thought that yesterday was a *Friday* the 13th rather than a *Monday* the 13th. The morning started with the blast of the pager in the wee hours of the morning. It was the mother of a young teenage girl, under my care for an enlarged ovarian cyst. Earlier in the month we had completed her work up for malignancy (it was negative), she had a significant amount of discomfort, and she was to follow up in the office this week to plan for surgery. Her mother's voice was strained as she explained that she had been up all night with severe pain, nausea, vomiting, and a low grade temperature. I was immediately wide awake, differentials running through my head. Topping the list? Ovarian torsion.

I bolted out of bed and told the mother that I would meet her at the hospital. I notified the OR about the possible surgery and headed in. While I was waiting for the patient to arrive, I checked on my admitted patients. One patient had been admitted the day prior for pre-term contractions at 32 weeks. I had placed her on magnesium sulfate for tocolysis and initiated betamethasone therapy for the fetal lungs. Upon admission she was 2 cm dilated. Overnight she had contracted irregularly on the magnesium, but the contractions had appeared to slow down. She had started complaining of increased pelvic pressure about 15 minutes before I arrived, so I re-checked her cervix and found her to be 4 cm dilated with bulging membranes. I made a few phone calls and arranged her transfer to UniversityHospital, about 30 miles north. Our nursery is not equipped for infant care less than 36 weeks, so off she went. Last I heard, she's still pregnant.

Next was my labor induction for post-dates. Her previous labor had lasted for over 24 hours, and she was convinced that she would labor all day long. About 7 am she was 3 cm and 90 percent effaced, and the head was at 0 station. I broke her water, told her she would have a baby before noon, and told her if she wanted an epidural, she'd better ask for one sooner than later. She laughed it off, as did the nurse. While I was admitting my ovarian torsion patient, the nurse paged me and told me that the patient had just gotten her epidural and was feeling pressure to push. I ran upstairs while they prepped the torsion patient for surgery and caught a baby; less than 2 hours from the time I had first checked her cervix.

Then it was back to the OR for the surgery. All of the imaging studies had suggested that the ovarian cyst was originating on the right ovary, so imagine my surprise when the patient's torsion was actually in her left adnexa! The right tube and ovary were perfectly normal. The adnexa was not twisted once or twice; it was twisted on the pedicle no less than 4 times. The Fallopian tube was a hematosalpinx and it was irreparably damaged and filled with clot. It measured 12 cm by 10 cm. The ovary appeared dusky, but I made an attempt to salvage the tissue. There was bleeding in the uterine cornu that was difficult to control, but it was all hemostatic by the end of the case. The real kicker is that there was no ovarian cyst at all! The ovary, while edematous from lack of venous drainage, had no cystic lesion. So where was the pelvic cyst? I'm not certain. I am awaiting pathology, but I guess it is possible that the cystic lesion in the pelvis was arising from the Fallopian tube, perhaps in the form of a hydrosalpinx. That is pretty rare in young patients, and even more rare in a women that is not sexually active, but until I have the pathology, I guess I'll just have to speculate. Today, the young girl, even after major abdominal surgery, says that she feels a million times better! I feel badly that she has lost her tube, but hopefully the ovary can regain some function.

Needless to say, I never made it to the office on Monday. This means more double-booked clinic appointments and hellish clinic days for me. Bleargh. It also means that I got a late evening phone call by a patient I have yet to see (her appointment was cancelled because I was dealing with emergencies). She was really very nasty, demanding that I order her another h.cg level, since she hadn't had one in 2 whole weeks and she was having some cramping. She was having no bleeding or spotting. I tried to explain that another single level would not tell me anything about the status of her pregnancy, and if she was concerned about the pain to go to the ER. Otherwise, I told her I would order an ultrasound in the morning (US department goes home around 9 pm, and suffice it to say her call was later than this.) She was still supremely pissed off when she hung up the phone because I had the unmitigated gall to cancel her first OB appointment due to other people's emergencies. Frigging shame on me. One day, I shall manage to be in all areas simultaneously, so as not to upset such delicate sensibilities.

(Before I get flamed, yes, I know she is worried. I understand this. Cramping can be scary, but it is also a normal early pregnancy symptom. She has already had 4 normally doubling betas and an ultrasound that shows a viable intrauterine gestation. I am not without compassion, but I recognize obsession when I see it. She is only 7 weeks, and it is going to be a looooonnnggg pregnancy at this rate. Maybe I'll transfer her to high risk? Tempting.)

As for Body for Life? This is day two. I'm doing pretty well with staying with the eating plan...except for getting all of those meals into a day. (Seriously, I barely have time to pee, much less eat every 2 hours). Right now I am procrastinating my upper body workout in favor of writing this blog, and dreaming about what I am going to eat on my "free day." Somehow, I don't think that this is the way it is supposed to go. Ah well. Enough rambling for the day, I've got surgery charts to dictate for tomorrow.


Anonymous said...

See? Standing back in awe. As for BFL - have you looked into the "BFL for Women" book? I borrowed a friend's ages ago and haven't read it yet. I suck that way. She swears by it, though.

Anonymous said...

I've been your crampy patient before and though I don't think I would have had the gall to be that snarky on the phone (nor do I have a doctor who would call me that time of night), I empathize--which you clearly do as well.

The early weeks of pregnancy can be so damn terrifying.

dr. whoo? said...

GG~ Sometimes I have to take a step back and realize that I have a pretty amazing job. Most days, it is just work craziness. We're just doing the regular BFL. I wonder if the "for women" means less crazy weight lifting. I'll have to check it out. I'm loving the chocolate shakes and protein bars, though. Yummy.

hi brooklyn girl~ I don't mean to sound like an insensitive lout. I know early pregnancy is pretty scary stuff. Especially if you have had a miscarriage in the past.

The other bad thing is that she and I haven't even met in person, yet. Once I get to know people, I know better how to counsel them about normal and abnormal signs. Her beta was well over 10,000 today, I am awaiting the ultrasound results. Thanks for reading (I'm really nice like 92% of the time, seriously!)

Anonymous said...

I wouldn't read your blog if I didn't think you were nice (well, mostly nice anyway).

As a patient, I'm fascinated by how things seem on the other side of the stirrups....

medstudentitis said...

I think we all lose a bit of compassion and empathy when it's been a long day, we're tired, and people are demanding. Sounds like you had a pretty good/busy night though! That was one slippery/quick baby!

Anonymous said...

WHOA you havn't even met yet and she was snarky?? I would never in a million years treat any of my drs that way. I have had a couple of times where I have waited well over an hour in my obgyn's office and I didn't cop an attitude, although several women did. One woman (had to be her first baby) threw a fit. The receptionist explained that they had three providers working (My dr's office is an obgyn with 2 midwives, 1 NP). Most of the low risk women see the midwives & NP. High risk like me see the ob (He is still the only one I see now that I am not pregnant). Anyway, she threw a fit. Me- they asked if I was willing to see the new NP that they had hired. I said no, I'll wait (I'm know the midwives are wonderful and I am sure the new np is too, but I see only the dr cause he has been through everything with me - 2 surgeries and a high risk pregnancy and early delivery). This woman just was stomping around the waiting room.

If it is your turn to have a problem or an emergency, you would want them to be there for you, so no reason to get mad and upset. So I don't get upset about it. Sometimes I'll even call the office and ask how if he is running late (very rare for him, he runs that office like a clock) and adjust accordingly.

I can't believe you havn't even seen her in the office yet and she was that way. How rude. She is not getting off on the right foot is she?

Anonymous said...

Another busy day for you. Maybe you can come on vacation and sit with me for my FOUR prenatals in a whole day ;) You might sleep through the whole thing!

My cousin's wife had 10 kids -- only had one really damaged tube left! Miracles happen.

dr. whoo? said...

brooklyn girl~ I am glad you aren't holding my snarkiness against me. I really enjoy reading OB patient blogs, too. I think it provides valuable insight into what my patients are thinking and feeling. Hope you keep reading!

medstudentitis~ It is hard to be seen as a human being when you are a physician. I really believe that some people do not view us as men and women with real lives and foibles (just medicine machines), while others just have no clue how much we actually do work without any kind of break.

One patient remarked last week, "Wow, you really do put some long hours in, don't you?" (after seeing me in the hospital late one evening, and then early in the morning the following day) as if they were surprised. Um, yes?Boggles my mind.

missgamecock~ Nope, we haven't even met in person. It is great that you are understanding of your physician's busy schedule. I've had to cancel a few patients this week due to emergencies, and they have been less that pleasant about it. I just can't do it all. Why don't people understand this? It's not like I'm cancelling patients to go play golf or something. Makes me crazy.

frectis~ Your four prenatals a day schedule sounds dreamy. I see a minimum of four prenatals in one hour! (I have 23 patients due next month.)

That is a really great story about your cousin. I believe that things happen for a reason, truly.

Anonymous said...

Suffice it to say, I have been that emergency a couple of times. Well he was there for me. I would expect him to do the same for someone else. If you have an emergency that is what you want. Fortunately I havn't had an appt cancelled, they always seem to be able to work around everything. I have been called the last two times and asked if I could come in earlier and I have agreed to it even though I had to take more time off from work. But I agreed because I have been that emergency before. Where I live it is a small rural community.

Jawndoejah said...

As a patient with a D&E at 17 weeks for no heartbeat at a normal appointment, I can understand a patient's fear of miscarriage...but don't understand her attitude. I had a quick miscarriage after the D&E and then a long healthy pregnancy right after that. I would never dream to yell at my ob or receptionist on the phone. I am extrememely sensitive, but also understand that life doesn't revolve around me. Anyway, in early pregnancy, not much can be done if there really is a miscarriage going on.
I have had an ob leave during an appointment...she had something come up and I was sitting right there in the office with my husband. We were going through a miscarriage (numbers were going down). She came in and said she had go. I only could imagine the emergency she had to go to. My situation was no longer an emergency but a "nature take it's course" sort of a thing.

I'm sure you deal with miscarriage so often it is scary. Personally, I think ob offices need a go between to deal with us "special" patients so that we feel we're getting care for our emotional needs while ob's can deal with the medical side of it all, or have a referral to someone outside the office. A social worker/counselor would help alleviate some of your burden. If the person had some medical knowledge of causes/statistics/how to deal/physical and hormonal responses etc that would give comfort. OB docs cannot do everything for the patient!