July 13th, 2005

Me dreamer


Two patients : 1:30 and 2:45. Awaiting anxiously to report my patient show rate today. We have grave doubts about the second one; her history suggests a no-show, but we shall see, O Best Beloved.

I did not get my sleep; I was paged back out and got to put my hands beside the obstetrician's during the vaginal delivery of full-term twins. This, O Best Beloved, is a sentinel event. This was not the careful catch of tiny two-pound wisps of babies, not done in the operating room. This was a delivery, and I got to help. The OB doctor who'd spent the day and most of the night with me, following his patients, telling me about a vacation spot I simply must see in Costa Rica, moved out of the way once the second baby was delivered and handed me the double-clamped umbilical cords. "Slow and easy." He is a waiter, a doctor who wants the placenta to separate on its own. So I held my hands on the cords, kept a gentle tension - just enough to know if the cord lengthens - and let him do the fundal massage.
"Twist it gently," he said; my face is easy to read - when the cord lengthens and the placenta begins to emerge, I am wide-eyed, startled, and a little panicky - "twist it gently and don't let it flop." He means that I am to catch the placenta as it slides out, twist it to lessen the tearing of the amniotic sac, and make a controlled and tidy delivery - without dropping it - into the waiting bucket. I learned with the last patient, and it went well. This time, a double placenta came suddenly, quickly, and I dropped the cords and tried to catch it, twisting a bit but mostly just slowing the descent. There was an audible "plop" as it landed in the bucket. I looked over at the obstetrician. That was a flop, wasn't it? Beneath his mask, the corners of his eyes crinkled: a smile. "That was a flop. But there wasn't anything you could do about it."
Twins did well, are doing well. Success.

And then deliveries and Cervidil placements and histories and triage. Once in a while now I am seeing a patient for the second - or, in one case, the third - time in triage. I am surprised that I remember them now. Sometimes not the names, but the faces and the families. I slept from four to six, was awakened by the pager beeping. Apparently a patient was bleeding heavily and trying to pass out over in postpartum; the OB had given orders but asked for me to go see her.
I don't know what exactly to do; I've never seen a postpartum hemorrhage patient. So I fell back on the default behavior: check the chart, look at the patient, do the best physical exam I can. And then report back as to what I saw. It seemed to satisfy, but served to drill in even further how little I know.

I have so much to learn, O Best Beloved. So very much to learn.
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