Lessons learned

Ok, so for everything I did right today, I made at least two mistakes.  I've definitely got a lot to learn.  One of the things I learned today is that attendings are attendings for a reason, and when you disagree with them, prepare to be proved wrong.  Twice today I was surprised by the conclusions and management plans of attending physicians, and both times it turned out that their "gut feeling" had caused them to interpret the evidence correctly (even though my explanations seemed more obvious).  [Also I should point out that I wasn't stupid enough to SAY anything in either case...good thing, too.]  First case was a little kid who had been in a couple of days ago after lacerating his eyelid with a colored pencil.  He had a superficial lac and was sent home with some erythromycin ointment (that's an antibiotic for the non-medical folks keeping score at home).  Today he came back because his eyelid was swollen shut.  And I mean SHUT.  It took four of us to hold the kid down that the resident could peel back his eyelid and the attending could get a quick look at his eye.  Still, though, his eye was moving ok and didn't look super-bad, and when we weren't poking at him the kid was in a pretty good mood, so I figured the attending would give him a dose of IV antibiotics (probably clindamycin as the kid had a history of drug reactions to penicillins), observe him for a while, and probably send him home on PO ( = oral) antibiotics.  Thus, I was fairly surprised when she said "You know, I wasn't able to get a great look at the eye, and I don't feel comfortable sending him home.  I think we should get a CT of his orbit to make sure there's nothing going on there."  I mean, it's a textbook superficial cellulitis, right?  ...not so much.  An hour later, I ran into the resident in the work station.  "You're not gonna believe this," she says.  She pulls up the CT, and there in the kid's orbit is a decent-sized lesion.  Apparently some of the lead from the colored pencil had embedded itself in the orbit.  Last I heard, he was scheduled to go to the OR with ophthalmology.  Bit of a turnaround from wondering if we could send him home, and my first lesson on the ability of the attendings to integrate experience, "gut" instinct, and data to arrive at the proper course of action.

The second case involved a teenage girl with abdominal pain.  A resident and I saw her together, and when we came out, we were pretty confident that it wasn't appendicitis.  After all, her pain had been getting a little better rather than worse, she was eating and drinking fine, and her obturator and psoas signs were negative.  So we were talking about ultrasounds and other testing for ovarian pathology and the like.  I presented our findings to the attending who listened attentively and then went to do a quick check of her own on the kid.  She was back five minutes later.  "I think this kid has appendicitis."  Again, I was skeptical.  Again, I was wrong.  As the day progressed, the girl's pain went from midline to right lower quadrant and it didn't improve.  She began to display rebound tenderness and her white count was elevated.  By the end of the day, it looked like pretty classic appendicitis.  Attendings 2, SL 0.  Once again, an integration of multiple sources of insight allowed the attending to reach the correct conclusion even before all of the data was in evidence.

Still, though, despite my stumbling and bumbling, I had the time of my life today.  I started picking up and following patients on my own (a 1 year old with possible dehydration + asthma-like symptoms and a 5 year old with a supracondylar fracture [translation: broken elbow]), and realized that I actually have the tools to be able to do this successfully.  It's a gratifying feeling to realize that even though I still have so much to learn, I'm already in a position where I can be successful in patient care (albeit with a little guidance).  I can't tell you how excited I am to go back tomorrow!  This is going to be a great month, and I'll be looking forward to every single shift.

Anyway, that's all for now...back tomorrow with more tales from the ED.  Till then, peace and God bless!

Starting Peds EM

Ah, the first day on a new rotation!  Actually, though, there's not much to say from today...all I had was a half-hour orientation to the CHP ED.  It sounds like this is pretty much going to be an AI (acting internship, for those of you who aren't crazy enough to do the whole med school thing) where I'll be responsible for taking care of patients largely on my own.  This makes me very happy :-)  Anyway, first shift is tomorrow from 10A - 6P; we'll see how that goes.  I'm just a teeny tiny bit excited.  For those of you who don't know, this is likely what I want to do with my life (pediatric emergency medicine), but this will be my first time with actual patient care responsibilities in the ED, so we'll see if that changes anything.  My money's on "no," but I suppose stranger things have happened.  At this point, though, I'm rambling, so I'm gonna head to bed before I crash.  Back with stories (hopefully) tomorrow evening...and with any luck, there won't be a need to focus on moral dilemmas this time around.  Till then, peace and God bless!

Quick wrap

I'll have to push back my more extensive comments till tomorrow, but here are some quick hits from the day:
-The Ob-Gyn test is basically written to force any pro-life students to choose between their beliefs and their grades.  Nearly a third of the questions on the exam dealt with abortion and contraception, and many of them were value-laden (e.g. "most appropriate contraception," "best method of terminating the pregnancy," "what counseling would you offer about abortion" and the like).  It was not a fair test, it did not reflect course content or learning objectives, and it punished pro-life students for our beliefs.  Assuming I pass the exam, I'll be having a chat with the dean about that little gem.
-Overall, I was pleasantly surprised by the residents but still worn down by the clerkship.  Being immersed in an environment like the one at Magee takes a significant toll and I think it'll be a while before I'm entirely over the effects.
-Something I never mentioned and have been meaning to...the ID badges we were given at Magee didn't have pictures, so most of my classmates opted to display their Presby photo IDs.  My little protest during the rotation was to display my Children's Hospital badge, a reminder that the kids (whether born or unborn) are our patients too.  It probably didn't make much of a difference, but at least it was something.
-The meeting with the new pro-life group was very promising and gives me hope that in the near future pro-life students will have viable options that will not suck every last drop of life out of them.  However, it also reiterated the scope of the problem here and just how hostile an environment this is.

Ok, that's it for now.  Hopefully a more considered post will follow tomorrow or Sunday.  Till then, peace and God bless!

What we have here is a failure to communicate...

Nothing is ever simple on this rotation.  Thanks to another communication foul-up between the course administration and the residents, the residents thought that the students were supposed to work tomorrow (our test day for the clerkship).  Apparently the residents have been hassled before for letting the students out too early before the test, and so they didn't want to get in trouble and didn't want to get us in trouble either.  However, getting up at 3:30 to work at 4:30 on the day of a major exam (which starts at 10:15) generally doesn't do much for reasoning capacity or resulting grades.  After much confusion and some consultations (one of which involved our no-nonsense AI telling us that under no circumstances were we to come in tomorrow morning or she'd phone the dean about duty hour violations), we finally had to end up talking (well, actually, my more courageous classmate did the talking, I just stood there and nodded occasionally) to the incredibly nice, helpful, student-friendly PGY-3 who had originally brought this up (it should be emphasized, however, that it was NOT her idea) to tell her that per the course director we wouldn't be coming in for rounds.  She took it really well, but it didn't stop either of us from feeling bad.  On the other hand, as the AI pointed out, we would feel a lot worse if we ended up failing the exam 2/2 sleep deprivation.  Again, I don't think there's any blame to be placed here except on a flawed communication system; the residents here (particularly the PGY-3 I mentioned) have been nothing short of outstanding (and I can say this despite my significant differences of opinion with them on major moral issues).  Anyway, we'll see how this works out.  Otherwise, it was a pretty slow day.  There were only 3 OR cases and a limited amount of floor work that we could help out with, and after sitting down with us and essentially going through the highlights of "things you need to know for an Ob-Gyn test" (interestingly, neither abortion nor contraception came up during the discussion...food for thought) our PGY-3 sent us home.

So that's that...the final hurdle will be this exam, which I hear is rather tricky.  We'll see how it goes.  Prayers would be appreciated; I'd really like to be done with this clerkship forever.  Anyway, I'm gonna go study for a while; back tomorrow (hopefully) to wrap things up for this clerkship.  Till then, peace and God bless!

One more day

Long day today, but a fairly decent one.  It helps when you're doing something that makes a difference, you know?  Even if your part in that is very small (as mine most assuredly is at this point), it remains a day well-spent.  And in this point is the fundamental irony of Magee (and of too many other hospitals around the country): that at an institution ostensibly dedicated to healing and saving lives, the business of death is the primary focus.  It's an unwelcome shock to look at the board where all the surgeries are listed and realize that a full third are abortions of one kind or another.  So while in one room we're doing a radical hysterectomy and lymph node dissection in an attempt to stage and begin treatment of endometrial cancer, the team next door is likely to be performing a suction dilation and curettage (which seems to be the favored form of abortion here).  And that spectre is always lurking in the background, particularly since it's just part of life at Magee -- virtually no one who works here has any problem with it (or even thinks anything of it).  So I guess my sense of satisfaction at being able to play a role in saving a life at least for a time is to a large extent annulled by a growing awareness of what's going on around me.

Regardless, however, I only have one more day to go.  One more day of getting up at 3:30 to pre-round at 4:30, round at 5:30, and present at 6:30.  One more day of trying to save lives surrounded by a culture of death.  One more day on a rotation I've dreaded since the first thoughts of applying to medical school entered my mind.  One more day.  I'll catalog that last day tomorrow, and then on Friday I'll share some closing thoughts about the rotation.  After that, it's on to pediatric emergency medicine, which I've been looking forward to since signing up for it back in March.  It's my payoff for surviving Ob-Gyn, and hopefully it'll bring good stories and ruminations much less discouraging than those from this rotation.  First, though, I need to get through my last day at Magee and survive the test, so prayers would be tremendously appreciated.  Hope you're all doing well...peace and God bless!

Exhausted

Memo to those who don't have a car: signing up for gyn-onc isn't really an option.  4:30 start time today, 4:45 tomorrow...buses don't start running (or rather, won't get to to Magee) until after 5.  The work is good, and there are really no moral dilemmas involved -- you're taking care of women who, for the most part, either are or may be in serious cancer-related trouble.  Sometimes things go well (specimens return from pathology as benign; tumors are resected with clear margins and no evidence of spread) and sometimes things go poorly (a routine procedure suffers a serious complication and the patient ends up losing several liters of blood into her chest or we go to do a simple laparoscopic procedure and find that the tumor has grown and spread), but either way you're doing something that's worthwhile.  If you can deal with the early wakeup times (3:30 or so isn't uncommon), I'd definitely recommend this service over benign gyn surgery (as one of my friends noted, "the case before and the case after mine were both abortions").

Today went more or less ok.  The attending I worked with was phenomenal, and I wouldn't at all mind working with him again tomorrow if circumstances allow.  I also got to see a robotic surgery for the first time -- unbelievably cool.  The machine is undoubtedly expensive, and so is the equipment for it, but the incredible freedom it allows the surgeon may ultimately end up justifying the cost as the technology improves and the surgeons gain more experience.  Unfortunately, also saw one of my patients made CMO (comfort measures only); she's unlikely to survive more than a few days (if that).  Once again, prayers for her and her family would be tremendously appreciated.

Anyhow, I'm exhausted and barely coherent, so I'm gonna head to bed so I can do this all again tomorrow.  Hope everyone is doing well...peace and God bless!

Not much to say

Not much happened today...got in at 5, rounded with the team, spent about 3 hours in the OR (all very short, straightforward cases), and then spent most of the rest of the day reading.  Even got to go outside for some of that reading.  Of course, this is sort of balanced by the fact that I'm supposed to be in by 4:30 tomorrow, which means I need to be up by 3:30.  Yikes.  Otherwise, not a lot to say. 

The rotation is drawing to an end, and I can't really find it in me to be sad about that.  Despite the pleasantly surprising lack of intolerance (with the one previously described exception), the culture at Magee is manifestly a toxic one.  Indeed, the lack of open confrontation is in some ways deceiving; things like abortion and contraception are here so ingrained that I'm afraid it would be possible, almost without realizing it, to begin to accept these things over time.  It is not the overt challenge of the abortionist that worries me most; it is the passive immersion that presents the greatest threat to one's beliefs regarding the value of life.  When the rotation finally ends on Friday, I'll give a few tips in this space on how I think that insidious trap can best be avoided.

Anyway, that's all for now.  If you haven't yet, please take a look at yesterday's post on randomized controlled trials and vote in the poll -- I'd really be interested to hear what people think.  Hope you're doing well, everyone!  Peace and God bless!

The debate over clinical trials

Just read an article about the ethicality of randomized controlled clinical trials, particularly in oncology.  The central argument that the author seems to be supporting is that these trials prevent patients from receiving treatments that could prolong their lives and / or relieve their suffering.  This, she indicates, is a more important consideration than the "statistics" and "science."  While I understand her position, I'm of the opinion that the reason we do randomized controlled trials is to make sure that the therapy being studied is a) safe, and b) effective.  Sure, we could prescribe it to everyone right off the bat, but what if it ends up (as so many chemo alternatives seem to) being less useful than existing medications, or has intolerable side effects?  I don't think it's corporate greed; I think it's good science and good medicine.  I appreciate that it's a terrible decision to have to randomize people into the control arm, to not offer them this hope, but I think it's crucial to know what we'll be offering if and when it is approved.  Would I think differently if I or one of my friends  or family was affected by melanoma?  It's possible.  But I think overall it's too important to know that a drug is more than anecdotally effective before making it available.  Any opinions or comments would be greatly appreciated.

Peace and God bless!

Road trip

Up at 4, in at 5, and freezing all morning...that was how the day started.  Fortunately, it got better from there thanks to having a good team and a very good senior resident.  After morning teaching (which was actually really good...one of the residents did some nice tumor board presentations and one of the surg onc attendings gave a really good look at a relatively new procedure that may allow partial rather than complete removal of the uterus for certain cancers, which in turn often permits retention of fertility -- neat stuff!), the senior told us that there were really no cases for us in the OR today, and that she was going to head to UPMC Passavant (about 30-40 minutes north of Pittsburgh) to help one of the attendings there with a couple of cases.  She told us that one of us was welcome to come along, but we were also welcome to stay and help out with floor work.  After a brief discussion with my classmate, I decided what the heck, why not?  A change of scenery would do me some good, right?

I have to say, it turned out to be a good decision.  I got to scrub in and assist with a pair of cases (including some suturing), got some studying done (our first case started almost 2 hours late), and got some really good one-on-one teaching with the attending and senior resident.  Our first procedure was a laparoscopic bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes, abbreviated BSO) and laparoscopic assisted vaginal hysterectomy (removal of the uterus through the vagina; it's actually a pretty cool procedure) in a patient with complex endometrial hyperplasia with atypia (very high risk of becoming or coexisting with cancer).  It was a semi-involved procedure, particularly the hysterectomy -- all three of us crowded into a small space, with the attending and I holding retractors so the resident could see what she was doing.  It went pretty smoothly, though.  Afterwards, I got to stitch up the umbilicus and got some very useful suturing tips from my very, VERY patient resident (subcuticular suturing is something I need a little practice at...).  The other case was just a brief dilation and curettage (D&C) in a 63 year old patient with cancerous lymph nodes but no known disease focus.  It took about 10 minutes to rule out endometrium as the primary source.

That was pretty much my day at Passavant (well, other than the nurses trying to set me up with their daughters...much laughter was had at my expense).  It was definitely a worthwhile experience, so if you're a medical student and doing gyn onc, definitely take any opportunities that arise to help out offsite.  It's good times -- and highly educational.

Anyway, that's it for me for tonight...I'm bone tired, so I'm gonna head to bed.  I'll be back on Monday with further updates and tales (and possibly briefly over the weekend to comment on football, but we'll see...I'd give that one a Bill Belichick "questionable.")  Till then, peace and God bless!

Gyn Onc

I'm exhausted to the point of incoherence, so this will of necessity be brief.  Gyn onc is, in some ways, a sad but fitting bookend to the experiences of labor and delivery.  In L&D, the patients are new mothers and their children as they make the transition from "unborn" to "born."  Every day is an encounter with the miraculous; every day is filled with lives just starting out.  In gyn onc, however, the spectre of death is very real.  One quick story for purposes of illustration.  Prior to heading into the OR for her surgery, I quickly met and introduced myself to the next patient on the schedule.  MRI had shown an endometrial cancer in her uterus, and the uterus needed to be removed to ensure clear margins.  She had been scheduled for a laparoscopic hysterectomy, and since she was nulliparous (no children) and hadn't had any prior abdominal surgeries, it figured to be a quick and easy case.

Of course, Linakis's First Law (coined by my father) states that "the plot ALWAYS thickens" and this case failed to become the first known exception to said law.  I had scrubbed in and was watching the procedure.  The attending was saying that it probably wasn't going to turn out having been worth scrubbing for; he correctly pointed out that during a laparoscopic procedure you can generally see as much from halfway across the room as you can with your hands on the operating table.  Less than five minutes after he made that comment, he finally located the uterus among all the abdominal adipose tissue.  It should have been normal-looking.  It was not.  A large gray-white tumor was clearly protruding from the top of the uterus.  Immediately things became more serious.  This was no longer a quick and easy procedure that could be done laparoscopically.  She needed a laparotomy; that is, her belly had to be fully cut open so that we could go searching to see whether the cancer had spread.  Still, though, we were hopeful; if this protruding tumor was an isolated lesion, the patient's odds would still be pretty good.  That optimism lasted an even shorter time than the laparoscopic attempt.  When we opened her abdomen, we found small, nodular tumors everywhere.  Her omentum (a large fat pat in the belly) was liberally spotted with metastatic disease.  The colon appeared to be involved.  And all of a sudden, the once quick and easy case had turned into a nightmare.  Don't know who had to discuss our findings with the patient, but I'm glad it wasn't me.  Please keep her in your prayers tonight; the prognosis is (obviously) pretty poor.

Anyway, that's it for me.  It's time for bed; up at 4 tomorrow to start work at 5.  Yay.  Oh well, at least I have a good team!  Back with more updates in the evening.  Till then, peace and God bless!

SNAFU

Today was kind of a short day, mostly spent in the OR with Dr. Jaja.  Saw a couple of patients with fibroids getting different kinds of myomectomies and one patient undergoing endometrial ablation for heavy bleeding.  I had some reservations about the ablation because of its apparent effects on fertility, but this patient was already infertile and was actually having the procedure for fairly legitimate reasons (including failure of more conservative therapy).  Because there were residents present and fairly little space available, I didn't scrub in; I just watched either on the screens or from whatever angle I had available.  Cases for the day finished about 2:30 or so; I talked with Dr. Jaja for a bit and then headed home.  All in all, my week with him was a good experience that I would recommend, especially in the absence of true pro-life alternatives.

Then came the snafu.  Ob-Gyn here doesn't require night or weekend shifts on the theory that then we have no excuse not to study.  I worked last Saturday because of the program with Dr. Jaja, so my schedule called for me to have tomorrow off.  In a classic case of a genuine favor backfiring, one of my classmates (currently on Gyn-onc) emailed me with instructions from the senior resident regarding who to contact for the start of my gynecologic oncology subrotation.  He cc'ed the email to the intern and AI who are in charge of where and when the students are supposed to meet the team.  Normally, this would be great because it's tough to get all of that information from outside the team; unfortunately, neither he nor the residents were aware that I was supposed to have tomorrow off.  Thus, instead of getting some sleep and meeting with my SP advisor, I will be at Magee at 4:45 tomorrow morning.  Oh well...there's no crying in medicine, right?  Although there might be if I don't get to bed stat; I'm pretty useless when I'm sleepless.  Anyway, back tomorrow with updates from the first day of Gyn-onc.  Till then, peace and God bless!

OB and ID

I really need to try to write these earlier...when it gets to this time of night, I have little energy and only marginally more motivation to write about the events of the day.  I was in clinic again today, and once again it was pretty standard.  I saw several patients, both OB and Gyn, wrote notes, and ended up accidentally walking off with one of the office Dopplers.  Oops.  Topics for today included leiomyomas (uterine fibroids), causes of urinary incontinence, and effects of pregnancy on the pulmonary and cardiovascular systems.  Also got a decent look at hormone replacement therapy in PBL thanks to a couple of trials from a few years back.  Anyway, not much exciting today, but also nothing in the way of moral dilemmas or controversies.

On a health-related but Ob-Gyn unrelated note, I very briefly saw an article on MSN about a new plasmid that's popping up in Asia that confers broad-spectrum antibiotic resistance on (generally) Gram negative organisms.  Apparently these bugs are resistant to any and all beta-lactams (carbapenems included), fluoroquinolones, aminoglycosides, and basically everything except colistin (which hasn't been widely used in the US for years).  Anyone know anything more about this?

Anyway, that's all for tonight.  In the OR with Dr. Jaja tomorrow; we'll see how that goes.  Till then, peace and God bless!

Another day at the office

Pretty run-of-the-mill day today.  Worked for a few hours, did a few histories and pelvic exams, and called it a day.  Not much in the way of learning points or interesting cases, just some very nice, very...well, patient patients who allowed me to sharpen one of the more awkward skills required of a medical professional.  The only small issue was that one patient wanted information and counseling regarding her IUD (IntraUterine Device, a contraceptive gadget implanted in the uterus for any non-medical types); Dr. Jaja basically told me not to worry about that, that he'd take care of it.  I really have to say (as I've noted before) that this is a very good alternative for anyone like me with issues of conscience surrounding some of the mainstay topics of Ob-Gyn until we get a truly pro-life alternative in place.

Anyway, that's really it from me for tonight.  Hopefully I'll have more to say tomorrow...second day in Wexford.  Hopefully I won't get lost this time!  Peace and God bless!

Sorrow and joy

This will come as no shock to anyone who's done an inpatient rotation, but rounding isn't very much fun. Especially when you're covering three teams and it lasts for four hours. UGH. Worst of all, the last patient we saw was on her first post-op day after a C-section to deliver a baby that had suddenly and unexpectedly died at nearly 40 weeks gestation. Dad told us that an ultrasound last week had showed that everything was normal. At this point, no one is really sure what happened. I wonder what they'll tell their other kids...I'm sure they said they would come home from the hospital with a new brother / sister. How do you go about explaining to children that their new little brother / little sister died? What a horribly, terribly sad situation...prayers for that family would be greatly appreciated.

On a happier note, to sort of balance out the sadness of death, I got to catch another baby, a 9 pound boy. Little fella was kind of slippery, but I managed not to drop him (dictum #1 on Ob-Gyn: "don't drop the baby." In case you're wondering, it's also #2 and #3). It's really hard to stop smiling after an experience like that. He was perfectly healthy and mom was in good shape; dad had a rather dazed grin on his face after the little fellow finally decided to pop on out. He got a rousing chorus of "Happy Birthday," but apparently our little buddy didn't care for the rendition -- he cried from start to finish and quieted down almost as soon as the song was over. *Sigh* everyone's a critic...

Anyway, that's all for now. I have tomorrow off, which means I most likely will not be posting, but I'll be back again on Monday. Till then, peace and God bless!

30 second post

It's late, I'm tired, and I'm working tomorrow morning, so this is going to be short. Today cured me of any smidgen of desire I might ever have had to a) practice anything related to Ob-Gyn, or b) to work as a primary care / outpatient physician. I got to do a fair amount (bimanual exams, speculum exams, Dopplers for fetal heart tone) but the work in an outpatient Ob-Gyn clinic is mind-numbingly boring. Seeing one patient after another for six or seven hours is draining after a while, particularly when four or five in a row are simply well checkups. Ugh. Oh well, working with Dr. Jaja is still very much a positive thing, as his humor and willingness to teach and get me involved help at least make the day productive. At this point, I'd suggest anyone in my position at least consider volunteering for the experience with Dr. Jaja rather than doing the resident clinic -- better variety, more continuity, a good degree of involvement, and respect for strongly held beliefs. Of course, if the rotation at Mercy comes through...

Anyway, that's pretty much it for me...back tomorrow with a weekly wrap-up. Till then, peace and God bless!

The good and the bad

On the surface of things, today was a pretty good day. I saw several patients with Dr. Jaja, did a couple of pelvic exams, and best of all I got to catch a baby more or less on my own (although I felt really bad for the family medicine resident who had probably spent more time with the new mom than I had). It was a good day for learning. The less promising part of the day was more subtle and centered on seemingly innocuous questions of language. Part of what I'm required to do each day for Dr. Jaja is to write a very brief (half-page or so) summary of a single patient to be discussed the following day. My writeup yesterday was about a woman who was worried because she'd had an episode of bleeding after being pregnant for several weeks. She verbalized this by saying "I'm nervous about my baby." Thus, in my writeup, I described her probable diagnosis as "threatened vs. complete miscarriage" and referred to her unborn child several times as a baby. Why is this significant? While I was discussing the write-up with Dr. Jaja, he mentioned in passing that the more correct terminology was "spontaneous abortion" instead of "miscarriage" and "fetus" instead of "baby." He brought these up just by way of explanation, and not with any ulterior motive, but it was emblematic to me of the culture in the country in general and at Magee in particular. Its net effect is to make the word "abortion" less loaded by linking it with something that unfortunately occurs naturally and to minimize the humanity of the unborn child. It is thus no surprise that the pro-abortion establishment has inculcated the use of this language in medical parlance, especially in the world of OB-GYN.

Anyway, that's all I have time for tonight...back tomorrow with reports on my first outpatient experience in Wexford. Till then, peace and God bless!

First day of clinic

Ok, so I know I promised details, but it's already 10:30 and I'm exhausted. So here's the abbreviated version. The schedule for today said that I was supposed to start at noon. I had a hard time believing that, but I found nothing to the contrary. Still, I couldn't countenance waiting till noon to get to the hospital, so I got there around 10:15 and found Dr. Jaja's office, then went down to the library hoping for a miracle. God came through. The library had purchased -- and JUST received -- several new copies of the Hacker and Moore textbook that's the recommended reading for the clerkship. So I spent the time until noon reading and then went up to meet Dr. Jaja. The afternoon was pretty good. After Dr. Jaja laid out his expectations and the learning objectives, and after I explained what as a Catholic I was and was not willing to participate in (he not only didn't have a problem but was supportive of my following my conscience), we dove into the rather extensive patient list headfirst.

Today I was largely just shadowing. This was due in no small part to the fact that I have virtually no experience with obstetric / gynecologic histories and physicals. I know most of the theory, but my comfort level is low and my skills are still poor. One of the major goals of this part of the clerkship is to remedy those weaknesses, and it seems as if Dr. Jaja has a plan for how that can be accomplished. Today I watched (and semi-participated in) several obstetric antepartum visits (learned how to perform the Leopold maneuvers among other things) and a couple of gynecologic exams (learned proper use of the speculum and how to perform a Pap smear). Tomorrow I'll be back in L&D, where I have at least a little bit better background (one whole week's worth!), and I think that'll be fun.

The rest of the afternoon was ok. The ethics session was intellectually stimulating (sort of) but not especially helpful, and PBL was decent (relatively poor cases on prenatal counseling followed by better ones on STDs). Otherwise not much to tell.

Anyway, that's all for tonight...back tomorrow with a report on L&D. Till then, peace and God bless!

Back to work

Ok, didn't post over the weekend. But it was back to work today, so back to blogging. For better or worse, not a lot to write about today. The woman I was following looked like she was on the verge of delivering all day...and finally started pushing just as I left for PBL. And there weren't enough C sections to go around. So I ended up doing a lot of reading today...hopefully that'll help me not embarrass myself tomorrow when I start doing clinic work with Dr. Jaja. We'll see how that goes, but having met and worked with him briefly last week, I think this might turn out ok. I'll be as detailed as possible in my description of how the days run to give anyone who might be interested in signing up for this alternative a feel for what happens on any given day.

I guess the one thing that did happen today was a PBL that spent a great deal of time discussing contraception and sterilization. It really sort of made me think...the way the facilitator approached the topic (and the way that medicine and, indeed, society in general approach the topic) was from a mindset of contraception being a fundamental right. The underlying corollary to this, of course, is that sex is also a fundamental right. Furthermore, there is an even deeper and more insidious understanding that we as human beings should be able to do whatever we want without consequences or responsibility. And by these flawed understandings, we have taken an act that stood at the pinnacle of human relationship as a total, reciprocal self-giving and turned it into a cheap tool of quick pleasure, a Saturday night "hook-up." It has been said by many theologians that sexual intercourse, the act of conjugal love, is the nearest we can come in this life to approximating the love of the Trinity. But by removing the consequences and the need for commitment, by removing the responsibility and gravity that once attended sex, the act itself has become meaningless and emotionless, having no particular value over and above any other means of showing affection or obtaining pleasure. The message today is that sex is fun, babies are inconvenient, and that the individual's enjoyment is the most important thing. Hakuna matata, right?

...but didn't Simba eventually realize he was wrong for leaving his responsibilities behind? Maybe, someday, we will too. Anyway, that's my sermonizing for the day. Back tomorrow with new and exciting stuff! Till then, peace and God bless!

Lots of cutting

Just a brief post today. It was a day for C-sections (kind of like yesterday), and I scrubbed in on two; I think we only had one or two women deliver vaginally during the entire day today. The only other clinical event of any significance was a pregnant patient who had a condition called for her when it appeared she was having a seizure. From what little I could gather, neuro thought that this was another (likely deliberate) pseudo-seizure, as she has been found to have similar events many times over the last few days. This was particularly sad because she had been told by one of my residents earlier in the day that seizure meds (Ativan) were bad for her baby but if she appeared to seize he'd have no choice but to give her that medicine because seizures would be even worse. I hope there's another explanation, but it'll have to wait until Tuesday.

The "I'm kicking myself" special of the day: I wasn't paying close enough attention right after I came out from my first C-section of the day, so I completely missed an opportunity to scrub on a delivery of twins. That may end up being the biggest regret I have from this rotation.

Anyway, that's all for now...if I have a little discipline, I'll post on other topics over the weekend. Till next time, peace and God bless!

A Tale of Two Days

It was the best of times, it was the worst of times. We'll start with the bad so that we can finish with the good. The day finished with a lecture on abortion delivered by a prolific abortionist(who, ironically, is associated with the "Family Planning Center"). The lecture, billed by the course director as being focused on the medical aspects of abortion, sadly failed to live up to that description. Instead, it was an hour long cheerleading session about the benefits of abortion and how low the risks are compared to delivering a baby with occasional tidbits of actual knowledge thrown in. The words "studies have shown" were thrown around a lot, but with no actual citations to back them up. Having reviewed the literature myself in the past, I think his claims were greatly exaggerated; when I have a little time, I'll go back through and find some of the articles I've read in the past. He also dismissed the pro-life movement as being "anti-choice" and our ethics, arguments, and evidence as "just rhetoric." Just for kicks, he also threw in an incredibly inappropriate description of the abortion process that is not suitable for print; if for some reason you really want to know, ask me by some other means.

Anyway, after the lecture ended, I introduced myself to him as one of the pro-life students he had spoken about. I said that I respected his opinion though I disagreed with him, and I asked him to please have a little respect for my beliefs and those of like-minded people. His response? "Sure, I respect your beliefs, but that doesn't change the fact that you're anti-choice." I told him that I respectfully disagreed, and that I didn't think that name-calling by either side was conducive to a productive dialogue. He replied "I won't argue with you. You can't call me anti-life, I'm very pro-life. I believe that people should be able to live however they want. You're anti-choice. You don't think a woman should be able to choose how she wants to live." I again told him that I respectfully disagreed and that I could produce evidence to support my beliefs ("It's just rhetoric," he snorted), but that I wasn't looking for an argument, merely for a little respect. "Psh," he said, "fine. I respect your opinion." And he walked out of the room. So yeah, first serious challenge of the rotation there. Dunno how this will play out long term, but if I never have to work with this individual again, it'll be too soon.

Anyway, the good...today I actually got to deliver a baby. Not to watch one delivered, not to have the intern's hands doing all the work over top of mine, but to really, truly be the one to work the baby out of the womb and into the world. Before too long, everything in the preceding paragraphs will be forgotten. This I will NEVER forget. It was a C-section delivery, and the PA had just incised the uterus so that we could bring the baby out when the attending said to me "Hey Seth, do you want to deliver this baby?" I don't remember what words found their way out of my mouth at that point, but the upshot (clearly) was "heck yes!" "Ok, here's what you need to do..." I had learned all the techniques, but many of them deserted me in the face of this actual delivery...and the fact that it's a lot less scary to push really hard on a mannequin than to exert serious pressure on a baby. And I do mean SERIOUS pressure. It takes a lot to get the shoulders out. I didn't do it perfectly, but I got the little guy out in one piece and in perfect health, and that's what counts, right? Hopefully I'll have a chance to do that once or twice more before this part of the rotation ends, but regardless, I think (and hope!) that this delivery will forever remain etched in my memory.

Anyway, that was the day. I'm sorry to have to spoil the delivery of such a beautiful, awesome creature with a story of a sad, confused, insecure individual, but I promised I'd chronicle the challenges associated with the rotation, and unfortunately, that's going to be one of them. Still, though, disheartening though that encounter was, it'll drift away with the morning breeze and leave the memory of a beautiful newborn baby boy screaming his lungs out while resting in my hands. Still can't get over the sheer awesomeness of that. Anyway, until next time, all...peace and God bless!

Long day = short post

Mostly a good day today. On post-partum rounds this morning got caught briefly in the awkward situation of being in the room while the intern was counseling a patient about contraceptive use. For better or worse, it was short enough that I didn't have time to leave the room. Otherwise, the day was highlighted by two vaginal deliveries (aptly described by one of my classmates as "so gross but SO AWESOME!") and an uncomplicated C-section resulting in three healthy children and three ecstatic families. The residents were also in full teaching mode today for some reason that I'm not going to question, so it was a productive day both in terms of skills and knowledge. No other real issues, blessedly. That will, unfortunately, likely change tomorrow when an attending with whom I've unfortunately crossed paths before delivers a lecture on abortion. Suffice it to say that if it's at all similar to the one he delivered 6 or 7 months ago, I'll have plenty to say about it in this space tomorrow.

Anyhow, I guess so far this hasn't been bad. I hope and pray that lasts, and that the good news delivered by another classmate (maybe we'll get a pro-life Ob-Gyn option after all!) comes to full fruition before next year. That's all from me for tonight; hope everyone's doing well. Peace and God bless!