Wildflower Willow after our pediatrics exam. “I loved my OB/Gyn rotation–actually doing something instead of just talking for hours about a patient on internal medicine. We would be relaxing in the resident lounge area and then hear a yell for BRT — that’s the Birth Response Team — and we would run.” She continued, “I am pretty bummed that I didn’t get to deliver a baby. I wasn’t proactive my first week. My second week I had four perfect multips [multiparous mothers, i.e., those who have previously delivered a baby] but each of them had a complication requiring either a CS or an operative vaginal delivery [vacuum delivery assistance].”
OB/Gyn orientation starts at 8:00 am Monday morning. The clerkship director, an attending obstetrician, provides a well-organized pamphlet with details about each component of the block, one week each: Labor and Delivery (“L&D”) days, L&D nights, outpatient gynecology, outpatient obstetrics, surgical oncology, and either Maternal Fetal Medicine (MFM) or Reproductive Endocrinology and Infertility (REI). She picks Device Denise, a short, cheerful 27-year-old who worked for two years in medical device engineering, as a schedule example. Denise comments, half sucking up (she wants to go into Ob/Gyn), half truthful: “This is by far the most organized clerkship we’ve had.” The clerkship director responds: “Well, it is the most complicated schedule. A lot of students complain about moving around among locations and specialties. You run around because we do so many different things in OB/Gyn.” My individually printed schedule shows that I will start with L&D nights.
At 9:00, we head over for a 30-minute tour of the hospital and end at the simulation center to practice suture technique and delivery of a baby on a $60,000 model. The simulation technician: “This isn’t even one of the more expensive ones. We have a $110,000 model of a kid the EM residents practice on.” Half of us have already done surgery so we are quite proficient in scrubbing in and sutring. The simulation model is a plastic female with her legs spread. Southern Steve comments: “Her feet look quite manly. Are they interchangeable with some other models?” Technician: “No that’s just the way she’s built.” She then presses start on a computer and a motor pushes a rubber doll out of the model’s vagina. This is followed by a rubber pancake connected to rubber tubing, representing the placenta and umbilical cord. The attending goes through correct technique to deliver a baby. When the technician and attendings leave the room, I ask, “Do you think this was a worthwhile investment?” Device Denise: “It’s better than not knowing what is going on with a real patient.” Lanky Luke: “It was helpful but it could have just as easily be done by observing a real patient.”
Orientation ends at 11:00 am, and I head home to take a quick nap. I come back in to meet the night team at 5:00 pm for the handoff from the day team. The team consists of an attending, the senior PGY4 High-Horse Haley, a mid-level (PGY2 or PGY3), a OB/Gyn intern Teacher Tom, a Family Medicine intern Tangled Tiffany, and myself. Despite having been an intern for only a couple of months, Teacher Tom has already been recognized with a teaching award due to great medical student evaluations in the preceding two blocks. Tangled Tiffany has long tangled red hair and an open personality. She is a great teacher, her patients love her, but she clashes with High-Horse Haley. If she were a man, Tiffany might not survive in a #MeToo world. When I ask her the brand of neck heating pad she recommended, she responds, “Well, I could look through the texts with my ex-boyfriend, but no… I shouldn’t. Nobody wants to see those.”
Tiffany asks if I want to interview her patient in Triage. I lead the interview by asking questions (how frequent are your contractions, any bleeding, prenatal care history, etc.), while Tiffany fills in the numerous gaps. She then performs a cervical exam to measure cervical dilation, effacement, and station (position of baby relative to hips). We then report to our mid-level and senior resident in the resident computer area. After 10 minutes, High-Horse Haley scolds Tiffany for performing a cervical exam without supervision. Apparently, a family medicine intern was not supposed to do this without either an upper level or the OB intern. She explains: “I was worried she was about to push the baby out any second.”
I scrub into a Cesarean section. The patient is a 26-year-old inmate at a nearby prison and suffers from Hepatitis B and C. She had been arrested for shoplifting and was then convicted of being a meth dealer. There are two armed guards looking through the OR door. (I asked them later how frequently they’re at the hospital. One responds “I’m here almost every day. I think I might have learned enough to work as a nurse.”)
It is unnerving that the patient is awake throughout the entire procedure talking to her sister behind the drape as the PGY2 makes the initial midline transverse incision. They bluntly dissect down to the abdominal fascial layer. The attending pimps me on the layers of the abdomen. Attending: “You speak like internal medicine doc — I would know, I’m married to one. Not a bad thing. You’ll find most OB/Gyn give short answers but we do have a few deep divers.” The resident makes a small cut with scissors into the fascia, then the attending and resident yank laterally ripping the fascia — it’s pretty violent. They then pull the uterus through the fascial opening — it looks like a turkey! The resident makes a small inferior transverse incision into the uterus. Membranes rupture with a gush of amniotic fluid and then the resident pulls the baby out. Whole process takes about 10 minutes. We suction the baby, clamp the cord after 1 minute, and then hand the baby to the neonatologist in the room. We don’t know what’s happening with the baby after that.
Haley then proceeds to suture the uterus as the attending guides through. They talk about different suture technique among attendings. After they place the uterus back into position, the PGY2 closes the fascia with help from the attending. The attending allows me to do a running subcuticular to close the initial incision. They were impressed because most of the students this year have not done their surgical rotation yet.
I ask the attending if she operates on patients with Hep C frequently? “Yes all the time. Also HIV. Some of my partners get tested every six months and I probably should start too.”
Around 10:00 pm, everything slows down. No triage patients, no one close to delivery. I go with the OB resident to watch him do two cervical checks for actively laboring. No one is past 5 cm dilation. Both the FM and OB resident know how to speak Spanish fairly well and could get their interpreter licenses. The FM resident asked the OB resident: “What do you think about the Spanish license and phone interpreters?” “The phone interpreters are terrible. I asked a patient if they were soaking more than three pads per day. They asked do you need three pads? I do not get certified because of the liability. If something happened to a Spanish-speaking patient, they will grill me on my Spanish. Even if you did nothing wrong, they’ll blame the language barrier due to not using an interpreter and cross examine you to see how well you speak Spanish. You will be made to look like an idiot on the stand.”
Tiffany: “My patient is 29 years old with six kids, soon to be seven, who doesn’t speak a word of English after living in the US for over 10 years. I have nothing against refugees or old people who are not going to be able to learn a new language. But she has been here for over 10 years and doesn’t work. I did my training in Miami and I use Spanish here more than there. Everyone speaks English [in our city]. How does she take care of her kids?” She added: “Geez, I’m sounding Republican now that I make money. Mom always said I would become one. But I’m not, I am a hardcore Democrat. Weird. I just can’t stand lazy people.” Teacher Tom: “Better get used to it.”
[Editor: She doesn’t like lazy people, but votes to give anyone who doesn’t work a free house, free health care, free food, and a free smartphone?]
Our team has very little patience for non-laboring patients. The surgery service “made us take care” of a multip at 24 weeks who underwent hemorrhoid surgery. The surgery service threw the patient on our service because of an unequivocal fetal heart rate test (Non Stress test) requiring a more expensive rule-out test (BPP). Surgery is consult, OB is primary even though the only reason she is in the hospital is for recovery from the hemorrhoid surgery. She was told this is an excruciatingly painful surgery that will take two days to be bearable. The surgery resident went into the wolfden. “She is a weiner, very low pain tolerance.” The resident came to us afterwards to say nothing is wrong with postoperative course, and no more pain meds can be given. “This is a direct quote from the surgeon, ‘I don’t see them for two weeks because they will chew me out.”
We read the operative note for the surgery. High-Horse Haley comments: “You see everyone says OB is disgusting. Look at this. During the surgery they dilated anus to get access. Babies are meant to come out of the vagina. Anuses not meant to be dilated.”
The mid-level explains that there is no medical necessity to be in the hospital and we are just giving you meds that can be given at home. You’ll recover better at home. The husband responded that they won’t leave because it would be difficult to get into the car and get her up the stairs to their bedroom. “Sleep on the damn floor. We’re not keeping them because he doesn’t want to deal with her at home.” Are they private or Medicaid? Private. “There is no way that Anthem is going to pay for this hospital stay. It’ll be out of pocket. Most expensive hotel stay ever. $4,000 just for the night, not including outpatient med costs.”
After they are informed about cost, they leave within 30 minutes.
Around 2:00 am, Tiffany delivers her patient’s baby with the attending and Haley and myself in the room. I get to deliver the placenta and perform a uterine massage. Haley: “Tomorrow we’ll try to get you a baby to deliver. Good job.”
Things become dead at 4:00 am. We don’t have any patients to report to the morning team so we make up names to put on the sign out sheet. We come up with: Bree, Frank; Rea, Gunner. Tom: “Let’s see how long until they notice they’re all fake.”
Wednesday night starts off with a few rule-out ROM (rupture of membrane) ferning tests. Tangled Tiffany swabs the vagina and wipes the swab on a glass slide. If the amniotic fluid has ruptured, the salts will crystalize into snowflakes at 40x magnification.
My patient for the night is a 24-year-old pregnant with her first child. I walk into her room at 6:30 pm to introduce myself. The similar-age father is snuggling on the pull-out bed with the patient’s sister. The expectant mother is concerned about pain. “I was promised I wouldn’t feel anything. Is this true?” There were enough similar questions that her day nurse requested reassignment. The epidural is in and we know that it’s working because she can’t move her legs, but the new mom continues to complain about pain. Haley joins five minutes later: “You are going to feel some pain. Delivering a baby is painful. Pressure is okay.” As delivery gets closer we finally acquiesce and ask the anesthesiologist to add another dose of fentanyl/bupivacaine. Haley: “She should have enough pain medication to not feel anything.” The patient is still uncomfortable. About 15 minutes before complete dilation, we have to adjust the fetal monitor on her abdomen. “We need to move this to make sure your baby is alive.” She screams: “I don’t give a fuck what happens to him. I need this pain to stop. Get him out.”
While walking back with Tom I ask, “Why can’t I see a happy family deliver like in the movies?” He responds: “You’re probably not going to see that. Med students are not permitted to see privately insured patients, so you’re stuck with a skewed population of Medicaid and uninsured.”
Haley coaches me in the resident lounge with a basic delivery model. There are four steps to deliver a baby in the desired OA [occiput anterior] position: (1) protect the perineal body as baby’s head comes out; (2) push down on baby’s head; (3) make a “C” with your hand around baby’s neck and push down until the shoulders come through; (4) pull up once shoulders are through. Our patient’s nurse interrupts and tells us that she feels like she needs to poop. I run ahead and begin putting on my sterile gown and gloves. High-Horse Haley supervises closely as I grab the baby, directing my arms to the right position. It happens so quickly that you have no time to think. APGAR 7 at 1 minute and APGAR 9 at 5 minutes.
The mother has moderate bleeding after delivery of the placenta. She tries to kick Tom while he performs uterine massage for bleeding after delivery of the placenta. Her nurse caught the leg. “We don’t kick.” The nurse had to leave the room before she said anything untoward. Haley contacted CPS (Child Protective Services) due to concern for the baby, but they decide to not take the case.
[Editor: In most states CPS tends to be busy because the typical custody lawsuit plaintiff can shortcut the process by dropping a dime on the defendant. See “The Domestic Violence Parallel Track” within Real World Divorce.]
Tom and I see A 20-year-old nullip [nulliparous, no prior pregnancy] at 24 weeks in Triage. She has depression and wants to deliver the baby now. We counseled her that the baby needs more time in the womb. Haley: “This is not uncommon. A lot of depressed pregnant women want their baby delivered now to give them company.”
Tom and I go see a 25-year-old pregnant mother, father, and cute chubby 3-year-old twins. Nobody in the family speaks English. She is 26 weeks pregnant and complaining of chest pain so was admitted despite being apparently healthy. We struggle to convey basic information about acid reflux and anxiety through a Swahili interpreter on the phone. Tom complains to the team in the resident lounge: “I just spent 30 minutes telling a patient how to take Pepcid. Why the hell is this patient in the hospital? This could all be done in clinic.”
Thursday night I have my real, “unassisted” delivery. My patient is a 26-year-old G2P1 (one prior pregnancy, brought to term) at “40+5” (40 weeks plus 5 days of pregnancy). She is here for IOL [induction of labor]. She has an uneventful labor until it is time to push. Haley: “She is a 26-multip but she’s acting like a child. Maternal effort is zero. Pit [Pitocin, oxytocin hormone analog] is not going to help unless she tries. She is contracting, but it’s also about maternal effort.” The delivery goes great. The attending comments afterwards: “That was one of the best student deliveries I’ve seen. You should consider OB/Gyn. Perfect mix if you’re torn between medicine and surgery.”
[When I share this recommendation story with Lanky Luke, he responds with “In 10 years it will be illegal for a man to work as an OB/Gyn. Maybe you could do an OB/Gyn residency if you start to identify as a woman.”]
Friday night. Haley: “Every night has a theme. Yesterday’s was lack of maternal effort. Tonight’s is preterm labor.” There are several laboring patients but they are all privately insured and thus I am prevented from being involved. I follow the mid-level to a few consults in the ED and hospital floor. The attending and I go see a patient in the ED for POD3 [post op day 3] after CS [Cesarean Section] pain. She has a small hematoma on CT imaging but this pain is from an anxiety attack. The attending takes 15 minutes to calm her down with slow breathing and applying pressure to her frontal bone pressure point.
A 19-year-old nullip at 24 weeks presents for onset of contractions. Her boyfriend brought her to a hospital one hour away and she was transferred to our NICU-equipped facility via ambulance. The OB intern performs a cervical exam which reveals bulging membranes. “I didn’t want to push too hard to feel the cervical dilation out of fear of rupturing her membranes.” Her family arrives quickly while the father’s family is en route from about 3.5 hours away.
Eventually there are 12 family members packed into the room. This includes three grandmothers: mom of patient, stepmom of patient, mom of father. The patient’s mother comes running out yelling, “I think her water broke.” We ask everyone to leave but they trickle back in as we perform a ultrasound to confirm. The patient lies exposed during the cervical exam in preterm labor with two-and-a-half families surrounding her bloody, wet sheets.
I go downstairs to the NICU to expedite the consult for PPROM of extreme prematurity (preterm, premature rupture of membranes). I return to the patient’s room with the neonatologist who explains the situation to an audience of 13. A baby at 24 weeks has a 50-60 percent chance of survival with a 25 percent risk of severe developmental delay. “Every week is crucial. There is about a 5 percent increase in survival per week.” The neonatologist explains: “She is going to remain in the hospital bed-bound for as long as possible. Our goal is to slow the labor so the baby can get a few more days in the womb. Because her membrane ruptured she is now at risk for infection. If she spikes a fever we have to deliver immediately .” She continued: “After the baby is delivered, she is going to have to stay in the NICU until at least term dates, so we are talking about a 2-3 month stay at least. A baby her age has about a 25 percent chance of requiring surgery.” I could see tears welling up in the patient’s mother’s eyes as she strokes her daughter’s cheek at bedside.
Statistics for the week… Study: 6 hours. Sleep: 5 hours/night; Fun: 0 night. Recovering from night shift.
The rest of the book: http://fifthchance.com/MedicalSchool2020