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| Sorry for the hiatus... for some reason, I tend to blog a lot while I'm doing OB, but not much any other time. Well, I'm back on the Resident Medical Team (ie inpatient adult medicine). Suzanne, Savannah, and I are working together this month, which is an extreme breath of fresh air. As much as I like everyone else in the residency, there is something very fun about working with your friends. Savannah is my upper-level resident, which means she supervises me! I thought this would turn out to be quite awkward, since Savannah is probably the most brilliant resident in the program, and I was nervous that she would find out just how big of a moron I really am! Luckily, I have managed to escape her smart radar, and she actually thinks I'm pretty competent. :) Inpatient medicine has its ups and downs. The best part is that I have a lot of autonomy. The worst part is that I have a lot of autonomy. :) Seriously, it's a steep learning curve. Even though I have an upper level resident and an attending available, 95% of the rest of the work and decision-making is all up to me. I haven't killed anyone yet, so I'll take that as a sign I'm doing something right. My toughest patient the last several weeks has been a man who was "found down" lying on his face for over 12 hours before his family decided he wasn't just "sleeping." Turns out this guy has a case of locked-in Parkinson's disease, which we thought was a reaction to one of his pyschiatric medicines. After some more history taking, we learned he has the real Parkinson's disease and not just a syndrome. For those who don't know, Parkinson's is a disease that affects a portion of the brain that helps control movement. The brain tries to send signals to the body to move, but there's a signal mixup. The disease presents classically with tremors, shuffling walk, and rigidity. Unfortunately, this man was showing signs and symptoms of Parkinson's disease for over a year, but his family didn't recognize it. His case is complicated by the patient having Bipolar disorder with psychosis. Some of the medicines that treats his psychiatric disease actually worsen Parkinson's disease by blocking an important neurotransmitter. And the medicine we're using in the hospital to try to treat the Parkinson's disease can send patients into psychotic episodes! After several weeks of experimenting with starting and stopping his medicines, our patient has not responded. He has minimal responsiveness, and he will barely move. The scariest part is that we all know that his brain is alive and working inside, but he is unable to express himself due to the advanced Parkinson's disease. It's like he's truly locked inside. He does moan quite a bit, and sometimes he will answer Yes or No questions after much effort. The medicine we are using to try to treat his Parkinson's disease is usually only moderately effective, and it will sometimes delay the progression of the disease, but it can't stop it. In our patient's case, it is probably too late. Since he can't interact with the world, it makes it difficult for him to get nutrition. We've been trying to spoon feed for several weeks and supplement with highly nutritious "Boost" shakes. After doing some calculating, I found that he is only getting about half of his caloric needs. If we don't put in a feeding tube, he will eventually weaken and die. I arranged another big family meeting last week, and his wife and children were all very adamant that he would NOT want a feeding tube. So we're going to keep feeding him by mouth as long as he has an interest. After several more weeks, it is likely that he will weaken significantly, and he might even qualify for Hospice. It's an incredibly sad situation, but I must admit that I am really impressed with the family for not pursuing aggressive life-support. They have done a lot of work in educating themselves about the long term prognosis, and they all agree about what his wishes would be. I just wish there was something else I could offer. Moral of the story: fill out advanced directives, or at least tell your loved ones what you want to happen should you become too ill to make your own decisions! I hope everyone had a great Christmas and New Year's! Alli and I are heading back home to Ohio in a few weeks, and then I'll be off to Mexico on a medical mission with our Mobile Clinic! Scott | | |
| Happy Holidays y'all! We had our first serious snowfall yesterday, and being stuck at the hospital on call all day and night, it was somewhat of a relief to get to see it fall and fall and fall and not have to drive home in it. When I left for home today, my car was covered in snow and ice, but the roads weren't bad enough to be worried. Strangely, Oregon prohibits the use of salt on the roads (environmentally friendly tree-huggers out here!). So instead, they drop this ash-like stuff and it seems to work fairly well. I switched OB calls with one of the other interns so he could be in an indoor soccer game, so I actually have BOTH Saturday and Sunday off! Yeehaw! We have a big holiday party to attend for the residency tonight, and then one of the OB nurses invited us to her house for a big OB holiday extravaganza on Saturday, complete with karaoke and Chinese food. Should be wild! Yesterday, I had my very first delivery that was completely unsupervised by another doctor. I was following this lady in labor, and her OB was across the street seeing patients at her clinic. Usually, when they get close to pushing, you call the OB and they come over and at least put on a pair of gloves in case they need to help. I had checked this lady and she was almost completely dilated and ready to push, but she still had what we call an anterior lip of the cervix, and you don't want a mother pushing against a cervix that is not out of the way (ie tearing cervix, ie massive hemorrhage, ie certain death). So I was giving her another 20 minutes to "labor down" and have the baby's head naturally push away that little piece of cervix. All of a sudden she starts yelping and saying she needs to push. So I check her and she's complete. Quick- call Dr. Burke! (she is a very quick 2 minute run from her office, though the falling snow probably slowed her down some). I could not keep this mother from pushing, and before I knew it, she was crowning. So I let her deliver, even though the OB hadn't made it over yet. To my complete surprise, this baby presented face up. Most babies come down the birth canal in the easiest way that they will naturally fit, which means their face is pointed down to the floor. This baby was completely turned around, facing up to the ceiling. This isn't necessarily a horrible thing, but it can be a bit more dangerous and make for a harder labor, since it doesn't fit quite as naturally as the alternative. To make matters worse, baby's hand was waving out above it's head! Again, not life and death, but another risky way to come out of the womb, as the outstretched arm can be crushed and you can end up with a floppy arm that never works. Parents don't tend to like it when their babies come out like that! Miraculously, this baby came out flipped upside down and waving to us, and no harm was done. Whew! Minutes later, the OB came rushing in. She wasn't too angry, but she felt bad that she missed it. Happens. Afterward, the OB nurse complimented me on how well I handled things-- which felt pretty awesome. Especially coming from her- she is one of the most high strung nurses I know. She's also one of the nurses I trust the most. Long before residents were here at the hospital, nurses would do the deliveries whenever the OB didn't make it in time, so I'm sure she would have handled it just fine without me. Later that night, when the OB nurse left and the night shift came on, I got complimented again! Apparently, during their nursing signout, they mentioned to each other how great it was. :) Sorry, I'll quit bragging. It just felt nice to be able to serve a purpose on OB, outside of just being there to get practice and learn. We all like to be needed, you know! Ok, off to make gingerbread men/women for the party tonight! Scott | | |
| Boooooo! I stink at keeping up. And to think I was doing so well in August/September. For all the wasted time I spend playing PacMan on the internet (google flash pacman if you want a new addiction), I could afford to blog now and then. But where to begin? Since my last blog, I've had another month of RMT (inpatient medicine), a month of Community Medicine (AKA Community Vacation), and now it's back to OB for more pushing and grunting. It's hard to believe I am nearing the halfway point of internship. While I feel like I've learned an amazing amount of material, I do not like to think that I am 1/6 done with residency, and then I have to go out and be a real doctor and not have anyone to clean up my mistakes! I had my first vacation week in late October, which rocked. Jes & E. Mae came out from Ohio and we met them in the Redwoods, before returning to show them around KFalls. The next weekend, we went to San Fran which was a blast- none of us had ever been, and we were able to stay on Telegraph Hill in one of the faculty's apartments. Definitely will be going back there- and it's only 5 1/2 hours away, which in Oregon driving is nothing. Alli and I had a pretty low key Thanksgiving. I was post-call from OB, and there is no way we had time to go out of town, so we stayed in and had a little potluck with a few other interns and their spouses. It was quite nice, and reminded me of all the things I have to be thankful for--- especially good new friends who support each other through what would otherwise be an incredible hellish year. We do three months of OB training in our first year, and I'm a third of the way through my second month of it. So I'm getting more comfortable in the land of babies and uteri. Last night, I had four deliveries, which made for a CRAZY morning. I didn't really get to sleep because by the time I was done with the deliveries and dictated and wrote all their labor notes (and sent home a woman who came in complaining that her "water broke" (it didn't)), it was already time to start rounding and seeing all my Moms and their babies. So eight (4 moms and 4 babies) patients to examine and notes to write and labs to check etc etc. I'm not quite fast enough to do all that in an hour, and the OB/GYNs get annoyed if they beat you to seeing the patient. I did have my first mental breakdown on the floor the other night. I always make fun of my intern buddy Suzanne because she wears her heart on her sleeve, and she's always breaking down in tears about something. Well, I got my just desserts. I saw a lady who came in concerned that she had ruptured her fluid, and when I did her exam, I got positive "nitrazine and ferning." Those are just tests that look to see if the fluid you collect from the vagina is actually amniotic. Her fluid was positive, and without thinking clearly, I did a cervical exam (with a sterile gloved hand of course). Then I called the patient's doctor to let her know she was her and ruptured and likely going to go into labor. Stupid Scott! There is very good evidence that when a patient is ruptured but not in active labor (meaning not contracting regularly), you DON'T stick your hand in the vagina, because you can introduce bacteria into the uterine cavity. So after getting chewed out over the phone, I felt like a complete ass. I apologized profusely, and retreated to the empty nursery where the tears just started flowing. I felt so stupid, and I knew I screwed up. Turns out this lady was NOT actually ruptured, and the testing I did was falsely positive, so no harm was really done. Thank God... but nevertheless, I had a few nurses feeling really bad for me since I was sobbing like a baby. My C-section curse has officially ended this month. I've only been in on ONE so far, and I think from my 3 calls so far, I've had about 9 or so deliveries (averaging 3 a call more or less). In a completely disgustingly related note, I now know what amniotic fluid tastes like. The other night, I was gloved and gowned and getting ready to catch this baby when the mom SROM'd (spontaneous rupture of membranes) all over my face. It was amazing-- she was pushing hard, and imagine her opening was about the diameter of an orange at this point, and just like that an enormous gush of amniotic fluid (baby pee among other things) came barreling up to my face... in my eyes, in my mouth, in my hair etc etc. Of course my sterile gloved hands and gown were spared... only my exposed face was involved. The two nurses behind me could not maintain professionalism and they began to burst into laughter. Of course I could not wipe my face off as I had "sterile" bloody gloves on (probably not a great idea). After a few seconds of sputtering the fluid out of my mouth (it tastes like a very salty rotten french fry), one of the nurses brought me a towel and dabbed my face. Yuck! Of course, the mother was COMPLETELY oblivious to this, as she was in her own version of agony trying to push through her pain. Thank goodness for that! Next month I'll be back into my 3rd month of inpatient medicine (we do 4 months in our first year). I'm excited, as I'll be working with Suzanne. I am working on Christmas, but I will have New Year's off. Our residency works so that half of us get Christmas off and half get New Year's off, so I opted for New Year's so that those with families could spend Christmas together. It will be worth it, though we don't have any big New Year's plans yet. Our January trip back to Ohio is rapidly approaching! I can't wait to see my family and friends. Until next time- I'm sure I'll have more gross delivery stories to share! Scott | | |
| Time flies when you're on call every third day! I only have three more calls for OB, before I rush back into the chaos of the medicine team for another inpatient medicine month. I'm looking forward to the change, as on medicine, you have a lot more autonomy and ownership of the patients you are taking care of. Last night, I had two vaginal deliveries right in a row. Both were with the same attending (a family doc), who was great to work with. One of the moms had a second degree tear after her delivery (which sounds bad but it's not that bad), so I had to sew her up, which was a fairly new experience. It can be pretty challenging, since the vaginal walls and cervix are so stretched out and edematous from the delivery itself, so when it tears, it's not always easy to figure out just where you need to reapproximate. But my attending was awesome at giving me the reigns and allowing me to work through it, while patiently offering suggestions when I wasn't quite sure how best to approach things. My C-section curse has finally ended (I had ZERO sections while on my last call). And I inherited a newborn for a patient! One of the moms didn't have a doctor lined up for her new baby, so I quickly volunteered! There's nothing more exciting than seeing babies or peds patients in clinic, since the majority of our patients are adults with chronic problems, so you get better training when you can disperse some peds patients in there. Last Sunday, we went to a big BBQ hosted by the Klamath Medical Society. It was a big bash to welcome new physicians to town (that's me!). It was quite odd to see so many physicians in one backyard, playing Bocce ball and drinking beer. Somehow makes them a bit less intimidating than when I have to call them and consult them in the hospital. Next time one of those surgeons is grumpy with me when I send him a GI bleeder, I'll remind him that I saw him half drunk in a goofy hawaiian shirt. While at the BBQ, I was introducing Alli to one of the family docs in town who actually did his residency at Ohio State. We were just chatting, and he asked if we had any plans later that night after the BBQ. Turns out, he and another family doc were planning to take their sailboat out on the lake! So we gladly accepted and took our first sailing trip! Granted, the wind was pretty low that particular night, so we used the motor for a good deal of the trip. The views are beautiful. There is nothing quite like the combination of water with mountains flanking all around, and the orangish pink sunset lighting everything up around. I should have brought my camera! Alli and I decided we want to buy a sailboat and start having a sailing hobby. Oh, and we also decided that since there is no local ice cream shop in the downtown, something needs to be done. Alli, Suzanne, and I have decided we are going to quit our jobs and invest in an ice cream parlor. We casually mentioned it to Celia (our residency coordinator), and she wants in on things too. She's got an MBA and has mad business skills, so she's definitely in. Today she told me that she got in touch with an old professor from OIT (the technical college in town) who knew of a bunch of ice cream making equipment that was for sale! Ironic, eh? School has started here (actually been going a few weeks now), and it is quite fun to see the kids milling around before and after school. Most days, I'm not around to see them, but sometimes, when I come home after being on-call, I will catch them going out for gym class or walking home. It's definitely fun living next to a school, and being in a neighborhood where a lot of kids can walk to school. Scott | | |
| What is it with me and C-sections? I just seem to attract them. Granted, the C-section rate in Klamath Falls is high (about the same as the national average, around 30%), but C'MON! Every laboring woman I touch turns into a surgical patient. Interestingly, there are four OBs in town who do sections, and EVERY SINGLE ONE that I've assisted has been with the same OB. I'm not complaining about that, but I find it ironic. As a result of my frequent dates with this particular attending physician, I think she is learning to like me. That's a good thing, of course. I would hate for someone NOT to like me, especially if I continued to find myself working with him/her. However, this particular OB has continued to perpetuate my nickname throughout the Labor & Delivery world- I am her Gentle Giant. Mortifying. Of course, the nurses just eat that right up. "Ooh Gentle Giant, how sweet!" "Gentle Giant, you have a triage patient!" Yesterday, after yet another C-section, I was invited to scrub into a GYN surgery in the main OR. Again, this is in general a good thing, because it means this particular physician likes me well enough to include me. However, this particular case was a vulvar abscess. Yuck. But there's no way I could even CONSIDER saying no when she asked me to join her, so I came along for the learning. It was actually pretty interesting, and she's a great surgeon. She'd be an awesome teacher, too, if she didn't mumble so much. I swear 90% of the things she tells me come out muffled through her mask and I can't hear a word. I ask her to repeat herself about 40% of the time, and the rest of the time I don't even bother asking. Alli and Suzanne joined me for dinner last night, which was awesome, since there was NOTHING going on on the L&D floor, and I appreciated the company. The night nurses on OB have been great, and I can usually kill plenty of time chatting with them, but the day shift is a harder bunch of nuts to crack. There are still a few nurses who A) don't even really know me and B) don't even bother including me. That can be frustrating. I slept almost the full night last night (that's how completely boring it was). There are two babies in the nursery (meaning they are sick and can't be with their Moms and Dads in the patient rooms). One is one of the babies I helped deliver from another C-section, and she had a tough time transitioning to the new environment. We call it Transient Tachypnea of the Newborn, which is a fancy way of saying, "Baby went from a water environment in the womb to an air environment outside the womb, and she had some trouble adjusting." She got a chest xray, which is sooo adorable. Here's an example (not my patient, or any other identifiable patient... I just wanted to show you how cute a baby xray is!). 
See those tiny little ribs and spine and heart (actually baby hearts look big compared to human xrays). Then there was another baby who had a fever, and any newborn with a fever gets a big old workup, including lots of lab tests and invasive tests like an LP (spinal tap). Brandon, one of my fellow interns, got to do the LP on the baby, since he's on outpatient Pediatrics this month, and they come in for all the admissions or things that come up with babies. Finally, there was a baby who had lost a BOATLOAD of blood during a vaginal delivery. Galen (another intern on OB with me) had been on the night this baby delivered, and I guess they clamped the umbilical cord and somehow it dissected and there was blood everywhere! And when it's a 7 pound baby, losing even a cupful of blood is a big deal... so she needed fluids and transfusions. Happy to report she was doing well by this morning, though, and going back to hang out with Mom & Dad. Last night I got one triage patient. I was chatting with the nurses when she came in, and I immediately felt a sense of dread. She looked sickeningly familiar to me, but I couldn't remember how I knew her. Had I seen her in the ER while I was on that rotation two months ago? Possibly, but I seemed to recall a much more unpleasant experience than a simple ER visit. Oh, yes, it was an office visit at Cascades East. She is one of the most unpleasant human beings I've encountered in awhile. She came in for some lower abdominal pain, and being that she is only 20 weeks pregnant, I quickly decided she was not in labor. She said her pain was a 9 out of 10, and yet she was joking and laughing with her posse of stinky cigarette-coated teenage friends. And she asked if we could do anything about some pain in her nose (ROLL EYES HERE), as she had JUST gotten her nose pierced and the area was hurting her. Trying desperately to rev up my sympathy card and remember that even annoying people get sick sometimes, I hooked her up to the monitor and began getting some basic labs. When I asked her to provide a urine sample, she scoffed and told me she didn't have to pee. She asked me to go ahead and cath her (WHAT human being in their right mind would ASK a doctor to stick a tube up their urethra when the alternative is to pee in a cup!?). I smiled and gladly obliged! Big surprise- nothing came back abnormal. So I gave her what she wanted (a low dose of pain meds) and sent her out the door. It's going to be a long 20 weeks until this lady delivers... I am guessing she will be back many times. Wanna see some pictures of where I work?? Sure you do! 
Above: The new facade of the hospital. Below: My favorite place to sit and watch the sunset (when I have the time!). 
Alright- enough. Alli and I are going with Suzanne to big Tulelake Fair today. Tulelake is a rural town just over the California border, and apparently, the CA state govt. subsidizes their county fairs, so it is a lot better than Klamath's. Alli (and maybe me too) is going to sit at the Habitat for Humanity booth for a few hours and try to raise money. My goal is to ride the Tilt-a-Whirl, see the rabbits and goats, and eat an apple dumpling or something. Then I will be content. Scott | | |
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