Ob/Gyn Notes

The following are a few observations I've made the past several weeks during my Ob/Gyn rotation. To bring you up to speed, obstetricians/gynecologists are the doctors that deal with the cooter. Now, somehow, working exclusively with woman patients brings out the nasty in most of the residents in this woman-dominated field.

• Gyn residents are catty, very catty. All the rumors about the Ob/Gyn field being a sorority have so far held true. In front of patients they maintain sufficient professionalism; but behind closed doors (and just barely out of sight of others), the gloves come off and the hissing begins. They hope a difficult surgery will be assigned to Resident A so "she can fuck up and get in trouble". Then they revel in how much they "fucking hate" Resident B even though she doesn't even know it. During none of the seven rotations I have completed this year, have I once encountered a group of residents that gossiped with so much malicious enjoyment.


• Gynecologists are surgeons. While some choose lifestyle-friendly careers that entail performing Pap smears over and over again, the majority of them stick with doing what they love: operating. What's my point? Gynecologists, as surgeons, are trigger happy to cut you up. And the one thing they love to do are hysterectomies. So . . . if you ever go to the gynecologist with any problem more severe than a cold, expect to have your uterus taken out.


• Despite all my bitching and moaning, I am grateful for this rotation for two important reasons. First, I learned how to perform a pelvic exam correctly, and with the little bit of practice I had (roughtly 5 pelvics), I feel that I'm finally (minimally) competent enough to do one effectively. Next, more importantly, I finally learned how to tie one-handed knots. The general surgeons never taught me (in fact, some of them forbid us to tie one-handed knots! [as one of my interns succinctly put it, "surgery cocksuckers"]), and I thought I had forever lost the opportunity to be cool.

OK, time to practice knot-tying now ....

Grand Rounds

Still new to the whole (medical) blogging phenomenon, I've recently discovered something called Grand Rounds, a weekly complication of medical blog entries. It is hosted by a different med blogger each week. I'm not quite sure yet how an article qualifies (whether articles are selected, or the authors submit their own article), but some of the articles are very entertaining.

So as a means to start communicating with the outside blogging world, I'll try to link to Grand Rounds every week. This week's Ground Rounds -- aka Grand Rounds #83 (Vol. 2, No. 31) -- is up at the Health business blog.

Enjoy!

Creepy Clothes

Our county's coroner office is located very close to the hospital at which I work (in fact, during my second year of med school we spent one morning there -- a field trip, of sorts -- learning about the work that goes on there and then observing an autopsy; that morning presented some of the horrifying sites I'd ever seen, including a blackened skeleton of a person caught in a burning car.)

Also close to the hospital is a little used-clothing shop that has racks and racks of clothes outside, selling them for very cheap (for example, "12 shirts for $10").

I see this shop everyday as I leave the parking garage, and I finally put two and two together, realizing that this was an odd location for a used clothing store.

Ask anyone, I'm the biggest fan of inexpensive clothing. But this ... this is just a little too creepy for me. I'm not a superstitious guy, but I'd feel like I'd be next if I wore a shirt last worn by a guy shot in the head.

Miracle of Birth, Part 2

My earlier post might have been interpreted as being disrespectful to women in labor, but rest assured that that was not the intention. It was simply intended as a graphic description of the several deliveries I witnessed, and contrary to what might be implied, I am actually very impressed by the stamina and pain tolerance demonstrated by women in the midst of child birth.

Still, in retrospect, the birthing process was neither interesting nor appealing to me, and I found myself only enjoying those moments that involved the baby -- starting at the time delivery was imminent, to seeing the crown, to pulling the baby out, to handing it off to the pediatricians. In fact, near the end of every delivery I was so mesmerized by the baby's presence that I would follow it around instead of focusing my attention on its hemorrhaging mother ... something my team noticed, too, as they frequently needed to pull me physically back to the table.

To sum up: deliveries are gross, babies are cute.

Maria Gonzales

Throughout this entire OB rotation, it's been extremely hard for me to keep track of the patients on our service. After thinking it through, I realized why: it's because all our patients are the same.

Whereas in other clerkships and specialties you can keep track of patients based on their sex, age, or varying medical problems, that is close to impossible on this rotation. First, you can't go by sex because ... duh ... they're all women. You can't differentiate based on race because they're all Hispanic, which is the norm for this hospital (on a related note, because of this fact, the variety of possible names is drastically reduced since their first name is either Rosa, Maria, or Juanita, and their last name is either Francisco, Lopez, or Gonzales; pick one of those first names, then pick one of those last names; I'll guarantee you there is a patient on our service with that name).

(On yet another related note, most of them speak little to no English. Not a word of English. Actually, the only word I believe they know is "English", so that upon hearing us ask "do you speak English?" they hone in on that word and know to respond "no." What the hell?)

Next, age can't be used because all our these pregnant women are in their 20's, which, by the way, is quite disturbing, because all these 20-somethings are presenting for their 3rd, 4th, or 5th pregancy, indicating that their first baby was in their teens. Again, what the hell ... but that's another story.

And it was then I realized why, for the first time in third year, the residents on my team always referred to patients by their room number. (e.g. "16 needs to be examined" or "44 is in active labor"). It's not a practice they would be proud of, especially thinking back to their idealistic pre-med days when they had illusions about how they would practice medicine, but one that's necessary given how all our patients are pregnant-for-the-4th-time Maria Gonzales.

Miracle of Birth, Part 1

What cries and smells like poop?

A baby. A freshly-ejected-from-mama's-swollen-vagina, still-tethered-by-its-cord, slippery baby. In case you thought fresh babies enter this world as cute as they appear in their crib, think again. Birth -- contrary to popular belief -- is only beautiful in theory, for in reality it is a prolonged, painful, and sloppy ordeal.

It starts with a mother -- a clean mother -- feeling slightly anxious; she has heard it's painful, but unless she has experienced this already, she has no idea. The situation then escalates over many hours to full-fledged, unfathomable pain, punctuated by squirts of blood, poop, and other juices. The mother is screaming and squirming, probably regretful she ever got intimate with the father. With every painful contractions she's being yelled at to push -- performing the exact same bodily maneuver as during a bowel movement -- by people she has just met (i.e. hospital staff, not random strangers). Every muscle in her body clenches as she attempts to squeeze out an object that's twice as large as the opening through which it must pass.

This continues for hours. Despite all the pushing and agony and "progress", the baby only descends a fraction of a centimeter at a time. With luck you'll see a patch of hair, which is the top of its head. If she pushes more, the entire baseball-sized head pops out. More pushing squeezes out a hand, its body, and the other hand. Finally, you end up with a wrinkled little hairy prune of a human, which, surprisingly, doesn't cry much. It just stares right back at you.

(And don't forget the placenta ... that sustainer of life that resembles a large raw steak, clinging to mama's insides until it is vomitted from the vagina after the baby comes out.)

Yes it's definitely a miracle ... not because a new life just entered the world, but rather because the new mom still likes this creature that caused her so much pain, and also because women willingly endure this process again to have more children.

Dr. DRE

My family medicine rotation began today, and I was about to see my first patient. I assumed I had all the skills necessary to carry out the entire patient encounter ... after all, I had completed medicine, surgery, and pediatrics (but not ob/gyn, so I hoped it wasn’t a female patient) and thus I felt prepared to handle whatever was needed for this routine check-up.

Walking into the exam room, I glanced over the sheet stating what parts of the history and physical I needed to perform and quickly reviewed how to perform them: heart exam (check), lungs (check), ears (check), and then my eyes fell upon the one exam I did not want to see…the didgital rectal exam. The exam I most hated. The exam I most feared. My nemesis. Precisely why I felt this way about the rectal exam I don’t know, but I do know that I’d rather perform any other component of the physical, including the genital exam, the breast exam, or hell, even the pelvic exam in which I’ve never been trained. Actually, it was probably because I’ve had the least experience with this exam, and the last -- and only -- time I’d performed one was at the end of second year in an artificial, evening workshop when all-to-eager volunteers lent us their rectums for educational purposes.

However I felt, when the time came, I had to do it. I tried hard to recall the instructions from that evening workshop one year ago, the first of which involved putting on two gloves. I then positioned my poor patient (I don’t know if I felt more sorry for him or myself) and regurgitated the only line I remembered from the workshop: “take a deep breath and then exhale”, with the intent of sending in my digit during his exhale.

He breathed in, and as he exhaled I took a quick survey of the terrain ... only to realize I didn’t see no rectum. Uh oh. Trying to buy myself some time, I asked him to breathe in again but still couldn’t find the right hole. I asked him yet again to inhale -- promising him it’d be the last time -- and I shoved in my finger like I was poking dough. I was inside, or so I thought. After some wiggling, I was quite disappointed to realize I had shoved my finger not into his rectum, but merely in between his thighs. Pathetic.

After several more iterations of “OK breathe in, now breathe out”, I finally did get my finger into his elusive rectum and took care of medical business. We were both relieved as he pulled up his pants, and I walked out feeling similar to how I had felt on my first day of third year, fresh out of the classroom and new to the wards. And while I can’t say there was a moral to be learned from this encounter, at least I can place one more mark on my rectal exam belt.

The First Time

I'm between rotations at the moment, so here is a little story from not too far back. It was the end of the second week of my cardiac surgery rotation, and I was at the point where I felt I should be a little more competent and useful to the team. An adolescent patient was being admitted to our service and was there with his mother. This patient had a rare autoimmune disorder known as RPC that caused his own body to digest certain types of his own tissue. The patient was being forced onto our service -- essentially against our will (yes, ours) -- for a possible valve replacement surgery or two.

But why didn't our team want him admitted? Why didn't we want to operate on him? Because based on the little we had learned of his obscure disease from the "experts" (the rheumatology consultants), chances were good that within a few years of a valve replacement operation, his body would just eat away the new valve and necessitate yet another replacement surgery.

Things did not look good for this patient. This poor patient -- mentally disabled, partially deaf, and often staring into space with a blank look on his face -- was, for now, being denied a surgery that could have improved his quality of life immediately, since his heart condition was so severe now that he couldn't stand up for more than few minutes without fainting and collapsing.

The eager med student that I am, I sought to see if anything helpful could be done. I searched the literature and found case report after case report of patients similar to ours that had valve replacement surgeries ... and all ended up with the same poor outcome: repeat valve replacement surgeries within a few years. But I then found one short, obscure article recommending a certain type of procedure that eliminated the need for future surgeries. Before bringing up this news with my team, I went and talked with the patient's mother to see what sort of life her son used to lead. She related that while he might appear sluggish and debilitated now, this was only a recent development and that until a few weeks ago, he lead a fairly normal life -- he was affectionate, he could communicate with others, and he loved to play basketball. In short, offering him the surgery would return him to a life that he enjoyed and where he was loved by others.

I presented the results of my search and interview to my fellow, and together we made a brief yet impassioned plea to our attending, convincing him how this patient wasn't simply some gomer sent to us to have a surgery only to be sent back to a gome home, unnoticed and left to die, but rather a young patient who had much of his life left and whose presence would be appreciated by a close family. Our attending agreed to do the recommended surgery, the patient did well, and for the first time in my brief medical career I felt I had made the proverbial "difference in someone's life".

My Special Hospital

The hospital that I work at is not your typical hospital. This huge behemoth is not what one would call a well-oiled machine or anything remotely similar. Besides the fact that it is over 100 years old and is still confined to most of the same buildings all these years, this is, after all, a general hospital, meaning that it treats everyone who walks through its doors, both insured and uninsured. It’s overpopulated with patients, understaffed (which is why students are allowed to do so much), and short on space ... a deadly combination that results in lots of work that doesn’t get done and also many disgruntled employees sporting the typical government employee attitude of “I don’t care”.

However, as unpredictable and quirky as this hospital is, there are definitely a few things you can always count on. Here are just a few:

The Smell
It hits you before you even reach the patient’s bed. You can’t tell if it’s the smell of the hospital in general, the disease itself (for awhile I was convinced that appendicitis had its own unique and disgusting smell), or the smell of a person who hasn’t showered for as long as they’ve been in the hospital. It’s a strong and foul odor that smells like a mix of vomit, poop, and bad breath and it makes you want to cut short your interview and physical exam so you can quickly run away to somewhere, anywhere, where there are no patients ... the hallway, bathroom, your car, somewhere, just get the rotten air out of your nose. Whatever it is, every patient has it, and there’s no escaping it.

So what was it? In the end, no one knew. Most of us just concluded that the smell was probably the nasty stench of someone who hasn’t brushed their teeth in days.

STAT Lab Tests
You know it from the show “ER” ... you probably don’t know exactly what it means but you’re pretty sure it means something like “do it now!”. It’s the phrase “STAT”, medicine’s popular yet cryptic term to describe some order — a blood draw, for example — that needs to be performed immediately. Even though on TV it’s yelled out aloud, in reality it’s only written on forms. For example, when ordering an X-ray, you check off one box indicating the level of urgency: Routine, Expedited, or STAT. Now, based on common sense (as far as practicing medicine goes), it’s assumed that ordering something as “Stat” means that whoever is in charge of processing that order will drop whatever they’re doing and immediately start your order. So a stat lab draw ordered at 3pm will hopefully be drawn by 3:05pm and have results back by 3:30pm. Right?

Riiight. Not here, as you might have guessed. At this hospital, one is lucky if that 3pm STAT lab is even noticed by the nurses at 4pm. Realistically, you are looking at blood being drawn by 5pm and results returned by 6pm.

And that’s for a fast test. If you think that’s slow, take an X-ray. Here, you’re lucky if it even gets done. Put in an order for a STAT chest X-ray for 3pm and then pray; if all the stars are aligned properly (meaning the nurse clerk doesn’t accidentally lose the order, the radiology techs don’t forget about you, and the computer system isn’t "down for upgrades"), you’ll have it by nighttime. Sad but true.

Now you see why the X-rays we need by 9am are ordered as “3am X-ray, STAT”. And now you also see why our patients never, ever leave.

Colorful Names and Useful Relatives

School is now in session, peoples. They say doctors can learn as much from patients as patients can from doctors. Yeah, I suppose this applies more to things like compassion and other touchy-feely values, but it's much more interesting when it involves practical and concrete skills that can help one on a day-to-day basis.

Case in point: today a black woman was brought in to the Psych ER while intoxicated and was very agitated. Extremely agitated. So agitated that despite her hands handcuffed behind her back, she was still thrashing enough to cause tons of mayhem and frighten half the staff. She also had a coarse, loud voice that barked out endless nonsense whenever someone looked at her.

But talk about a silver lining. Unbeknown to most, as destructive and annoying (but still entertaining) as this patient was, she shared some valuable insight on various subjects ... such the ethnicity of names, one in particular, as evidenced by this brief conversation:

Patient: Hey, Scott!

Axis: My name's not Scott.

Pt: I know, I was just calling yous a typical white name.

Axis: White name? So, are there white names and black names?

Pt: Yuh, of course!

Axis: Alright so what are some black names?

Pt: Uh, we got Lawanda, Theresa, Montisha, Shantella, ...

Axis: Cool ... so what about [patient's first name]

Pt: Ooooh! That be one unique nigga name!

Wow! She was so excited that for a second she didn't realize that that was her name. But once she did:

Pt: Ahhh, you got me, you got me!

-----

Not to cut the lessons short, she also taught me about the role of a new kind of father.

Axis: Why haven't you taken your meds?

Pt: The little daddy didn't give them to me.

Axis: Why not?

Pt: I told you, little daddy didn't wanna give me none.

Axis: Wait, who's this little daddy?

Pt: Do I gotta explain everything? [SIGH] It's the nigga I brought home to fuck.

-----

Now don't tell me those aren't useful nuggets of information. Anyway, Axis 101 is now adjourned. Thanks for stopping by.

Lasers and Tasers

My current rotation of the month is psychiatry, and specifically I spend my days in the Psychiatric Emergency Room. Technically, the Psych ER is where patients with emergent psychiatric issues -- such as suicidal or homicidal ideations or an inability to take care of themselves -- are brought in, where, just like a "regular" medical ER, they are stabilized and either sent home or shipped out to an inpatient facility; they are typically brought in by police or paramedics after a call to 911 is made. In short, it's where the crazy people are brought as they calm down from their craziness.

It is not uncommon to see people brought in, for example, because they were discovered slicing their wrists; or because they were found wandering the freeways naked trying to climb onto passing cars; or even because they were observed to be defecating, picking up their poop, and then rubbing that same poop all over themselves. Yeah, it's that kind of place. And it is also quite common for all our patients to be on involuntary holds, where they are held against their will for either 3 days or 14 days.

It's a jail of sorts, but for crazy patients. I don't particularly like that word, because the psychiatry field is already fraught with and stigmatized by such descriptions, but if you want a quick-and-dirty description of the Psych ER, that's what it is: locked-up crazy patients. Thus, given our patients, it's a very unpredictable place. A bizarre and exciting place with rarely a dull moment. There's no telling when the peace will be disrupted by an event such as a formerly quiet patient yelling at the top of his lungs demanding that demons leave his body. Or ... the exciting, yet slightly frightful, event that happened today.

The day began with me re-evaluating a young patient who was admitted the night before for suicidal behavior. When I first approached him, he was sound asleep on a couch. As I tried waking him up, he repeatedly refused, and the best response I got was an occasional eye-opening that lasted no longer than several seconds. I attempted my usual round of questions that seek that determine whether the patient has shown enough improvement since the previous day to warrant his/her release ... basic orientation questions such as "do you know where you are?" and "what is today's date?" to questions about their current mental health, such as "do you still want to hurt yourself?" and "are you still hearing the voices that told you to strangle your neighbor?".

However, this guy was in no mood to answer questions. Not only would he not answer, he would neither open his eyes nor open his mouth. The extent that he held up his end of the conversation involved him pulling out a piece of paper and pointing to some words he had written down earlier. The most productive part of our conversation went like this:

Axis: "Where are you?"

Patient: [points to the word "hospital"]

Axis: "How are you feeling?"

Patient: [points to "I want 2 trays of food"] (technically, a non-sequitor, but never mind that).

With the conversation going nowhere fast, I walked away, reported back to my attending, and he was left alone, fast asleep on a couch, with his response-papers, still wanting 2 trays of food.

End of story? Not quite. One hour passed while I followed up some errands, and returned to the Psych ER only to see a few cops running inside as fast as the little doorway would allow them. Once they had funneled in, they were surrounding something at the opposite end of the room. I struggled and stood on tiptoes to see what they had so swiftly surrounded, only to see my mute patient from earlier! How a sleeping guy with slow hand movements piqued the interest of 5 trigger-happy police officers was beyond me, but the scene was enough to keep my attention.

Allegedly Mr. Mute has snapped out of his silence and began demanding -- aloud -- to receive those 2 trays of food. Talk about perseverance. Anyway, he had earned himself the privilege of a gurney with 4-point restraints. All but one of the cops stood around Mr. Mute, waiting, I assume, for him to bust a move, while that last cop then unholstered the weapon strapped to his left: a Taser gun.

Damn, a Taser! I don't know much about Tasers, except that once that little rectangular gun is fired, it causes the victim to collapse in a fit of painful spasms and howling. For now it was pointing down, away from the patient, with its malicious little red laser aim dot swirling around the floor like a jittery disco light. The police urged the patient to comply peacefully to avoid using force and the Taser; the patient responded with rude grunts, while his eyes were fixated on the red laser light floating on the floor. After several rounds of verbally going back and forth, Mr. Mute begrudgingly agreed to walk over to the gurney.

Finally arriving at the gurney, the patient sat down and announced, "this is as far as I'm going". But then this confidence was quickly turned to compliance, and mild fear, when the officer with the Taser firmly stated to "lay down now" and pointed his Taser at the patient's chest. With the red menace dancing around his heart, Mr. Mute quickly lay back with looks of death in his eyes aimed at everyone.

He was then restrained without incident -- except for the mouthful of swear words he let loose -- and the curious crowd in the ER slowly dissipated. Once all the cops left and the patient was restrained and curtained off, everyone resumed their tasks from before this tense stand-off. So goes the Psych ER.

That patient, however, did get in the last word. In protest to the preceding event, spotting a slit in the curtains and clearing his throat loudly, he spit out one well-aimed snotball through the slit ... launching it over 10 feet away, nearly tagging a nurse. Nice.

Welcome

Welcome to my blog, axis deviation, reporting the non-medical side of medical training.

First, a little background on me. I am a 3rd year medical student in southern California, which means that I'm in the clinical years (years 3+4) of my medical education ... thus I'm no longer sitting in the classroom but rather working in a hospital. The hospital in which I do all my work is a huge, county-like general hospital that is short on staff and money, but overflowing with patients and red tape.

As of now I have about 1 1/2 years of medical school left, at which point I graduate. What happens next will be as much as a surprise to me as it will be to you, although I'm working everyday on fixing that as much as possible.

So for a first-hand account of a simple little doctor-to-be just trying to make it by in this long, cruel hazing process known as medical training, stick around for frequent (ok, periodic) posts. Otherwise, just stick around for some entertaining stories.