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."
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Musings of a physician in private practice for 24 years, now teaching in a residency program and working as an ob-gyn hospitalist in a large metropolitan hospital.
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The Local MD
Having now been a physician in private practice for twenty-one years, twenty-six days and about an hour and twenty minutes, it occurs to me that I have become what in medical school was often a derogatory term, the local MD.The presentation on rounds often went something like: "This 45 year old Caucasian male was seen last week by his LMD, and diagnosed with a viral upper respiratory infection..." At that point everyone knew that the LMD had missed the diagnosis. Otherwise the poor patient would not have ended up in a tertiary medical center with three consulting specialist, a fellow, a resident and four medical students at his bedside.What we, the medical students, the resident, the fellow and even the attending hospital physicians did not realize is that we would never know John Smith as well as the LMD. We would never speak to his wife using her first name. We would never be able to recall the names of all his children and know where they were in the world. We would never remember his favorite hobby let alone joke with him about it. Nor would we shed a heart felt tear when we gave him the diagnosis of the aggressive small cell carcinoma of the lung that had landed him in our midst and would kill him in less than three months despite our aggressive treatment that was the best medical science has to offer.At that point in my life I was very proud to be even the lowest ranking person on the team that was on the cutting edge of the diagnosis and the treatment of the gravest of conditions that plagued mankind. I felt so very lucky that I was being initiated in to this sacred fraternity. That I would soon be able to write "MD" after my name. I am still proud of my vocation yet I believe there is a wisdom that has only come with those twenty-years of practice.Today I realize what people want most of their physician is that he or she is someone who cares.Yes, we all want "everything medical science has to offer." Yet, what most of patients need is someone who will listen with their heart as well as with their head. Physician eyes are important, not only for seeing signs of disease in the body but for making contact with the patient's eyes where we are often allowed to see into their soul. All of the technology in the world will not replace a warm clasp of the hand or sitting at the bedside to share a few moments of the day along with the test results.So, I have created this blog. In large part it is a place for me to put my feelings. My hope is that at least some of these posts will resonate with others out there. Not just physicians, but others in caregiving vocations and even those for whom we care. If we are not here for each other then why are we here?
1 comment:
wow. I can only imagine how quickly all of your decisions have to happen. And you do it all with complete calm...that was my observation! We were just watching the video of Billy's birth (in honor of his second birthday!), and I couldn't help but notice how quickly the room became calm and focused when you walked in! Those residents are so lucky!
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