Clinic

Funny how fast clinic can be when u know ur patients. Still seems like there is so much to know and learn, even on things that seem simple. Need to read more. It was cool that a lady isaw in my intern year who I referred to psych remembered me after all this time.

There is no crying in medicine...

Yes, yet again I have shed public tears. I was an intern on my first call on medicine wards. In hour 27 of a 30 hr call I had to call a cardiology consult on a patient. The patient was in his mid 50's with metastatic cancer essentially everywhere, he was aware, and after this admission In which he was found to have dic he was ready for hospice. To this day I am not sure what our question was for cardiology, but given his medical hx we were unclear if the ekg changes we saw were merely from demand ischemia. Or if they were something we should act on. I was just one phone call away from getting to go home and sleep. I was tired, uncertain of myself, and vulnerable. So I paged and awaited the call back. Little did I know that I was not paging a fellow resident but rather the attending. Right away before I could even present my case he ripped on me, telling me that I was paging the attending and that I needed to know that and god know wat else. I finally was able to proceed and tell him about the case. He again was upset and questioned my consult, repeatedly asking me why I was asking for the consult. I replied that my attending had requested it. To which he responded. - your the physician caring for the patient you should know why you are calling this consult. I attempted to explain again. And again he kept asking why? At this point I was at a loss, I could feel my throat closing and my chest tightening, I couldn't speak, I just kept quiet. " are you still there? Answe me I am the attending!" he said. "I don't know," I choked out. "are you crying?l. "no," I lied. He moderately softened and disgruntled accepted the consult not before again lecturing me on the importance of knowing the consult question and taking responsibility for my patient. By this point I couldn't speak and was choking back large sobs. And of course all parties in the work room could hear and could see and hear me sobbing. And once I start it's hard for me to stop, my whole body convulsing in an effort to choke back tears, to appear strong, but ultimately look sad and hopelessly weak. My senior tried to console me and told me that that attending was notoriously mean and that I should talk to the medicine coordinator to report my mistreatment. One of the other seniors who now is actually a chief later told me he spoke to that attending whom told him that he felt very bad for what had happened and apologized. Too little to late Ofcourse as by that time I was embarrassed for one crying in the work room, crying to an attending, and for being made to feel like a complete and total idiot. A feeling that as an intern I was already trying so hard to suppress and deny. And make my self believe in myself and my knowledge. I was mortified and terrified of ever calling or running into that man in the hospital. I came home and cried and cried. My bf consoling me, and yes angry at that man but also angry with me for not standing up for myself and letting that man make me feel so bad, his belief that no one can make you feel some way and that how you feel is up to you. In theory a nice idea but oh so difficult, especially when it feeds iinto a feeling that you already have about yourself. I never did seek recourse and go to the medicine director.
There is no excuse for that attending behavior. And it also serves as a reminder to us when we are on either end of a consult, whether we aree the consultant or the consultee, to be patient and respectful, take the opportunity to educate and remember we are all on the same team- with the common goal of helping people. And that we don't know everything. Regardless of how tired we are or overworked that is no excuse to take it out on our colleagues.

Last days on the deck...

I must say that ultimately one of the most important things we leArn about medicien and being a physician is being confident, making the best decision you can in any situation. This is so difficult in a field where things are always changing, there is so much to know, and you want to keep your patient safe. I began to feel so much more comfortable on this rotation when I just manned up, accepted the great uncertainty I felt, and just kept an open mind. My last few days I had three deliveries. I got t work with the midwives and felt confident manning triaged. Seemed so much more simple and straightforward compared to when I was a intern. (let's hope I feel that way going back to labor and delivery in April). I still haven't had a successful rupture of membranes, but I at least tried. My repairs are getting better, far from being able to do it alone, but getting there. It's hard to learn on the job with people watching but I guess it has to be done. So it goes with the theme you just have to be confident with the uncertainty.

Labor deck adventures

Nights are killing me. Everything is ok until about 3am, then my whole body gets chills, and my eyes start to burn. It's terrible. And miraculously around 530am you start to wake up again, regardless of what is going on. Anyways - yet again I got caught up with a pusher. A young lady with hx of alcohol abuse and PTSD/depression, delivering her first baby. This inevitably translates to whiny, needy, and "difficult" pt for most folks.
For me this meant a young girl without guidance, who is understandably scared, and not able to cope as well as someone with a different hx. She had a terrible time pushing, vomiting in between pushes, and continually complaining of pain preventing her from being able to push well. Two frustrating hours later, the nurse exasperated and tired o f coaching and encouraging and who was having a hard time emphasizing with the poor girl, the supportive bf, and myself the semi useful resident, we got anesthesia to give some more pain med thru her epidural. One hour later she was pushing better but but not enough. End of story she got a forces delivery and a second degree tear. The sweetest thing - most deliveries dad gets all caught up in baby and totally forgets about poor mom, but In this case he did not rush over to baby but rather stayed with mom and made sure she was ok.
Next awesome thing was I delivered a 10lb baby! The mom was pretty large herself. And the most exciting part - I did a successful repair, my senior was so patient and really guided me thru it which was awesome. I think with a few more I'll get the hang of it.
I think one of the hardest parts of ob but also medicine in general for me is being aggressive. You need to be confident in your management even if ur not and lead, make decisons and so forth. This is hard for me because one I don't always feel confident in my decisions and I am just so afraid to be wrong. I'm working on it and imagine it improves with time, but man it's hard.
One more funny thing, how there is truly no shame once ur in labor. I mean ur on the bed naked essentially on bottom with ur legs open and sometimes these ladies push on their sides with their giant thighs and buttocks just out there all up in the dads face haha. Also interestingly many of the ladies I've been seeing are shaven!

On the deck

Got two more deliveries under my belt yesterday, of course not without pain and sweat. The first one went along smoothly but when she had a second degree tear and the resident was watching me repair it it was mortifying. As is when ur down there its hard to tell the tissue apart wat goes to what etc. secondly I'm bad at repairs. And thirdly my skills with a needle and knot tying are poor. Finally I am traumatized from my experience on deck as a first year. Oh and I'm supposed to be a second year! Ha. So after a lot of sweat and an hour later she was finally fixed but even then my approximations were poor.
My last delivery was a woman who said the thing she was most afraid of was going to csection. So sure enough an hour of pushing went by and baby hadn't moved an inch. She started to get worried but we reassured her she was making progress. Then we brought out the bar and did that for a half hour, that didn't make much diff. Then we even got her on all fours hanging off the bed. Nothing. The senior threatened forceps or vacuum. She was back on herback and my some miracle she was crowning! We rolled the car in and got ready to deliver.
Baby's head was just peaking out but still stuck. Lubricant and a hell of a lot of coaching plus threat of episiotomy got that big honking head out. We had thought baby was looking up but turn out she was facing down. I thought I. Was going to break baby's neck off the amount of force I had to put to get that shoulder out. But sure enough we got that baby out with minimal years just a.few bilateral superficial years. And after three hours of standing, coaching and screaming I sure as hell did not want to do the repair. I let the resident do it. I mean at 6 am after being up all night I just couldn't bare to go through that embarrassment yet again.
My legs felt like lead weights when I got home. And I fell right to sleep.

Clinic speak

What a joy it was to be in clinic today, after being on the labor deck and feeling clueless and unhelpful. My first pt has been suffering from "dolor del Cuerpo" that has been minimally responsive to meds plus a two year old with diarrhea and a 7month old with some reflux.

Where has the time gone?

It is 2012 and I haven't written anything for the past year and one half.and I am now a second year in residency! So much has happened. There has been so much growth. I resolve to write a bit more this year . Next up labor n delivery. After my experience last year it is a rotation I dread and fear. It was really difficult because of the house as well as challenging working with senior residents who I felt were not always very respectful. So I suck up my fear now and try to remember that itisall worth it just to see the moment that baby and family take their first breath together.

I have also gotten more comfortable with my title. At first it was so strange for people to say Dr to me. I would look around and say,"who r they talking to? I think just having the title gave u the feeling of so much more responsibility than just med student. I remember I was freaked to just write for Tylenol! Every decision pt was scary. And it was even funnier to have med student following me around and asking ME questions. Ha! Gotten more used to it def but it took time. I also think of my senior on trauma surgery, when the pt tried to cal her "sweetie" or "honey" or try to read her first name on her badge she told him , "no, that's dr to u.". That level of assertiveness may be the most important thing I learned on trauma surgery - I am the doctor.