Nescafe rabbit

Alpha and Omega

It's another sad story, O Best Beloved.  I promise I've got some happy ones to tell you too.

Morning section day - around noon I headed back to do a C-section with
The World's Fastest Physician ("I'm going to have to let you do things
eventually, aren't I?"). Twenty minutes later, I walked out to a huddle
of nursing staff.

"Doctor B!"



Triage room contained a patient a month shy of her due date whose last
reported fetal movement was over twelve hours ago. "Having trouble
getting heart tones." Intern on OB call has only ever touched an
ultrasound machine twice. Ultrasonography tech is on her way. I walk in
the room and introduce myself to a tearful and clearly terrified woman
with a full-moon belly, her husband. We turn the lights down. And I
watch as a motionless baby scrolls past, with a motionless heart, and I
feel myself go cold and trembling, and you have to say it. Someone has
to.



I'm sorry. Your baby has died.



And moments later our ultrasonography technician comes in, and she
doesn't waste words or questions, taking the report from me, probe
flickering over a belly now quivering with sobs. Color flow confirms no
cardiac activity. She's gone as quickly as she came.



And I'm standing in a room with a woman I've known for ten minutes,
telling her some of the worst news I can possibly imagine, and all I
can say is "I'm so sorry." And she looks at her husband and sobs, and
her mother is there at a run, and all the medical degrees, all the
education, all the years of experience in the world can't change that
moment where the only thing I am good for is to hand over the box of
Kleenex and let her wring my hand until the fingers feel like they're
melding into one.



And I can't help in the moment but to cry myself, feel the raw terror
that someday I will be this woman, and even now to wonder why things
like this should ever come to pass. It's a question without answers,
and one that leaves me hopeless and drowning in the test of faith.
Nescafe rabbit

All Alone

Sunday day shift in $ER.

I walk in at 0700 and the night doc says "Boy, am I glad to see you."  Never words you want to hear.  "Full arrest 15 minutes out.  I was going to tell you there was nobody to see, but..."  He grins, claps me on the shoulder, and heads for the door.  A wise man.  He's gone before the Code call goes out overhead.

Found down in bed in the early morning.  Late 40's, chronic medical problems, a hundred-ten pounds at the outside.  Scars and stigma of medical interventions now rendered futile.  CPR is going.  Two rounds of code drugs, bicarb, all given by EMS.  The ET tube is in, and I confirm position with a stethoscope and a chest X-ray without interrupting the flow of the resuscitation, wheeling her in. 
Stop CPR.  She has a rhythm.  A pulse.  Is she breathing?  No. Keep bagging.

They know what to do - I'm just the overseer.  Lab arrives, looks down.  I know her.  Her name is Laura.  Shall I call her family?  I nod.  There's not much happening now - lab draws, watching the monitor, the steady hiss of suction and the fft-ahh of the bag being squeezed.  Holding pattern.  Stably unstable.
And her family arrives, confirms what Lab had thought - No Code Blue.  We call her doctor in $city.  No Code Blue.

And all the time the crash cart monitor is ticking a steady hundred-and-five a minute, and I can feel it flutter in her wrists, and the biox probe is reading 100%.

It's an old joke among ER nurses, and they're half-serious when they say it.  "I'm going to tattoo No Code Blue on my chest."  Because this happens, O Best Beloved.  And now what do you do?  Because the emotional distance between withholding and withdrawing support is a chasm.
I call the brother in, explain the situation.  Her arterial gas has a pH of 6.8, she's making no effort to breathe, there's a helicopter on standby right now to take her to $major_hospital for ICU care, if we're going to continue.  "She wouldn't want that," he says, reflexively.  Automatically.  "She wanted us to let her go."  And his words catch up with his mind, and he shakes his head.  She's not breathing on her own.  If we stop breathing for her, she'll die.  I can't make that decision for you, but her chances of her brain returning to normal, ever, are slim.
"I have to call my brother." Life sometimes gives you a phone-a-friend.  Fifteen minutes later, he comes back.  "No more." 

They look at me.  Stop bagging her.  No more CPR.  No code.

We take the tube out of her throat, wash her face, wrap her hair in a towel.  It takes half an hour for her to reach asystole, and the last ten minutes are the worst, an agonal rhythm at 10 beats a minute that won't stop.  I explain to the family about the way heart muscle cells work, the tiny automata without direction from the cerebral cortex.  Lab reminisces about her fried chicken.  And then I count out seconds as the flatline sweeps across the screen, three, four, five times, and doesn't waver. 
She's gone.  Everyone looks at me again.  It's over.  Oh-eight-seventeen.

We disconnect everything at last.  Within minutes her skin is the cool ashen color of death.

"Look at it this way, Doc," the EMT says as we walk out of the room.  "At least your day can only go up from here."  And me - I know better, but I say it anyway.  Don't know how it can get any worse.
Nescafe rabbit

open season on interpretation: "cut"

I am I am
     in the moment before the scalpel falls
   eviscerated laughter
           am compromise
       I am I will
be.

      Mother/lover
   surgeon, child
               and healer.  I am all
of these and none.
       
       I am I am
   and watching you
            madonna/jezebel
       great round
with child

     the scalpel falls.
               6-Oct-8 "cut"

Nescafe rabbit

Deep dilemmas

It's 1:45 in the morning, here at $hospital.  I'm on OB call, so I handle OB triage.  Somewhere on this floor is a woman who's walking.  Sometime in the next hour she'll return to the triage room and I'll get paged to go check her cervix.
If I never see another vagina it will be too soon.
I have been doing this almost nonstop since 7:30 PM or so, when the first wave of "I think I'm in Labor" washed over this city like a full moon (is it? It isn't, I don't think).  The day was stunningly, excruciatingly quiet after a hectic start - seven deliveries including a c-section and a vaginal breech (I love you, Dr. C, and your magic hands, but tell me when you're going to go deliver the single-footling breech, so I can watch) before noon - all ten labor rooms devoid of patients from 2 pm on. 

I was sociable and chatted with people and played around on the Internet instead of sleeping today; I am afraid these bipolar tendencies are on the downswing and I find that being a hermit is not helpful to keeping my sanity or my Angel's.  I also am on call with one of the few obstetricians who still intimidates me: his father started the practice that delivered my baby; he is blunt and doesn't sugarcoat his opinions; and he is a born surgeon. 
As I have told our maternal-fetal medicine specialist before, I am not a born surgeon.  I am a born family medicine physician - a generalist, an eclectic - who is trying to become a surgeon, because that's what I have to be to serve my patients the way I want to.  It's a learning process. 
"I wasn't sure about you," he said the other day.  "I had my doubts about how you'd do.  But you've really improved your skills.  I'm impressed.  You're doing well."  I didn't know he didn't think I was going to be able to do it. If I'd known, I would've been too terrified to try.

I walk into the operating room terrified - every time - but sometimes I am more terrified than others.  And with him, I know I am being evaluated.  His standards are high - he expects I'll be able to perform well, not just perform.  But to my amazement, I seem to be reaching - slowly - that level.
Dr. F stopped me in the hall outside a section the other day.  I'd resigned myself to just assisting him forever, as nice as he is, so my heart went into my throat when he spoke.  Think you're comfortable running the show?  "Yes, sir."  And I did, but I must have nearly collapsed from anxiety before even setting foot in the theater.
I want to do well.  This is vitally important to me - like it never has been before.  As I make this awkward transition into becoming an independent physician (I'll be taking boards in December!) I'm coming to realize just how important it is, and just how afraid I am that I'll come up short.

Sometimes I wish I'd taken some other route, where I went home at night and slept well and didn't worry about people dying because I missed something.  Where I'm not sitting up at oh-dark-hundred philosophizing about the importance of learning to tie a knot with my left hand (he asked me.  I was so glad I could say yes, I can, and prove it) or how straight my incision is.

There's no day and no night on OB call.  The windows are all UV-treated and tinted so the outside can't look in and we don't have to close any drapes in labor.  Dawn looks like dusk looks like noon; midnight is dark.  It can be 3 AM or 5 PM and the only way I know the difference is by how fatigued I am.  I sleep when I'm tired, eat peanut butter and cheese sticks when I'm hungry.  I hide in my room and wait for the intolerably cheerful warble of my pager to go off to tell me that I have to go make sociable with someone else, try to ignore the surreality of my job.

And in between - do I sleep?  She might be fifteen minutes, might be an hour.  I might have another triage patient soon - or there might be no-one until morning.  It's a gamble.  Uncertain.  How long does it take from four centimeters to seven? From six to complete?  There's no baby clock, no pop-up timer to warn me when I shouldn't plan on doing something else.
Went down to do a D&C today on a patient with a septic missed abortion (that's a miscarriage where not all of the tissue passed, which has now gotten infected) and was handed the suction curette, carefully walked through the procedure.  Came back upstairs and they'd kindly filled triage with patients who thought they were in labor.

It's late now, or early.  I can't tell in the constant fluorescent light, but in the mirror I look older by a factor of years.  By now I could have had almost an hour and a half of sleep, and just as I am thinking that I'll try and catch up to it the pager goes off again.
Nescafe rabbit

What a long, strange trip it's been...

I find myself getting more and more paranoid, O Best Beloved.  Recently, a colleague of mine who's graduated sent us all an e-mail.  "Our family blog is now invitation only, because one of T's crazy patients Googled him and found it." 
Do you remember, O Best Beloved, when all of this started and I was a medical student who didn't know how it all worked, and I was so excited to find out?  It's been quite a while since then, and the Internet has evolved, and we've evolved.  And I find myself thinking about Next Year, when I'm a Real Doctor.

And I know I don't post much any more, but when I do I'm glad I did.  Things still happen to me that remind me how much I have to learn, and people still surprise me on a regular basis - both with the good and the bad.  And I'd like to keep it up, but I'm going to be in a small town, and you know how things are in a small town.
So I'm still thinking about how it'll happen, then.  How do you keep your anonymity in this world where everything's linked?  Your name becomes increasingly only one of the thousand ways to identify you - as evidenced by my secret excursion into Facebook, which became an explosion of connections; a veritable spiderweb of people I never knew I still remembered.
And I don't always know where to post my secrets any more, that cold dark callous bit of me that gloats when people get what they deserve, because I'm afraid someone will find me - and know I'm talking about them.

So I'm going to take you with me this year, and I'm going to write about things and save my posts and skew their times and obfuscate numbers and names and I'm going to never again post from work, because they made me login to the Internet, so they can track who goes where, and somewhere Big Brother is watching, and that's the scariest part of all for me.
Because some lawyer somewhere can decide that it's not important for you to know what it's like to watch a baby die or treat a crack addict or to see what's inside my mind in the witching hour.  Someone can decide that I wrote too much of a story and made it too real and they can track me down and take away my license if they like to.  Someone can decide that just because I don't like everyone all the time means I don't treat them right.  And all the Someones in the world these days, I just don't know.

This sounds like a paranoid fantasy.  I wish I hadn't started thinking about that email from T.

So at the moment I'm at $local_er, a long way from home, doing a couple of 12-hour shifts and I don't have anyone looking over my shoulder, not a single attending here.  It's just me and my ATLS certification and all of a sudden I have to decide what to do, and call people I don't know and tell them about their patients.
I'm a Real Doctor, down here, nobody's resident or fellow.  I write orders and people follow them.  I tell them to send people home or keep them or X-ray this or scan that and that's it.  That's all there is, out here.
18-month-old with croup, had me worried for a bit before he perked up.  Chest pain I can't explain.  A fall.  A wrestling match gone wrong.  Please do not put a needle in your gum for any reason unless you are a medical professional, and even then do think twice.  Coughs and colds and vomiting.  Bee stings.  All the usual stuff that I would see anywhere else, except now...
Now I don't have that tiny safe feeling in the back of my mind that says "You can always just have someone else look at them."  It's funny, because I see patients and I decide what I'm going to do and I make it happen, every day in clinic.  I adjust medications.  I call for admissions.  I tell them it's going to be okay and they don't need anything.  And I do it every day without needing someone to hold my hand.  But now that there isn't anyone there...

It's terrifying and exhilarating all at once.  And I know I'm going to make mistakes.  It had better not be a surprise to any of you, O Best Beloved, that we make mistakes.  I just hope I don't make any of the wrong ones.  And I keep watching my steps, trying to be my own attending, replaying conversations with ER doctors in my mind.  I want to do it right.

This year, I'm the obstetrics fellow.  I operate on people, and they tell me I'm pretty good at it already.  But I find myself looking up at my attendings still, for the unconscious movements they make when they know what comes next in the surgery.  Double-checking myself. 
The best surgery yet was the second one with Dr. J, when she smiled at the scrub tech and said so sweetly, "Don't hand her a single instrument until she asks for it by name."  And then folded her hands and smiled at me.  "I know you know how to do this.  Show me."

Independence is scary, O Best Beloved.  I've been a student for twenty-four years now, and it's finally coming down to the moments of truth.  There will be plenty.  I hope I have the courage to tell you about them.

Kodama

News from New Orleans....

My dad was headed down to direct disaster relief in New Orleans, before the Gustav news hit. He sent a lengthy email tonight.
After leaving $city to go to New Orleans as the Project Director for the month of September, and mulling over the fact that September 10 is the peak of the Hurricane season in the Atlantic and August 29 is the third anniversary of Katrina's landfall, I received a call from New Windsor letting me know that the site was in the process of evacuating in anticipation of the possibility of Hurricane Gustav.  I decided that maybe I could help and made it to the project house in one day instead of the two I had planned

Long story short, O Best Beloved, the city's on mandatory evacuation. He's waiting out the storm in Atlanta with the regional director.
We will see what happens but as most of you are watching the news, you realize that this has the potential of being a more devastating storm than Katrina was.  People in the area are still hoping it turns out to be a "shoo-shoo" (a storm that chases everyone out but doesn't do a lot of damage) but they said that for the first time in Louisiana history,all the elected officials agree on something and that is that this could be a terrible storm.  I don't know what will happen but we will return after the storm and figure out what to do.  What a month to be project director, there may not even be a project to direct but there also may be a lot more work to do in recovery.  I will try to let you know what is happening.  As of now, I am in Atlanta, over 400 miles away and think I will just enjoy being here while I wait.  Keep all of us and the citizens of New Orleans and southern Louisiana in your prayers over the next few days.  This may hit an entirely new area of the state but someone is likely to get some devastating effects. We will see what happens.


I'm so proud of him I don't know what else to say. I hope there's a project to direct.
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Nescafe rabbit

The best dentist EVER...

This is a non-work-related story. You see, I'm a bad patient. Before last month, I hadn't been to the dentist since my sophomore year of high school...

My two top front teeth were both chipped - one from an accident with a swingset chain when I was ten or twelve, one from a lifetime of bad habits. And one of the lower ones had suffered a run-in with a bottlecap a while back. And I guess I'd always just resigned myself to living with this crooked little jag in my smile.
I went to the dentist last month. He poked around in my mouth and cleaned off ten years' worth of accumulated ick, and complimented me on how little ick that was. And then he said "We can fix that old cap for you, and the tooth next to it."
It was like a little light going on. And I didn't actually care how much it would cost me to get it done, but the price wasn't that bad, and now here I am with three newly-normalized teeth and I didn't realize how much exactly that would mean to me.

I feel like a different person.
Hush angel

Sometimes, it's not so much fun.

If you're easily upset or softhearted, skip this one. I'm talking about "a bad outcome" in obstetrics.

I'm still raw from this one, shaking inside. I don't know what to say, quite, so I'm just going to tell the story.
I'm on OB call this block - every third day, 7 AM to 7 AM, in the hospital catching babies. The other day, Dr. S was on for the perinatology (high-risk obstetrics and maternal-fetal medicine) service. She's a tiny woman - probably about a third of me - with a soft voice and a military manner. And she's so very very good with her patients.
I knew her patient was in-house because the nurses had made sure of it. I leave the perinatology patients alone unless requested - and Dr. S does make requests of me, from time to time - or an emergency develops. It was pure chance, therefore, that I was standing at the nurses' station when the nursing staff called out from the room. "Get Dr. B in here - now." I didn't glance at the monitor until I was in the room, and my heart just stopped.
Fetal heart tones in the basement - 50's, 40's, instead of 150. Nobody in the house but me, and Dr. S on the way already. There's one algorithm in obstetrics that nobody forgets: Fetal Distress = Proceed to most rapid route of delivery. I gloved up, checked for baby's head, and started breathing - it was right there, available for delivery. Not the time to wait on niceties like "your doctor's coming, hold on," so we had her start pushing. Baby's heartbeat hovered in the 50's the whole time.
Dr. S arrived, threw a gown on, and reached down. I'm not sure exactly what she did with her hands, but it was like magic; baby's head came flying out, followed by the rest of baby, pale and small but moving at least, trying to breathe, followed by the end of the umbilical cord. Abruption. She tossed the word out matter-of-factly, handed baby over to the NICU folks who were waiting by, and exhaled, looking at me. Now we wait.

NICU means neonatal intensive care unit, O Best Beloved, and they're the folks who come when we're worried about baby. They took him, warmed him, and then started muttering to each other. Dr. S stood up, looked over at the baby on the warmer, and her military came out in a little growl. Get someone else in here right now.
The advanced people came running for the Code Green siren, which is the scariest sound I ever hear. There was a lot of bustling and rubbing and getting out the bag-and-mask ventilation, and someone said "Check now, do you have a pulse yet?" and I thought I was going to die.
They did compressions for a few minutes, maybe five, seemed like forever, while Dr. S sat on the bed and I knelt beside it and the baby's mother just watched in silence. There was nothing to say - holding our breath, praying - waiting.

And then they had a pulse, and spontaneous breathing, and there was a little hand waving up over the edge of the warmer, and the universe seemed to take a giant gasping breath. Time started. They were still giving oxygen, but he was moving and breathing again and I thought, O Best Beloved, I thought everything was going to be okay. His father came over from his silent vigil in the corner, looking down at him and taking his hand before they picked him up to show him to his mother and whisked him away to the NICU for post-resuscitation care.

I heard from the nurses an hour or so later, sitting at the table in the station between triage patients. "Don't tell mom - NI hasn't told her yet - but the baby has a diaphragmatic hernia."
My heart stopped, O Best Beloved. Suddenly the whole resuscitation picture made sense, and it was a horrible sinking kind of sense. A diaphragmatic hernia is a congenital defect where the diaphragms don't completely develop, leaving room for the intestines to occupy the space in the chest where the lungs ought to be. In best-case scenarios, babies require intensive care and likely have lifelong lung problems. In the worst case, the lungs don't develop at all, and I don't think I have to explain that outcome to you.

I went down to the NICU first chance I had, found the on-call physician. He didn't bother with niceties, just beckoned me over to the X-ray viewer and pulled up a series of films. I know him - he knows what my clinical skills are. He didn't have to say anything. Baby was born with maybe 1/3 of one lung developed at all, and that one blew out at the first attempt at ventilation. There was air where air should never be, and a tiny pathetic shadow of a lung silhouetted in the left chest, while bowel coiled through the right, a serpentine intrusion preventing any pretense that his right lung was formed.
I was there for an hour, watching the oxygen monitors, the heart rate, the tiny baby form swelling with subcutaneous air, drained off with an IV catheter, little arms waving in protest. The last-ditch efforts of the team got his saturations to 70% for a few seconds, before they dropped back to 50%, hovering there. $children's_hospital was on the way via chopper, hoping that there was something more that could be done.

I took a call from Dr. S, who'd heard the news. "Go upstairs. If mom is stable, get her out of the hospital so she can go with baby." I scampered, not sure what to tell mom. She'd seen, by then. She knew he was sick. I hedged. You know he's very sick. He needs his mommy, we're going to let you go with him to $children's_hospital so you can be with him. When they get here, we'll know more. What good is it to tell her that her child might never make it there? Wait for the experts to decide.

I got paged to C-section, slept fitfully while waiting for yet another section to be ready, and met Dr. S over the OR table. That's when they paged me to tell me. Your baby expired. Mom still wants to go home. So clinical. We do that, O Best Beloved, to keep from crying.
I met the NICU doctor over breakfast a day or two later and got the story.
The chopper had arrived in time, but even with both NICU teams working their hardest, baby never recovered enough to be safe to transport. The neonatologists from $children's_hospital looked at the films and heard their team and decided that he wasn't a candidate for ECMO (lung bypass machine), which is the only thing they have that we don't. So they took the tubes and the wires off and let his mother hold him until he died.

Five hours and twenty-five minutes old. It tests the faith, sometimes. It really does.
Nescafe rabbit

Philadelphia

It is storming outside.
I am on the thirtieth floor; the storm clouds are right outside my window; I can barely see the street.  Lightning fills both windows of my corner room.

The Doors are playing on the iPod.  Guess which tune?

Met a woman in the airport going the same place I was, the same conference.  Tonight, we went out to dinner, to a Japanese place where my Angel and I would have loved to eat, if he were here.  We spent a lot of money.  I drank sake, she drank Gewurtztraminer.  We split the edamame, the spicy tuna roll, the chicken-ramen soup, the salad with seared ahi tuna.  We talked about traveling to other countries, and speaking French, and delivering babies.

It is less lonely here, with a friend.  And another friend surprised me in the hallways.  The three of us are going on the Tippler's Tour, tomorrow, so pray that it doesn't rain, or we will be very wet as well as lightly intoxicated.

The conference is going well, thank you for wishing me good luck.  As long as I am not electrocuted in my bed, I plan to enjoy the rest of it.

My Miricups was asking about me, at home.  It's hard to be away.
Nescafe rabbit

On the go...

Getting ready to board my flight to Philadelphia. As far as I know, my last patient is still pregnant. Selfishly, I hope she delivers a few days late so I can be there, buit babies will what they will, and I know full well I can't tell them what to do.
Much love to my watchdogs whwo commented me back into line, and to you who were wondering after the last post...the only "convenience induction" I've ever done was for a G3 on her due date. There were some complex social circumstances surrounding the date itself, but not something worth endangering bay for. What tipped the scale was her history. Baby 1 was 8-6. Baby 2 was 9-8. Baby 3 was a solid few centimeters over dates and mom had a 4 cm and 80% dilation head start on labor, so we hesitantly decided it was probably best to go ahead.
I broke her water. She labored for hours while the nurses flipped her from side to side and rolled her every which way. Baby took his time, but when he decided to deliver it got exciting fast. Ten and a half pounds of baby almost got stuck, and we were doing all the secret shoulder dystocia moves. Mom and baby came out fine, but it was a harrowing moment.
I was glad, after the fact, that we hadn't waited, but that special set of circumstances is rare, and we could have wound up with a c-section if I'd been the impatient type.

In general, O Best Beloved, babies know what they're doing. Our best medicine is to let them do it.

See you in Philadelphia, where I'll be spending the week at the Family-Centered Maternity Care Conference. Tomorrow is the ALSO instructor course. Wish me luck!