Be forewarned: this is a rant more than a post. In addition to losing my car keys recently, I've lost my PDA, some notes from my cardiology rotation and who knows what else. Then today we get hit with expenses galore. Santa is bringing us a new refrigerator, new car tires, brake rotors, brake pads and a windshield. Yipee!
The one silver lining is that I've already ordered a new cell phone/PDA that is on the way. My PDA was showing it's age (I bought it used on Ebay) and I found a new T-mobile MDAs on Amazon for $25. I just hope it performs decently. I sure liked the Dash (Becky is getting one of those from Santa), but it wouldn't run most of my medical software (Windows Smartphone vs. Pocket PC). For another $30 I got a 2GB minSD card in case I ever purchase an UpToDate subscription for it.
As usual, my break will be spent (partially) working on choirs, gadgets and computers. It will be nice to have one device to carry around, but it's going to take some time setting up Epocrates, Feri's, Tabers, Netter's Anatomy, Ultimate Anatomy, Shots, Midnight Medical, Medical calculators, Outlook sync and the ones that I don't use on a daily basis. Somehow that seems more enjoyable than tackling the sprinkler system...again.
Monday, December 18, 2006
Sunday, December 17, 2006
Reflecting on a maternal death
While it's fresh, I wanted to post on an important but unpleasant topic. In the U.S. we do a pretty good with average maternal deaths around .01%. One of the top causes is maternal bleeding during labor & delivery. But it can also happen prior to labor due to improper implantation of the placenta.
In this case, the OB/Gyn group I worked with thought their patient had placenta previa where, by ultrasound, the placenta can be seen covering some of the cervix. This is a concern for bleeding but very rarely leads to a fatality. However, this patient had placenta acreta, where the placenta is implanted deep into the uterine muscle and its vasculature. There is currently no test or exam that diagnoses this condition. However, if placenta acreta is found incidentally, delivery is usually scheduled as early as possible (36-37 weeks) before contractions start.
This young lady of 28 was close to term with her second child. Previa bleeding was a concern at prenatal office visits, but she hadn't reported even any spotting. When she was admitted it was estimated that she'd lost almost half her blood volume. This was at 8am, not long after I had left Dr. Mourad in a C-section that ended my 7pm to 7am shift. He and ten or so other physicians from his group and perinatalogy rushed and frantically tried to get blood products into her hypotensive body, but could never gain on her profuse blood loss.
Resuscitation was attempted until 11am when the death of mother and child was called. I arrived that evening as scheduled at 7pm to find the entire labor & delivery unit in grief. Not tears, no one present at the bedside was still around, but real sadness from everyone coming on hearing the news like I did.
I talked to and overheard conversations from many nurses and several attending physicians from my group. I also heard from other physicians who made up a committee investigating the incident. My group even requested that the case be reviewed by an outside group of physicians (OB, perinatology and anesthesia) at a different hospital.
It sounds like the findings will be some minor procedural changes (chain of command, blood product availability) but nothing that would have changed the outcome. Now a five year old is left to be raised by his grandmother surely grieving for her daughter and unborn grandchild.
The whole case was an educational experience to go through, even from the outside. It showed a lot of care, humility and professionalism from my attendings. I don't look forward to experiencing my patient's death, but I feel a little more prepared for handling such an event.
In this case, the OB/Gyn group I worked with thought their patient had placenta previa where, by ultrasound, the placenta can be seen covering some of the cervix. This is a concern for bleeding but very rarely leads to a fatality. However, this patient had placenta acreta, where the placenta is implanted deep into the uterine muscle and its vasculature. There is currently no test or exam that diagnoses this condition. However, if placenta acreta is found incidentally, delivery is usually scheduled as early as possible (36-37 weeks) before contractions start.
This young lady of 28 was close to term with her second child. Previa bleeding was a concern at prenatal office visits, but she hadn't reported even any spotting. When she was admitted it was estimated that she'd lost almost half her blood volume. This was at 8am, not long after I had left Dr. Mourad in a C-section that ended my 7pm to 7am shift. He and ten or so other physicians from his group and perinatalogy rushed and frantically tried to get blood products into her hypotensive body, but could never gain on her profuse blood loss.
Resuscitation was attempted until 11am when the death of mother and child was called. I arrived that evening as scheduled at 7pm to find the entire labor & delivery unit in grief. Not tears, no one present at the bedside was still around, but real sadness from everyone coming on hearing the news like I did.
I talked to and overheard conversations from many nurses and several attending physicians from my group. I also heard from other physicians who made up a committee investigating the incident. My group even requested that the case be reviewed by an outside group of physicians (OB, perinatology and anesthesia) at a different hospital.
It sounds like the findings will be some minor procedural changes (chain of command, blood product availability) but nothing that would have changed the outcome. Now a five year old is left to be raised by his grandmother surely grieving for her daughter and unborn grandchild.
The whole case was an educational experience to go through, even from the outside. It showed a lot of care, humility and professionalism from my attendings. I don't look forward to experiencing my patient's death, but I feel a little more prepared for handling such an event.
Piano Recital
Until Friday I don't think that I had ever seen a piano recital. But after five months of great teaching from a classmates wife, my boys were ready to perform. I should mention that this is no ordinary piano teacher. She taught middle school last year but due to the commute. She quickly filled up her studio hours at home and has over 20 kids on the waiting list! My boys adore her and the recital was very well run.
I helped the boys tie their first real ties. Then all five of us (Becky, her sister, the boys and I) headed over a bit early to get seats and do something about our gitters. Below is a picture we took before the recital started.
Twenty-five kids played and/or sang. Some better than others, but pretty good all in all. Connor and Colton were fantastic. They had two solos each, then a duet performed together which can be seen at Handbell Choir piano duet by Connor and Colton
Christmas shopping is mostly done (thank God for Amazon) so now I have no more excuses to avoid study for the OB/Gyn shelf test on Tuesday. Well maybe one more.... The boys have requested that the four of us go see the new movie Aragorn based on one of their favorite books. That would be a priority over a pass/fail test any day.
I helped the boys tie their first real ties. Then all five of us (Becky, her sister, the boys and I) headed over a bit early to get seats and do something about our gitters. Below is a picture we took before the recital started.
Twenty-five kids played and/or sang. Some better than others, but pretty good all in all. Connor and Colton were fantastic. They had two solos each, then a duet performed together which can be seen at Handbell Choir piano duet by Connor and Colton
Christmas shopping is mostly done (thank God for Amazon) so now I have no more excuses to avoid study for the OB/Gyn shelf test on Tuesday. Well maybe one more.... The boys have requested that the four of us go see the new movie Aragorn based on one of their favorite books. That would be a priority over a pass/fail test any day.
OB/Gyn done!
Well it's been an interesting two weeks. The first week (two weeks ago) was gynecological surgery. It was a fairly easy week, not at all the 6am to 6pm days we were told to expect. It was usually 7:30am to 3 or 4pm with even lighter days on Th and Fr when we only had one long morning surgery each day.
I lucked out in that I was able to scrub for some unusual surgeries. For example, a laparoscopic sacral colpopexy was pretty cool to see. I usually just stood next to the First Assist cutting suture and suctioning blood. Occasionally I got to suture or staple when closing up the patient. But it was still very interesting and I learned a ton.
Last week was days on Labor & Delivery (L&D). The first two days were awful. Nothing happened at all. I got a lot of reading in, but could have done that without the hour plus commute to Desert Banner. Wednesday picked up a lot and was attended by my favorite teacher during the rotation, Dr. Mourad. I had three deliveries and I caught the baby on each one. On the third I was pretty self-sufficient and just needed a little help repairing a couple small tears. It was amazing to see how much better moms push without epidurals. While it is more painful, the moms sure get through the whole process much more quickly. I also got in one C-section with Dr. Mourad where he even let me cauterize some with the bovey. The most amazing thing was that we delivered a healthy (Apgars 7 @ 1m and 8 @5m) 24 week old! The mom had been bleeding, had ruptured membranes and was on steroids for fetal lung development. It's hard to know how well the baby will do over the next few years, but the birth couldn't have gone better.
Fate then decided to play a role in my week. I realized that I lost my last car key in one of the goop bags for the three vaginal deliveries I handled. The nurses were great and helped me look everywhere else. If I had to feel through one garbage bag of used garments and bloody rags I might have considered it. But not three with no guarantee it was in any of them. So I did my Friday 24 hour shift on Wednesday. The bonus was that Dr. Mourad was the attending, it was a relatively easy night and this would allow me to see my boys first piano recital Friday night.
We had one more C-section that night, then I slept in one of the physician sleep rooms until Becky called me at 8am! I actually slept better and more hours than I had been getting at home. When the locksmith was late I called a local Honda dealership. Glad I did because even in 2000, Honda had electric chips in the keys at the locksmith would have had to replace every lock in the car. By 1:30pm I had two new keys and was $270 dollars lighter. I took the rest of the day off.
Friday was pretty uneventful. I make it in time to see observe one delivery which definitely wasn't as much fun after catching half a dozen babies myself. Then I scrubbed in on one C-section that was very messy. At one point we had at least five locking forceps closing squirting arteries. All three of us (surgeon, first assist and myself) were splattered in blood. My two hands were put to good use holding retractors, suction, bovey, etc. I felt fairly useful for a change.
I had a chance to scrub in a twins C-section, but decided to head home early to get ready for the recital. My attending actually encouraged me to go. I turned in my badges, said goodbye to the staff and got home well before traffic started.
I never did get over the dichotomy of old guys with tons of serious conditions and diseases last month at the VA and generally healthy young women having healthy babies this month. If it wasn't for the horrible hours, insane legal atmosphere, stratospheric malpractice insurance ($150k per year) and endless office hours staring at vaginal discharges OB/Gyn would be incredibly cool!
It was a rotation filled some incredible highs with a few great attendings. But it also some of the most mind numbing hours I had with awful attendings, who while good physicians, had no place dealings with students in any capacity. Now it's time to study for the shelf exam on Tuesday and get ready for the Holidays and my long two months in Toledo, OH.
I lucked out in that I was able to scrub for some unusual surgeries. For example, a laparoscopic sacral colpopexy was pretty cool to see. I usually just stood next to the First Assist cutting suture and suctioning blood. Occasionally I got to suture or staple when closing up the patient. But it was still very interesting and I learned a ton.
Last week was days on Labor & Delivery (L&D). The first two days were awful. Nothing happened at all. I got a lot of reading in, but could have done that without the hour plus commute to Desert Banner. Wednesday picked up a lot and was attended by my favorite teacher during the rotation, Dr. Mourad. I had three deliveries and I caught the baby on each one. On the third I was pretty self-sufficient and just needed a little help repairing a couple small tears. It was amazing to see how much better moms push without epidurals. While it is more painful, the moms sure get through the whole process much more quickly. I also got in one C-section with Dr. Mourad where he even let me cauterize some with the bovey. The most amazing thing was that we delivered a healthy (Apgars 7 @ 1m and 8 @5m) 24 week old! The mom had been bleeding, had ruptured membranes and was on steroids for fetal lung development. It's hard to know how well the baby will do over the next few years, but the birth couldn't have gone better.
Fate then decided to play a role in my week. I realized that I lost my last car key in one of the goop bags for the three vaginal deliveries I handled. The nurses were great and helped me look everywhere else. If I had to feel through one garbage bag of used garments and bloody rags I might have considered it. But not three with no guarantee it was in any of them. So I did my Friday 24 hour shift on Wednesday. The bonus was that Dr. Mourad was the attending, it was a relatively easy night and this would allow me to see my boys first piano recital Friday night.
We had one more C-section that night, then I slept in one of the physician sleep rooms until Becky called me at 8am! I actually slept better and more hours than I had been getting at home. When the locksmith was late I called a local Honda dealership. Glad I did because even in 2000, Honda had electric chips in the keys at the locksmith would have had to replace every lock in the car. By 1:30pm I had two new keys and was $270 dollars lighter. I took the rest of the day off.
Friday was pretty uneventful. I make it in time to see observe one delivery which definitely wasn't as much fun after catching half a dozen babies myself. Then I scrubbed in on one C-section that was very messy. At one point we had at least five locking forceps closing squirting arteries. All three of us (surgeon, first assist and myself) were splattered in blood. My two hands were put to good use holding retractors, suction, bovey, etc. I felt fairly useful for a change.
I had a chance to scrub in a twins C-section, but decided to head home early to get ready for the recital. My attending actually encouraged me to go. I turned in my badges, said goodbye to the staff and got home well before traffic started.
I never did get over the dichotomy of old guys with tons of serious conditions and diseases last month at the VA and generally healthy young women having healthy babies this month. If it wasn't for the horrible hours, insane legal atmosphere, stratospheric malpractice insurance ($150k per year) and endless office hours staring at vaginal discharges OB/Gyn would be incredibly cool!
It was a rotation filled some incredible highs with a few great attendings. But it also some of the most mind numbing hours I had with awful attendings, who while good physicians, had no place dealings with students in any capacity. Now it's time to study for the shelf exam on Tuesday and get ready for the Holidays and my long two months in Toledo, OH.
Saturday, December 02, 2006
Labor & Delivery Nights
The OB/Gyn office week was cut short by Thanksgiving. I don't think I missed that much and was able to study my rotation book during the family trip to San Diego for the Holiday.
Things changed a lot this week for Labor & Delivery nights. The first night, Monday 7pm to 7am, was with the worst attending I've been with yet. She was a decent Doc technically, but a stuck-up b**** to the nursing staff, a sourpuss to patients and non-existent as a preceptor. It was the worst rotation shift I had to that point. I had to chase her around and get my bearings of the busiest L & D ward in the SW USA! They deliver 8500+ babies a year at Banner Desert. So she was worthless, but I managed to pick up a few things on my own, watch a C-Section and attend a few deliveries.
Unfortunately I had her again on Thursday night (7pm - 7am). That night was dead so I read a lot and tried to stay out of her way so she could get her "precious" sleep. She didn't have the courtesy to let me know about the one delivery of the night on our service so I did absolutely nothing! That was just about my most worthless 12 hours in medical school and I had to stay up through the night for it.
Tuesday was much better. I scrubbed for two C-Sections and got to cut sutures, hold retractors, etc. I was a little more involved in deliveries and saw some interesting cases. Wednesday was even better with an awesome attending. He let me catch three babies, deliver the placentas and get even more involved in a C-Section. It was a tricky one with fibroids and a lot of bleeding so I learned a lot. Even though I was tired driving an hour and a half through Phoenix rush hour traffic at 7am, I felt awesome having helped with those deliveries. The downer is that I left at 7:10am and learned later that the attending lost a mom shortly afterwards when she bled to death from a placenta accreta. The baby was delivered at 8am, but the Code for the 28 yo mom was called at 11am. The entire staff was shaken up and I heard the attending took it really hard.
Thursday was the let-down I already mentioned, but Friday made up for it. I was with one of PPA's (Phoenix Paranetology Assoc) attendings and she was terrific. We were extremely busy and she didn't get any sleep, but she was still the most gracious attending I've seen at Banner yet. The nurses love her too. I read maybe two paragraphs the whole night but loved it. I caught three babies, wrote lots of notes and started to perform some sutures on my own to repair torn vaginal walls. I need a lot more practice on suturing and started working on my catching technique so I can do single-handed someday.
I learned that the Doc hardly gets to see the baby at all. You deliver his/her head, bulb suction the goop, rotate the shoulders, deliver the body and cradle him/her, clamp the cord, cut the cord and hand the baby off to mom or the nursery folk for a high risk case. You get a few seconds at most to look at the baby when s/he is usually covered with goop and still blue. Then, with amniotic fluid running down your leg, you get to stare at a new mom's privates for an hour or so trying to deliver her placenta and repair any lacerations while the nurses, parents and anyone else present enjoy the infant.
In fact, one of the babies I delivered last night was given a clinical diagnosis of Down's by the nurse that took him from me based on facial features alone. Neither my attending or I had time to notice any of the findings as we were dealing with the placenta, lacerations and cleaning mom up. Afterwards, we spoke to the visibly upset parents (dad had seen his son in the nursery when the nurse talked to him). The attending was great and I appreciated her bedside manner. We had the advantage of having a nurse nearby that had raised a 10 yo daughter with Down's. She talked to the family for quite awhile and gave them lots of information on support groups, web sites, etc. However, we warned the patients the chromosomal studies would take 10-14 days and the baby may be just fine. The weird thing is the baby had pericardial effusions (usually associated with a viral infection) and a level II ultrasound. None of the usual "soft" findings like missing nasal bones, thick nuchal fold, short femur, heart/GI problems, etc. showed up.
All in all a great week some of the highest highs and lowest lows I've experienced thusfar in med school. I can see the attraction of OB/Gyn for male and female Docs (healthy patients, procedural, gracious parents and continuity of care). It is something that I will definitely consider incorporating into a rural practice. But the concerns of uncontrolled hours, malpractice costs and legal liability are pretty discouraging. Two more weeks to go though and I have to study up on three Gyn surgeries on Monday.
My parting thought is remembering the rural IM/FM doc from Texas I met on a flight coming back from Seattle. He mentioned doing a crash C-Section in one hour and nine minutes. This is how long it took the ambulance he was in to get the 120 miles to the nearest hospital with L & D services. At this point I can't fathom ever having the courage, knowledge and skill to do that. As a classmate told me; "your knees get weak after an intense delivery" - with all the resources of one of the busiest L & D departments in the country a few feet away.
Things changed a lot this week for Labor & Delivery nights. The first night, Monday 7pm to 7am, was with the worst attending I've been with yet. She was a decent Doc technically, but a stuck-up b**** to the nursing staff, a sourpuss to patients and non-existent as a preceptor. It was the worst rotation shift I had to that point. I had to chase her around and get my bearings of the busiest L & D ward in the SW USA! They deliver 8500+ babies a year at Banner Desert. So she was worthless, but I managed to pick up a few things on my own, watch a C-Section and attend a few deliveries.
Unfortunately I had her again on Thursday night (7pm - 7am). That night was dead so I read a lot and tried to stay out of her way so she could get her "precious" sleep. She didn't have the courtesy to let me know about the one delivery of the night on our service so I did absolutely nothing! That was just about my most worthless 12 hours in medical school and I had to stay up through the night for it.
Tuesday was much better. I scrubbed for two C-Sections and got to cut sutures, hold retractors, etc. I was a little more involved in deliveries and saw some interesting cases. Wednesday was even better with an awesome attending. He let me catch three babies, deliver the placentas and get even more involved in a C-Section. It was a tricky one with fibroids and a lot of bleeding so I learned a lot. Even though I was tired driving an hour and a half through Phoenix rush hour traffic at 7am, I felt awesome having helped with those deliveries. The downer is that I left at 7:10am and learned later that the attending lost a mom shortly afterwards when she bled to death from a placenta accreta. The baby was delivered at 8am, but the Code for the 28 yo mom was called at 11am. The entire staff was shaken up and I heard the attending took it really hard.
Thursday was the let-down I already mentioned, but Friday made up for it. I was with one of PPA's (Phoenix Paranetology Assoc) attendings and she was terrific. We were extremely busy and she didn't get any sleep, but she was still the most gracious attending I've seen at Banner yet. The nurses love her too. I read maybe two paragraphs the whole night but loved it. I caught three babies, wrote lots of notes and started to perform some sutures on my own to repair torn vaginal walls. I need a lot more practice on suturing and started working on my catching technique so I can do single-handed someday.
I learned that the Doc hardly gets to see the baby at all. You deliver his/her head, bulb suction the goop, rotate the shoulders, deliver the body and cradle him/her, clamp the cord, cut the cord and hand the baby off to mom or the nursery folk for a high risk case. You get a few seconds at most to look at the baby when s/he is usually covered with goop and still blue. Then, with amniotic fluid running down your leg, you get to stare at a new mom's privates for an hour or so trying to deliver her placenta and repair any lacerations while the nurses, parents and anyone else present enjoy the infant.
In fact, one of the babies I delivered last night was given a clinical diagnosis of Down's by the nurse that took him from me based on facial features alone. Neither my attending or I had time to notice any of the findings as we were dealing with the placenta, lacerations and cleaning mom up. Afterwards, we spoke to the visibly upset parents (dad had seen his son in the nursery when the nurse talked to him). The attending was great and I appreciated her bedside manner. We had the advantage of having a nurse nearby that had raised a 10 yo daughter with Down's. She talked to the family for quite awhile and gave them lots of information on support groups, web sites, etc. However, we warned the patients the chromosomal studies would take 10-14 days and the baby may be just fine. The weird thing is the baby had pericardial effusions (usually associated with a viral infection) and a level II ultrasound. None of the usual "soft" findings like missing nasal bones, thick nuchal fold, short femur, heart/GI problems, etc. showed up.
All in all a great week some of the highest highs and lowest lows I've experienced thusfar in med school. I can see the attraction of OB/Gyn for male and female Docs (healthy patients, procedural, gracious parents and continuity of care). It is something that I will definitely consider incorporating into a rural practice. But the concerns of uncontrolled hours, malpractice costs and legal liability are pretty discouraging. Two more weeks to go though and I have to study up on three Gyn surgeries on Monday.
My parting thought is remembering the rural IM/FM doc from Texas I met on a flight coming back from Seattle. He mentioned doing a crash C-Section in one hour and nine minutes. This is how long it took the ambulance he was in to get the 120 miles to the nearest hospital with L & D services. At this point I can't fathom ever having the courage, knowledge and skill to do that. As a classmate told me; "your knees get weak after an intense delivery" - with all the resources of one of the busiest L & D departments in the country a few feet away.
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