Philip Greenspun’s Weblog

As part of our OB/Gyn rotation, we selected a week-long surgical subspeciality, either urologic oncology (“UroGyn”) or gynecologic oncology (“GynOnc”). GynOnc is known to be an intense rotation featuring surgery hours with operations that frequently last more than four hours and extend well into the night. Lanky Luke responds to hearing that I chose GynOnc: “I loved UroGyn last week. It’s all old ladies with urinary incontinence, but the surgeries are really neat.”

GynOnc begins at 6:30 am on the oncology floor. My Chief, Marvelous Martha, is a big and tall 34-year-old who loves talking about her adventures on the Bumble dating application. The residents and my classmates adore her. Nervous Nancy: “All her patients are taken care of, even the small details about nausea, ambulation, pain. I don’t know how she stays so on top of all the patients on the floor.” The intern is a short, 45-year-old mother of two college-age kids. She worked as a project manager for GE before going to medical school. Nervous Nancy was shocked to hear about the two kids in college: “She looks so young!”

[Editor: How long would a 34-year-old guy talking about his Tinder adventures last at this hospital?]

The case load is light so I go to the medical student lounge and meet Lanky Luke and Particular Patrick. Particular Patrick says that he misses the “intensity of surgery” and is “bored out of [his] mind on Family Medicine.” Lanky Luke is not enjoying L&D nights. “I have to watch what I say around my team. They were complaining that Medicaid would pay for the Mirena IUD, but would not pay to remove the IUD unless medically indicated. I wanted to say, ‘Maybe we shouldn’t be taking it out. If you can’t pay the $100 fee to have it removed, maybe you’re not able to afford a child. Taxpayers paid for five years of contraception. They’ll pay for 18 years of housing, health care, and food if a baby is pushed out. Why can’t the Medicaid customer scratch up $100 in the middle?'”

Luke’s team was not entirely humorless. “This hippie couple brought in an eight page labor plan document. The [male] resident showed me a cartoon in his locker in which a sheet of paper labeled ‘labor plan’ was being shoved up someone’s butthole.” Proving the old adage “no plan survives contact with the enemy,” labor was prolonged and the fetal heart rate was “nonreassuring.” They got a C-section. The father took his shirt off in the middle of the OR and had the newborn placed on his chest (“kangaroo care”) while the mother was getting sewn back up. A nurse joked: “It’ll latch onto you if you’re not careful.” The father was excited. “Really!?” Should I let him?” Luke fought the urge to add “No, no you should not. You want that baby to suck on your hairy nipple? He’ll never latch onto another one after that traumatizing experience.”

Our weekly afternoon lecture begins at 1:30 pm and is on contraception and miscarriages. The generalist OB/Gyn describes the different techniques for an abortion (medical versus surgical). “Most states limit abortions beyond 24 or 26 weeks and some as early as 22 weeks. Most women do not get results for their fetal anatomy ultrasound until 22 weeks. Whether or not you support abortion, it’s important for everyone to understand the harrowing choice some women have to make, sometimes in a matter of days to get an appointment.” We also go over the various types of birth control and the uses of OCPs [oral contraceptive pills] beyond contraception per se. For example, patients with BRCA1 mutations have a 60 percent chance of getting breast cancer by age of 70, and a 50 percent chance of getting ovarian cancer by the age of 70. Every year that a patient takes COCs (combined oral contraceptive) decreases the risk of ovarian cancer by 5 percent.” We get out at 4:45 pm and are done for the day.

Tuesday is more typical. I get to the hospital at 5:45 am to pre-round on two patients. Both  were admitted for intractable nausea and vomiting. The first was admitted two days after getting her first cycle of carboplatin/paclitaxol chemotherapy for stage IV endometrial cancer. She’s about 55. My other patient is a 57-year-old with ascites (fluid in her belly, in this case over 20 liters) that has led to the classic protuberant “beer belly” that suggests ovarian cancer (stage IV in her case).

We have four cases today: two “majors”, both TLH/BSO (total laparoscopic hysterectomy with bilateral salpingo-oophorectomy); two “minors”, a laser ablation and a cervical stenosis repair. The attending is a 55-year-old gyn onc surgeon. She’s sarcastic, but quite patient. 

I run to meet the first two patients in pre-op before heading to the OR for gown and gloves. Our first case is a robot-assisted TLH/BSO with lymph node removal and an omentectomy (removal of a fatty lining) for ovarian cancer staging. The 53-year-old patient underwent neoadjuvant chemotherapy before this surgery. “Ovarian cancer responds well to chemotherapy,” says the attending. “Sixty percent of ovarian cancer will go into remission. That’s why we need to be thorough and not leave any protected spaces of tumor that the chemo can’t access. Unfortunately, 90 percent of our patients will have recurrence and over time the cancer develops resistance. The big ticket item in ovarian cancer research is finding a maintenance therapy that prolongs remission.”

Two of the OR technicians have been on staff for only a couple of months. It takes 90 minutes before we get the robot docked, and the arms attached to the laparoscopic port sites. The attending and Martha head to the robot control panels, about 15 feet away. They’re still in the OR, but they’ve scrubbed out for comfort. I hold the uterine manipulator and the mid-level resident uses a grasper under direction from the attending. The attending sounds frustrated as she coaches Martha: “Never buzz with the scissors open.”; “Angle the scissors. Use your point of strength!”

We begin to remove the omentum from its connections to the gut tube. “This is the biggest omentum ever!” says the attending. “I just don’t know.” After more came out: “This is unreal how big this omentum is.”; “This is a really fucking big omentum.” After 3.5 hours with the robot, we give up and perform a laparotomy (conventional opening of the belly with a large incision; the opposite of laparoscopic) to finish the removal. The da Vinci Xi robot ($2 million base price; accessories additional; $10,000 in disposables for each operation) turned out to be useless.

It is nearly time for a UroGyn lecture covering content easily found with UpToDate or OnlineMedEd.com.

I tell Martha that I will skip the lecture because the surgery is far more interesting. “Sorry we can’t let you do that,” she responds. “We’ve gotten in so much trouble for students being late to lecture. Appreciate the enthusiasm.”

The next case is a laser ablation of the cervix to prevent cervical cancer. The OR staff lug in a giant CO2 laser. The attending commands, “Arm the laser beam”. Just as in Austin Powers, the nurse responds, “Laser armed and ready.” The attending lets each of us have a quick experience looking through the microscope and aiming the laser. The nurses made the surgeon insert a wet 4×4 gauze into the anus to prevent the release of any methane gas that might be ignited by the laser.

Thursday features two hysterectomies and a fibroid removal. We use the robot (da Vinci) for the first two cases, and opt against it for the more challenging third case. Our attending is relatively new and extremely cautious, so each case takes at least three hours (one hour would be normal). The residents are not afraid to express their frustration in the OB lounge. “I hate working with him. Everything takes three times as long as it should.” The second case is removal of a two-centimeter fibroid at a patient’s insistence. The 40-year-old Eastern European is convinced that all of her problems stem from this benign tumor. The intern ungratefully complains about the attending to another OB/Gyn team: “No one should ever remove a fibroid that small.” The Gyn Chief adds: “I cannot believe [the attending] went ahead with that surgery. Either do a hysterectomy or tell her we’re not removing it.”

The third case, removal of a uterus with a 10 cm fibroid, starts at 3:30 pm, right when we would ordinarily be heading home. The chief is driving with the laparoscopic graspers while I wield the uterine manipulator. By the time we get the fibroid dislodged, it is 8:30 pm. Then the fibroid won’t fit through the vagina. We then have to do a laparotomy (open the belly with a knife, thus rendering all of the laparoscopic work and extra time pointless). On the bright side, the attending allows me to make the incision with the scalpel. It feels heavy. The attending sends us home at 10:15 pm while he closes up. He felt bad for keeping the chief from her 14-month-old. 

We sit in the OR lounge and chat with another OB/Gyn attending. He explained to the young team members that our medical education and experience would transform us into superior beings with respect to uncovering microaggressions and revealing implicit bias: “Doctors are more in tune with bias than other people in society because we deal with the consequences of bias all the time. A patient comes in for the 10th time in two months for the same nonsense problem, we are prone to blow it off and send them out. The patient comes back to the ED in crisis because of what we missed. Every doctor in practice for more than twenty years has had this experience.”

[Editor: “Your Surgeon Is Probably a Republican, Your Psychiatrist Probably a Democrat” (nytimes, October 6, 2016) lends some credence to this theory. Surgeons, notorious for not doing any long-term follow-up with their patients (so they would never learn about the consequence of holding a bias), are much more likely to be Republican than Internal Medicine docs.]

I leave early for lecture on Friday. I chat with Nervous Nancy in our medical student lounge. Nervous Nancy, age 31, confided: “After going through L&D, I sometimes think to myself, screw it I am going to have a baby. I am vastly irresponsible, and underprepared. But look at some of these mothers. Then I remember that they are terrible people. They’ll have a child without batting an eye when the kid is going to the NICU because of the mother’s unrepentant cocaine use.”

[Editor: In the 1990s, a social worker friend in her mid-30s said that she had been agonizing over whether she was sufficiently prepared to take on the responsibility of caring for a child. She then reflected that one of her clients was 15 years old, pregnant with her second child, and living, without apparent health impacts to mother or child, almost exclusively on a diet of Coca Cola and Doritos.]

Statistics for the week… Study: 2 hours. Sleep: 5 hours/night; Fun: 0 nights. I leave the hospital early on Friday afternoon to catch a flight to a college classmate’s wedding. We chatted with the groom’s cousin the morning after the wedding. My best friend, also a third year medical student at a different school, asked, “Did you notice something about him?” I quickly responded, “Yep, pinpoint pupils.” He grins back, “Yep, must have been partying all night with some opioids.”

The rest of the book: http://fifthchance.com/MedicalSchool2020

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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.

Pinterest Penelope:

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.

The

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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

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The last week of inpatient pediatrics is shortened by Thursday’s Shelf exam. I am woefully unprepared, having completed only 100 of the 400 pediatrics UWorld questions. Gentle Greg, a soft-spoken classmate: “No one has figured out a good balance between clerkship and studying.There is just no time.”. His father is a critical care hospitalist who trained as a physician in his native India and practiced in both India and England before emigrating to the US.

A new team of residents and attending start on Monday. I introduce myself and take on two overnight admissions, both asthmatics. Our hospital has had two deaths from asthma attacks the past year. The pharmacist who joins us on morning rounds comments: “There is no excuse for kids dying from asthma. It’s a completely controllable disease. More so than even T1D [Type 1 Diabetic]. The best insulin  control and medical communication can still sometimes not be enough to control hyperglycemia. The five-month-old who died from status asthmaticus is tragic but can be justified as unavoidable. There was no prior history. But that 16-year-old who died at her Subway job should have been flagged by her family and physician for using a rescue inhaler [albuterol] every few hours rather than taking her [steroid] controller medication daily as instructed.”

I take care of a 13-year-old T1D admitted for DKA [diabetic ketoacidosis]. We were taught about different types of insulin, but we were never taught practical lessons, for example, the three types of standard sugar control regimens, how to administer the insulin, how an insulin pump works. I ask my resident to go through the basics before I go into the room and make a fool of myself and the team. Most diabetics take daily or twice daily long-acting insulin (Lantus or Levemir)  to act as the foundation. In addition, after every meal they do a carbohydrate correction (e.g., 1 unit for 15g carbs for lunch and 1 unit per 30g carbs for dinner). Lastly, they do a sliding-scale adjustment every 2 or 3 hours, where they administer 1 unit for every 30 mg/dL glucose above 130 mg/dL. She has been hospitalized six times in the past 2 years for DKA after relatively good glycemic control since the diagnosis at age 3. We are not exactly sure what happened. The residents suspect that, given her age, she is refusing to take insulin as prescribed as a weight loss strategy (“diabetic anorexia”).

[Editor:A friend who has managed Type 1 Diabetes since childhood wrote the following private message: “I always see people posting on Facebook how they go to CVS to buy insulin and it is $500 a bottle (lasts me a month but lasts fat people 2 weeks) and they are so mad that companies are ‘allowed’ to charge this. I ask them why they go to CVS and pay retail when the same insulin is $40 a bottle mail order from Canada, including shipping. And the older kind is $29 a bottle at Walmart. Almost no one in the UK has insulin pumps because their health system doesn’t provide them for free. Pumps are $6000 here new, but I got two for free on Facebook and you can buy them on Craigslist for $300 except do-gooders report the listings and get the listing taken down as Facebook, eBay, and Craigslist don’t allow them to be resold.”]

An 8-year-old is admitted for poor weight gain (4th percentile for weight and BMI) and acute episodes of diarrhea. We need to get his charts from an outside institution also on Epic to determine when he fell off the growth chart. In theory this should be easy with Epic’s “Care Everywhere” reconciliation. However, we spelled his last name wrong in our system, causing a failure to synchronize with the outside institution. IT informs us we that it is impossible to correct this error until after the patient is discharged.

Part of the medical student’s role is to get medical records from outside institutions. How does this work, nearly 10 years after the American Reinvestment & Recovery Act, which included the “Health Information Technology for Economic and Clinical Health (HITECH) Act” that provided taxpayer funds for computerization of medical records? The core technologies are the telephone and a FAX machine. Here are the steps:

1. 20 minutes on hold
2. speak to the medical record department
3. get their institution-specific medical request form faxed to us
4. fill out the form with help from the family, e.g., to learn the Social Security number
5. fax the request form back
6. wait 30 minutes for the requested documents to appear on our fax machine

This is not to say that the electronic medical record (EMR) has had no effect on the process. EMRs may automatically add vitals at 15-minute intervals to the record and therefore even the simplest data request usually results in at least 10 pages of irrelevant notes before you get to the information that is sought. I learned that it is more efficient to ask the patient to call the institution and speak with a nurse who can relay relevant labs over the phone. I then type them into our Epic system. Even triple-checking the values on a voice call, the total time and effort is much less than using EMR+fax.

I say farewell to my team and head off Wednesday afternoon for a lecture on childhood GI bleeding. The lecturer speaks in a monotone, reading verbatim off the slides of a presentation that someone else created. I ask classmates if it was obvious that I was dozing off. Anki Alex, a class gunner who does 300 Anki cards daily on rotation: “Big Dawg, every person was dozing off. There was a wave of head bobbing. The few times that I myself wasn’t sleeping it was hilarious to watch.”

We take our exam Friday morning. Crisis ensues at the exam. The hospital WIFi is intermittent so every 10 minutes the private secure browser in which we take the NBME Shelf exam shuts down. Nervous Nancy’s computer works fine and she is taking her exam while the other 25 students shriek and hollar. Exams are typically proctored by two people: a clerkship administrator and someone from IT. Today, the IT proctor is sweating and scrambling. His best theory is restarting each computer after every shutdown, but today this is providing only another 10 minutes before the next shutdown. After 30 minutes, the clerkship coordinator kicks everyone out to give Nancy some quiet. We are then called in one at a time to log on and restart the exam. This process of getting people restarted for the 2-hour, 45-minute exam takes about 2 hours.

The exam is probably the hardest exam I have taken throughout medical school.The average is low enough the passing score is rumored to be 60 percent correct.  The pediatrics shelf includes questions on childhood skin lesions, upper airway versus lower airway disorders the amoxicillin drug reaction from mononucleosis, several challenging autoimmune disorders (e.g., compare Bruton-K agammaglobulinemia versus Common Variable Immunodeficiency), and an annoying nephrology biopsy image (Pinterest Penelope: “blast from Step 1 past”).

Type-A Anita complains to the administration that the disruptions affected her exam performance after we finished the exam. We got an email on Saturday:

We apologize for any added stress caused by the technology issues during testing this week. Thanks to the determination of our IT professionals, we understand now that the issue was beyond our control and that it has been resolved with the necessary groups.  … Although we will not receive results from the NBME until this weekend, please understand that all contextual factors will be considered in the case of any undesirable outcomes.

Statistics for the week… Study: 15 hours. Sleep: 7 hours/night; Fun: 1 night. We grab burgers and beer with Mischievous Mary who just finished her OB rotation. “You hear the most ridiculous stories. The residents and students sit in an alcove that is obscured by walls from the patient hallways. An African-American in his late 20s came up to the nurses and said: ‘Ma’am, my wife and girlfriend are in rooms next to each other. Could we move them so they are not near each other.'” She continues: “You’ll also hear the worst baby name choices. I asked the attending if she ever tries to change their minds? The attending responded: “Only once: the patient wanted to name their daughter Chlamydia. I talked them out of that.” She concluded: “I never appreciate how obstetrics is such a surgical field. I am actually considering OB now instead of CT surgery.”

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First week of inpatient pediatrics starts at 7:00 am. The team consists of a PGY3 (“senior resident”), a PGY2 (“the mid-level”), two interns (would be “PGY1”), an M4 in the role of an intern (“Acting Internship”  or “AI”), and two M3s, including me. The PGY3 pediatrics resident is a short quiet 31-year-old. He looks at the floor and around when he speaks to someone. He took several years off after college to live in NYC with his librarian girlfriend. The idea was to work as a researcher to improve his medical school application, but working as a “manny” for wealthy Upper West Side families turned out to be the job that paid enough to afford an apartment. The PGY2 is a 29-year-old Oregonian native who loves her three cats and is married to a tenuously employed man back home. Rockstar Rita is the attendings’ favorite intern. Her girlfriend is a resident in a city that is a four-hour drive away so they rarely see each other.

After meeting the team, I shadow the interns and residents on Monday while getting accustomed to the basic structure of the day. First, we preround on each intern’s 3-4 patients. The interns plus the “AI” write notes at the resident station until morning handoff at 8:00 am, packed into a 10-person conference room attended by the residents, interns, medical students, our pediatric hospitalist attending, and the hematology/oncology attending and/or fellow as well. We first go over the oncology kids. Rockstar Rita has all of these notoriously complicated cancer kids. She presents a patient summary for each of the four “regulars”: two acute myelocytic leukemia (“AML kids just get sick” [from the drugs used to destroy their white blood cells]), a rhabdomyosarcoma, and a Ewing’s Sarcoma. She highlights actionable items such as thresholds to transfuse platelets or red blood cells, when to draw another blood culture if they have a fever after 24 hours, and pain medication regimens. The night team then presents the new patients admitted overnight. Finally, we leave the conference room to round on each others’ patients in our pack of 8 and finish at the resident station for everyone to write notes.

The resident station is a short hallway outfitted with five computers that connect the nurses station with the snack room in the middle of floor. It is hidden from patient’s view but clearly not out of range from the loud conversations going on. “Alright, team lets get em out,” as he whistles. “The Discharge train begins.” Rockstar Rita complains that her “T1D” [12-year-old type 1 diabetic admitted for diabetic ketoacidosis] should be ready to leave the hospital, but is acting lazy: “She just won’t get up. She is lying in bed, not drinking or walking. This is a perfect job for a medical student [looks at me], Go get her up. I don’t care how you do it but get her to chug a glass of water.” What do we do if a patient doesn’t want to leave?” The senior resident chimes in: “Same exact thing with gastroenteritis girl. Vomiting is not a reason to be admitted to a hospital. They were admitted for concern of an appendicitis, which we have now ruled out. Go have diarrhea at home like everyone else.” The AI chimes in: “We ask him if he wants to go home and he replied, ‘No, let’s stay, it’s fun.’ Could we take the TV cord? (Oh no, cord broke what happened?)”

The senior resident added afterwards: “It sounds heartless, but we need to get these patients out of the hospital. The PICU is completely full so when we don’t have a room patients may have to be transferred to a less capable hospital. Also, the best thing for these patients is to get home and back to a normal schedule.”

I wake up our T1D, walk her to the water station for a drink, then drop her off with the video games in the Teen room. 

I then sit down with my classmate Diva Dorothy, one of the younger class members at 24. She’s a great resource now that our class has dispersed because she keeps up with gossip from every year within our school. She started a week earlier and gives me some advice about Inpatient Peds. “Unlike with adult medicine, pediatric patients recover so quickly that it’s tough to do any patient presentations. Grab any patient who will be here for a few days. Also, bring your own laptop because there won’t be room at the resident station.”

She confides her struggle during the previous week. “They think I’m lazy or not interested and ignore me. I’m sitting in the next room over and they’ll just leave and go to the consult without me. No one gave me any orientation, each medical student has had to rely on the previous medical student to get situated. We have no idea what note templates to use [within Epic]. No one gives me the AM rounding sheet showing new patients that they print out for everyone else. How did you get one?” (me: “I try to get in at least 15 minutes before the official 7:00 am start time. Then I can ask the night team resident for a printout.”) 

Dorothy: “I’m sad about this whole experience because I loved outpatient pediatrics. I’ve had such a bad time here that it’s making me question doing pediatrics.” I agreed that it is a shame that an unapproachable team during a clerkship can discourage someone from pursuing a residency. She complained last week to the clerkship director. Apparently this was conveyed to the pediatric hospitalist attendings because Dorothy remarked that this week’s orientation was substantially improved.

[Discussion with Jane that night: “all of the rotations are poorly organized.” By Wednesday, Diva Dorothy is absent. Our team is told that she is sick with a stomach bug, but she texts me to say that she has been moved to hematology/oncology clinic at a different location.]

After rounds we sit at the residents’ station. I am surprised at how little we actually see patients. After the initial morning round, most patients do not get seen by a physician until the next day. The night team does not go in unless a nurse asks them to. Residents during the day spend most of their time writing notes, ordering labs, and finishing discharge summaries. The senior resident mentioned that one thing a medical student can do to help the team is check periodically on patients. [Editor: Doctors are so busy typing at computers that the medical students have to do the actual doctoring.]

We get two new admits from the ED at 4:00 and 4:30 pm. Diva Dorothy was packing her stuff. The attending had to convince her to stay later than the normal 4:00 pm sign out. The attending: “You can go, but it would be good practice to admit a patient.” She responds: “Okay, I’ll stay.” (We are only supposed to do one late sign out per week). The residents/interns regularly stay late. 

Tuesday is a typical day. I get in at 6:45 am for prerounding on my one patient. At 8:00 am, I head to the conference room for morning handoff. Diva Dorothy is complimenting Rockstar Rita on her new short haircut. “I love short hair, but I never know if I should get it. My parents are Sikh so they frown when I cut my hair.” (She references a tattoo, though, but I have never seen it.) Once everyone is present, we hear about the cancer patients. Rita is doing a fabulous job despite constant interruptions from the PGY2. The Attendings are chatting with each other, oblivious to this rivalry between the two young women. I pick up a new patient who was admitted by the night team.

The medical student or intern present the patient to the patient and the whole team in the room. We are instructed to use “layman’s terms” or explain the term if you use it to a patient: e.g., “afebrile means no fever overnight”; “leukocytosis with bandemia means high white blood cells with markers suggestive of immune response”. The quality of our presentation is a big part of how we’re evaluating, but it is challenging to select the right amount of information for the team and the desired level of detail will vary considerably depending on whether we’re ahead of or behind schedule. One attending later complimented me after I brought up a potentially disturbing question with him privately before we entered a patient’s room. I didn’t tell him that it was Rita’s whispered idea.

I struggle to present my patient in the clear “SOAP” format [Subjective, Objective, Assessment, Plan], forgetting a few lab values and symptoms that I mention in the wrong section. I need to work on this. Much different that presenting a surgery patient. 

She’s six months old and was taken to her pediatrician for a three-day history of diarrhea, nbnb (non-bilious, non-bloody) vomiting, and lethargy. The pediatrician gave the baby some Pedialyte and sent her to an outside ED, which administered a fluid bolus (20 mL/kg). and took an x-ray to look for possible obstruction. The extra hydration led to rapid improvement in her symptoms. The x-ray did not show any signs of obstruction, but there is a concerning left upper quadrant opacification suggestive of a mass. An abdominal ultrasound showed a large, heterogeneous mass separated from the kidney and spleen. The outside hospital did not feel prepared to evaluate this patient, so an 80-mile helicopter transfer to our tertiary hospital was ordered.

[Editor: Yay! Creating jobs for East Coast Aero Club graduates and Eurocopter mechanics.]

The baby arrived looking well and entertained the residents as the cutest kid on the floor.  Morning report from a night intern: “Given the location of the mass, our differential needs to remain wide. This includes: Wilm’s tumor, nephroblastoma, neuroblastoma, lymphoma, and other neoplasms of the adrenal gland, kidney, stomach cancer, etc.” PGY2 chimes in with statistics about the most common pediatric malignancies. Our Attending: “I called down to radiology and our pediatric radiologist is not convinced this is a mass. He wants us to insert a NG [nasogastric] tube to better visualize the stomach.” The heme/onc noted that the abdominal ultrasound did not show much vascularization of the unknown mass. We need to CT before we can have a definite plan. I’d like to CT before we biopsy.” The hematologist/oncologist attending goes in and tells the parents that there is a concerning mass that may be a tumor. The parents start crying.

A few hours later, after we get through our critical note-typing, I am tapped to insert the NG tube under Rita’s guidance. Every NG tube must have a x-ray to confirm correct placement, i.e., not in the lung or perforating the stomach into the peritoneal cavity. The baby gets her second x-ray.. We send the baby down to get another abdominal ultrasound while water is poured into the NG tube for better visualization of the stomach. 

I look at the NG tube-confirmation x-ray and notice that the mass is gone. I bring this up to the resident. “Hmmm that is very interesting.” A few minutes pass and the ultrasound tech calls to say that she cannot locate the mass. We go down to the radiologist who believes this “mass” was just a distended stomach. “Look at the air-fluid levels on the ultrasound. It’s just a really distended stomach from a large feed.” We learn that mom is feeding the child 9 oz of formula every 2-3 hours, about 3 times the recommended amount.” The senior resident jokes: “We just discovered a new disease: malignant constipation.”

We have two boys on our floor for constipation requiring manual disimpaction. The senior resident: “This would be a perfect job for our medical student. Ask the nurse to supervise.” The nurse explains how to do the procedure before we go in. I perform the digital disimpaction and insert an NG tube hooked up

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