July 6th, 2005

Hush angel

Some people live on sponge cake.

I missed the dinner hour. I don't remember what I was doing, O Best Beloved, when five-to-seven rolled around and disappeared again. I might have been walking into a room, saying hello to a patient and having her twist and moan in pain - we had more than one girl today whose epidurals came almost too late. I might have been catching a baby - I've done that a few times. I might have been triaging. I might, O Best Beloved, have noticed if I were overwhelmed, but today has been a steady trickle of patients.

Two infiltrated IV's and four-to-delivered in forty-five minutes; she was crying and cursing and the baby came out en caule, with the amniotic sac still enclosing its little head like a ghostly shroud. I didn't have time to put my shoe covers on.
I live on string cheese from the doctors' lounge fridge.

Today's highlight: she was twenty-something, pregnant, and a privacy patient. She wanted only her best friend to know she was there. The problem was that her mother had called the ambulance for her. Security had to escort the baby's putative father out; he'd heard her screaming in agony and knew where she was. It was a nightmare of trying to keep people away while still letting her best friend in. And then, O Best Beloved, I found out why.
This girl had decided to give her baby up for adoption - she didn't want it at home, she was in a bad situation, she was a strange bird, whatever. Private adoption via a legal firm to some couple somewhere else. But what she'd told her mother, baby's dad, everyone around her was something else: The baby has complications. It might die. And here is this girl planning to go home and tell everyone that the baby died instead of that she was giving it up for adoption. I don't know the legal ramifications of this; she and babydad aren't married. But I do know that the ethical implications are staggering. Literally. So we did the only thing we could: we called social work. And social work will be working with her.

O, Best Beloved, some people terrify me.

Teenagers who seem oblivious to the fact that there is a whole person growing inside them. They come in crying and writhing in pain because they've spent the day drinking Mountain Dew and eating potato chips and walking the mall trying to induce labor. They come in screaming at cervical checks and sometimes they are so tense one wonders how they ever got pregnant. They don't drink, they don't eat right, they don't get prenatal care.
And their mothers who do nothing to improve my outlook for them.

I have good doctors here, good proctors to work with. I have goals for my next call: I need to learn to tie knots two-handed so that Dr. M will let me tie. He was very nice to me. Very nice, and I do not want to ruin my chances for C-section experience by fumbling a two-handed tie the first time I am allowed to do one. I need to be collected and together so that I can deserve all the patience and the trust they put in me here. Today, T grabbed me for a second circumcision. This time, he barely watched me at all; he let me explain to the medical student and to B what I was doing and why; he walked out of the room for a while. He says: "I have utmost trust in you. You've done nothing to show otherwise." Dr. M torments me about knowing the four signs of placental separation; I knew it because I was burned in third year. He insists it was because I was asked earlier that day. Attendings talk about us. I must remember.
These good doctors, some of their patients are wonderful wonderful people. I am waiting for a primagravida to go from nine to pushing as we speak, and she is funny and beautiful and her family is gathered around her. There is a girl with twins who is on magnesium and still has a sense of humor. The woman who screamed when I placed a cervidil - posterior fornix, not a pleasant procedure - laughed up at me a few moments later. "Hi, been great getting to know you." The surreality of intimacy in a hospital, and the unspoken is spoken.

I said I was hoping to sleep last call. Forty minutes later I was awkwardly delivering an infant on the bed; the patient's doctor came in five minutes after that. Hello panic. And I didn't return to my room to sleep until six AM.
We shall see.
Modern Art

Everyone makes mistakes.

I admitted a patient last night, O Best Beloved - I admitted her at 3 cm, I'm sure about that. And she hung out at 3 cm and she hung out at 3 cm and nothing really changed, and so the attending started pitocin and I called the intern who followed me on call because I missed a page after I woke up today and he says "hey, just a heads-up. That baby turned out to be breech, we did a c-section. And Dr. was kind enough to tell me that this is why we do ultrasounds when we're not sure." And he talked about how he wasn't really sure on his exams, had to do a lot of double-checking, and I think he was trying to empathize, not scold, but my mind was already scolding me enough.
Because I admitted this lady, and either I said she was cephalic or the nurse assumed she was cephalic because I didn't say. And either way I made a mistake. Because I don't know if she was the woman I remember or not, but at some time in that night I remember a tiny voice in the back of my head saying "hm, that's odd, that feels different" and I remember thinking it was just my inexperience. And I thought, O Best Beloved, I thought that I had asked the nurse to check after me on that one, but I must not have, and nobody noticed until I was gone, and I've never worked with the attending who had to deal with my mistake so all he knows is that I'm the intern who left him an unpleasant surprise, and my co-intern is the one who called him to help do an ultrasound when he wasn't sure of his positioning.
And it's not even my reputation I'm worried about, O Best Beloved, but I'm here in tears because suddenly I am terrified. And I had gotten out of the practice, a little bit, of asking nurses to check behind every initial exam, because they kept saying I was right. And I didn't stop and heed that tiny notion. And I left a surprise that could have been bad for mother and baby. And the fear is back: I'm not going to be a good doctor. I'm not going to do the little things that make the difference. Someone is going to get hurt because of me.
And we all make mistakes. But I'm so scared now.


Addendum: It's a silly thing, O Best Beloved, to sit at home alone and fret. I know it is, because I have told quinby this many many times. It's a silly thing that I am, nonetheless, very good at. But there's an e-mail client on our medical records that I can use to send in-house e-mails, and when I pulled up my charts for tomorrow's clinic I remembered it existed, so I e-mailed one of the staff doctors at the residency, a woman I admire and like a lot, who does OB in her practice. And I told her what happened, and how awful I felt, and I asked what I could do to ensure that it didn't happen again. And the response came back, flagged in red, high priority.
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And I think that nothing could have helped more. I'm feeling a little better, O Best Beloved, eating a late lunch around the lump in my throat, feeling my heart rate return to normal. Maybe I am going to make it.
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