Delivering babies

Let's see... what is going on in my life since last time I wrote?... I did a month of Toxicology at Bellevue hospital which was fascinating as always. I did two weeks in the Columbia ER where I got pretty effectively bitch-slapped once or twice (can always count on Columbia for that) and I caught babies for 2 weeks up at the Allen Hospital (Inwood) on Labor and Delivery. Basically, life has been good.

I wish I could regail you with "The tales of labor and delivery!" I basically walked away from my time on L&D thinking "wow, what a wasted, boring two weeks! I saw about 2 patients a day!" However, upon further reflection, I realized that I saw some very important things.

An eclamptic mother in status epilepticus seizing uncontrollably all the way to the operating room to emergently c-section her baby. She has since been in and out of the ICU twice for further complications of eclampsia.

A woman who I now have the highest respect for who did the entirety of labor and delivery without ANY pain control (and let me tell you, it was NOT an easy delivery by any means even if she would have had pain control). I'm actually not entirely sure if she deserves an award or a brisk shaking and an exclamation of "why in the world did you DO that?"

There was the "day of post-partum hemorrhage" where it seemed that every patient was bleeding uncontrollably after delivery (I got very good at calling for HemeAbate). Those are interesting. Looks like a faucet running red water.

Then there was my last day on L&D. I had a 23-week patient who presented in active preterm labor. There was no way to stop the process. The issue is this: there is a 50/50 chance of survival with all of the modern NICU technologies possibly available if a baby is born at 24 weeks. Younger than 23 weeks, there is no chance. 23 weeks is the grey zone. 10% chance of survival, only 5% chance of survival neurologically intact. As we laid the facts out for a distraught couple whose primary language was not english (we used a spanish interpreter for ALL conversations), the emotional stress began to completely block their ability to understand the situation.

Finally, they were able to make a decision, to rationalize SOMETHING out of the entire situation. The attending who had been explaining for an hour that the two options were to a) deliver the baby and provide warmth until the baby passes away in a few minutes or b) delivery the baby and intubate the baby and do everything humanly possible for a long-shot of survival. Finally the father looks at the attending and says "we want an abortion."

HUH?? Abortion wasn't even an option. The word abortion was never even SAID and yet, this was how they were able to rationalize their desire not to have the potential of having a severely disabled child for the rest of their lives (assuming best case scenario). Our jaws dropped and there was silence where we didn't know how this leap had been made. Then the husband went on to ask for us to just take our instruments and tools and go inside and take the baby out. We went through all of it again... explicitly. Mom was going to have to push the baby out. It was a delivery. She was in labor. We were NOT going to go in and take the baby out, it was coming out on its own. The family agreed to let the baby be born and pass away. No heroic measures.

An hour later we are called into the room. It's almost time. There is a new person there -- an extended family member who is fluent in english. She turns to us and demands, "What are the options? Why are they telling me that they are getting and abortion?" If I ever felt like smacking my own forehead, THIS would be the moment. The attending, however, handled the situation with grace by simply stating, "The matter is closed. We have discussed it extensively with the parents and we have agreed to let the baby pass away after it has been born. This is NOT an abortion. This is early labor." We got the interpreter again and went through it again with the parents. Their faces showed complete confusion. But then it was too late for more discussion -- the baby needed to be delivered.

I delivered at 1lb baby boy. He made a single cry and then had no further respirations. He did not move. The room was full of crying, wailing family members. They named the baby, held him, cried and screamed his name, took photos. After all the technical aspects of the delivery were completed and condolences were given, I left. I've never dealt well with rooms full of crying people. I'm a sympathy crier -- not a good trait as a physician. After the parents said goodbye, the baby was taken to the Neonatal ICU and finally pronounced as deceased 3 hours later. I filled out a birth certificate. The pediatrician filled out a death certificate and the matter was closed.

I don't know how those parents will eventually think of the events of the birth and death of their first child. Will they realize what happened -- early, preterm labor -- or will they always rationalize as somehow "choosing" an abortion at 23 weeks? If they rationalize the latter option, how many more pregnancies will they loose because they are passing on incorrect information to future physicians who may be at a different hospital and therefore not have access to our records? It is a terrible dilemma, the stress response of the human psyche.

People Watching

Something that I enjoy as a NYC resident is the so-called pastime of "people watching." Fortunately, Rob is also a world-class people-watcher and the two of us can go to a park or sit in outside at a restaurant or starbucks quietly and completely comfortable with each other watching the world go by. Occasional comments pass such as "awwww" or giggles and most often, "did you see that??"

I, however, also tend to go on a people-watching tangent. It's called dog-watching. Yes, I watch all the NYC pups go by. Take my walk this afternoon before sitting down to write this post. I was walking through a local park near our apartment and fell into my "dog-watching" routine. There was the adorable Great Dane puppy in the dog run who just didn't seem to understand play with non-litter mates yet. The Golden who, upon realizing that they were near the dog park suddenly jumped to the end of its leash to drag its owner to the run.

There was the gay couple riding their bikes on a beautiful summer afternoon -- each with a tiny chihuahua strapped to his chest. (tiny yippy chihuahuas) ... then I passed a couple carrying their CAT on a leash... kitty did NOT look happy.

One of my favorites is a woman in our neighborhood who owns two HUGE and overweight bulldogs who can barely make it around the block in the august heat. She spends most of her time futilely pulling at the leashes, then coaxing and finally tempting inch by inch with doggy treats.

The point is, new yorkers are a great bunch with hillarious dogs.

Funny stuff

So, recently I have a had a number of truly fabulous ER quotes. I thought I would share some of them... some may be funny, some may not...

"well, we come here 'cuz you got doctors good here, yo." Patient's primary language: English.

"Why are you putting in a breathing tube? He fell and his pinky hurts."
-- family of a stridorous patient being intubated for respiratory distress.

me: "are you pregnant?"
patient: "no..."
"you're pregnancy test is positive."
"I'm on birth control!"
"well, amazing things ARE happening here."
"huh?"
"Pee in the cup again."

"well, the blood transfusion raised your hemoglobin from 3 to 6."
"great! so you don't need to admit me anymore?""no..."
"so, one more unit and it will double again and then I'm ok?"
"uh, no. It doesn't really work like that. You're still bleeding. Which is generally considered bad."

"Why do I need surgery? It's just a stab wound."
"You cut the artery. That's why the blood was pumping out."
"so, you can't just give me stitches?"
"no."
"fuck."
Charge nurse: "here's your cell phone. call your mother." (patient's scowls, charge nurse raises an eyebrow and shakes the phone, patient takes phone)

In Remembrance

It has been forever since I last wrote in the blog. Many things have happened -- work, birthdays, vacations, fun times... and I plan to write about all of those, but this post is about something else.

This post is about a being very special to me -- Oscar, one of my family's cats. Born in late 1998, my family adopted Oscar and his brother, Felix from the North Shore Animal League in early 1999 and he was always a wonderful kitty. Being in high school at the time, Oscar and Felix were the first pets my family owned who were pretty solely "my" responsibility -- they lived in my room, their food, water and kitty litter were in my room and I cared for them (and dealt with them waking me at 4:30 in the morning with the now-infamous "double-pounce").

Oscar was instantly dubbed the "purr-box" or "motorboat" for his loud purr heard across the room and incessant demands for attention. Always more outgoing than his brother Felix, he was also the "smart" one of the pair (we missed on the odd couple naming).

Recently, Oscar's health had been deteriorating... he required multiple surgeries to repair problems with his colon. His kidneys were starting to fail. He was loosing weight. 6 months ago a vet recommended we put his to sleep. At that time, my family declined -- he was still running around, purring and head-butting everything as always.


A few days ago my parents called me to see Oscar -- his health had taken a turn for the worse and the decision was made that it was time to let him go. We all miss him sorely -- especially his brother, Felix, but we are all getting through. And so, I raise my glass and drink in remembrance of one fine kitty.

On Restraint (or Lack Thereof)

I'm sick.
For the 3rd time in the last month.
It hasn't been a good month in that respect.

So, I'm feely crappy. I sleep, drag myself to the shower and then decide "you know what? I'm going to lie of the couch and listen to some relaxing music." I sifted through my iPod and picked 1) August's Rhapsody from August Rush, 2) Massenet's Meditation from Thais and 3) Ravel's ballet, Daphnis and Chloe.

The Daphnis is actually what spurned this post. Maybe it's just because I was lying with my eyes closed the only task on my mind to listen to the music or maybe it was because I had a headache and had therefore tweaked the settings on my stereo to turn to volume down and flatten the dynamic range so the louds were softer and the softs louder... I don't know. What I do know is that the Daphnis just sounded so controlled -- too much in control.

A few years ago I had the opportunity to hear one of my favorite pieces, Stravinsky's Rite of Spring, played by first a professional orchestra and then the Julliard Symphony in the same month. The Rite is an incredibly challenging piece and is seldom performed by professional orchestras. It is much more common as a graduate orchestra piece -- something for the soon-to-be professional musicians to sink their teeth into and put on their resume. I forget which professional orchestra I heard -- not the NY Phil... maybe the London or the Berlin.

What struck me about the two performances was that I enjoyed the Julliard Symphony significantly more than the professional orchestra! Sure, the professional orchestra's version as technically perfect -- all of the complicated rhythms and counter-themes interlocked exactly. All the dynamics were there, the tempos were accurate and the precision of the performance was incredible. Amazing what a group of professional musicians do when they really concentrate!

The Julliard Symphony was not technically perfect -- a flub here or two. The themes interlocked beautifully, the tempos and dynamics did more than just give a professional orchestra a "run for it's money." They were professional. These were the best musicians in the country playing at the peak of their masters degree education. Here were performances by two groups who should have been on a par but, in my opinion, the Julliard orchestra blew the professional orchestra out of the water!

Why? The Julliard orchestra got excited over the music. You could feel in the crazy, fast, intricate sections that the orchestra was just one hair's breath away from flying completely out of control. The rhythms caught with milliseconds to spare almost like when you have two interlocking cog-wheels but they don't interlock well and there's that second when you say "oooh, it's not going to work" and then the wheels catch and turn to the next cog. The tempos pushed just on the leading edge of the conductor's beat with the conductor holding his students in with the sheer mental will of making them follow him instead of the other way around.

The professional orchestra, as I said, played the piece flawlessly. I cannot find any way to fault the performance but to say that during their performance, I sat back and enjoyed. During the Julliard performance I was on the edge of my seat, gripping the armrests chanting in my head "yes, yes, get that! Yes!! eek eek eek... yes! got it! go!" with my jaw hanging open at the sheer enormity of the performance I was witnessing. My head was reeling with the Julliard performance for days.

That's what classical music is REALLY about.

A sad story...

I know I just wrote an entire post pretty much criticizing my time on the pediatrics floor, but there is one case the will stick with me.

There was a patient who my service inherited from one of the other pediatrics services because the attending on my team was willing to take on this very difficult patient. Ms. M turned out to be a patient that I had seen around the floor on numerous occasions. I always wondered what was wrong with her because the poor girl was always crying and seeming to be in severe pain while walking around the floor. She looked to be about 12, always was hunched over, face contorted in pain, wailing or, on a good day, snuffling as she walked past with a feeding tube dangling from her nose. While working on the floor, I could hear wailing coming from her room on a regular basis.

When my team picked her up as a patient, I was curious to find out what was making this little girl so sick.... Turns out she wasn't a little girl. She was actually 17, looked 12 and acted 3. She had major depressive disorder, severe fear of abandonment and anorexia nervosa as a result. Ms. M was being force-fed through the feeding tube to keep her alive. She would periodically vomit up her feeds due to emotional distress. Her parents would string her along about visiting and then not visit for days on end adding to her fragile psychologic state. When her parents finally did show up the first week we had her, they asked if they could just take her home to let her die. Needless to say, they were sharply reprimanded for that statement by the senior medical staff. Unfortunatley, they had said it to Ms. M as well, which caused two days of the worst wailing and crying I have ever heard -- it was horrible to bear.

I always tell people that there are cases you come across that bring home the severity of a disease for you. Those are the cases that make you respect a disease entity. A prime example is Asthma. So many people have "asthma" (there is a theory, actually, that many who are diagnosed with asthma may not actually have it). There is so much mild asthma out there that it can be easy to brush it off as "not that bad." After seeing my first case of truly life-threatening Asthma, I will never underestimate the disease again.

For me, Ms. M is my bar -- my disease-defining entity for anorexia. To say I was shocked when I learned that she was 17 is an understatement. To watch her suffer with the psychiatric burden to the point that her parents were willing to let her die to relieve her suffering was jaw-dropping. Not only were those things amazing to me -- but to watch how a firm hand, a set of rules, absolute 100% structure could turn a patient around was one of the most interesting things I watched on Pediatrics.

Immediately after the "can't you let our daughter die" conversation, the attending on our team decided to structure absolutely every aspect of M's life -- including demanding and holding her parents to a daily visiting schedule with set arrival and departure times. She had a daily schedule posted in her room with shower time, school, nap, everything written in. She had rules about where she was allowed to do what -- she had to vomit in the bathroom, she was not allowed to have the vomit basin in her bed. There was much more the the elaborate plan, and somehow it worked. I returned from a weekend off to discover that M was eating of her own accord. Another week later, she was smiling as she walked the halls. Another week after that and she had befriended one of the much younger patients and we would seem them laughing as they walked. It was a different person from the one who had caught my eye my first days on the ward.

She has been transferred to a long-term psychiatric care facility specializing in adolescent eating disorders. I hope they can continue the work that was begun in the Children's Hospital and that someday Ms. M can go home to her family.

It's been a while

I know, I know, I'm a horrible blogger. I go for long stretched of time without writing anything!

Let's see, I was noticing that my last post was about Jason's wedding in Oklahoma. What have I done in the past month?? I've been on the Pediatric in-patient floor in the Children's Hospital of New York at Columbia. This is a rotation that has gotten fairly unanimously panned by my co-residents. I am pleased to say that it was more enjoyable than I was expecting!

As part of training for emergency medicine, we do a number of "off service" (ie- out of the ER) rotations. The goal is multifactorial. First, the foster relationships between the ER and other services. Second, to give us some compassion towards our colleagues when we wake them up at 3am to admit a patient. Finally, to hopefully teach us a bit about the specialty.

Here is the problem: (mostly, it's reason #3). Interns in places outside of the ER and pretty much overqualified underpaid secretaries without any responsibility to make clinical decisions. In fact, on the peds ward, the intern is the equivalent of a trained monkey. Clinical decision making is actively discouraged. I wrote notes, I put in orders, and I answered mundane questions. That being said, I had a good month. I got in a 6am, got my work 90% done by 7am, rounded until noon, had an hour off for lunch (!!!!!), rounded from 1:30-2:30, finished the last 10% of my work and then went home generally between 3-4pm. In-between I played lots of solitaire and had all my decisions made for me by my seniors.

Did I just say 3-4 pm?? yep. I did. I was like being a normal person!! And with Rob currently working from home, he was there! We got to eat dinner together, go out with friends, meet other people for drinks... sigh. We've never seen more of each other than we did this past month and that was worth all the frustration and solitaire-playing that occurred while on Peds. The number of game apps on my iPhone doubled over the past month... I kid you not.

What else did I learn from peds? I'm not going to have kids anytime soon. I can do the little babies, their cute and not that bothersome. I can do the teenagers -- despite the attitude at least you can talk to them (even if logic probably doesn't apply). Everything in-between I can do without. I am sure that when I do have kids someday I will be all about every phase of their lives... just hell no, not yet.

Sum up: it was a nice, relaxing month where my days were filled with an hour and a half's worth of work spread out over 10 hours and I got to enjoy having a wonderful relationship with a fabulous, handsome man. ;) siiigh... back to work (yessss!).

Ooooklahoma, where the wind comes sweeping down the plains...

Yep.

In the past 72 hours, I have visited 2 new states for me -- Texas... and Oklahoma. "Why?" you might ask. Rob's good friend from his childhood, Jason, got married this past weekend in Oklahoma City to a very cool gal, Cathy. Rob had the honor of being a groomsman.

When we first got the invitation, we just assumed the wedding was in Philadelphia. Or the midwest, where Jason used to be. Careful scrutinizing of the invite showed address, address, address... Oklahoma City. eep. Two hard-core northeastern city-ites had already RSVP'ed "yes" before realizing where the wedding was. So we sucked it up and went to Oklahoma.

We get off the plane and look around at the wide expanse of flat. Trees here and there, but mostly flat. Meh, it's the plains. (by the way, we had to look up WHERE Oklahoma was on the map in the airport). The airport was empty even though it's 3pm. Walking outside the terminal at the "taxi" sign we could almost hear the crickets. Not a car in sight. Fortunately a passing security guard showed us where the single taxi was hiding, behing a giant pillar in the outermost lane. He was a friendly guy, instantly chatting away with Rob (I don't handle "interested" cabbies very well -- too much paranoid new yorker in me).

By the end of the cab ride, Rob and I were giving each other the "oh dear god, what have we gotten ourselves into!?!?!" look. Fortnately, the cabbie was the only scary interaction in the trip. He did have one good line: He reminded Rob, "now, we here in Oklahoma are nice people. It's not Vegas. What happens here will get back to that pretty lady there."... I think I might have snarled at that point.

The city was dead quiet over the weekend. The downtown skyline is 3 buildings about 20-30 stories tall. However, the people (other than the cabbie) were great! The group at the wedding were highly educated, highly intelligent and very interesting people. Jason is in the Air Force, so a number of guests were in the armed forces or married to people in the armed forces -- mostly engineers. Cathy is a trained pilot and flight instructor who now sells private jets for mucho bucks whose friends were mostly aviation people. Both bride and groom are avid fencers and they actually met at the local fencing gym (this is how Rob knows Jason). It was a fun, friendly and eclectic group of people which made for a very nice wedding. Rob stood out a little as the one groomsman not in uniform, but Rob always takes all of that in stride.

Would I go back to Oklahoma as a tourist? No. Would I go back to visit Jason and Cathy? Definately! Am I still scared of Oklahoma (total state-wide population 3 million)? nope =). Just to note that there are over 3x the number of people in NYC alone than in the entire state of Oklahoma. Just for perspective.

'

Recap

Half way done with Intern Year!

how in the world did that happen!?! and why don't I feel like I've gotten much better and what I do? (in defense of that statement, I did ask one of the attendings one night when the feeling like I know what I'm doing thing starts happening... the answer was half way through NEXT year, so... )

Maybe it's just a "the more you know, the less you realize you know" phenomenon. I have had 2 successful intubations now (of 6 attempts), put in my first femoral line on my first try (yay for anatomy class), have seen cool stuff, have seen some sad stuff, have had patients drive me crazy and have had patients I really liked. I have figured out which Cornell attendings I like, which I love, and which one (singular) I could really do without.

by the way... I survived surgery. 'nuff said.

Now it's a new year and, for me, a new hospital. My entire second half of the year will be spent up at Columbia -- time to re-learn an entire hospital system, 100% new ER staff, new ordering systems and a different chart. Not to mention almost double the patient volume, at least half of whom don't speak any english. Columbia is the place where you don't bother to call the primary doctor because 90% of the patients don't have one.

wish me luck! (I'm gonna need it...)