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.