Trauma Surgery: first week

Phew. So trauma surgery. Whew. Yeah. So its better than general surgery but its not.....surgical. Its a crazy mix of IM & ER.   ER part comes from dealing with the traumas. But when we get a trauma but we don't just stop there. Trauma service manages patients for days until they get discharged from the hospital. We even have trauma clinic where those patients follow up even after leaving the hospital.

So that said, traumas are surprisingly simple, if you can get over the frantic, bloody, crowded, chaotic atmosphere. Because the truth is there are only so many things that can kill you in the next 5 minutes. And trauma's job is to make sure those things are identified as quickly as possible.  Broken bones, lacerations, bleeding, pain are not even on the radar for trauma. The one and only job is to make sure you stay alive for the next 5 minutes even if it means hurting the patient (aka no pain meds, yanking on broken bones, always checking rectal tone).  Standard procedure involves cutting off your clothes, do a trauma series (aka CT head, neck,chest, abdomen, pelvis) and stat chest xrays, 50 very personal questions, exams of every part of your body, including rectal exams on everyone, checking pulses, listeinng to heart and lung sounds, and more in under 60 seconds. To be a real trauma center, we must have all these things done (by multiple people) in literally under 75 seconds. It def helps to increase the frantic atmosphere. It is hard to not constantly feel like you are in the way. It also makes it hard to help if you don't know what to do or exactly how to do it, while staying out of everyone else's way.

Despite the word 'trauma', the service is disappointingly devoid of blood and guts. We've only really had about 1 trauma per day. It seems to be primarily consults when patients turn critical or other services won't admit.  Its frustrating because oftentimes, we are just babysitting a patient for neurosurgery because they do not admit their own patients. To top it off, trauma surgeons must stay licensed in general surgery which requires 'typical' procedures like a PEG tube, placing a trach, taking out an appendix, etc.  So for 1 week of each month we take 'surgery call' so whenever surgery needs to be consulted, they call trauma instead.

When there are traumas they are classified in 3 levels of trauma in order: consults, priority, alert. Alerts are rare, but if they come, you run. So here are some patients, to better explain this.

CONSULTS

An older gentleman shows up at the ER (war veteran- predictable right?) because of a fall 2 days ago. He thought it would be okay, but despite extreme bruising on his shoulder(craziest bruise i've seen yet), he let it go a few more days.  And soon it was 2 weeks later and he admits to not moving his right arm since the fall. And he is profusely uncomfortable that he had to come in at all. He is apologizing and promising he's not a wuss but he is extremely tender and said something might be "grinding around in there." And then of course we get this xray back. Yeah. That's CRAZY broken.

PRIORITY

This was a 21y.o. male who was in a MVC (motor vehicle collision) he was a backseat passenger where he was ejected. The car rolled over him. The driver, his girlfriend, was fine because she was wearing her seatbelt. He arrived at the hospital awake but on a backboard and cervical collar. There was blood in lots of places from a scalp wound as far as we could tell. He had a tibial fracture and back pain. We put in a foley catheter (for urine) and he starts getting upset because he can't feel it.  Then we roll him over (per protocol) and do a rectal exam, which reveals gross blood and no rectal tone. He starts screaming and finally we figure out he can't feel it. We do xray and CTs and find something strange: a completely isolated, shattered L1 vertebral fracture.  If you look up at this close up I provided you can see some pieces that are pushing on the cord. This is bad. So we try to calm him down because the cord itself isn't broken, its just being pushed on.  I rounded on him this week, because obviously this is a trauma case we admitted for.  Its important that I mention that he can move his legs and walk fine, despite his broken ankle.

So I walk in his room to find out how he's feeling and he's laying in his hospital bed sleeping (cuz its 5am) and there is a woman in his bed who is spooning him and rubbing his chest. I am a little shocked, is this his girlfriend?  Didn't he just ask me for my number in the trauma bay? I go ahead and waken him up and do the exam and whatnot and discover this is his MOTHER.  Weird. Then i get in trouble at rounds because i didn't think to ask him about his genital sensation and his function. So i return over the next several hours and have to ask him in front of oh, maybe 6 people who are his friends and family if he's had sensations or erections. He says he doesn't know, would i look for him....  and now i don't know if he's flirting or actually scared to look. Um, way to go bioethics for not preparing me for this dilemma. anyhow, i choose not to look obviously.  But i get chewed out during rounds for not being able to answer all the attendings questions, but half of the residents are laughing.  And I'm seriously confused about what i'm actually expected to do medically.  I mean I've seen plenty of penises, but rarely in front of family members and rarely do i want the patient to stimulate an erection.  Can't he go into the bathroom or something?  Isn't there a morning wood phenomena?  Anyhow, I actually haven't asked him yet. And just chose to be yelled at by the docs this morning instead.  He did have surgery to fix his back and they discovered an anal tear which we fixed. He still wasn't having sensation (which was assessed by me waiting for several awkward moments while he played with himself in front of his mom and it wasn't under the sheets). However, we did a void trial (took out the foley to see if he could pee on his own) which he couldn't.  So we also did another rectal exam, in which he couldn't feel still but he doesn't have any more blood.  So its been several days and still no changes (this isn't looking good) so we had to consult urology and teach him to catheter himself.  So I'll update this post with edits on his progress, but the real possibility we talked about at rounds is he might have to get a colostomy bag and may never be able to use his rectum or penis again, even tho he can walk.

Now this whole situation brought up another weird medical joke/issue that is for real and people did studies on it. Throckmorton's sign. Its a real thing, tho I question how they got research grants for this. Google image it. I dare you.

ALERT

And sorry, but with alerts things were so crazy... i didn't get many pictures. Its hard when you're running about. However, we had two cases this week.

The first was a 5 month old that was lifeflighted in from a smaller hospital. Apparently the story was several days ago he was seen for nausea and vomiting, he was given antibiotics but he returned that morning for seizures.  They couldn't figure it out so they did scans. We didn't know anything but this story when we got the kid.  He was awake and looking at everyone, he moved all four of extremities, but something about the kid was off.  For example, we needed and IV and stuck him at least 8 times including on his head (for scalp veins, this is common practice for babies because they are big vessels for emergencies)... but this kid didn't cry. He just whined the first time and only once. Then he just watched us.  Something was definitely off.  We got a CT scan and saw a huge brain bleed.  Apparently it came out slowly that this was my very first case of shaken baby. The saddest part of this story is that he did not get better.  He went directly to the pediatric surgeon whom i hunted down and he said he expects the kid to be mentally retarded. He will probably never be potty trained, will only learn to walk if he's lucky and may not be able to speak.  Likely he will be put in some facility to stare are the walls and lights in permanent nursing home for the rest of his life.  I looked at the parents when we told them this and I don't think they realized until that moment. Shaking your baby, even in a moment of anger, is something you can't ever take back. Not only will the kid be taken from you but they will cease to be the kid that you could have had. After they were told, the entire staff treated the parents worse than i've seen anybody treated, they were outright ostracized, glared at, and one of the surgeons even flipped them off. (professional i know).  It was strange because it was very emotional for everyone on staff.

The other case I have to talk about quick. A lady slammed on her breaks because she wanted to avoid running over an animal on the highway. The semitruck behind her slammed into her car, shoving her into oncoming traffic where another semitruck hit her head on.  We referred to this as a semi-sandwhich. Surprisingly, she was awake and lived. Though her injuries were extensive and had quite alot of blood loss.  It took 3 medical students to suture her wounds closed and I (by myself) threw about 32 sutures.  Plus we had 1 resident sewing up her face. The weird social situation that surrounded this lady was her daughter who was in the waiting room. I went to get her after my sutures and she was more nervous than usual. I guess she was adopted as a child and had only met her biological mother (the one we just sewed up) about 2 months ago. She had no idea how to feel or what to say. It was very awkward.  This picture is of an acetabular fracture (the bony cup that holds the femur head in your hip), its on the patient's left-- and its kinda tricky to see. The biggest thing that we worry about in trauma's with pelvic fracture is bleeding. Usually if you bleed from a vessel, it will bleed until the pressure around the vessel is more than the pressure in the vessel which stops the bleeding. In pelvic fractures the bone structure is broken, allowing the soft tissue to slack. There is a lot of space in the pelvis. So much so that it could hold half your body's blood supply-- more than enough to cause death by bleeding out. However,  if your pelvis in intact then the pressure will eventually overcome the bleeding, if it is broken, you can bleed out fast, with no outward signs.

So anyway I have to sleep or I might die....

OB/GYN: No Residents

SO there is one day every so often all the residents in one particular specialty has to go to a special conference for skills tests out of the city. This leaves the hospital without a single OB/GYN resident.  This means that of course-- the shit will hit the fan, because teaching hospitals run on the backs of residents.  There is an in-house resident at ALL times for almost every specialty and the attendings are only called when the resident is in over their head or for approval of high level procedures.  Without the residents, the attendings suddenly become responsible for everything-- something they aren't used to.  This means they pull together all the students on the service and make us handle the little day-to-day details while they handle the bigger things. Things like yes, you can give tylenol to this patient with a fever or no, she cannot have any food before surgery (etc etc). These are things that we learn through out the month.  Now I am almost done with OB/GYN and the other two students are new in their first three days.  This means that not only are the nurses asking us questions but the other students are asking me questions, which the nurses notice and then start assuming i'm in charge.  BIG MISTAKE. Not because i messed up (that i know of-- which i was scared out of my mind about) just because suddenly i was getting all the calls.  And now I understand why docs think nurses can be annoying.  When i was in charge, the nurses didn't ignore me anymore they just started trying to pander to my ego, which was very confusing. Telling me I was gunna be a great doctor and how i knew so much blah blah... which would be nice if this same nurse hadn't just complained to the attending last week that i kept getting in their way and not doing anything useful. Weird. And then they started asking me just ridiculous questions. When i put in an NPO order they call me and ask is jello considered a food?  Is a cough drop? They page me overhead to ask if i can come look at this lady because she has this new rash, so i come down and find out she's had it for 4 days and there is already an antifungal written for it. I wondered if they were doing it on purpose but it was so many different floors i don't think it was. Anyhow, despite all that it was neat because i felt like i got a small taste of being a resident. I got to make tiny medical decisions and it was at least for this one day AWESOME !

It was a crazy day. We had 7 births that day with 1 attending, who was running about like crazy.  I got a phone call that we have a life flight coming in 5 minutes of a 19 y.o. who is 24weeks pregnant (remember that 24weeks is the bare minimum number that fetus can survive outside of the mom-- not guarenteed survival but possible survival).  She is having vaginal bleeding, abdominal pain, and of course she had done cocaine yesterday. Awesome right?   So she gets here and the baby's heart rate is in the toilet (i don't know much but i know the baby is tanking) and this girl is screaming her head off because she is scared out of her mind.  And she rolls in and we just divert her down the hall to c-section. We didn't scrub we didn't put on hats, we ran down the hall to the OR.  Where we ripped off her clothes, started prepping her for surgery while the doc put on gloves. At this point she's clinging to me with all her 90pounds of strength and screaming.  The nurses and doc are screaming for anesthesia who is not here and they page them stat overhead.  but the baby's heart rate is falling and now mom's heart rate gets questionable and anesthesia still isn't here. So the doc decides she's going to cut without anesthesia -- she makes the first cut and the girl is like freaking out.  Of course she doesn't let me go so they put the blue sterile sheet on top of me.  Finally anesthesia comes running up and they freak out until the doc sternly tells em to put her under NOW.  And then they intubate and i get out of her grasp and next thing i know that baby is whipped out-- most purple baby i've ever seen.  2pounds 3 oz.  And baby had to be intubated.  I still don't know whether or not the baby made it because as OB/GYN we are responsible for the mom once birth happens, not baby.  The mom made it.

But i had to leave the OR because I had to manage the other 3 ladies in labor who were quite literally delivering now. I had to go from room to room to check them and make sure baby's head wasn't falling out. And of course with one check i saw the nose and almost delivered the baby on my own. It was terrifying because here i am trying to be calm trying to coach her through the pushes, the breathing, and the contractions, nervously exchanging glances with nurse and making her run for the doctor, while i have my hand on the baby's head and PRAYING that nothing would go wrong because I wouldn't know what to do...   Luckily the doctor came in just as the head popped out.  She left me to deliver the placenta while the woman across the hall delivered. The rest of the women on the floor musta heard about it or maybe there is some crazy hormone we don't know about but man those babies just came out one after another after another after another.  So i assigned the other medical students to one laboring patient each. And the PA student who was new. And then ran about trying to transfer patients to post partum and manage the nursery transfers etc.  It was exhausting and exhilarating at the same time. And i am sure now, that I could do OB/GYN and like it.

Last patient of the day is a bigger girl who presented to ER for abdominal pain of what she thought was appendicitis. And low and behold the ER doc did an Ultrasound to see if the appendix was inflammed and oh, there is a baby. And oh she's in full term labor.  And somehow she didn't know she was pregnant.  And when i went down to talk to her, she's was eating a big mac and talking, "this happened last time with my last baby. I thought the movement was indigestion. Isn't that funny?" Half way through the exam, the boyfriend brings her 2 more big macs. Only patient i've ever seen eating big macs DURING labor. Like for real.  Plus she didn't know she was pregnant. That was also weird.

The big question is now is what do i think of ER. Do i like ask much as OB/GYN or vice versa?  Anyhow. sorry this was so quick.

OB/GYN: patient comfort & ovarian torsion

So. A few things to follow.  First just finished my 24 shift. I dunno 24 hours isn't that bad if you don't have to do it all the time, which according to the OB/GYN attendings you do.  Not to mention the malpractice insurance and suits are SO out of control. I guess several of them were being sued because kids they delivered turned out to have learning disabilities or Austism.  The saddest thing is lots of these doctors loose because  ingenius lawyers or the truth that we don't know what causes Austism-- so they use theories of anything and everything  including hypoxia during birth.

Anyhow. So the patient I described in my previous post, in the botched DiVinci robotic surgery. The one with the bowel perforation-- she's someone I have to 'round' on (check up on) everyday.  Anyway she's not doing particularly well.  She's a rather anxious person and who can blame her after being admitted for what was supposed to be an outpatient surgery and now she has tons of complications. Not just the bowel perforation which healed by the way. But also now multiple blood clots in her lungs. And today she was told she needs an MRI because they were concerned about her mental status because she forgot the word for 'hairbrush'.  Anyway I think they are only freaking out because she has had so many complications-- that they are trying to cover their asses.  But in the meantime, she's closterphobic and these tests are racking up a large hospital bill that she can no longer afford.  I was faced with an ethical dilemma when she asked me up front, "Ignore your job for a minute. Would you get the scan done?"  because the answer for me is--- no.  But if i tell her that and if i'm wrong-- then I could be sued for it. So when do you stand up for yourself and for your patient's comfort and when do you cover your ass (CYA)?  Its a shame that medicine has become more CYA than not. I ended up telling her that if she doesn't want the test she doesn't have to have it. But she should talk to the neurologist who ordered the test to make sure they had good reason for ordering it, being sure to tell them all of her problems with it and see if they thought it was necessary or if it was CYA.   It was the most legal way I could tell her-- no you probably don't need it without making the decision for her.

So there was a patient who was admitted before my shift for extreme abdominal pain.  She had multiple imaging studies that showed this odd mass that nobody could identify.  So when I got on shift, we all debated what it could be but decided to do exploratory surgery. She has been in pain for at least 24 hours and nobody could figure it out.  The image was blurry, and the mass could be attached to the uterus or the bowel or ovary or floating alone.  And the surgeons argued about who would have to go in blind, so the OB/GYN decided to just do it. Anyway we get in there and its a quick surgery. Because the mass is huge and purple and... it turns out to be the ovary and giant baseball sized ovary. And the blood supply is twisted on itself. This is a condition called 'ovary torsion' it is very rare.  Most people hear about it in males, the dreaded twisted testicle that causes extreme pain and is an emergency.  Its easy to twist testicles but very hard to twist the ovary.  Anyway I got a picture. Its something that you only read about in textbooks...

OB/GYN: Fibroids part 2

So i was a little unsatisfied with my previous post on fibroids, since I needed to make sure to get more facts straight.  Also i wanted to post pictures of an intact uterus with fibroids. SO i have this post :) 

This is obviously not a normal uterus. It is enlarged because of the fibroids. A normal uterus is about the size of the palm of your hand. Of course that is without a baby or fibroids inside.  Anyhow. You can see the cervix and you can see the circular fibroids all over the uterus

• Known risk factors are African-American descent, nulliparity, obesity, PCOS, Diabetes, hypertension
• fibroids are hormone dependent. So after menopause and before your period, you don't have fibroids
•  seals an dogs also suffer from uterine fibroids
• there is a genetic component but it doesnt mean you'll get them because your mom does...
• we don understand why or how they develop
• the only treatment for fibroids is hysterectomy

 This uterus is 8 inches long and its 470 grams. It was bigger than some babies.  This lady was experiencing significant bleeding and a weight gain.  And that's about all i know.   And i'm bored already of fibroids....

asdf

OB/GYN: malformations

so.  I know i've made the sad parts of ob/gyn obvious.  But I have followed up on one of the babies born without a right ear.  I wasn't allowed to take a picture, because she has other malformations and the parents didn't want her seen as a freak.  So I will just tell you about her.  She has a cleft lip and palate. Her head shape is just a little too round and her right jaw is obviously smaller than her left side.  The chromosome typing hasn't come back yet.  I am doubting it is any chromosome problem since its not on both sides, but then i guess what happens in books isn't always what happens in real life.  The only other way she could have gotten this way is if the mom had ingested something toxic to the developing fetus. Any illegal drug will do or a few different kinds of actual medications. But mom of course denies these possibilities. 

Anyhow, what I am able to show is her MRIs.  You can see that she has a big malformation in the bottom part of her brain where her cerebellum would be.  This congential lack of cerebellum is called dandy-walker syndrome.  In most cases, it refers to a complete absence of the middle of the cerebellum called the vermis.  When this happens, the person is usually just fine and develops normally.  Our path teacher once said, "i walk just dandy without my vermis."   But her malformation isn't just the vermis, its the whole cerebellum is smaller than it should be.  See the black triangle at the bottom of this picture. That black shows empty space and just so you know, there shouldn't be just empty space in the brain like that. If you refer to some of those neuro pictures from way back when i'm sure you can compare for yourself.

This picture here, is the more standard MRI. Here not only can you see the cerebellum problems but you can also see the shape of her head. The weird jaw line.  You can see that she has neonatal teeth (most babies aren't born with teeth).  You can see that her eye sockets are smaller than normal and even her brain tissue just isn't quite right.  You can  see the palate malformation as well. 

Alright here i'll insert a labelled pic.  Its not terribly obvious but its the best i can do for now.

OB/GYN: Fibriods

So i Finally got to see a very awesome surgery... the only surgery of the day (but don't worry, that doesn't mean a day off for me, it means more ob).

It was a partial hysterectomy with a known 10cm fibroid.  A 36 y.o. woman who wanted this surgery because of extreme abdominal pain and significant bleeding during menses. This was presumed be because the fibroid, which was outside of the uterus. She tried for seven years to conceive and finally decided to accept her fate. And decided on the surgery.  She wanted to keep her cervix and ovaries which is why it is only a partial hysterectomy. When we opened the abdomen, we found the fibroid- which is a ball made entirely of excess muscle. Before you ask, we have no idea why some women get them and others don't. We do know that obesity is a very high risk factor, though.  Anyhow below is the fibriod I'm holding. It is shaped like a heart.... see

However, the real surprise was her uterus. It was very large and there were so many blood vessels.  We had to cut the uterus in half to get it out of the incision so, when we cut we found that the uterus was filled with nothing but fibroid tissue. It filled the uterus so completely there was no way she was ever going to conceive or come close to stop bleeding.  If we hadn't already cut out a fourth of the uterus we could have cut out the fibroid and allowed her to try for a kid. But she had already signed the consent and we had already cut off the uterine blood supply.

For those that don't know: the uterus gets up to a quart of blood a minute.  So imagine cutting that artery and the sheer amount of bleeding. Women can and do die because the uterus breaks (during labor, trauma, etc). So cutting the uterus results in significant amounts of bleeding and with fibriods, this lady was no exception. She ended up getting two bags of blood because we kept getting bleeders. It was crazy fun.

Anyway, below are the pieces of the uterus... look at how thick and almost meaty it is.  Believe it or not, the strongest muscle in the body.... the uterus. Yeah. Take that. 

EDIT: I just went back and updated a few of the previous posts by adding more pictures, etc. And I added a few new posts, check out the general surgery section.

OB/GYN: robot surgery

I'm now on ob/gyn surgery... which actually means just GYN stuff not any babies, which is a little bit of a change of pace.  (although i do note that i've seen so many c-sections that i'm 100% convinced that I could do one on my own.  I'm even willing to bet my grade on it... which is saying a lot from a med student's position. now if only the residents would let me..)

GYN surg seems to be primarily hysterectomies (removal of the uterus) 'hyst' for short. There are so many ways you can do it: abdominal (cut a pfannenstiel incision then remove the uterus out thru the hole), laproscopic (like a lap chole, make 3 tiny holes called 'ports' to stick our tools then watch the monitors to cut it up and take it out), vaginal (you take it out only thru the vagina, cut by cut, which is super neat and my favorite), or finally the DiVinci...

The DiVinci is this new fancy robotic way where the doctor sits at this console and watches the surgery from inside his little cubicle while the robot looks like a spider overtop the patient, the uterus does come out the vagina still.  Hence my cheesy picture... thanks google images!

 Its like playing a video game only way way more tedious and in 3D. The reason we do this is because it helps the patient heal faster, but its a bigger pain in the ass for the surgeon.  As a nurse or resident, it sucks because all you do is change the tools for the doctor. As a medical student, it sucks because you sit between the woman's legs and after inserting a fluid filled balloon-stick (yes that's a fancy surgeon term) into the uterus thru the vagina and you move the stick around to help out the surgeon.

A normal hyst takes say max 2 hrs ... a DiVinci takes 3 or 4 because you are working with such small instruments.  Have i also mentioned that it takes doctor 2 years of EXTRA training before they can operate these?  yeah...

Anyhow, my first DiVinci gave me a migraine... quite literally.  It was a 7.5 hour surgery and stare at this tiny little screen for hours... I can't get up, pee or eat. And i have to move the uterus around but i can't wiggle it wrong or the doc will have to start over.  Not to mention the controls are inverted! (right means left, up meand down, etc). GAH!  So this doc accidentally 'forgot' to cut the uterus totally free (its a circle, you have to cut the cervix out of the vagina in a circle) but he thought he cut it but he didn't. So he's telling me to pull out her cervix and shouting all these mean things at me, when i'm like.... uh, dude its still attached. The resident decides i'm incompetent and comes down out of the sterile zone (vagina and bowel are two areas that are known as 'dirty sterile') to assess me and realizes the uterus is still attached like i SAID.  And so the surgeon gets all in a huff and accidentally breaks one of the DiVinci robot instruments, called the 'Grabber' which no longer shuts. So we have to get it out thru this tiny port hole without closing it, which is hard. And somehow a piece of bowel gets stuck on the grabber when it got pulled out, so its half in and half out of the abdomen and the doc starts using the robot arms to try and pull the bowel out and it RIPS. He's officially cut open the BOWEL!! (the biggest no-no in surgery is cutting the pancreas. the second biggest is cutting the bowel). So we have to call in the general surgeons because the bowel is open and leaking contents everywhere. In the meantime the uterus is bleeding and leaking into the vagina. So we are trying to get the uterus out before the general surgeon gets there which of course we don't get done.  Anyhow this is why the surgery took 7.5 hours.  It was a painfully agonizingly long time trying to fix mistakes that the THIRD YEAR MEDICAL STUDENT could point out.

I get that surgery is harder than it looks, but SERIOUSLY.  Anyhow, patient came out fine, no bowel problems thanks to the general surgeon who took an hour to suture up those holes. Not to mention, I actually left the surgery thinking i might pass out at any minute because my head was killing me, i hadn't eaten all day, i needed to pee and my vision was actually wavy...  I had to pull over twice before i was able to drive home. So i am a huge non-fan.  If surgery is headed in that direction... count me out.

OB/GYN: the 48 hour shift.

so the worst thing everyone always talks about when it comes to OB/GYN is the hours. I mean who wouldn't love the breath of hope and happiness that our patients add. They are happy to be there and happy to go home, etc. Plus its a little clinic, surgery and hospital.

But I got to the hospital at 5am wed and left at noon on friday. I only got 4 hours of sleep total. And it was ridiculous. I saw so many c-sections and births and there were so many things we had to do.  And it wasn't as bad as i thought.  I learned a secret. Well several. Constantly eat and don't sit down if you don't want to fall asleep.  SO i just stayed up.. and had no caffeine. I was very proud of myself.  I

I feel a little... drunk or something. Like if i stop moving, the room kinda spins. SO i am sleeping instead of updating this STUPID BLOG... I probably shouldn't have driven.  I have another long shift later.

OB/GYN: twins

Over the last several weeks we've seen somehow tons of twins. I've seen 5 different sets of twins. Some were bad and some were good.

The first set was a 19 year old who came in for a check up-- just a standard check up. And so we ultrasounded them...but there were no heartbeats.  It was horrifying to tell this new mom, who had been disowned by her parents and living with her boyfriend and only making it work because of the babies, that both twins were dead. What was worse, is that they were big enough that she still had to deliver them.... she had to be induced and go through all the pain. And see them.  It was awful.

There was another girl who was another teenager who already had one baby and was at term. She was scared and wanted a c-section.  Silly thing thought with twins that she'd have to labor twice as well as giving birth twice. The residents begged her and bullied her for a vaginal delivery. They are very rare these days. So she finally agreed and i question the ethics of what they did. Especially since for some reason her cervix wouldn't dilate past 6-- so we ended up c-sectioning them anyway.  They are doing fine.

We saw one girl who had a history of a hpv on her cervix to the point that it was close to cancer. So previous to her pregnancy the doctor performed laser surgery cutting out the portion that was diseased. Now she was pregnant. About 21 weeks.  But her cervix couldn't hold the baby inside, and it literally fell out of her. It was about the size of my hand, maybe larger.  Still attached to the umbilical cord.  21 weeks old is painful because the lungs can't be saved until bare minimum of 24 weeks.  So with only 3 weeks left to go, it came to early.  It was still alive too, moving about and the was the mom held it. The good strong heart beat.  But once the baby is out, there is no way to put it back.... and once its out, the placenta will start to seperate from the mother.  So we only had two tough choices.  Let it die slowly after the placenta ruptures, or cut the umbilical cord and let it die quickly. And the choice was made to cut the cord.  It took two hours for that baby to die.    It was agonizing.

But beyond the sad stories, there are alot of good ones too.  Lots of normal, happy , healthy babies. Those stories that aren't worth telling because there was nothing eventful.  It was nice to see them.   I've been apart of many c-sections probably 70% of deliveries are now a days.  And most of the rest are done under epidural.  And despite all that... the easiest and fastest births are still the natural ones.   And nobody really screams..... the pain of labor isn't as horrifying as i'd imagined.

So that's one good thing.  And I still feel that ob/gyn has a breath of hope left in medicine. And my personality fits here.  but the hours suck.... and it can be very sad.....  i'm still waiting to make a decision. So right now... ER & ob/gyn are tied.


current baby count:39