Thursday, January 26, 2012

3rd and 4th Weeks of OBGYN

Phew, it has been an intense couple weeks.  Have barely had time to think.  I'll start with my 3rd week (last with Preceptor #1).  As far as the clinic days went, we had some interesting cases - an IUD expulsion, a retained tampon, trichomoniasis, and lots of pregnant women with whom I got to practice finding fetal heart sounds.  The most recent thing I can remember is my last day there - Thursday which lasted 24 hours.  We had clinic during the day, then that evening we had an overnight call shift from 6:30pm-6:30am.  I think it was that night that at the start I joined the doctor for a laparoscopic ectopic pregnancy removal.  She was somewhere between 12-20 weeks.  Apparently it is rather rare for an ectopic to get as far as surgery because they usually catch it early enough to use medical interventions.  Anyhow, that was interesting.  Then I slept for a while and got woken up for the delivery at the end of the shift.  My preceptor let me sit in the front seat for this one and I delivered the baby, handed it to the mother, clamped the cord for the dad to cut, and delivered the placenta.  My preceptor sutured up the tears, of which there weren't very many, and we took care of that.  There was some retained placenta (I think because he was trying to get it out before it was fully detached, I would have given it more time but that's my side of things), but he got it out with a loop scraper. 

A few other things of note - I was following a patient who I had assisted on a delivery for.  She was a caesarean section because of a placenta previa.  As a result of excessive bleeding that was suspicious for retained placenta or at least failure to clot, we took her back to the OR but in the room the uterus had essentially stopped bleeding so we inserted a 'balloon' to help plug the bleeding via compression.  We took that out the next day.  There was another patient for who had a urethral sling, vaginal/cervical suspension and anterior and posterior repairs done on the pelvic floor.  Her posterior repair (the easy part at the end) wouldn't stop bleeding and she developed a painful hematoma so an hour after taking her out we had to bring her back into the OR to redo the stitching.  That was a bit of a pain.

Now onto my 4th week (1st week with Preceptor #2).  My new preceptor is very nice, a bit more 'preceptor-like' than my previous ones - a lot more teaching, more presenting, more following patients, more is expected of me but I am rising to the challenge without much problem.  It's more mentally stimulating and it's nice to have a little autonomy.  The first day I saw one delivery that went well, and then there was another one that ended up being a shoulder dystocia.  Shoulder dystocias are one of the most scary complications in obstetrics because a healthy baby manages to get it's head out of the vaginal canal, but one of the shoulders gets caught beneath the woman's pelvic bone.  This causes compression of the cord, and compression of the baby - so the baby is getting less oxygenation from the mother, and is doubly unable to expand its lungs to breathe air from the outside.  At this point the team starts a timer and begins various maneuvers to free up the shoulder - including hyperflexion of the mother's legs at the hip, suprapubic compression, reaching into the uterus and trying to free up the arm, and various clockwise/counterclockwise rotations.  Last resort includes breaking the collarbone and/or humerus.  Many complications can occur as a result, one of the most notable ones is a brachial plexus injury which results in nerve damage to the impinged shoulder.  The baby comes out with an arm that doesn't rise, it is pinned to the baby's side and it's hand is facing behind it - Erb-Duchenne Palsy (or "Waiter's Tip" palsy).  Anyhow...this baby they got out and it ended up having decreased arm movement, it looked like it had some nerve damage.  Luckily, even when these signs are present at birth, 85-90% of the time the baby recovers in the first 2 months.  By the second day after the delivery, the baby was starting to move its hand and shoulder. 

Now onto today - a nice long 24 hour shift from 7am to 7pm.  This L&D floor is a lot smaller than the previous department that I was in so there aren't too many active patients, and there's a bit more down time.  However, as luck would have it, we had ANOTHER baby with shoulder dystocia today. The first baby ended up being 9 pounds 11 oz, and this one was 10 pounds 1 oz.  Needless to say, it is well documented in the literature that large "macrosomic" babies have a higher incidence of shoulder dystocia.  This one didn't have any real nerve damage though.  The mom was pushing for a good 2.5 hours, it was a little challenging with language barriers but it worked out okay.  From what I can tell, shoulder dystocias are not very common occurrences - some previous students haven't even seen a delivery period, so for me to see two dystocias is pretty crazy.  I'm glad the outcomes have been relatively good.

We also had an interesting ED consult for gynecology - a woman with a 14cm possible tubo-ovarian abscess.  We have started her on empiric antibiotic therapy while we wait for GC/Chlamydia results.  There is some concern that it may be a tumor, or have some tumor involvement because she has had significant unintentional weight loss over the past 6 months.  No way to know at the moment - just gotta treat.  I'm gonna nap now, I'll be woken up if we have any new admits - on the plus side, I get the day off tomorrow.  More studying, wooh!

Wednesday, January 11, 2012

Call Night and Week 2

OB-GYN is coming along without much of a problem.  I had my on-call night, and I thought I had been warming up to the whole baby thing, but I think the first vaginal delivery was kind of the ideal situation, along with ideal family responses, and environment.  The call night started out with figuring out logistics essentially - talked to the doctor for the evening, and it was my preceptor and this other female doctor on call that evening.  They divide the night into shifts, and so my preceptor slept from 9pm-2am, and the other doctor got to sleep from 2am-7am.  Like all medical students, I wanted to show my enthusiasm, so I decided to spend as much time with the other doctor before caving into sleep.  We had a couple interesting cases.

First case - fetal demise in an orthodox Jewish woman, 3rd pregnancy (has two living children).  A couple things are wrong with this case.  First, she was inconsistent with her prenatal care and was taking a lay midwife's advice over going to prenatal checks with her physician.  The doctors that I work with at the hospital have made a distinction between the midwife nurses at their hospitals and the lay midwives who are not affiliated - that in the hospital, their threshold for thinking a baby is in trouble (and thus, needing to interfere with the 'natural' progression of a gestation and vaginal birth) is a lot lower.  As a result, the hospital midwives are more willing to consult a doctor about a baby's status, or suggest a C-section.  Anyway, the woman stopped feeling any fetal movement around 23 weeks and the lay midwife said that was "normal".  The woman finally comes into the hospital after a WEEK of her baby not moving and there are no fetal heart tones of course, so it's dead.  The second problem is that a lack of prenatal screens/ultrasounds didn't catch what is most likely an anencephaly (or lack of a head) on the baby.  It could have been caught a couple weeks earlier, but no.  People like to talk up natural traditional methods of health care, but there's a reason we have these tests.  The third problem with this case is the orthodox religion - mostly it just makes patient care more difficult, but they need to consult another rabbi (even though her husband is a rabbi) to determine if they can test the placenta (dead baby is definitely off-limits) for chromosomal abnormalities.  Often when a woman has a fetal death, it is reassuring and relieves guilt to know that the baby had a chromosomal abnormality or other problems inherent in the baby that would have made it nonviable no matter what.  

Next case of the night... this really pretty Asian girl, possibly Filipina, late twenties, on her third child.  Her husband was with her, kinda ugly, but I gave him the benefit that maybe he's just a really sweet supportive guy to win a gal like her.  She decided to go through the vaginal delivery without any epidural anesthesia, and she barely made a peep - she did a great job, trembled a lot, but delivered the baby pretty quickly.  Right after this, the husband essentially ditches his shaking wife and stands with his back to her filming the baby in the warmer with his phone.  Once or twice the wife seemed to try to get his attention but he either glanced briefly or didn't respond.  This went on for at least 10 minutes, the whole time I was in the room anyway.  There also wasn't anyone else in the room, no other family.  I never saw him go over and ask her how she was feeling, or tell her she did a great job - made my blood boil.  

Next case before I went to bed - 21year old girl, second pregnancy, husband was this short kinda meek white guy - she delivered like a pro too - she did have an epidural, but she basically had no problems.  The husband on the other hand just about passed out when he saw the baby crowning - he wasn't intending to look, he was walking around where we were to the other side of her and his face just went white and he just about fell to the ground right there.  It was kinda funny, but at least all the family were supportive, smiling, and the husband stayed next to his wife this time.  

After that I went to sleep and my preceptor called me when he had a new case - we did a few checks to see if any girls' water was breaking, interesting stuff.  Around 8am I was done and in the car.  

That was it for that week - yesterday we started in the clinic and I got to do some Pap smears and some prenatal checks where I measured the uterus size (to see if it was consistent with the gestational age) and checked fetal orientation and heart rate.  The first one or two were a little challenging to find the heart beat for me, but I think I've started figuring out where the baby's body is oriented, so I was spot on the last 3 heart rate checks.  We saw a woman with an expelled IUD - usually that doesn't happen to women who have had pregnancies, but apparently she was told she has a short cervix.  

Today had two surgeries - one was a mid-urethral sling insertion, which is to help with incontinence.  The woman was awesome - she was a feisty, energetic, humourous elderly woman.  It's always reassuring to see older people with such vitality!  So that surgery took 35 minutes, no problem.  The next one was significantly longer, a laparoscopic vaginal hysterectomy, on a woman with an enlarged uterus and multiple fibroids - had to cut it up a lot and bring it out piece by piece.  The doctor my preceptor was assisting actually thanked me at the end for my help because the extra pair of hands made it go a lot better than they were expecting.  Yay!  

Tomorrow is a morning/afternoon of surgeries, and then another evening of call duty - I think I will try to sleep when my preceptor does this time, since I will not have had all day to relax.

Sunday, January 8, 2012

1st Week in OB/GYN

Well, almost done with my first week in OB/GYN.  The first day we were on gynecological duty, so we were seeing patients in the hospital for ovarian cysts, pyelonephritis, etc.  However, we did assist on two C-sections and I got to observe a vaginal delivery.  It feels very odd to see a family react to a "birth" in scrubs while surgery is still technically taking place (suturing everything up, still have half the environment sterile).  The vaginal delivery setting makes a lot more sense - the delivery I saw only took about 40 minutes too so that was a pretty quick delivery.  Watching the men is the funniest part because they look terrified and helpless at the same time - after all, it's not like they can relate in any way and they can't really participate in the actual process - she's doing it all herself.  Of the two delivery methods, I'd definitely rather do the vaginal one personally (with epidural of course) - it just looks a lot more impressive.  

The next time I was in the hospital we were rounding on patients and doing a lot of gynecological surgeries so several hysterectomies and salpingo-oophorectomies (tube/ovary removal).  Not the prettiest of surgeries...especially when they do a hysterectomy through the vagina.  Before heading into this rotation, I had no idea that OB/GYN doctors do so much surgery.  Anyway, tonight we are on-call from 7:30pm to 7:30am, so I best be getting off to that - should be interesting.  I like night time, and I'm packing an energy drink - I hear there will be many deliveries.  I will post about it next time I have a spare moment!

In other news though, I got my loan disbursement, so money is not a problem for a little while.  I emailed my school contact about year 4 rotations and I am still studying for the boards - Feb 4.