I arrive for L&D days at 7:00 am and meet the all-female team before our 7:30 am handoff. Nervous Nancy is leaving from the night shift: “I’m loving OB/Gyn. All the good parts of surgery, with none of the soul crushing.”
The Chief resident is a wide-shouldered fit new mother who periodically attaches her $480 wearable Willow breast pump. The Chief explains to me: “You’ll find that days are full of admissions from clinic and triage. You will have some elective C-sections, but nights are where all the deliveries happen.”
The intern is an Indian-American only half the size of the Chief. Though specializing in OB/Gyn, she’s still struggling to perform a cervical exam and gushes when talking to the Chief. She asks how to rotate a baby from OT to OA [Occiput Transverse to Occiput Anterior, positions of the baby’s head during delivery]. “Wow, that is so amazing.”
My first patient: a 39-year-old G9P8 (9 pregnancies; 8 births) admitted the previous day for induction of labor at 37 weeks for “PreE” (preeclampsia; high blood pressure with proteinuria). The night team resident, Teacher Tom: “I asked her why she keeps having kids. She explained that all her previous kids were taken away from her so she needs to have another one. Does she think she’s taking this one home? CPS took her kids away because of her meth habit.” Nervous Nancy: “I had a G13P11, with no twins. At first I read it as G1, but then realized we were in double digits. Just how?”
I follow the mid-level resident who is in charge of all OB consultations in the hospital outside of L&D. For example, there is an “antepartum” unit for pregnant patients who are not expected to give birth. We check on a 26-year-old African-American G3P2 patient with a BMI of 62. She stopped taking her birth control while breastfeeding the second child. The resident attributes this to a “lactation consultant who told her not to keep taking her Micronor because it’ll decrease milk production. This is what happens, when people go outside their expertise. Do they realize how dangerous short interval pregnancies are on the mother and baby? The only studies show that estrogen might have an impact on breast production. No study has shown any change in breast production with progesterone. It’s online voodoo and look what’s happened.”
Our 350 lb. patient is 29 weeks pregnant and on tocolytics (medications that prevent labor) and BMZ (betamethasone steroid). “The purpose of the tocolytics is not to prevent preterm labor,” explains the resident, “but to give the steroid enough time to improve fetal lung development.” The patient was taken to the OR for a classical C-Section (vertical incision rather than low transverse incision of the uterus) due to non reassuring neonatal stress test (NST) and a malpositioned baby (transverse). A classical C-section has a much greater risk of uterine rupture in future vaginal births and therefore all future deliveries will require a C-section.
Our next consult is in the ED. A tearful 26-year-old mother, PPD #5 (postpartum day 5) from LTCS (low transverse C-section), is panicking. In between tears, she sobs, “I need to be at home taking care of my baby, but my belly hurts so much.” The resident, in a calm voice: “Breath in, Breath out. Slow your breathing.” A CT scan shows a small hematoma in the abdominal wall, which is why we were consulted. The resident explains: “She is totally fine. Everyone is going to have that size hematoma after a CS. This is simply a panic attack from being a new mother. She needs to get evaluated for postpartum depression, but doesn’t need to be in the hospital for this.” The resident applies pressure with her thumb on the patient’s forehead at a “trigger point” to calm her down. As we walk back to the elevator, she explains, “A lot of what you do as the mid-level [resident], is finesse and coddling patients.”
Thursday afternoon I deliver a 22-year-old “self-pay” (did not fill out the Medicaid paperwork) G1 African-American mother. Unlike with any of the previous deliveries at which I had been present, the father had accompanied the mother to the hospital. He was a 21-year-old Caucasian pacing and asking questions every few minutes.
She appeared to be progressing slowly, typical for nullips. She started to feel the urge to push at 8 cm dilated, but the resident said to wait until completely dilation (10 cm) so as to avoid cervix damage. The team steps out to see other patients, leaving me and the 45-year-old highly experienced nurse in the room. Having heard the word push, I eagerly gown up. Five minutes after the team left, she starts pushing and the baby pops out. The nurse and I rush with outstretched hands toward the newborn boy, but I am closer and catch him. I put the baby on mom’s chest, as the nurse and I scream for the BRT (Birth Respond Team). The nurse and I clamp the cord while the team rushes through the door and gowns up. With supervision from the attending, I instruct the father to cut the cord, and then I deliver the placenta. I earn a “good catch” comment from the nurse.
While shadowing the intern the next morning, we see the mother again. She complains of belly/breast pain. The intern is anxious to get back upstairs and deliver babies. She listens, but doesn’t touch the patient’s abdomen. During the intern’s presentation to the attending, a 60-year-old who had his own practice for many years, she explains that the first-time mother is ready for discharge. The attending says “Something doesn’t add up. Why is she still in pain after a vaginal delivery?” We return to the patient’s room together. When the attending presses on the patient, she jumps off the bed: rebound pain (inflammation of abdominal cavity). We get an ultrasound and CT of the abdomen showing appendicitis. I chalk this one up as an example of specialists having a tough time seeing the big picture.
The attending debriefs us in the resident room afterwards. He comments: “My favorite quote from teaching was by an intern. ‘I don’t know what’s wrong with the patient, but I don’t think we need to do anything.'” The Chief replies: “Dr. P, you told me intern year that I didn’t have even the competence of a second-year medical student.” Dr. P: “That sounds like something I would say.”
Also Friday morning, I ask my favorite family medicine intern, Tangled Tiffany, if she’s examined the postpartum patient we are both following. She responds, “No, let’s go in together. You do the talking.” I ask the 28-year-old PPD #1 after SVD (spontaneous vaginal delivery) basic questions: “Are you walking, eating, stooling, passing gas, peeing. How are you breastfeeding? Any pain? Has lactation come?” She reports a mild cold. I then conduct my physical exam. After just one week on OB, I had become accustomed to performing a half-hearted physical examination. I use the stethoscope through her robe and report, “Everything sounds good, maybe a few occasional wheezes, on her right lung base.” We have only a few minutes before I have to get my note in and head to the 7:30 am handoff. Tiffany replies, “Are you sure, look again. I came in before and found a few things. Maybe take her gown off.” I take her gown off, and hear inspiratory wheezes, likely from a cold. She also has a Grade III/VI diastolic (heart) murmur.
Tangled Tiffany smirks at my shame: “This was a test. I came in before and examined her. She was nice enough to play along, and [to the patient], might I add, you did it perfectly! She’s had this murmur since childhood, but has never gotten it checked out. She promised me she would follow up this time.” When we leave the room, she comments: “Not a single OB/Gyn mentioned this in a note at any time during this pregnancy. Just remember, don’t skimp on the physical exam. It takes two seconds, but I see this all the time. A doctor listening through clothing is not doing a full exam. Unless the patient has a Grade VI murmur, you’re not going to hear anything.” We arrive for handoff at 7:35 am, but people are still strolling in.
This was the first week where I did not feel welcome and had to chase after team members who seemed anxious to see patients without me. One time I ended up following the intern on the way to the women’s bathroom. I confided this to Nervous Nancy the next day. “Oh, yeah, that happens all the time with me. I just play it off that I was also going to the bathroom.” When I offered to stay late on Tuesday for a C-section, they responded with, “You can go home now. We don’t want to violate your Duty Hours.” When I offer to stay for handoff to present my patients: “You can go home. It’ll be too crowded in the resident room. Go home.”
It is small consolation, but they don’t seem to like the patients any better. There is a lot of trash talk in the lounge, and sometimes just outside patient rooms, about obese patients. Example:
“I still have to do cervical checks. I’m elbow deep struggling to keep the legs out of my way.” (our intern)
The team is only slightly more impressed with family medicine colleagues, one of whom notes “It’s family medicine not family practice. I wouldn’t mind when they call us family practice, but it’s in context of everything else. It’s just the icing on the cake — they have no respect for us. They look down on us as if we don’t know how to correctly deliver a baby. We do C-sections. I do them just as well as the interns. We know how to handle intrapartum complications. They think that because we are not as specialized as they are, we don’t need to know how to practice these skills.”
Classmates are active on Facebook regarding the Brett Kavanagh nomination hearings. Type-A Anita and Pinterest Penelope get one-day excused absences to attend a protest. There is a picture of them holding signs of “KavaNope”. After the confirmation:
well this is horse shit, but what else would I expect from white men in power? welcome to the bench Kavanaugh, I look forward to losing the rights I’ve won in the past 5 decades.
One hour later, she admonishes “Ladies, make sure there are video cameras and eye witnesses the next time a man violates you” and brackets a quote from President Trump:
Absolutely. Fucking. Disgusting.
“I do stand with women, but we need to show the evidence. You cannot just say to somebody, ‘I was sexually assaulted,’ or, ‘You did that to me,’ because sometimes the media goes too far, and the way they portray some stories it’s, it’s not correct, it’s not right,” said Trump
Absolutely. Fucking. Disgusting.
She also shares her boyfriend’s Facebook post:
I stand with all the survivors currently reliving their traumatic experiences and seeing their legal and justice systems fail them. I cannot apologize on behalf of all men, but I can say that I’m a proud feminist 100 percent and you have an ally in me.
Male friends: how many of you called senators? How many of you made the time to protest? How many of you had hard conversations with your other male friends? Don’t talk to me about much “this sucks”. Goes double for @white people for issues on police brutality and gerrymandering
[Editor: The construction of bizarrely shaped districts to make certain that one party wins (gerrymandering) may be required by the Supreme Court’s 1986 decision in Thornburg v. Gingles to protect the rights of minority voters from having their votes “diluted”.]
Statistics for the week… Study: 8 hours. Sleep: 7 hours/night; Fun: 1 night. Christopher Robin movie night with Jane.
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