Sunday, January 31, 2010

I delivered a Klingon

The one word I would never be able to use when referring to my current position is dull. When a new patient rolls in at 2 or 3 AM, I am almost always greeted with an entertaining story. This morning the entertainment happened to be the fact that the partner of my new patient believed himself to be part Klingon. For those of you would are non-Trekkies out there, the Klingons were often the bad guys on Star Trek.

This part of the social history became apparent when the admitting nurse ask the patient what language she spoke. If you have been reading along, you will know many of my patients do not speak English as their first language. In fact, many do not speck English at all. So, in answering the language question, the patient stated she spoke, "English, French, and a little bit of Klingon."

Well, not to be out done, the nurse, who has a great sense of humor, clucked her tongue twice, and said, "So do I honey, so do I."

Later, talking to the dad I learned he had many roles (or personalities) and Klingon was only one of them. I think he had been with Arthur at the round table, and with Lawrence in Arabia. I am not sure where we were this morning but I was very hopeful it was in a labor and delivery unit somewhere around the year 2010 on my small spot of the planet Earth.

Everyone did just fine and a beautiful baby was the result. The residents did waste some time on the Internet where there is a translation site. Several of the staff now know how to say, "live long and prosper" in Klingon. Of course these are the people who's ears are slightly pointed and can separate their middle and ring finger of their raised right hand.
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Thursday, January 28, 2010


This week we are working on our skills managing the complications of labor. I would prefer exercises from a book or a lecture series but it seems the scenarios are coming courtesy of the unassigned patients. Two days ago I was receiving checkout and a premature laboring patient's bag of waters ruptured spontaneously and the umbilical cord prolapsed. This is an emergency and we quickly moved to the delivery room to preform an emergency Cesarean section.

Today a patient rolled in by ambulance almost completely dilated with her fourth baby. The baby did not appear particularly large, the woman was not obese, and none of us were there that long before we had a shoulder dystocia on our hands.

To me having the baby's head out and the shoulders stuck behind the pubic bone is the most frightening situation in obstetrics. I called for the nurse to put the patients legs back as far as they would go on her chest, McRobert's maneuver. Asking for suprapubic pressure, I tried first to screw the anterior shoulder counter clockwise, Wood's screw maneuver, then the posterior shoulder clockwise, Rubin's maneuver, and finally I reached in and was able to get the posterior hand and bring the arm out reducing the diameter of the shoulders and dislodging the baby. She is fine and not a huge baby, only 7 and 1/2 pounds.

Precipitous labor is a minor risk factor for shoulder dystocia but unlike the prolonged second stage, from the cervix becoming completely dilated until the baby delivers, which is normal less than two hours, precipitous labor gives you less time to think about the maneuvers you will preform if the baby does get stuck. Today we got it right. Tomorrow there will be other problems. More practice. I wonder when we will be "knowing medicine."
PracticingSocialTwist Tell-a-Friend

Wednesday, January 27, 2010

A night's work

I smelled like a goat. Well, I have never been that close to a goat but after my two hour nap, not only did I smell like what I imagined a goat would smell like, if I ever got next to one, but I felt a bit like I had been herding them all night.

For the third time in eight months, I took a nap when I got home on Monday. I went straight to bed taking only my shoes off before plunging beneath the sheets. It was almost noon and I set my alarm for 2. I do not want to become one of those people who sleep in the day on their days off. Or in the day on the days I am working, as is frequently the case with some of the other hospitalists.

While the daytime is occasionaly slow, the nights are not. I worked Wednesday, Friday, Sunday last week. Here are a few vignettes.

Just as the nightly news is over two nurses from the antepartum floor came through the doors of labor and deliver pushing a patient on a stretcher. A man who looks to be the husband is following them. Much of the talking I do not understand because the patient only speaks a Vietnamese dialect.

Taking the chart from one of the nurses, I read that her pregnancy is 23 weeks and 6 days gestation (about 17 weeks shy of term) and she has been in the hospital 4 days for an incompetent cervix dilated to 3 centimeters on admission. This was her first pregnancy and the patient had been having pain for 2 hours but was monitored and no contractions were detected. When she began bleeding the nurses rushed her downstairs. No one had ever called me about the pain. Grabbing the portable sonogram, I determined that the baby was a double footing breech presentation with the feet in the vagina. Fetal heart tones were good. Calling for anesthesia, I asked for the translator phone. "Yes, the patient wants a C-section to increase her baby's chance of survival." Quickly the risks and benefits are explained to she and her husband.

We all move to the delivery room where I help the nurses get the patient on the operating table as the anesthesiologist gets the drugs and equipment ready to induce anesthesia. I put a Foley catheter in the patient's bladder while the nurse listens again to a strong fetal heart. Rubbing antiseptic gel on my hands, I gown and glove myself while the scrub nurse and circulator count instruments, and sponges. Placing the drape on the patient, I have another nurse hold the translator phone to her ear. "Tell her we will take very good care of her, I will not start until she is asleep." I can't believe she is not struggling. She is just waiting. Her baby weighs 590 grams (1 pound and 1 ounce) but is doing well in the nursery on day 4 of life. I will have my fingers crossed for months to come.

Next I am off to the emergency room. There is a 16 year old miscarrying. Her parents dropped she and her boyfriend and the older sister off but went to eat dinner because the wait was so long. This girl is bleeding a lot and I cannot get all the tissue out of the uterus so the bleeding continues. Giving her pitocin in the IV slows the bleeding a bit. She will need a curettage to get the tissue out. I am never sure a 16 year old can consent for herself when she is not actually pregnant. There has been much in the news about this in Texas and I want her parents back. The sister is calling them on the cell phone.

While this is happening in section C, a morbidly obese woman in section D has a fever of 103 degrees. She could have appendicitis, gastroenteritis or pelvic inflammatory disease. Of course medicine and surgery think I should admit her for PID. When I examine her she simultaneously vomits and urinates on me. She gets admitted - to surgery. I told them I would follow with them and we agree on antibiotics as I write my note.

The 16 year's parents are back, consent is obtained and I change clothes on the way to the OR. Once this is done, the curettage is easy and she is off to the recovery room. Talking to the parents, the mother is upset and wants to know how this could happen. At first I think she is asking how her daughter got pregnant but I soon realize she is upset about the miscarriage. I want to talk with all these people about how to keep this young woman, who is smart as well as beautiful, from getting pregnant again. The mother and I have a discussion that night. The girl and her boyfriend, who is 17, and I have a detailed discussion the following morning.

I could go on. In one of the routine deliveries, I catch the father of the baby just before he passes out. The patient is 15 and he doesn't look like he shaves more than one a week. His mother and hers are both in the room pushing with the patient during the second stage of labor, from the cervix being completely dilated to the birth of the baby. They could care less about the 'baby daddy.'

All of these events were between the 6 pm news and midnight. Other events happened after that and I was too busy to take my 7 am shower before rounds with the residents. After rounds, I just wanted to get home and get into bed. I hate to sleep in the day but I knew some rest was necessary if I was going to survive to tell this tale.
A night's workSocialTwist Tell-a-Friend

Friday, January 22, 2010

A story

I first met MW when she presented to labor and delivery for contractions. Her cervix was not dilating but her blood pressure was elevated. She still had five weeks until her due date, set by the residents at the country hospital. Looking at her records she had not been seen by a doctor for at least two months.

Admitting her to the hospital for her elevated blood pressures, known as gestational hypertension, I tried on two occasions to get a twenty four hour urine collection to determine whether she had preeclampsia. This was the medical situation, the social situation was another story.

First she told me "my child's father is not paying me enough attention." Then I found him in bed with her on early morning rounds. Though she did not go into labor, her blood pressures became so high, her labor had to be induced. She quickly tired of labor and begged for a C-section. Despite epidural anesthesia, labor "hurts too much." She told me. I tried to explain that incisional pain after a C-section was also a problem.

After a long induction her labor did stall and she was on the operating room table when she asked me, "I get to eat after this, right." My reply of "No, not exactly..." and an explanation of the need for a clear liquid diet until her bowel function returned was met with cursing and crying. I understand frustration. My oldest was the product of a Cesarean section after 27 hours of labor, but this seemed a bit much. The entire OR staff allowed her to ventilate before bringing "the father of [her] child" to the delivery room.

I pulled screaming baby boy out of the incision in her abdomen about 15 minutes later. Being cleaned and dried, weighed and measured by the nursing staff, I exchanged several glances first with the circulating nurse and then "the father of [her] child." The baby's skin color did not match his.

Despite bracelets placed on baby, mother, and daddy in the delivery room, the next day this young woman was claiming those of us in the delivery room had some how drugged her and exchanged babies. She got no support from the boyfriend in this and finally gave it up.

On the day she left the hospital, I discharged her with an appointment in two weeks to see her clinic doctors. She complained about this but in a much more subdued way than all the issues of the past 8 days. As I removed the staples from her incision, she said, "But I want to come to the clinic and see you." When I explained to her that it didn't work that way, that she only had me for the days she was in the hospital due to the fact that I was on call, it began to dawn on her that our relationship was ending.

The reward for my eight days of patience came with the very last words she spoke as I turned to walk out the door. Sitting in the bed holding her son, she meet my eyes and quietly said, "Thank you."
A storySocialTwist Tell-a-Friend

Wednesday, January 6, 2010

Least favorite

This month called January is my least favorite of the year. One reason maybe the weather. Even though I am located in the south where it is often sunny, January is usually cold and cloudy. Winter has just set in and spring is far enough away, I rarely think about it.

Another reason for my discomfort during this season is the resident training cycle is half over. Often, I think I am the only one who realizes the true meaning of "half." Interns are now much more comfortable presenting patients they have evaluated. Good skills have been developed, things begin to move a bit more quickly, and yet, it is a common time for them to begin missing things, too. There will usually be a few cases which make us all pause, reflect, learn the importance of being thorough once again. I find myself becoming hyper vigilant once again. As a person who makes few New Year's resolutions, I think this is a time for my favorite one: To do better.

Better can be a confusing term but in the sphere of my work, it means I will strive to be more accurate in my diagnosis, more compassionate with my patients, a better colleague to those with whom I work. I will learn at least one new thing each day and at the end of the year I hope I will be a better physician than I was at the beginning. Medicine is no place for complacency. If this year's class of interns are learning this then my enjoyment of these cold winter weeks will increase. Hopefully, so will the temperature.
Least favoriteSocialTwist Tell-a-Friend