Mishmash

I just finished day 14 of 26 in a row. Because I just got off night shift (no weekends while on night shift) and because I chose to work Xmas instead of NY, I’m working many days in a row.

Today I broached the subject of the divorce with my kids. It is not something that they’ve really wanted to hear about before but since their dad is coming out here again in a few days and since it was a HUGE elephant in the room that caused all manner of psychic distress for my kid, I thought we should at least start a discussion. I think it took nearly this long for me to be able to have this conversation and be as fair as I needed to be to my co-parent in explaining the whole thing to them.

I studied today for CREOGs. This is an annual exam we take in January to evaluate our knowledge of the content you need to know to be an Ob/Gyn. It was a day that was busy in pieces, but gave me time to answer questions and review my notes. Not as many deliveries in the last couple of weeks, but I’m in for the long haul, I can wait.

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Been feeling pretty crappy lately but it turns out I wasn’t burnt or depressed, I was just in need of a damn day off. Mercifully, once I figured out that I was working 26 days in a row, we were gifted with the world’s slowest Monday on L&D and my chiefs let me go home for the day. I walked my dog, cleaned my room, did some fun errands, made dinner, did stockings with the kids and baked peanut blossoms. I didn’t swing a nap but the day was great anyway. Only 2 weeks (well 12 days) until my next day off. Can’t wait to do it again.

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Every service has its upsides and downsides. When I’m on an L&D rotation I’m reminded what a creature comfort predictability is for me. On L&D from day to day, hour to hour, you never know what you’re going to get. I guess that you can remember that Tuesday is high risk clinic day and to expect a bunch of you-know-what to hit the fan in the afternoon - patients coming for extended monitoring, to rule out pre-eclampsia, ultrasounds, EKGs, etc. The sucky part is when that semi-reliable day happens in addition to a bunch of walk-ons with all manner of complications. Life on L&D is like a box of chocolates, you never know what you’re going to get. And sometimes it just kicks your ass.

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We got an admission recently that is making everyone varying degrees of sad and angry and frustrated. A patient with a terribly sad, avoidable outcome has been handed into our care by an out of hospital birth attendant who works in the area. This is my own personal first horror story of tragic, avoidable outcomes due to this person’s poor standard of care but I understand that it isn’t likely to be my last. There have been reports to the medical board, by patients and doctors, yet somehow this person is still peddling their toxic product. I have known that there were people like this out there - allowing women to get sick or permanently injured and babies to die (I’m not exaggerating) and still offering substandard prenatal care that doesn’t provide recommended evidence-based surveillance or have necessary back ups in place. 

I can only imagine safe out of hospital birth when it is coupled with seamless integration into higher levels of care - knowing when you are performing at the edge of your scope and where to get the next level of care and accessing it quickly. I think the thing that bothers me the most about this is that even in the setting of harming women and babies, this person sets themself up on a pedestal, revels in the title of “infamous” and considers themself the one true champion for women & babies in Western North Carolina.

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I get a lot of feedback. My actions are under a lot of scrutiny and that is right and good. I need to be careful, precise and as correct as possible in my actions and decisions. I accept this as necessary. At this point, I’m not (usually) a danger to patients, so the feedback is mostly fine tuning. It seems to be having unexpected consequences on my psyche.

I get correction from 3rd & 4th year residents frequently. Sometimes we have responsibilities that overlap. So I might see a note or orders placed by someone who is also responsible for making sure I do my job correctly. Because they are also still being trained and learning, they do things incorrectly as well. Also because they are human. None of these things are dire or consequential. Like much of the feedback I get.

There is this little “first thought” that I get that is a petty “A HA!” when I see a mistake made by an upper level. As in, “Not so perfect, are you?!?” I’m immediately layering a second thought that gently reminds myself that they never claimed to be perfect and to stop being petty. But the first thought is there and I need to recognize it so I don’t let it sneak into my attitude and relationships with my co-workers.

Halfway

I feel like I haven’t published in a million years but I see that it has been less than 3 weeks. (It's been longer than that by now but it was about 3 weeks when I wrote this)

I noticed recently that my posts that talk more about work seem to get more views and I was trying to think of things to say about work but having a little bit of writer’s block for lots of reasons.

Today I managed a 16 week loss. The patient was admitted and stable when I came on this morning but she was going through something called an “inevitable spontaneous abortion.” The pregnancy wasn’t over yet, but we knew it was just a matter of time.

This wasn’t a situation where the pregnancy was no longer viable, when there’s no heartbeat and we’re just waiting for the body to notice that it was no longer gestating. This wasn’t a “passenger” problem, it was a “passage” problem. These sorts of problems can be infections, very early rupture of membranes, labor, painless cervical dilation to name a few. In these cases, there’s still a heartbeat and if we were cruel enough to put an ultrasound on the uterus, we’d see it. And the fetus moving, oblivious to the looming danger.

In these situations, there are a few ways we can manage things but before I do I want to state very clearly that this is a pregnancy that Is. Going. To. End. 100% chance of miscarriage. No chance of survival. No chance of waiting until the fetus is big enough to be viable and benefit from a neonatal intensive care unit. This is a hard, hard day, for everyone involved. It is heartbreaking and tragic and absolutely no one’s fault. It didn’t happen because someone was fat, used drugs, had bad teeth, didn’t pray enough. ANYTHING. I really don’t want some anti-abortion troll to find this post randomly and call me a baby killer.

Patients need some time to come to grips with this reality. It doesn’t fit in a brain - the baby is alive, but it won’t be for long, and there’s nothing I can do about it except choose the manner of its passing. Sometimes while they are coming to grips, the situation changes and our path is limited by the circumstances - bleeding, infection, retained placenta. This is exactly what happened today. Our stable, very sad patient was taking some time with family to mourn when her body decided it was time.

Had we not had our hand forced by our patient’s uterus, we would have offered her 3 different options: (continued) watchful waiting, induction of labor or dilation and evacuation or a D&E. I think a D&E is what is known as a “partial birth abortion” in political spheres but I couldn’t honestly tell you because there is NO SUCH THING as a partial birth abortion. It is a made up term used by non-medical people to misrepresent a heart breaking and sometimes life saving medical procedure.

We know some things about placentas in the middle of pregnancy - they are now big enough to do work and pool blood, despite what else is happening. And they are often still very adherent to the uterus, if they don’t come out all the way, we need to go in and get them or they cause deadly trouble. If a patient is already sick or just doesn’t want the risk, a D&E is, hands down, unquestionably the safest way to get to manage a second trimester loss. The downside from patient perspective is that they don’t have a baby to hold, For some people that is very important and they are willing to risk needing manual extraction of a placenta, a D&C, a blood transfusion. It isn’t a guarantee but it is common.

You may have noticed that this is a fairly clinical description of these events. It was an oddly clinical day for me - I kind of forgot to be sad about the baby dying. I was thinking about managing a sick patient who was not conveniently (or as it turned out, safely) located relative to the supplies, staffing and OR. I was deciding about when to give her medications, how much to give and what signs would mean I needed to do something different. I actually had to make an emergency call at one point. People were moving slowly toward a goal and I said “We need to go NOW” and what do you know, people reassessed their needs and moved a lot faster after that. This was MY patient. I managed her (with help, guidance, supervision, of course), I counseled her, I met with her family afterward. I was very busy and it was a huge growth experience for me. But I forgot to feel sad. And now its been a few days (I’m finishing this post up a few days later) and I don’t think I can unpack that sadness at this point. Maybe later, when managing the medicine is not as new and intense, I’ll be able to hold sadness while getting shit done. Life goals.

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Today in clinic I helped a experienced nurse practitioner diagnose an unusual problem she encountered in a postpartum patient visiting for an IUD. Bodies are weird, this one was doing unusual things and she couldn’t make heads or tails of it. I did an exam and identified and evaluated the problem. Then I put in the IUD. Proud little “I’m becoming the next level provider” moment.

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Had something of a personal curveball last week. I’m on a leave from work for the last 7 days, will probably be heading back in about 4 days. It wasn’t my curveball, it was a parenting curveball. No, I’m not going to say more about it than that at this point. When your kids get older, the stories aren’t really yours to tell anymore. This is going to be one of those things that comes out over a series of small posts, peppered throughout my blog. Stand by for more.

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I've not been feeling great recently, realized that I haven't been reaching out, not trying to talk to friends, just keeping my head down and moving forward. Feeling a bit out of sorts. I'm publishing this stuff that I've already written so that I can clear the plate and maybe do some blogging again. I need to get back to the quick vignettes so it can feel more accessible to blog. My life is hard but my life is also amazing. I need to remember the second part a little more readily. 

We're about halfway through 2nd year and it has indeed been a tough year. Last year I liked the second half a lot better, I sure hope that's the case this year too.