I am whipped, as the laboring patients just keep on coming. I've also 4 big surgeries tomorrow. CindyLou is all better. No more pukiness, but she hasn't been sleeping all that well since the vomit incident. Hopefully she will settle back down soon, and she seems none the worse for wear. She is back to her normal sunny self, thank goodness!
As for the little July bean, it is still only a bean. The USG shows a 5w2d gestational sac with yolk sac. (EDC July 29) It seems to look ok (good decidual reaction, etc.), but I'm concerned because I figured my dates to be about 6 weeks. It is definitely feasible (TMI) that conception happened on Nov. 4th, but I figure that's a little late for ovulation. HcG is about 10,000 (ok, but really should see a heartbeat around this level) and progesterone is a little lower than I am happy with at 14.5. So, I may be dealing with an SAB, which sucks, but it happens. I'm waffling on supplementation, since there really is no evidence that it helps (it just may make me feel like I am doing *something*!)
Nothing to do but wait and see. I firmly believe that everything happens for a reason. I'll repeat the USG next week and pray a lot between now and then. The good news is that I conceived within 2 months of trying, so I still have decent fertility. This may be the universe's way of telling me to get into better shape before I start a pregnancy. Thank all of you for your wonderful comments and concerns. I promise to write more this weekend when I am finally free of laboring women for a full 2 days. (Yippee!) You guys are awesome, I mean it.
Tuesday, November 28, 2006
Sunday, November 26, 2006
Water is Breaking All Over Town
I've decided that I don't like being OtherDoc for the week. I seriously don't know how that man functions with so many patients! This whole weekend has been overtaken by OtherDoc's patients, and I feel like I am a resident again with deliveries and emergencies around the clock! I got called away from Thanksgiving dinner to do an emergency surgery on a second trimester miscarriage that hemorrhaged half of her blood volume in the ED. What a terrible experience for this poor woman. She was OtherDoc's patient, scared to death, and she didn't know me from some idiot off the street...as evidenced by her query, "So, have you ever *done* this before?" I guess I understand her concern, but criminy! She had already been started with a transfusion in the ER. The surgery went really well, and the source of her bleeding was a retained placenta. I kept her overnight to observe her blood levels, and fortunately they stabilized. What a horrible Thanksgiving for her, though.
The multiple hits kept on coming through Thursday evening, between the ER and OB triage, I think I was paged every 1-2 hours. Not very conducive to rest, I might add! Earlier in the week, I had gotten the early morning (5 am) bathroom report two mornings in a row from one of OtherDoc's patients, QuestionWoman. I was treated to a fantastical description of the appearance of QW's mucus when she wiped (clear with a few brown spots if you must know). I was thrilled beyond belief to tell this woman (not a first time mother, either) how normal she was, both mornings. Fast forward to 1 am on Friday morning when I got the ruptured water report, followed by the question of what to do? (Hmmm, I wonder?) I pushed back my jaded cynicism and tried to be a pleasant and understanding sleep-deprived physician. I put my very best phone voice on and urged her to get up to OB triage, and then silently prayed that she had peed. No such luck, the call came in from triage at 2:30 am, she was definitely ruptured.
CindyLou's daycare was closed on Friday, and in an unprecedented show of optimism, I had figured that I would be able to bring her to round at the hospital, then spend the majority of the day at home, having mother-daughter time. Well, that all went out the window with a labor patient, so I asked Mr. Whoo to take CindyLou to his office during my rounds, where I would pick her up in between rounding and delivering QW. I discharged the one patient that had the miscarriage, and got QW tucked in with her epidural right around 10 am. I was about to fly to Mr. Whoo's office to pick up the munchkin and get her home for lunch when I received the wonderful news that another of OtherDoc's patients was in triage with ruptured membranes. "That's funny!" I told the triage nurse, "Great joke." Only she wasn't joking. Ok, make that two labor patients. I called Mr. Whoo back and broke the news that it was he that got to keep CindyLou for the work day, and I felt terrible. He was his ever-gracious self, though. I love that man.
Long story, short, between the two labor patients and multiple triage visitors and admissions(some of whom were actually *my* patients), I was at the hospital until about 6:30 Friday evening. I got to see CindyLou for about an hour before she was ready for bed. I stayed up until around 10:30 or so, more just to decompress from the day than anything, and I then became as dead to the world. I was awakened by tiny fingers on my arm at 1:45 in the morning. In my sleep fogged brain, I didn't question the rarity of a middle of the night venture into our bedroom, I simply began to lift CindyLou into the bed...and then I touched something damp on her PJs. That smelled like vomit. (Mental note to self, do quick puke check on darling child *prior* to lifting her into your own bed and fouling your own sheets.) The poor thing had vomit all over the front of her PJ's. The smell was just a little too much for my super-sensitive nostrils, and it triggered my extra-sensitive gag reflex. Before I made my own mess, I handed her off to Mr. Whoo, composed myself, and set about cleaning the bed.
Vomit was *everywhere;* on her pillow, on the side of the bed, and piled on the floor. I couldn't believe that we didn't hear her puking on the monitor. I felt like a really bad mommy. Between the two of us, with Mr. Whoo dealing with most of the vomit clean up due to my constant gagging, we got CindyLou cleaned up, clothes changed, hair washed, her bed remade, and tucked her back into bed. Then we changed our own bed and puke tainted clothes, and were back in bed by 2:30. Cue the pager at 3:16 am. ( I am not kidding.) One of my patients (1 of the the remaining 2 due this month) was in triage, a mere 8 cm dilated. I was out of the bed, dressed, and back at the hospital by 3:45 am. The patient delivered her baby in about 15 minutes, and sustained a partial 4th degree tear in the process, despite my best efforts. Ah, there's just nothing like fixing a 4th degree on a woman without an epidural at 4 am. Fun times.
I finished the delivery, and dragged myself to the nurses' station to write orders, where I was greeted with more wonderful news that OtherDoc had yet another term patient in triage, who had (you guessed it!) ruptured membranes. I considered dissolving into a raving, sputtering heap at that very instant, but somehow kept it together enough to find out her stats and determine that I could, at least, go back home and sleep in my own bed for a few hours. I drove, zombie-like, back home, narrowly missed hitting a deer, and fell into my bed at about 5:15 am. At this point, sleep was fitful and disjointed, and punctuated with pages at 7 and 9 am. OtherDoc's patient was requesting an epidural, so I dragged myself out of bed and back to the hospital by 10:30 am. I rounded on a gazillion patients, admitted yet another one of OtherDoc's patients with ruptured membranes (are you seeing the pattern, here?) for a repeat C-Section, did the C-section, caught a baby, and made my way back home in time to watch my Seminoles blow opportunity after opportunity to beat the hated Gates. I don't think I did much more than stare blankly at the TV for the remainder of Saturday. I was too tired to even nap. Mr. Whoo is amazing, and he had the whole kitchen cleaned up, and even did laundry all day yesterday. He is Superman.
I had a few more pages for wanna-be labor contenders last night, but no further admissions, thank you, lord. I still have 7 or 8 patients to round on today, and 5 o'clock (when OtherDoc starts taking his own patients again) cannot get here fast enough. Unfortunately, I'll not have much of a reprieve this week. I have a few inductions, a few surgeries, and full clinic days looming ahead. Thank goodness for a weekend off in the not too distant future. I can't keep this frantic pace; I am getting too old for this!
The multiple hits kept on coming through Thursday evening, between the ER and OB triage, I think I was paged every 1-2 hours. Not very conducive to rest, I might add! Earlier in the week, I had gotten the early morning (5 am) bathroom report two mornings in a row from one of OtherDoc's patients, QuestionWoman. I was treated to a fantastical description of the appearance of QW's mucus when she wiped (clear with a few brown spots if you must know). I was thrilled beyond belief to tell this woman (not a first time mother, either) how normal she was, both mornings. Fast forward to 1 am on Friday morning when I got the ruptured water report, followed by the question of what to do? (Hmmm, I wonder?) I pushed back my jaded cynicism and tried to be a pleasant and understanding sleep-deprived physician. I put my very best phone voice on and urged her to get up to OB triage, and then silently prayed that she had peed. No such luck, the call came in from triage at 2:30 am, she was definitely ruptured.
CindyLou's daycare was closed on Friday, and in an unprecedented show of optimism, I had figured that I would be able to bring her to round at the hospital, then spend the majority of the day at home, having mother-daughter time. Well, that all went out the window with a labor patient, so I asked Mr. Whoo to take CindyLou to his office during my rounds, where I would pick her up in between rounding and delivering QW. I discharged the one patient that had the miscarriage, and got QW tucked in with her epidural right around 10 am. I was about to fly to Mr. Whoo's office to pick up the munchkin and get her home for lunch when I received the wonderful news that another of OtherDoc's patients was in triage with ruptured membranes. "That's funny!" I told the triage nurse, "Great joke." Only she wasn't joking. Ok, make that two labor patients. I called Mr. Whoo back and broke the news that it was he that got to keep CindyLou for the work day, and I felt terrible. He was his ever-gracious self, though. I love that man.
Long story, short, between the two labor patients and multiple triage visitors and admissions(some of whom were actually *my* patients), I was at the hospital until about 6:30 Friday evening. I got to see CindyLou for about an hour before she was ready for bed. I stayed up until around 10:30 or so, more just to decompress from the day than anything, and I then became as dead to the world. I was awakened by tiny fingers on my arm at 1:45 in the morning. In my sleep fogged brain, I didn't question the rarity of a middle of the night venture into our bedroom, I simply began to lift CindyLou into the bed...and then I touched something damp on her PJs. That smelled like vomit. (Mental note to self, do quick puke check on darling child *prior* to lifting her into your own bed and fouling your own sheets.) The poor thing had vomit all over the front of her PJ's. The smell was just a little too much for my super-sensitive nostrils, and it triggered my extra-sensitive gag reflex. Before I made my own mess, I handed her off to Mr. Whoo, composed myself, and set about cleaning the bed.
Vomit was *everywhere;* on her pillow, on the side of the bed, and piled on the floor. I couldn't believe that we didn't hear her puking on the monitor. I felt like a really bad mommy. Between the two of us, with Mr. Whoo dealing with most of the vomit clean up due to my constant gagging, we got CindyLou cleaned up, clothes changed, hair washed, her bed remade, and tucked her back into bed. Then we changed our own bed and puke tainted clothes, and were back in bed by 2:30. Cue the pager at 3:16 am. ( I am not kidding.) One of my patients (1 of the the remaining 2 due this month) was in triage, a mere 8 cm dilated. I was out of the bed, dressed, and back at the hospital by 3:45 am. The patient delivered her baby in about 15 minutes, and sustained a partial 4th degree tear in the process, despite my best efforts. Ah, there's just nothing like fixing a 4th degree on a woman without an epidural at 4 am. Fun times.
I finished the delivery, and dragged myself to the nurses' station to write orders, where I was greeted with more wonderful news that OtherDoc had yet another term patient in triage, who had (you guessed it!) ruptured membranes. I considered dissolving into a raving, sputtering heap at that very instant, but somehow kept it together enough to find out her stats and determine that I could, at least, go back home and sleep in my own bed for a few hours. I drove, zombie-like, back home, narrowly missed hitting a deer, and fell into my bed at about 5:15 am. At this point, sleep was fitful and disjointed, and punctuated with pages at 7 and 9 am. OtherDoc's patient was requesting an epidural, so I dragged myself out of bed and back to the hospital by 10:30 am. I rounded on a gazillion patients, admitted yet another one of OtherDoc's patients with ruptured membranes (are you seeing the pattern, here?) for a repeat C-Section, did the C-section, caught a baby, and made my way back home in time to watch my Seminoles blow opportunity after opportunity to beat the hated Gates. I don't think I did much more than stare blankly at the TV for the remainder of Saturday. I was too tired to even nap. Mr. Whoo is amazing, and he had the whole kitchen cleaned up, and even did laundry all day yesterday. He is Superman.
I had a few more pages for wanna-be labor contenders last night, but no further admissions, thank you, lord. I still have 7 or 8 patients to round on today, and 5 o'clock (when OtherDoc starts taking his own patients again) cannot get here fast enough. Unfortunately, I'll not have much of a reprieve this week. I have a few inductions, a few surgeries, and full clinic days looming ahead. Thank goodness for a weekend off in the not too distant future. I can't keep this frantic pace; I am getting too old for this!
Thursday, November 23, 2006
"Thanksgivvinnnggg
....is a very special night. Jimmy Walker used to say Dyn-o-mite." (Gotta love Adam Sandler!) I awoke with this very appropriate song running through my mind, at the crack of dawn, of course. One day (I hope) little Miss CindyLou will learn the value of sleeping in! No matter, we had to get the monstrous bird into the oven pretty early. My grandparents are driving up for Thanksgiving dinner, so we did the 8 am power clean once the turkey was in the oven. Now the house is filled with the wonderful aroma of roasting turkey, stuffing, and simmering giblet gravy. We watched the Macy's Thanksgiving Extravaganza, er, Parade, and now I'm sitting here tearing up over the Detroit Lions football players talking about that for which they are thankful. Ah, the holidays.
Mr. Whoo and I have the Thanksgiving dinner down to a science. I'm almost positive that we have had Thanksgiving at home for the five years that we have been married. I cook the stuffing, he preps the bird, I peel potatoes, he mashes them, I set the table, and he carves the turkey. We are a well-oiled, Thanksiving dinner making machine. I baked my pumpkin pie last night, and had CindyLou help me mix it all together. It was so much fun to "cook" with her. She is growing up so fast. I only had to make a quick run to the hospital this morning to round on one patient (that I released this morning to go to her own Thanksgiving Dinner). I figure that this Thanksgiving will play out much like Thanksgivings that I have worked in the past, very peaceful, until, that is, after everyone has finished their dinner! Then, either they figure "Hey, the family is all together! What better time than now to head to the hospital en masse to see if Sally Jo happens to be in labor?" or the pregnant moms start mistaking their indigestion for labor pain. It never fails. It goes the same for Christmas, as well.
I have so very much for which to be thankful this year. My wonderful husband and daughter, my family and extended family, our wonderful friends, a lovely home, a job that I love (most days), good health, and the promise of new little miracle, due sometime in July. God has truly blessed our lives, and I am so thankful, today and every day. God bless and Happy Thanksgiving!
Mr. Whoo and I have the Thanksgiving dinner down to a science. I'm almost positive that we have had Thanksgiving at home for the five years that we have been married. I cook the stuffing, he preps the bird, I peel potatoes, he mashes them, I set the table, and he carves the turkey. We are a well-oiled, Thanksiving dinner making machine. I baked my pumpkin pie last night, and had CindyLou help me mix it all together. It was so much fun to "cook" with her. She is growing up so fast. I only had to make a quick run to the hospital this morning to round on one patient (that I released this morning to go to her own Thanksgiving Dinner). I figure that this Thanksgiving will play out much like Thanksgivings that I have worked in the past, very peaceful, until, that is, after everyone has finished their dinner! Then, either they figure "Hey, the family is all together! What better time than now to head to the hospital en masse to see if Sally Jo happens to be in labor?" or the pregnant moms start mistaking their indigestion for labor pain. It never fails. It goes the same for Christmas, as well.
I have so very much for which to be thankful this year. My wonderful husband and daughter, my family and extended family, our wonderful friends, a lovely home, a job that I love (most days), good health, and the promise of new little miracle, due sometime in July. God has truly blessed our lives, and I am so thankful, today and every day. God bless and Happy Thanksgiving!
Sunday, November 19, 2006
A View from the Couch
In true slug fashion, I spent the whole of yesterday on the couch in a near catatonic state. I only stirred to use the bathroom, care for the kidlet, and to eat. Usually, I feel supremely guilty about locking an active toddler in the house all day long, but yesterday was rainy and blustery, so outside play was out, anyway. She spent the morning "cooking" in her play kitchen and bringing delightful plastic food dishes out to me and to Mr. Whoo to sample. We also curled up with a few movies. CindyLou has a small lap-sized DVD player that she calls her "'puter (computer)." We bought it for it's sanity saving value on long trips and airplane rides. The DVD player is silver, and it looks very much like my laptop ("mommy's 'puter"). So she snuggled next to me on the couch and we watched "Rudolph the Red Nosed Reindeer" (the cool claymation one) and "Lady and the Tramp" on the DVD player, while college football reigned supreme on our living room TV. Those two movies just happen to be my childhood favorites, as well, but I swear that she picked them all on her own! She is my mini-me. It was really nice and relaxing, and just what I needed.
Mr. Whoo was a bit more productive (as always), and he even took it upon himself to groom our fatty-bobolatty cats. You see, once a kitty reaches such gargantuan proportion, it is damn near impossible for them to clean their backsides. Therefore, it is up to us to brush and groom the hapless creatures. Our girl kitty bears the brunt of having "bad hair." She has tons of kitty dandruff, and her fur gets really oily. Mr. Whoo brushed the equivalent of a whole cat's worth of hair from her back, and then remarked how nice it would be if someone would just invent a handy-dandy spray in order to spruce the cats up with minimal effort. "They could even call it Ca-breze," he quipped. Hilarious. Everyone knows how fun it is to give a cat a bath, so Cabreze sounds like a phenomenal idea to me!
We also had our Body for Life "free day" yesterday, in honor of college football. We ordered Chinese delivery at 11:00 in the morning, y'all. We are pathetic. It was sooooo good! So far this week I am down 4.2 pounds, and I haven't even been getting all of the meals into the day, so I am pumped. It is a good start, at any rate. I used to live every day like it was a "free day" so eating on track this week was a true eye-opener. This week I need to try a little harder with the weight lifting. I am such a puss, and I know I'm not pushing myself as hard as I should be. I am really proud of Mr. Whoo, as well. He's lost over 6 pounds! (He has been much better about sticking to plan and really utilizing the workouts. I think it is because he made the mistake of telling one of his buddies about BFL and now said buddy is starting the program, too. Ever the competitor!)
Today we went to church and I cried through a really nice service about giving thanks and counting blessings. It was really very touching. Then we braved the masses and hit Sam's club and the grocery store to stock up for our Thanksgiving feast. Now CindyLou is napping, Mr. Whoo is out scouting hunting sites (insert eye roll here), and I am blogging, procrastinating dictating my delinquent charts, and watching a herd of deer in the backyard. It's been a good weekend; let's hope this trend continues throughout the week!
Mr. Whoo was a bit more productive (as always), and he even took it upon himself to groom our fatty-bobolatty cats. You see, once a kitty reaches such gargantuan proportion, it is damn near impossible for them to clean their backsides. Therefore, it is up to us to brush and groom the hapless creatures. Our girl kitty bears the brunt of having "bad hair." She has tons of kitty dandruff, and her fur gets really oily. Mr. Whoo brushed the equivalent of a whole cat's worth of hair from her back, and then remarked how nice it would be if someone would just invent a handy-dandy spray in order to spruce the cats up with minimal effort. "They could even call it Ca-breze," he quipped. Hilarious. Everyone knows how fun it is to give a cat a bath, so Cabreze sounds like a phenomenal idea to me!
We also had our Body for Life "free day" yesterday, in honor of college football. We ordered Chinese delivery at 11:00 in the morning, y'all. We are pathetic. It was sooooo good! So far this week I am down 4.2 pounds, and I haven't even been getting all of the meals into the day, so I am pumped. It is a good start, at any rate. I used to live every day like it was a "free day" so eating on track this week was a true eye-opener. This week I need to try a little harder with the weight lifting. I am such a puss, and I know I'm not pushing myself as hard as I should be. I am really proud of Mr. Whoo, as well. He's lost over 6 pounds! (He has been much better about sticking to plan and really utilizing the workouts. I think it is because he made the mistake of telling one of his buddies about BFL and now said buddy is starting the program, too. Ever the competitor!)
Today we went to church and I cried through a really nice service about giving thanks and counting blessings. It was really very touching. Then we braved the masses and hit Sam's club and the grocery store to stock up for our Thanksgiving feast. Now CindyLou is napping, Mr. Whoo is out scouting hunting sites (insert eye roll here), and I am blogging, procrastinating dictating my delinquent charts, and watching a herd of deer in the backyard. It's been a good weekend; let's hope this trend continues throughout the week!
Saturday, November 18, 2006
Week in Review
Finally, a day off! I am so thoroughly exhausted, all I want to do is occupy a corner of my couch and vegetate. Monday's busy start was just the harbinger of the week to come. On Tuesday I had nearly 50 patients scheduled in the office. Mr. Whoo had a late work meeting, so I had to dash out of the office at 5:45 (minutes after seeing my last patient) to pick up CindyLou before the daycare closed. Needless to say, I left in my wake a mountain of patient charts to complete so enormous you couldn't even see the wood surface of the desk. (More on that later.) On Wednesday I only had two surgeries because a patient had to cancel at the last minute, but I had 3 labor patients.
Labor patient number one had been plagued by pre-term contractions since her 32nd week of pregnancy, but finally came into labor on her own at 39 weeks. I checked on her before my 7:30 surgery and found that she was 4 cm and getting comfortable with her epidural. The nurse requested an internal monitor, because her contractions weren't tracing well, so I broke her water and placed an intrauterine pressure catheter. Her contractions were just one minute apart! I predicted she would be the first to deliver, but I was very surprised to be called out of my second surgery (a hysterectomy) at 10:00 because the patient was ready to push! Fortunately, I had another physician assisting me with the hysterectomy, and he stayed with the surgery patient (we had half of her uterus dissected already) while I ran upstairs to deliver the super speedy baby! I was in such a rush to get back to the surgery patient that I ended up sticking myself with a needle whilst repairing LP#1's perineal laceration.
Stupid, stupid, stupid. I berated myself all the way back to the OR. Most of our OB patients are very well screened for communicable diseases, but it is always scary to get a needle stick. I hadn't had one in over 3 years (back when I was a resident, on night float, and pregnant to boot). I re-scrubbed and finished up the surgery with my colleague. It went very smoothly, as it always does with another physician assisting. I wish I had this luxury all the time! After the hyst was finished, my surgery day was over, and I went to the depths of the hospital basement to complete the necessary forms and get the requisite blood drawn for the needlestick panel. Ouch. Everything came back fine, with the patient's bloodwork and my own, thank goodness.
My second delivery of the day was an induction for mild pre-ecclampsia at 38 weeks. I had used m.isoprostol overnight for cervical ripening, and the patient was already 5 cm on her first cervical exam. It wasn't surprising when she delivered the baby shortly after noon. The delivery itself was quite smooth and very touching. I just love it when the Daddy cries. It really tugs at the heartstrings. Even better, the patient's blood pressures stabilized almost immediately after delivery.
My third (and most unexpected) delivery of the day was an induction of labor for an LGA baby at 37 weeks. The baby was macrosomic (measuring just over 9 pounds by ultrasound) and the mother was a primigravida with an unproven pelvis. The patient is employed by the hospital in a health care capacity, so that usually means some kind of complication. I know it sounds paranoid, but physicians, nurses, physician's wives, and health care professionals in general have some of the most complicated and bizarre labor and delivery outcomes of any other group. I have no idea why. At any rate, upon her initial exam, her cervix was so closed and so thick and high that my stubby little fingers could barely reach it. I psyched her up for a 2 day induction, reviewed c-section risks, and placed misop.rostol the evening prior. Overnight she had gotten a total of 3 doses of mi.soprostol. The night shift nurses told me that they never could find her cervix overnight, so imagine my delight to find her 2 cm dilated and 90% effaced when I checked her!
I immediately broke her water to place internal monitors because the patient was a little, well, "fluffy" and the externals were not even registering contractions and the fetal tracing was spotty at best. The patient had been asking for an epidural for a few hours, so she finally got her wish, and I got on with my surgeries and other deliveries of the day.
I still fully expected the labor to last well into the evening. I walked out of my second delivery to find that my third patient was complete and pushing! Crazy. In true primigravida form, it took her a little time to get the hang of pushing, and after a little over an hour, the labor nurse came to me, expressing concern about the patient's pushing progress. She had also started bleeding a little more briskly than usual. The epidural was turned off, and I stayed in the room for the next 45 minutes and helped push with the patient. When I checked, I could feel a posterior vaginal laceration, and I worried about a posterior fourth degree. She did very well with just a little encouragement, and she was able to push the baby out without forcep or vacuum assistance. The laceration was a cell membrane away from a fourth degree, but did not go completely through. However, it did extend along the left vaginal sidewall all the way up to the posterior fornix, and due to her habitus, was more than a little difficult to repair. I put two layers of suture in, and the repair took nearly 40 minutes. I guess she didn't completely escape the health care provider curse, after all. The baby weighed over 8.5 pounds, and I am certain that her mother did not have even one more millimeter of room to push her out, so I was very glad that we induced labor when we did!
Thursday was more clinic, more paperwork, and a stat c-section for fetal bradycardia. (Mom and baby both came through ok.) Friday was a half day of clinic and a half day of charting. I didn't leave the office until nearly 6 pm, but I finished every last one of this week's clinic charts. I can actually see my desk! Now I have to tackle my delinquent dictations this weekend (alas, my weekend off is not even a *true* weekend off) and I may finally be caught up...until Monday starts the process all over again. I am also covering for OtherDoc for the whole of next week, so I am hoping that he delivers all of his November patients this weekend! Geez, I am tired just writing about this week, and I am sure you are all snoozing at your computer by now. Happy Saturday!
Labor patient number one had been plagued by pre-term contractions since her 32nd week of pregnancy, but finally came into labor on her own at 39 weeks. I checked on her before my 7:30 surgery and found that she was 4 cm and getting comfortable with her epidural. The nurse requested an internal monitor, because her contractions weren't tracing well, so I broke her water and placed an intrauterine pressure catheter. Her contractions were just one minute apart! I predicted she would be the first to deliver, but I was very surprised to be called out of my second surgery (a hysterectomy) at 10:00 because the patient was ready to push! Fortunately, I had another physician assisting me with the hysterectomy, and he stayed with the surgery patient (we had half of her uterus dissected already) while I ran upstairs to deliver the super speedy baby! I was in such a rush to get back to the surgery patient that I ended up sticking myself with a needle whilst repairing LP#1's perineal laceration.
Stupid, stupid, stupid. I berated myself all the way back to the OR. Most of our OB patients are very well screened for communicable diseases, but it is always scary to get a needle stick. I hadn't had one in over 3 years (back when I was a resident, on night float, and pregnant to boot). I re-scrubbed and finished up the surgery with my colleague. It went very smoothly, as it always does with another physician assisting. I wish I had this luxury all the time! After the hyst was finished, my surgery day was over, and I went to the depths of the hospital basement to complete the necessary forms and get the requisite blood drawn for the needlestick panel. Ouch. Everything came back fine, with the patient's bloodwork and my own, thank goodness.
My second delivery of the day was an induction for mild pre-ecclampsia at 38 weeks. I had used m.isoprostol overnight for cervical ripening, and the patient was already 5 cm on her first cervical exam. It wasn't surprising when she delivered the baby shortly after noon. The delivery itself was quite smooth and very touching. I just love it when the Daddy cries. It really tugs at the heartstrings. Even better, the patient's blood pressures stabilized almost immediately after delivery.
My third (and most unexpected) delivery of the day was an induction of labor for an LGA baby at 37 weeks. The baby was macrosomic (measuring just over 9 pounds by ultrasound) and the mother was a primigravida with an unproven pelvis. The patient is employed by the hospital in a health care capacity, so that usually means some kind of complication. I know it sounds paranoid, but physicians, nurses, physician's wives, and health care professionals in general have some of the most complicated and bizarre labor and delivery outcomes of any other group. I have no idea why. At any rate, upon her initial exam, her cervix was so closed and so thick and high that my stubby little fingers could barely reach it. I psyched her up for a 2 day induction, reviewed c-section risks, and placed misop.rostol the evening prior. Overnight she had gotten a total of 3 doses of mi.soprostol. The night shift nurses told me that they never could find her cervix overnight, so imagine my delight to find her 2 cm dilated and 90% effaced when I checked her!
I immediately broke her water to place internal monitors because the patient was a little, well, "fluffy" and the externals were not even registering contractions and the fetal tracing was spotty at best. The patient had been asking for an epidural for a few hours, so she finally got her wish, and I got on with my surgeries and other deliveries of the day.
I still fully expected the labor to last well into the evening. I walked out of my second delivery to find that my third patient was complete and pushing! Crazy. In true primigravida form, it took her a little time to get the hang of pushing, and after a little over an hour, the labor nurse came to me, expressing concern about the patient's pushing progress. She had also started bleeding a little more briskly than usual. The epidural was turned off, and I stayed in the room for the next 45 minutes and helped push with the patient. When I checked, I could feel a posterior vaginal laceration, and I worried about a posterior fourth degree. She did very well with just a little encouragement, and she was able to push the baby out without forcep or vacuum assistance. The laceration was a cell membrane away from a fourth degree, but did not go completely through. However, it did extend along the left vaginal sidewall all the way up to the posterior fornix, and due to her habitus, was more than a little difficult to repair. I put two layers of suture in, and the repair took nearly 40 minutes. I guess she didn't completely escape the health care provider curse, after all. The baby weighed over 8.5 pounds, and I am certain that her mother did not have even one more millimeter of room to push her out, so I was very glad that we induced labor when we did!
Thursday was more clinic, more paperwork, and a stat c-section for fetal bradycardia. (Mom and baby both came through ok.) Friday was a half day of clinic and a half day of charting. I didn't leave the office until nearly 6 pm, but I finished every last one of this week's clinic charts. I can actually see my desk! Now I have to tackle my delinquent dictations this weekend (alas, my weekend off is not even a *true* weekend off) and I may finally be caught up...until Monday starts the process all over again. I am also covering for OtherDoc for the whole of next week, so I am hoping that he delivers all of his November patients this weekend! Geez, I am tired just writing about this week, and I am sure you are all snoozing at your computer by now. Happy Saturday!
Tuesday, November 14, 2006
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.
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.
OMG!!!!
Jeff Bowden Resigns! Am I dreaming? Is it wrong to immediately think...oh no, what if he leaves and we still suck? Ah well, woo hoo for now!
Saturday, November 11, 2006
Ha ha ha ha HA!
FSU football sucks! God, please let this be a catalyst for change in our program. Distressing, this night. What a freaking joke. WAKE FREAKING FOREST OWNS US!!! I am laughing...if not, I would be crying. Unbelievable. Fire Jeff Bowden. That is all.
Shameless Plug
I am loving the XM radio that came with my new car. It totally rocks. They have a station for every genre of music that you can imagine. I knew that XM was for me when I found myself jamming out to "Poison" by Bel Biv Devoe en route to a delivery. It made my freaking night. Today, while driving to the hospital for rounds, perusing my preset stations, I got to hear Salsbury Hill by Peter Gabriel, followed by Everything Falls Apart by Dog's Eye View, next was Parents Just Don't Understand by DJ Jazzy Jeff and the Fresh Prince, Shimmer by Fuel, After the Rain by Nelson (Freaking hilarious video. Ahh, the cheesy goodness), and She Hates Me (trust, she effing hates me, la la la la) by Puddle of Mudd. Music that I do not own, but love, just the same. It really helped lift the rather foul mood that has been overshadowing my life this week.
Also, I'm not quite sure if I should be insulted or not, but today the nurses on L&D were asking me how old I was; I told them that I was 31, and they seemed, well, disappointed! They thought that I was a lot older than they (alas, I was not!) I guess that I don't look as young as I think I do, but the nurses were sure that I was 35+ years old. That freaks me out, because I have always looked younger than my age. I think a lot of the problem is the extra weight that I am carrying. It definitely adds age to my face. I am also pretty sure that I am about to start another period, and while we haven't been *trying* to get pregnant, per se, we have not been preventing pregnancy, either. I know that I am not in the best physical shape for a pregnancy, so maybe God and the universe are trying to tell me something.
In other news, Mr. Whoo and I are starting Body For Life this week. I am going to try to post updates, in order to motivate myself and also to keep me in line! This is the program that worked so well for us, prior to our first pregnancy. I abruptly had to stop the BFL secondary to severe nausea and vomiting. I couldn't even look at chicken for the entire pregnancy. Crazy. Since there is no pregancy holding us back, we are getting back with the program. Maybe now I won't have to feel like such a hypocrite when I counsel my patients on weight loss. It is grey and dreary and rainy here, I hope that the weekend is brighter wherever you may be.
Also, I'm not quite sure if I should be insulted or not, but today the nurses on L&D were asking me how old I was; I told them that I was 31, and they seemed, well, disappointed! They thought that I was a lot older than they (alas, I was not!) I guess that I don't look as young as I think I do, but the nurses were sure that I was 35+ years old. That freaks me out, because I have always looked younger than my age. I think a lot of the problem is the extra weight that I am carrying. It definitely adds age to my face. I am also pretty sure that I am about to start another period, and while we haven't been *trying* to get pregnant, per se, we have not been preventing pregnancy, either. I know that I am not in the best physical shape for a pregnancy, so maybe God and the universe are trying to tell me something.
In other news, Mr. Whoo and I are starting Body For Life this week. I am going to try to post updates, in order to motivate myself and also to keep me in line! This is the program that worked so well for us, prior to our first pregnancy. I abruptly had to stop the BFL secondary to severe nausea and vomiting. I couldn't even look at chicken for the entire pregnancy. Crazy. Since there is no pregancy holding us back, we are getting back with the program. Maybe now I won't have to feel like such a hypocrite when I counsel my patients on weight loss. It is grey and dreary and rainy here, I hope that the weekend is brighter wherever you may be.
Thursday, November 09, 2006
Venting
It has been quite the week. I feel like my life is stuck in fast forward, and it is all that I can do to just keep ploughing through each day. Today, I really just need to vent and get these thoughts out of my head; so if you dislike negativity, please stop reading now!
Right now I am Hating....
....being on staff call.
....working for the last 12 days straight.
....not having a day off until next Friday evening.
....getting a combined 10 hours of sleep in the last 72 hours.
....jumping as though shocked every time I hear a beeping noise, even if it is only the gas pump and not my pager.
....missing CindyLou's bedtime on Sunday, Tuesday, and Wednesday.
....the fact that CindyLou's daycare is closed tomorrow.
....that I can't just cancel my patients for tomorrow.
....that my house is a wreck.
....the fact that OtherDoc is going out of town for the *entire week* of Thanksgiving, leaving me to cover his umpteen-million patients (that, most likely, will collectively go into labor on Thanksgiving Day and ruin my dinner plans.)
....not having clean laundry.
....politics - local, national, and global.
....the 642 charts littering my desk, waiting for me to document exams that happened days ago.
....having major schedule issues, and no office manager available to correct them.
....that the office manager is OtherDoc's wife, and thus not easily fired.
....not having another vacation planned until the very end of December.
....feeling like a hypocrite when I am counseling other people on how to lose weight.
....having to argue with a nurse about Methergine injection location semantics, whilst my post-partum patient (another nurse!) was hemorrhaging.
....being so used to living in the hospital, that I actually dialed a "9" (to get an outside line, you see) on my HOME phone.
....inducing labor.
....pelvic pain.
...."dropped bladders" and incontinence.
....chin acne.
....the PMS monster.
....being a crappy friend.
....feeling guilty about being a crappy friend.
....that none of my close girlfriends are within a weekend's driving distance.
....dreading seeing my office schedule every day, and thus, dreading work.
....wishing my life away, just to get to the next break from being on call.
Whew, I think that is enough for now. Just can't wait to see the Google hits I get from that post! It is really strange how I feel so much better after writing it all out. Thanks for cyber-listening, and I promise to return you to your regularly scheduled snarking as soon as possible.
Right now I am Hating....
....being on staff call.
....working for the last 12 days straight.
....not having a day off until next Friday evening.
....getting a combined 10 hours of sleep in the last 72 hours.
....jumping as though shocked every time I hear a beeping noise, even if it is only the gas pump and not my pager.
....missing CindyLou's bedtime on Sunday, Tuesday, and Wednesday.
....the fact that CindyLou's daycare is closed tomorrow.
....that I can't just cancel my patients for tomorrow.
....that my house is a wreck.
....the fact that OtherDoc is going out of town for the *entire week* of Thanksgiving, leaving me to cover his umpteen-million patients (that, most likely, will collectively go into labor on Thanksgiving Day and ruin my dinner plans.)
....not having clean laundry.
....politics - local, national, and global.
....the 642 charts littering my desk, waiting for me to document exams that happened days ago.
....having major schedule issues, and no office manager available to correct them.
....that the office manager is OtherDoc's wife, and thus not easily fired.
....not having another vacation planned until the very end of December.
....feeling like a hypocrite when I am counseling other people on how to lose weight.
....having to argue with a nurse about Methergine injection location semantics, whilst my post-partum patient (another nurse!) was hemorrhaging.
....being so used to living in the hospital, that I actually dialed a "9" (to get an outside line, you see) on my HOME phone.
....inducing labor.
....pelvic pain.
...."dropped bladders" and incontinence.
....chin acne.
....the PMS monster.
....being a crappy friend.
....feeling guilty about being a crappy friend.
....that none of my close girlfriends are within a weekend's driving distance.
....dreading seeing my office schedule every day, and thus, dreading work.
....wishing my life away, just to get to the next break from being on call.
Whew, I think that is enough for now. Just can't wait to see the Google hits I get from that post! It is really strange how I feel so much better after writing it all out. Thanks for cyber-listening, and I promise to return you to your regularly scheduled snarking as soon as possible.
Monday, November 06, 2006
You Just Never Know
Recently, a blogger, who shall remain nameless, linked to my site stating that " if it weren't anonymous, it would be a lawsuit waiting to happen." I just wanted to reiterate that when I post patient related stories, the facts are altered and omitted to protect these patients and their confidentiality. I can't very well change the sex or the general theme of my posts, because, let's face it, I'm an OB/GYN and I only see women! I just wanted to get that off of my chest; I feel much better now!
I recently saw a patient in the office as a new OB patient. I noted from her chart that she was in her 40s, which, while quite common in more urban areas, is practically unheard of in this rural area of the country. I also noted, based on her stated last menstrual period, that she was nearly into her third trimester! Unsure of what to expect, I entered the room to find a very pleasant, very anxious couple. Ms.X had a long history of irregular periods, and it was not unusual for her to skip several months at a time. She stated that she had been very tired for several months, as well. Over the last week, she went to an urgent care center to be treated for symptoms of a URI. She also complained of nausea and vomiting, and, because of her remote LMP, the PA ordered a urine pregnancy test. It was positive. Unfortunately, the center did not do a pelvic exam, order an ultrasound, or a serum beta.HCG (!) So, this poor patient and her husband had no idea exactly how far she was into the pregnancy, and they had been agonizing for the past week, awaiting her appointment with me.
Ms. X has had 2 previous cesarean deliveries, and both of her children are in their 20s. One of her children is currently fighting in the war overseas. She is shell-shocked, and cannot believe that she is pregnant. Over the last week, the flutters she once attributed to gas pains, she now recognizes as fetal movements. On exam, her fundal height was greater than 34 weeks, and her cervix was 1 cm dilated. The fetal heart tones were nice and strong in the 140s. I don't have an ultrasound in the office, so I set up an appointment for a full ultrasound. It may feel like the shortest pregnancy on record, if she ends up actually being as far along as I believe her to be. Limited or no prenatal care can be problematic, especially in a patient that would be considered somewhat high-risk, based on age alone. I am anxiously awaiting the dating from the ultrasound to proceed with proper testing. The kicker of the story, though, is that her child that is overseas is coming home for a surprise visit, right around the time that the baby would be due to deliver. Her husband took me aside, told me of the surprise visit, and his eyes teared up as he asked if it would be possible to deliver the baby during the homecoming. I told him that I would do what I could, but given such little information at present, I could make no guarantees.
As they left, it struck me how this child is going to rock their proverbial world. Imagine, thinking you were done with child-rearing, looking forward to menopause and retirement, only to be faced with starting all over again! I've probably mentioned before that "the best laid plans of mice and men often go awry" is kind of like my own personal mantra. It just goes to show that sometimes you just don't know what life has in store for you. It is definitely a wild ride!
I recently saw a patient in the office as a new OB patient. I noted from her chart that she was in her 40s, which, while quite common in more urban areas, is practically unheard of in this rural area of the country. I also noted, based on her stated last menstrual period, that she was nearly into her third trimester! Unsure of what to expect, I entered the room to find a very pleasant, very anxious couple. Ms.X had a long history of irregular periods, and it was not unusual for her to skip several months at a time. She stated that she had been very tired for several months, as well. Over the last week, she went to an urgent care center to be treated for symptoms of a URI. She also complained of nausea and vomiting, and, because of her remote LMP, the PA ordered a urine pregnancy test. It was positive. Unfortunately, the center did not do a pelvic exam, order an ultrasound, or a serum beta.HCG (!) So, this poor patient and her husband had no idea exactly how far she was into the pregnancy, and they had been agonizing for the past week, awaiting her appointment with me.
Ms. X has had 2 previous cesarean deliveries, and both of her children are in their 20s. One of her children is currently fighting in the war overseas. She is shell-shocked, and cannot believe that she is pregnant. Over the last week, the flutters she once attributed to gas pains, she now recognizes as fetal movements. On exam, her fundal height was greater than 34 weeks, and her cervix was 1 cm dilated. The fetal heart tones were nice and strong in the 140s. I don't have an ultrasound in the office, so I set up an appointment for a full ultrasound. It may feel like the shortest pregnancy on record, if she ends up actually being as far along as I believe her to be. Limited or no prenatal care can be problematic, especially in a patient that would be considered somewhat high-risk, based on age alone. I am anxiously awaiting the dating from the ultrasound to proceed with proper testing. The kicker of the story, though, is that her child that is overseas is coming home for a surprise visit, right around the time that the baby would be due to deliver. Her husband took me aside, told me of the surprise visit, and his eyes teared up as he asked if it would be possible to deliver the baby during the homecoming. I told him that I would do what I could, but given such little information at present, I could make no guarantees.
As they left, it struck me how this child is going to rock their proverbial world. Imagine, thinking you were done with child-rearing, looking forward to menopause and retirement, only to be faced with starting all over again! I've probably mentioned before that "the best laid plans of mice and men often go awry" is kind of like my own personal mantra. It just goes to show that sometimes you just don't know what life has in store for you. It is definitely a wild ride!
Saturday, November 04, 2006
Embrace the Inner Redneck
I live in an area of the country that is nationally notorious for being rather "backwoods." After living here for a little over a year, I can see where that stereotype may originate. However, I have also noticed a strange kinship with my redneck bretheren. Here, the rednecks are loud and proud. They drive trucks with "Cowboy Up" emblazoned on the rear window. They watch Nascar, football, and carry guns. They decorate to the hilt for every holiday. They dress up for every football game and every holiday. They are fiercely pro-America, pro-armed forces, and country music fans. You see, I have a little theory. I believe that humans have inherent, default redneck tendencies, and we must sometimes stifle these tendencies to move to cultural "next level." We are all a little bit redneck.
My husband's redneck trait? His penchant for hunting and killing poor defenseless animals. My redneck trait? I'm a packrat, and I like to drink just a wee bit more than your average citizen. My mother's redneck legacy? She is a Christmas freak. She has every sort of Christmas decoration known to man, and keeps buying more every year. My friend, ChurchMom, loves shopping at Nordstrom. Her whole house is decorated in Pottery Barn, and she is a bit of a label junkie. Her favorite pastimes? Watching Nascar, baseball, and drinking beer. I can think of a redneck trait in every single one of my (usually refined, and quite well-educated) friends. We all buy more than we need at Wal Mart. We secretly enjoy Jerry Springer, even if we would never admit it to our seemingly "classy" friends. Maybe this is bourgeoise rhetoric. Perhaps the truly aristocratic of our society wouldn't dream of collecting snow globes or decorating the front lawn with huge, blow-up characters; nor would they be caught dead at a Nascar rally. Perhaps you can breed the redneck traits right out of your lineage, but I like to think otherwise.
I have patients that could write the book on being a redneck; yet they are the most genuine, passionate, and generous people that I have ever had the good fortune to know. Being a redneck, in many ways, can be a positive personality trait. It all hinges on your perception. How do you embrace your inner redneck?
My husband's redneck trait? His penchant for hunting and killing poor defenseless animals. My redneck trait? I'm a packrat, and I like to drink just a wee bit more than your average citizen. My mother's redneck legacy? She is a Christmas freak. She has every sort of Christmas decoration known to man, and keeps buying more every year. My friend, ChurchMom, loves shopping at Nordstrom. Her whole house is decorated in Pottery Barn, and she is a bit of a label junkie. Her favorite pastimes? Watching Nascar, baseball, and drinking beer. I can think of a redneck trait in every single one of my (usually refined, and quite well-educated) friends. We all buy more than we need at Wal Mart. We secretly enjoy Jerry Springer, even if we would never admit it to our seemingly "classy" friends. Maybe this is bourgeoise rhetoric. Perhaps the truly aristocratic of our society wouldn't dream of collecting snow globes or decorating the front lawn with huge, blow-up characters; nor would they be caught dead at a Nascar rally. Perhaps you can breed the redneck traits right out of your lineage, but I like to think otherwise.
I have patients that could write the book on being a redneck; yet they are the most genuine, passionate, and generous people that I have ever had the good fortune to know. Being a redneck, in many ways, can be a positive personality trait. It all hinges on your perception. How do you embrace your inner redneck?
Wednesday, November 01, 2006
Change of Shift
Change of Shift, Volume 1, Number 10 is up at DisappearingJohn. He has done a beautiful job with this edition, and I'm honored to have a post that is included! Check out a carnival of nursing posts from around the blogosphere.
Tricks and Treats
It's been a busy week, and it is only Wednesday. Halloween was an interesting day for me. The morning started off with a Halloween delivery. The patient, SpacyMom, had only a handful of pre-natal visits, due mostly, I think, because she just "forgot" to come to the appointments! Luckily, her pregnancy was very low risk. I had seen her in the office on Monday, and I had a feeling she would deliver this week. My intuition was on target. She arrived at L&D with ruptured membranes at 6:15 am. She delivered at 10:30 am. Her labor was fast and furious, and she literally went from 5 cm to completely dilated in 20 minutes. She pushed for another 20 minutes, and had a beautiful (and not in the least scary) baby girl. I'm so glad to have this delivery to replace my last Halloween delivery. That delivery involved honest-to-goodness self-proclaimed witches, whose entire coven was at the delivery, chanting, they chose Halloween as an induction date, and wanted to do questionable things with the placenta. Shiver. Now *that* was scary. The rest of the day was spent in the office, seeing 22 patients in between 1 and 5:30pm, and rushing home for the Halloween festivities.
I've always liked Halloween, even though I am the world's worst costume idea originator. Seriously, I suck. I don't think I have ever had an original costume idea. In Halloweens past, when I was younger and more lithe, it was an excuse to dress in a risque fashion (once I was a black cat in a one piece bodysuit, once I was a sexy devil, you get the picture) Ah, to have that body once again! This year, we asked CindyLou what she wanted to be for her first trick-or-treat. (Yes, she *is* two-and-a-half. Yes, she has been alive for 3 total Halloweens. Yes, we have dressed her up. No, we have not taken her trick-or-treating. Color us lazy.) She decided to be a "purple firefly," or purple butterfly in toddler-ese. Deciding what to be was the easy part, piecing together an actual purple butterfly costume, however, was an entirely different endeavor. My first bright idea was to order a pair of purple butterfly wings online, thinking that I would be able to find a toddler sized purple leotard and tights at the local dance shop. Maybe I could have, if only I had gone to the store 6 weeks in advance to order a leotard in her teensy size. And size 2 purple tights without a print? The single hardest clothing article to locate....ever. I had to settle for a long sleeved purple onesie (it is chilly here) with a slightly different shade of flower print purple tights. The two shades of purple looked funny to me, so I decided to get a different colored tutu to minimize the difference between the two. Part of the original costume idea was to buy a headband with sparkly antennae. Great in theory, but my child's head is still too small and her hair too fine to hold such a headband in place. Her final costume ended up looking like some kind of deranged pink and purple fairy ballerina, but she was happy as a clam. That's all that counts, right?
We live in a very hilly neighborhood, so we decided to just take CindyLou to the immediate neighbors' houses. She was appropriately adorable, and got way more candy than she (or we) needed. Our next door neighbors even prepared her a little Halloween gift bag, complete with toys, candy, and a PEZ dispenser! The people in our neighborhood are so awesome, and they give out great candy, but we have very few trick-or-treaters. (I believe it is due to the HILLS, we were dying just going to 6 houses!) Last year we had 4 total, this year we had 2 kids. Mr. Whoo and I decided that next year we are going to reward the trick-or-treaters that make the climb to our house with King sized candy bars. We had made the rounds by 6:30 pm, and made our way home for a dubious dinner of pizza and candy. It was fun, and CindyLou really enjoyed her sugar high. After we put our purple butterfly to bed, we snuggled on the couch and watched some exorcism show on the History Channel, that should have been scary, but must not have been since we both fell asleep 10 minutes into the show! Exciting times in the Whoo household, folks. When did I get old? Anyway, Happy Belated Halloween!
I've always liked Halloween, even though I am the world's worst costume idea originator. Seriously, I suck. I don't think I have ever had an original costume idea. In Halloweens past, when I was younger and more lithe, it was an excuse to dress in a risque fashion (once I was a black cat in a one piece bodysuit, once I was a sexy devil, you get the picture) Ah, to have that body once again! This year, we asked CindyLou what she wanted to be for her first trick-or-treat. (Yes, she *is* two-and-a-half. Yes, she has been alive for 3 total Halloweens. Yes, we have dressed her up. No, we have not taken her trick-or-treating. Color us lazy.) She decided to be a "purple firefly," or purple butterfly in toddler-ese. Deciding what to be was the easy part, piecing together an actual purple butterfly costume, however, was an entirely different endeavor. My first bright idea was to order a pair of purple butterfly wings online, thinking that I would be able to find a toddler sized purple leotard and tights at the local dance shop. Maybe I could have, if only I had gone to the store 6 weeks in advance to order a leotard in her teensy size. And size 2 purple tights without a print? The single hardest clothing article to locate....ever. I had to settle for a long sleeved purple onesie (it is chilly here) with a slightly different shade of flower print purple tights. The two shades of purple looked funny to me, so I decided to get a different colored tutu to minimize the difference between the two. Part of the original costume idea was to buy a headband with sparkly antennae. Great in theory, but my child's head is still too small and her hair too fine to hold such a headband in place. Her final costume ended up looking like some kind of deranged pink and purple fairy ballerina, but she was happy as a clam. That's all that counts, right?
We live in a very hilly neighborhood, so we decided to just take CindyLou to the immediate neighbors' houses. She was appropriately adorable, and got way more candy than she (or we) needed. Our next door neighbors even prepared her a little Halloween gift bag, complete with toys, candy, and a PEZ dispenser! The people in our neighborhood are so awesome, and they give out great candy, but we have very few trick-or-treaters. (I believe it is due to the HILLS, we were dying just going to 6 houses!) Last year we had 4 total, this year we had 2 kids. Mr. Whoo and I decided that next year we are going to reward the trick-or-treaters that make the climb to our house with King sized candy bars. We had made the rounds by 6:30 pm, and made our way home for a dubious dinner of pizza and candy. It was fun, and CindyLou really enjoyed her sugar high. After we put our purple butterfly to bed, we snuggled on the couch and watched some exorcism show on the History Channel, that should have been scary, but must not have been since we both fell asleep 10 minutes into the show! Exciting times in the Whoo household, folks. When did I get old? Anyway, Happy Belated Halloween!
Saturday, October 28, 2006
Cat Trouble and other Tidbits
Mr. Thumbs (a Hemingway, 6 toed kitty) and FattyMcGee (Mr. Whoo's once-upon-a-time slender kitty, who now tops 20lbs) are a part of our dysfunctional little family. Nevermind that I am pretty well violently allergic to cat dander, I love them, and the cats are here to stay. In our pre-child days, Mr. Whoo was as fond of the kitties as I. Lately, it's been a different story. We've moved several times in Fatty McGee's lifetime, she's older and really pretty well adjusted. Mr. Thumbs, however, has been having potty issues ever since we moved to our new house a little over a year ago. More specifically, Mr. Thumbs' potty problem seemed to arise from a holiday visit from my family. My brothers chose to sleep down in our basement (aka Cat Heaven) during their stay. Ever since that time, even though no one else has deigned to sleep down there, Mr. Thumbs has been leaving solid presents all over the carpet in the basement. The problem became so annoying that we have been enclosing the cats in one of our partially finished basement rooms (it has a lot of space, all of their food, water, litter boxes, and piles of carpet remnants, tons of toys, and it is heated/air conditioned) during the day while we are at work. When we get home, the cats have the run of the basement and first floor. The upstairs bedrooms are off limits by way of the baby gate, which also keeps CindyLou from attempting to end her short life by jumping on the stairs. Mr. Thumbs has taken to using the carpet remnants upon which his food bowl rests as his own private litter box. What kind of animal poops right in front of where it eats?? It doesn't seem to matter if the litter boxes are clean or dirty, he uses the floor just the same. So far, since we've relocated them, it has been confined to the unfinished room, but it is so frustrating! Any cat psychologists out there? What can we do to remedy this problem?
In other excitement, it is a blustery, windy, and rainy day. I am awaiting the FSU/Maryland game with the appropriate amount of dread and gloomy thoughts. We are currently in the process of disposing of the 13, 547 magazines and paper clutter which grace our end tables and kitchen countertops, and I may just get my laundry done this weekend. Woot! Oh, and I got a new car. It is badass. It's the kind of car that talks back to you and will respond to certain voice commands...like Kit from Night Rider. We would not have gotten it, but we got a really sweet deal, way less than sticker, since the dealerships are trying to move their 2006 stock. Mr. Whoo was actually next in line for a new vehicle, but he is enjoying the search too much to settle on one just yet. I am off to have a glass of wine and read 7 back issues of Parenting magazine (how's that for being the model wife and mother?) Hope your weekend is relaxing!
In other excitement, it is a blustery, windy, and rainy day. I am awaiting the FSU/Maryland game with the appropriate amount of dread and gloomy thoughts. We are currently in the process of disposing of the 13, 547 magazines and paper clutter which grace our end tables and kitchen countertops, and I may just get my laundry done this weekend. Woot! Oh, and I got a new car. It is badass. It's the kind of car that talks back to you and will respond to certain voice commands...like Kit from Night Rider. We would not have gotten it, but we got a really sweet deal, way less than sticker, since the dealerships are trying to move their 2006 stock. Mr. Whoo was actually next in line for a new vehicle, but he is enjoying the search too much to settle on one just yet. I am off to have a glass of wine and read 7 back issues of Parenting magazine (how's that for being the model wife and mother?) Hope your weekend is relaxing!
Thursday, October 26, 2006
Why I Love My Nurse(s)
When I left you last, I gave you the somewhat faulty impression that I had, indeed, become SuperMom, curing sore throats and doing household chores at the speed of sound. In reality, my sick baby took a 3 hour nap, I sorted and did exactly 2 loads of laundry, passed on cleaning the kitchen in favor of reading blogs, and, instead of cooking, my husband brought home take-out for dinner. Domestic goddess, I am not. Fortunately, CindyLou awakened from her power nap afebrile and happy as a clam. I expect she will make a full recovery, and she is back to requesting chocolate for dinner (she is totally my daughter). I went back to being a physician, and had a relatively good Wednesday.
I fully expected to have a crappy day today. I had 14 new patients on the schedule, and I had 45 total patients on my list. I also was continuing an induction from yesterday, a primip that was post-dates with pre-ecclampsia. She never dilated more than 1 cm all day long yesterday, so I was worried about her progression, and I was really hoping to avoid a C-section, if possible. I don't know what is up with my schedule, but I started the day in a foul mood. My clinic nurse, SuperNurse, listened to my venting and told me that it would all be alright.
Let me expound, for a minute, on why I love her so very much. She takes care of me like I am one of her own children, she trusts me enough to let me care for her daughter (her daughter is 20 weeks pregnant), she loves my daughter like a grandchild (and CindyLou loves her!), she has been CindyLou's babysitter by choice, she answers my phone messages, deals with difficult patients, triages my patients, and assists me with exams and procedures, she gave me my flu shot and it didn't even hurt, and today, since she was worried that I wouldn't have time to eat, she brought me a salad and pepperoni roll from her own house so that I would have lunch. I love her to pieces, and she is never allowed to leave me. I had my own private hissy fit about my schedule for the day, she listened patiently, and then I got to work.
By the grace of God, I had numerous cancellations today, lightening the schedule significantly. As I trudged through clinic, I was in touch with my patient's labor nurse often throughout the day. Yesterday this patient had received Multiple doses of cytotec, yielding many contractions, but very little cervical change. When I rounded in the morning, she was 2cm/70% effaced/ and -2 station. I was hopeful for a vaginal delivery, but whenever you encounter such an unfavorable cervix, it is always a concern that the induction will fail. I was surprised (and pleased) to learn that she had dilated to 5 cm in just under 3 hours. The labor nurse, a seasoned professional with 20 years of experience under her belt, stated that the patient was having a few decelerations, but the baby was responding to scalp stimulation, and the labor was progressing well. I trusted her clinical judgment, and proceeded through my clinic day. Imagine my surprise when she paged me at 2:30 pm, stating that the patient was completely dilated! I quickly completed my remaining office visits, cancelled the remainder of the afternoon, and dashed to the hospital.
My patient delivered her long-awaited baby in a mere 4 pushes, and the baby was perfect, with Apgars of 9 and 9. After the delivery was completed and I sat at the nurses' station, completing paperwork, I asked the labor nurse to pull the strip from earlier, when the baby was having decelerations. Ladies and gents, the strip was U.G.L.Y. (you ain't got no alibi you ugly, hey, hey, you ugly...um, sorry, latent cheerleader tendencies emerging, here...nothing to see) It showed repetitive late decelerations and minimal beat to beat variability, for a good 20 minutes. Any other, less experienced, nurse likely would have pulled the plug on this patient due to the non-reassuring strip. This nurse, however, repositioned, started oxygen, gave positive scalp stim, and did not panic. It was fortutitous that this seasoned nurse held steady with the patient and worked steadfastly to improve the fetal status. Because of her expertise and confidence in the face of a non-reassuring strip, not only did she save my patient's peace of mind, she preserved her ability to proceed with a vaginal delivery.
Nurses save my butt every single day, and while I do my best to thank them, I fear it just isn't sufficient. So, to all you nurses out there, regardless of your specialty, thank you a million times over for everything that you do. Nursing can be such a thankless job, and you deserve so much more. Hug your nurses today, folks, they are the heart and the soul of good medical care, without them, we physicians would be lost.
I fully expected to have a crappy day today. I had 14 new patients on the schedule, and I had 45 total patients on my list. I also was continuing an induction from yesterday, a primip that was post-dates with pre-ecclampsia. She never dilated more than 1 cm all day long yesterday, so I was worried about her progression, and I was really hoping to avoid a C-section, if possible. I don't know what is up with my schedule, but I started the day in a foul mood. My clinic nurse, SuperNurse, listened to my venting and told me that it would all be alright.
Let me expound, for a minute, on why I love her so very much. She takes care of me like I am one of her own children, she trusts me enough to let me care for her daughter (her daughter is 20 weeks pregnant), she loves my daughter like a grandchild (and CindyLou loves her!), she has been CindyLou's babysitter by choice, she answers my phone messages, deals with difficult patients, triages my patients, and assists me with exams and procedures, she gave me my flu shot and it didn't even hurt, and today, since she was worried that I wouldn't have time to eat, she brought me a salad and pepperoni roll from her own house so that I would have lunch. I love her to pieces, and she is never allowed to leave me. I had my own private hissy fit about my schedule for the day, she listened patiently, and then I got to work.
By the grace of God, I had numerous cancellations today, lightening the schedule significantly. As I trudged through clinic, I was in touch with my patient's labor nurse often throughout the day. Yesterday this patient had received Multiple doses of cytotec, yielding many contractions, but very little cervical change. When I rounded in the morning, she was 2cm/70% effaced/ and -2 station. I was hopeful for a vaginal delivery, but whenever you encounter such an unfavorable cervix, it is always a concern that the induction will fail. I was surprised (and pleased) to learn that she had dilated to 5 cm in just under 3 hours. The labor nurse, a seasoned professional with 20 years of experience under her belt, stated that the patient was having a few decelerations, but the baby was responding to scalp stimulation, and the labor was progressing well. I trusted her clinical judgment, and proceeded through my clinic day. Imagine my surprise when she paged me at 2:30 pm, stating that the patient was completely dilated! I quickly completed my remaining office visits, cancelled the remainder of the afternoon, and dashed to the hospital.
My patient delivered her long-awaited baby in a mere 4 pushes, and the baby was perfect, with Apgars of 9 and 9. After the delivery was completed and I sat at the nurses' station, completing paperwork, I asked the labor nurse to pull the strip from earlier, when the baby was having decelerations. Ladies and gents, the strip was U.G.L.Y. (you ain't got no alibi you ugly, hey, hey, you ugly...um, sorry, latent cheerleader tendencies emerging, here...nothing to see) It showed repetitive late decelerations and minimal beat to beat variability, for a good 20 minutes. Any other, less experienced, nurse likely would have pulled the plug on this patient due to the non-reassuring strip. This nurse, however, repositioned, started oxygen, gave positive scalp stim, and did not panic. It was fortutitous that this seasoned nurse held steady with the patient and worked steadfastly to improve the fetal status. Because of her expertise and confidence in the face of a non-reassuring strip, not only did she save my patient's peace of mind, she preserved her ability to proceed with a vaginal delivery.
Nurses save my butt every single day, and while I do my best to thank them, I fear it just isn't sufficient. So, to all you nurses out there, regardless of your specialty, thank you a million times over for everything that you do. Nursing can be such a thankless job, and you deserve so much more. Hug your nurses today, folks, they are the heart and the soul of good medical care, without them, we physicians would be lost.
Tuesday, October 24, 2006
Home Sick
CindyLou is sick. You have to love day care for all of the ways it, um, strengthens your child's immune system. If I had been a better, more "in-tune" mother, I probably would have realized that her (most unusual) grumpiness on Monday morning was a sign of impending illness. Unfortunately, I just chalked it up to the fact that we had altered her schedule by me dropping her at day care instead of her Daddy. Mondays are supposed to be a "half day" in the office for me, but, as you may have read previously, this is seldom the case. Yesterday, I was finished with seeing patients by 2pm, but then I had the ever-present paperwork and dictations to complete. I left the office by 4 in hopes to pick up CindyLou early to go Halloween costume shopping. When I arrived in her room, I found her lying down, with a fever of over 102 degrees. Her teachers had not yet phoned my husband or myself, which made me a little upset, but I think that they had just taken her temp a few minutes before I arrived. The teachers said that she hadn't been acting herself all day long. I felt terrible that she had to be in school all day, feeling as badly as I knew she must.
Luckily, I was able to take her straight to the pediatrician, and they diagnosed her with tonsillitis. Since she's considered contagious for at least 24 hours after initiation of antibiotics, that meant no day care for her today, and a mad scramble for Mr. Whoo and myself to get things in order. We did some juggling, and decided that he would take the "morning shift," and I would see the patients scheduled in the morning, and cancel my afternoon patients in favor of staying home. Mr. Whoo could then head to the office and take care of some appointments and prep for an early morning meeting on Wednesday. I felt bad canceling the 19 patients that I had scheduled between 1 and 4:30, but I really didn't think that bringing CindyLou to an OB office, where she could spread her germs to pregnant people, was the best idea, and Mr. Whoo, while his job is far more flexible than my own, still has plenty of responsibilities. I don't think it is fair to always ask him to make sacrifices at work when problems arise at home.
So, here I am, home in the early afternoon, feeling as though I am playing hooky! Little CindyLou is taking a much needed nap. Her temp was still up to 101 this morning, so we've been alternating Tylenol with Motrin, and she's taking lots of fluids. Most of the day has been spent on the couch watching Disney movies and cuddling. Just what a sick day should be! For me, staying home sick with my mom meant Sprite, soup and saltines, Phil Donahue, and Days of Our Lives. I always felt cared for and safe, and I want CindyLou to feel that way. Even if my job is demanding, I want her to know that she comes first. Now I am going to do laundry, clean the kitchen, and cook a real dinner for tonight. (Color me domestic!) For today, I get to be a normal Mom, tomorrow, I'll get back to being a physician.
Luckily, I was able to take her straight to the pediatrician, and they diagnosed her with tonsillitis. Since she's considered contagious for at least 24 hours after initiation of antibiotics, that meant no day care for her today, and a mad scramble for Mr. Whoo and myself to get things in order. We did some juggling, and decided that he would take the "morning shift," and I would see the patients scheduled in the morning, and cancel my afternoon patients in favor of staying home. Mr. Whoo could then head to the office and take care of some appointments and prep for an early morning meeting on Wednesday. I felt bad canceling the 19 patients that I had scheduled between 1 and 4:30, but I really didn't think that bringing CindyLou to an OB office, where she could spread her germs to pregnant people, was the best idea, and Mr. Whoo, while his job is far more flexible than my own, still has plenty of responsibilities. I don't think it is fair to always ask him to make sacrifices at work when problems arise at home.
So, here I am, home in the early afternoon, feeling as though I am playing hooky! Little CindyLou is taking a much needed nap. Her temp was still up to 101 this morning, so we've been alternating Tylenol with Motrin, and she's taking lots of fluids. Most of the day has been spent on the couch watching Disney movies and cuddling. Just what a sick day should be! For me, staying home sick with my mom meant Sprite, soup and saltines, Phil Donahue, and Days of Our Lives. I always felt cared for and safe, and I want CindyLou to feel that way. Even if my job is demanding, I want her to know that she comes first. Now I am going to do laundry, clean the kitchen, and cook a real dinner for tonight. (Color me domestic!) For today, I get to be a normal Mom, tomorrow, I'll get back to being a physician.
Sunday, October 22, 2006
OPP (Other People's Patients)
If you recognized the title of this post as the title of a rather questionable rap song, you are old (just like me). I have mentioned in previous posts that OtherDoc has finally agreed to share weekend call with me. The inordinate luxury of having 2 whole weekends free of the pager is well worth the 2 weekends of double the patient responsibility. I have come to realize, however, that OtherDoc's patient management is a bit different from my own. This leads to occasional patient care dilemmas.
OtherDoc has been practicing for nearly 15 years, and sees probably quadruple the patients that I see, he is board certified, and sticks to the standard of care in most cases. Sometimes, I think, he gets just a little too busy, and can neglect certain duties essential for transfer of care like writing notes in the chart. I come from an era in training where the threat of lawsuits lurk at every turn, and documentation is your very best friend. We were taught that the chart should be able to stand on its own. After being in solo practice for so long, I can see where you could let note writing fall by the wayside, since *you* know what you are going to do/what you have done/what you are concerned about, etc. I, on the other hand, cannot divine the true purpose for hospitalization/plan of care without some documentation. I'm also finding that OtherDoc doesn't get a chance to do a lot of patient education (as evidenced by multiple pages over simple questions this weekend), nor does he share his plan of care with his patients all that often. Such was the case with one of his pregnant patients in the hospital this weekend. As per usual, we did a quick sign out at the office on Friday, where he basically stated the patient was a "chronic hypertensive in for rule out pre-ecclampsia, oh, and her sugars are a little out of whack, too." I left check out with the impression that the patient was to have a 24 hour urine protein, and if her BP was controlled on her new medication regimen, she was to be discharged. Imagine my surprise when I pulled the patient's blood sugars for the last 2 days, 90% of which were over 200 (!) OtherDoc had written for low dose insulin the day prior, but did not tell the patient his reasoning, and therefore she was refusing the meds. I also found, after a little digging, that her 1 hour glucola value (taken last month!) was well over 200 and the baby was macrosomic with polyhydramnios. Woo hoo. Her blood pressure, ironically, was just fine on the meds she was taking.
I sat and had a long talk with the patient, who was (more than a little) in denial about her condition, about uncontrolled blood sugars and the effects on the baby. She still refused insulin, so we compromised and settled on a trial of Glyburide, with the caveat that if Glyburide did not control her glucose, we needed to proceed to insulin. I also had the dietician come in to teach the patient about carb counting and diet control. Her 24 hour urine protein was consistent with mild pre-ecclampsia, but she had not had a baseline 24 hour urine, and I have the feeling that she may have had some proteinuria prior to the pregnancy. In the end, it all got straightened out, but I feel as though I may have taken a different direction than OtherDoc was intending to take. I surely don't mean to question or undermine his management, because there are several correct ways to approach clinical problems. I'm just trying to do the best for the patient under the circumstances. I'm sure, if he desires, he can tweak the adjustments I made when he sees her next. If anything, this weekend has just reinforced how very important it is to document your plan of care, and to share that plan of care with your patients. The good news is that this weekend is nearly over, and I will then have the next two whole weekends off! O frabjous day!
OtherDoc has been practicing for nearly 15 years, and sees probably quadruple the patients that I see, he is board certified, and sticks to the standard of care in most cases. Sometimes, I think, he gets just a little too busy, and can neglect certain duties essential for transfer of care like writing notes in the chart. I come from an era in training where the threat of lawsuits lurk at every turn, and documentation is your very best friend. We were taught that the chart should be able to stand on its own. After being in solo practice for so long, I can see where you could let note writing fall by the wayside, since *you* know what you are going to do/what you have done/what you are concerned about, etc. I, on the other hand, cannot divine the true purpose for hospitalization/plan of care without some documentation. I'm also finding that OtherDoc doesn't get a chance to do a lot of patient education (as evidenced by multiple pages over simple questions this weekend), nor does he share his plan of care with his patients all that often. Such was the case with one of his pregnant patients in the hospital this weekend. As per usual, we did a quick sign out at the office on Friday, where he basically stated the patient was a "chronic hypertensive in for rule out pre-ecclampsia, oh, and her sugars are a little out of whack, too." I left check out with the impression that the patient was to have a 24 hour urine protein, and if her BP was controlled on her new medication regimen, she was to be discharged. Imagine my surprise when I pulled the patient's blood sugars for the last 2 days, 90% of which were over 200 (!) OtherDoc had written for low dose insulin the day prior, but did not tell the patient his reasoning, and therefore she was refusing the meds. I also found, after a little digging, that her 1 hour glucola value (taken last month!) was well over 200 and the baby was macrosomic with polyhydramnios. Woo hoo. Her blood pressure, ironically, was just fine on the meds she was taking.
I sat and had a long talk with the patient, who was (more than a little) in denial about her condition, about uncontrolled blood sugars and the effects on the baby. She still refused insulin, so we compromised and settled on a trial of Glyburide, with the caveat that if Glyburide did not control her glucose, we needed to proceed to insulin. I also had the dietician come in to teach the patient about carb counting and diet control. Her 24 hour urine protein was consistent with mild pre-ecclampsia, but she had not had a baseline 24 hour urine, and I have the feeling that she may have had some proteinuria prior to the pregnancy. In the end, it all got straightened out, but I feel as though I may have taken a different direction than OtherDoc was intending to take. I surely don't mean to question or undermine his management, because there are several correct ways to approach clinical problems. I'm just trying to do the best for the patient under the circumstances. I'm sure, if he desires, he can tweak the adjustments I made when he sees her next. If anything, this weekend has just reinforced how very important it is to document your plan of care, and to share that plan of care with your patients. The good news is that this weekend is nearly over, and I will then have the next two whole weekends off! O frabjous day!
Saturday, October 21, 2006
How To End a Fight
Let's face it, married people fight. No matter how blissfully happy you are, no matter how much you have in common, no matter how good your life is in the bedroom, you are still individual people, and are apt to disagree. In our marriage, we have adopted the mantra of never going to bed angry, and, to tell the truth, we don't have terribly major fights. More often than not, we just irritate one another and nib at each other from time to time. Often, after spending a lot of time with one another, you start to develop your very own secret language. You have special looks, inside jokes, and phrases, while non-sensical to others, that hold a great amount of meaning to you as a couple. Most of our general bickering is halted by a few catch phrases, that, more often than not, make us laugh and forget about the squabbling.
In the early years of our relationship, Mr. Whoo and I seemed to only fight when we were around his buddies. Invariably, early on, this was because one of us was more intoxicated than the other, and that divide between states of consciousness was just not easily bridged. One of our more major fights occured over a Thanksgiving weekend, when 2 of his buddies and their wives came to our house to celebrate Thanksgiving, as we were all too far from our respective families to travel for the weekend. The day after Thanksgiving, all of the boys went outside to throw the football around, leaving us girls to our own devices. It was nearly 11:30 in the morning, so we did the most logical thing; we started drinking wine. We drank and giggled and watched, I think, some dog show on TV for a couple of hours before the guys came back in from playing in the yard. I think they were surprised (and maybe a little miffed) to find us absolutely blitzed in the living room, but whatever. Strike one. We decided to go see one of the Harry Potter movies, and since we were still riding the wave of intoxication, we decided to try to sneak wine into the theater in sport bottles, concealed in bulky coats and purses. We arrived in the theater where I promptly fell asleep (ie. passed out) for the duration of the movie. Strike two. When the movie was over, Mr. Whoo had to jostle me to wake me up, and I decided it was a good idea just to stay in the theater and sleep it off. Strike three. "I'm not going without my Richmond!" my drunken-self proclaimed. What I meant was that I had forgotten my still full sports bottle in the theater. Mr. Whoo, clearly at the end of his rope at this point, refused to let me go back to retrieve the "Richmond." We loaded into the car, where I spat across 2 rows of seats that I was "Sooooo, effing-sorry!" Except I didn't say "efffing," I said the "Queen Mother of all Curse Words." Since it was obvious that I wasn't sorry at all, things went from bad to worse. Our friends, of course, thought that this was hilarious. We finally worked it out, no harm done, but to this day, all sports bottles in our house are "Richmonds" and one way to end a fight and get a good laugh is saying "I'm so efff-ing sorry!"
Other choice phrases in our house to end a fight include the circa-4th grade retort, "You are." (Variations on which include, "You're the one," or "You're the one that is.") "You don't even know." (Thanks to a comic that we both watched once upon a time.) and the very versatile "Suck it," or "You can suck it." The wonderful phrase, "Suck it" was perpetuated by my good friend YogaGirl and her husband, and let me tell you, it is a most amusing way to agree to disagree. When any of the above phrases are uttered, we know to drop the subject, and we can end the conversation with a smile.
Here is a sample Whoo household squabble:
The complaint, "You forgot to put a new roll of toilet paper on the roll (do the dishes, bathe the child, etc.)"
The initial reply, "You're the one that did."
The insistence, "I mean really, how hard is it?"
The volley, "You don't even know!"
The resolution, "You can suck it."
"I'm soooo effing soooorry."
End of fight.
Do any of you have special "fighting words?"
In the early years of our relationship, Mr. Whoo and I seemed to only fight when we were around his buddies. Invariably, early on, this was because one of us was more intoxicated than the other, and that divide between states of consciousness was just not easily bridged. One of our more major fights occured over a Thanksgiving weekend, when 2 of his buddies and their wives came to our house to celebrate Thanksgiving, as we were all too far from our respective families to travel for the weekend. The day after Thanksgiving, all of the boys went outside to throw the football around, leaving us girls to our own devices. It was nearly 11:30 in the morning, so we did the most logical thing; we started drinking wine. We drank and giggled and watched, I think, some dog show on TV for a couple of hours before the guys came back in from playing in the yard. I think they were surprised (and maybe a little miffed) to find us absolutely blitzed in the living room, but whatever. Strike one. We decided to go see one of the Harry Potter movies, and since we were still riding the wave of intoxication, we decided to try to sneak wine into the theater in sport bottles, concealed in bulky coats and purses. We arrived in the theater where I promptly fell asleep (ie. passed out) for the duration of the movie. Strike two. When the movie was over, Mr. Whoo had to jostle me to wake me up, and I decided it was a good idea just to stay in the theater and sleep it off. Strike three. "I'm not going without my Richmond!" my drunken-self proclaimed. What I meant was that I had forgotten my still full sports bottle in the theater. Mr. Whoo, clearly at the end of his rope at this point, refused to let me go back to retrieve the "Richmond." We loaded into the car, where I spat across 2 rows of seats that I was "Sooooo, effing-sorry!" Except I didn't say "efffing," I said the "Queen Mother of all Curse Words." Since it was obvious that I wasn't sorry at all, things went from bad to worse. Our friends, of course, thought that this was hilarious. We finally worked it out, no harm done, but to this day, all sports bottles in our house are "Richmonds" and one way to end a fight and get a good laugh is saying "I'm so efff-ing sorry!"
Other choice phrases in our house to end a fight include the circa-4th grade retort, "You are." (Variations on which include, "You're the one," or "You're the one that is.") "You don't even know." (Thanks to a comic that we both watched once upon a time.) and the very versatile "Suck it," or "You can suck it." The wonderful phrase, "Suck it" was perpetuated by my good friend YogaGirl and her husband, and let me tell you, it is a most amusing way to agree to disagree. When any of the above phrases are uttered, we know to drop the subject, and we can end the conversation with a smile.
Here is a sample Whoo household squabble:
The complaint, "You forgot to put a new roll of toilet paper on the roll (do the dishes, bathe the child, etc.)"
The initial reply, "You're the one that did."
The insistence, "I mean really, how hard is it?"
The volley, "You don't even know!"
The resolution, "You can suck it."
"I'm soooo effing soooorry."
End of fight.
Do any of you have special "fighting words?"
Thursday, October 19, 2006
Post Operative Complications
Prior to any scheduled surgery, I usually have a pre-op appointment with the patient to review the surgery, do a quick exam to check for any brewing acute illness, and cover the risks of the surgery. I can do this spiel in my sleep. "With any surgery there are risks: bleeding, infection, damage to internal organs such as bowel or bladder, risk of hemorrhage requiring transfusion, risk of anesthesia, or even risk of death." I also will cover additional risks specific to the surgery the patient is having. There is an adage in medicine that the surgeon that has never had any complications has not done enough surgery. While frightening, it is true. Eventually, if you operate enough, you are going to have surgical and post operative complications. Like it or not. Last night, between every 3 hour pages (all night long) for normal blood sugars (!) and worrying about my post-operative patients, I got very little sleep.
I've sailed through several weeks without any surgical complications, and that lucky streak came to an end yesterday. It started off as a diagnostic laparoscopy for pelvic pain. The patient was taking narcotic pain meds like tic tacs, without relief. She was convinced that it was her uterus, so we took her to surgery to find a cause of her pain. Her uterus, tubes, and ovaries looked as normal as they could be, but she had pelvic adhesions from her intestines, criss-crossing her abdomen from top to bottom. I was able to dissect the majority of the bowel adhesions without complication, but one area, upon inspection, appeared as though I may have dissected too close to the bowel mucosa. I called a general surgeon in to take a peek, and he blustered and cursed, and finally agreed that he thought it was a little too close, too. I extended her umbilical incision by just a couple of cm, and we were able to bring the bowel up to the incision and oversew the questionable defect. I kept her overnight, just in case, but she did well and went home this morning.
My next worry was a patient with pelvic prolapse and urinary incontinence. Every Ob/Gyn has an area of surgery they love to do, and, more often than not, an area of surgery that they dislike. I. Hate. Urogynecology. I don't like anterior repairs ( I don't think they work). I hate vault suspensions. I hate mesh. I'm not particularly fond of Burches. TVTs are pretty cool, but the urologists in this hospital have domain over that procedure and get a little pissy (heh) if you step on their toes. No skin off my nose, since I really would rather not mess with Urogyn. Since there are no urogynecologists in my hospital, I had to co-schedule her surgery with a urologist so that he could do a sling. She had quite a bit of prolapse, and she really wanted a vaginal hysterectomy. No problem, right? She is also post-menopausal, so she wanted her ovaries out, no matter what (risk of cancer and all). Vaginal hysterectomies, as a general rule, are really cool surgeries, but the flow of the surgery is completely dependent upon the skill of your assistants. The name of the game is visualization, so your assistants need to know what you need to see. Skilled assistants are difficult to come by, and between my med student (that had never even scrubbed a case before this rotation) and the scrub tech that never does GYN, I was screwed in the assistant department. The uterus came down and out without too much of a struggle, but the ovaries were plastered to the pelvic sidewall. This means, for my non-medical readers, it is more difficult to completely remove the ovary and tubes, and more risky for not completely securing the big bad blood vessel leading to the ovary, thereby increasing risk for post op hemorrhage. I struggled with the stubborn ovaries for a solid hour, and finally coaxed them from their happy homes, there was a little oozing on both sides from the dissection, but I was fairly certain there was no active arterial bleeding at the end of the case. I did the obligatory anterior repair, and then the urologist did the sling. We had very little blood loss, and even though the entire surgery ended up taking over 2.5 hours, I felt satisfied that it had been successful. There is always that niggling doubt in the back of my mind about post-op complications, and for her, I knew, it would be bleeding.
After the surgery, I spoke with her family, and they were so happy that we were able to do the entire surgery vaginally. Fast forward to this morning, when I found that her hematocrit had dropped 10 points. That's a lot of blood, folks. Her vitals were stable and she had good urine output overnight, and her abdominal exam was normal for post-op day #1. She had very little vaginal bleeding, but I know that she bled somewhere. I didn't go rushing back to the OR, like my panicked little brain wanted to do. Instead, I checked another blood level, 6 hours after the morning level, and held her diet in anticipation in heading back for re-exploration. Then I prayed. God must love me, or, more pointedly, this woman, because her level at 12 noon was exactly the same as it was at 6 am. So, she bled somewhere overnight, but she is no longer bleeding. Yee haw. Most of the time, a source of the bleed is never found. It is usually venous oozing, and it could have been from my ovary dissection, but suburethral slings can cause some serious hematomas, too, so we may never know. For now, she is doing well, and maybe I can get some decent sleep tonight. Here's hoping!
I've sailed through several weeks without any surgical complications, and that lucky streak came to an end yesterday. It started off as a diagnostic laparoscopy for pelvic pain. The patient was taking narcotic pain meds like tic tacs, without relief. She was convinced that it was her uterus, so we took her to surgery to find a cause of her pain. Her uterus, tubes, and ovaries looked as normal as they could be, but she had pelvic adhesions from her intestines, criss-crossing her abdomen from top to bottom. I was able to dissect the majority of the bowel adhesions without complication, but one area, upon inspection, appeared as though I may have dissected too close to the bowel mucosa. I called a general surgeon in to take a peek, and he blustered and cursed, and finally agreed that he thought it was a little too close, too. I extended her umbilical incision by just a couple of cm, and we were able to bring the bowel up to the incision and oversew the questionable defect. I kept her overnight, just in case, but she did well and went home this morning.
My next worry was a patient with pelvic prolapse and urinary incontinence. Every Ob/Gyn has an area of surgery they love to do, and, more often than not, an area of surgery that they dislike. I. Hate. Urogynecology. I don't like anterior repairs ( I don't think they work). I hate vault suspensions. I hate mesh. I'm not particularly fond of Burches. TVTs are pretty cool, but the urologists in this hospital have domain over that procedure and get a little pissy (heh) if you step on their toes. No skin off my nose, since I really would rather not mess with Urogyn. Since there are no urogynecologists in my hospital, I had to co-schedule her surgery with a urologist so that he could do a sling. She had quite a bit of prolapse, and she really wanted a vaginal hysterectomy. No problem, right? She is also post-menopausal, so she wanted her ovaries out, no matter what (risk of cancer and all). Vaginal hysterectomies, as a general rule, are really cool surgeries, but the flow of the surgery is completely dependent upon the skill of your assistants. The name of the game is visualization, so your assistants need to know what you need to see. Skilled assistants are difficult to come by, and between my med student (that had never even scrubbed a case before this rotation) and the scrub tech that never does GYN, I was screwed in the assistant department. The uterus came down and out without too much of a struggle, but the ovaries were plastered to the pelvic sidewall. This means, for my non-medical readers, it is more difficult to completely remove the ovary and tubes, and more risky for not completely securing the big bad blood vessel leading to the ovary, thereby increasing risk for post op hemorrhage. I struggled with the stubborn ovaries for a solid hour, and finally coaxed them from their happy homes, there was a little oozing on both sides from the dissection, but I was fairly certain there was no active arterial bleeding at the end of the case. I did the obligatory anterior repair, and then the urologist did the sling. We had very little blood loss, and even though the entire surgery ended up taking over 2.5 hours, I felt satisfied that it had been successful. There is always that niggling doubt in the back of my mind about post-op complications, and for her, I knew, it would be bleeding.
After the surgery, I spoke with her family, and they were so happy that we were able to do the entire surgery vaginally. Fast forward to this morning, when I found that her hematocrit had dropped 10 points. That's a lot of blood, folks. Her vitals were stable and she had good urine output overnight, and her abdominal exam was normal for post-op day #1. She had very little vaginal bleeding, but I know that she bled somewhere. I didn't go rushing back to the OR, like my panicked little brain wanted to do. Instead, I checked another blood level, 6 hours after the morning level, and held her diet in anticipation in heading back for re-exploration. Then I prayed. God must love me, or, more pointedly, this woman, because her level at 12 noon was exactly the same as it was at 6 am. So, she bled somewhere overnight, but she is no longer bleeding. Yee haw. Most of the time, a source of the bleed is never found. It is usually venous oozing, and it could have been from my ovary dissection, but suburethral slings can cause some serious hematomas, too, so we may never know. For now, she is doing well, and maybe I can get some decent sleep tonight. Here's hoping!
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