I've officially completed three weeks of OBGYN. This week I made progress in terms of I now know how to do pelvics and pap smears, albeit not great. I've been in the OR a couple of times for couple of procedures, and delivered a few more babies. Overall, things are going well.

Last night though was probably the lowlight of my clinical experience. I was on call. We had a woman come in who had been seen a week before as an inpatient for oligohydraminos (low amniotic fluid). She was treated and discharged. Two days ago, she stopped feeling the baby move, and thus went to see her midwife, who was unable to find a heartbeat. She was admitted to L&D again, and determined that the baby was stillborn at 26 weeks. We then had to induce this poor woman to deliver the fetus and placenta. I'll spare the details, but it's not a pleasant experience overall, it can take hours and hours for the delivery to occur, and there's the emotional distress the mother goes through throughout the process. After the fetus has delivered, we have to examine it to figure out why the death occurred. It's a very sad process, as you can imagine.

yay 30 hour call!

I survived my first 30 hour call! Here is what happened for the most part (from what I can remember)

We had morning rounds, and I got through my patient ok, thanks to some help from a fellow student to told me pertinent things to comment/check on. We went to breakfast, and then had student presentations with the doc in charge of the students. We went back to L&D, and I met the midwife whom I would be following with for the week. Since I was the student on call though, and the other student went home sick, the attending asked me to scrub in with her for a tubal ligation. I did that, and everything went well. Hung out with the midwife some more, did some scut, then went to lunch. Came back, saw a circumcision, was asked to go see a patient in the ER with the ER resident on the OB service. Did that (pt had a miscarriage), then had a 15 yo come in with severe preeclampsia, so we put her on mag with orders for a c section if no progress . Had a csection for a breech baby around 10 pm, finished around 11. Attending tells me to go sleep for an hour and a half since we were going to break the water of another patient, and she would deliver within the next couple hours.

So I take a short nap, wake up (body hates me for waking up), go see patient, who eventually delivers a baby around 2:30 am. This was my first full vaginal delivery and I had no idea it was that bloody....yech. I also did not receive a formal orientation to L&D since I got called into the tubal ligation, which made things interesting when my (very chinese/unintelligble) attending put my hands on the baby's head and told me to start delivering! I told him I didn't know what to do so he basically just pulled the baby using my hands. Same thing when he handed me scissors and tubes and I guess expected me to get the cord blood. We got things cleaned up and all was well and good...

At that point it's 3:30 am I think to myself "Ok, we have no one in labor, the doc said 'ok thank you we are done,' so maybe this means I can sleep until morning rounds." Good thing I put my phone number on the call board (which my classmate said to do but the nurses would never call if something came up), because sure enough around 4:30 I got a phone call "Where are you? The patient is bleeding and she is in the OR right now.' At that point I'm thinking oh crap, I could get in trouble for sleeping...thankfully the attending was a nice guy and didn't get mad but I'll have to remember to not always assume everything is well after a delivery. I guess the patient who had delivered had a cervical tear that needed to be repaired, so we did that for two hours...it kept on bleeding and bleeding and the doc had to cut everything he had just sewn up and redo it. Finally we got the bleeding taken care of, and it was time to round. Thankfully the morning attending was late to rounds because it gave me time to actually go see a patient. A lot of students in that case actually BS the presentation and just present the info from the resident's note without actually seeing the patient, but I think that's wrong and lying and can't do that.

We then head to breakfast, and then to the administrative meeting, which we are required to attend but is basically all the docs going over housekeeping stuff, and some case review. The case review was mostly surgical stuff and them debating different techniques and equipment. It was interesting but it took 2 hours! Sitting on a hard aluminum chair when you've only had 2.5 hours of sleep listening to stuff that is over your head and that you can't contribute to was difficult in the sense that I was trying not to nod off. I actually didn't feel that tired at that point. I felt much better than I expected.
I got home around 11, and slept until 1:30 or so. I didn't want to sleep too much and interrupt tonight's sleep schedule. I have call four more times in this rotation (twice in one week at some point) and hopefully I get lucky and have one of the good attendings, because I've heard not all of them will let you sleep for anything.

First Day of OBYGN!

Crazy. I am not in Kansas anymore!
First off, the streets and traffic of NYC and my car (huge station wagon) do not mix. Especially when people double park.
Secondly, it's a good thing that I spent a lot of time talking with my classmate who was just at this rotation, because the current students were not helpful at all.
Thirdly, I can't understand most of my patients and the majority of my staff. English is the minority language.
Fourthly, what happened today.

• Drive through narrow streets of the Bronx
• Find hospital
• Find orientation site
• Get oriented
• Find OBGYN floor
• Spend a lot of time reading. Really nice midwife teaches me about reading fetal heart strips.
• Lady in labor comes in at 9 cm, get cleaned up and ready to help with delivery. Was asked to go call a pediatrician because the amniotic fluid coming out was tinged with meconium. Try to call pediatrician, no one is answering. Go back in room, baby has already been delivered.
• Another OBGYN attending marches in and states "They need a student in the csection NOW." Since the other student was scrubbed in for the delivery, that meant I had to go do it....didn't know where I needed to be, didn't know scrubbing protocol (thank goodness I have had my surgery before this). Get yelled at some more for not knowing what to do and having to ask. Scrub in only to watch them close (sew patient's abdomen back up)....?? They really needed a student for that?
• Get told to go see a patient in the ER. Find ER. It's a madhouse...exactly what you would picture for an inner city ER. Try to find patient, apparently you just yell the patient's name really loudly and wait for someone to answer. Find patient. Interview patient. Wait for resident to arrive. Get told to go back to Labor and Delivery
• Back in labor and delivery. Spend rest of time reading/learning about basic L&D stuff.
• Drive back home in NYC rush hour, gridlock traffic. Ai yi yi.

Well I made it to NYC. I will be here for six weeks doing my OBGYN rotation. School is paying for me to stay at a Hampden Inn during my rotation, and it's pretty nice. My room is huge!! My classmate who just finished this rotation told me he saw the schedule and saw that I am going to be on call Tuesday....my first 30 hour shift, and I don't do coffee, so it shall be interesting.

It's been awhile since I've written but everything has been so wonderful. This is the first rotation I actually got comfortable at with the routine. I also could definitely see myself doing peds some day. Tomorrow is my last day and everyone wants to keep me on longer, which is comforting. It's always my goal to make my preceptors lives easier, not harder (due to the burden of having a student), and I thought I did ok at that this time around.

I did my first circumcision today....the end result looked great, getting there was a little rough. There are some motor skills that you need to learn in order to do those smoothly, and I wasn't the greatest at them, ha. I also got to take care of a baby all by myself after a c-section since my preceptor just had a rotator cuff repair. I got a little caught up in the birth and forgot how fast I needed to move in terms of cleaning the baby and examining it, but it was still a great experience nonetheless!

"A good home remedy for recurrent [ear wax] impaction is a few drops of oil such as mineral or olive oil a couple of times a week, warmed to body temperature to prevent dizziness"

Didn't know that...interesting!

I just finished my first week of my pediatrics rotation. It's been awesome. I love it. This has probably been my favorite rotation so far. I'm up in rural PA in a cute little town that would be very close to an environment where I would want to live, if only we were closer to the ocean. However, there's a river running through town, so it's still nice.

I spend the mornings at the hospital rounding on babies in the nursery and any kids admitted to the hospital. Because it's a small rural hospital, the docs actually cover the hospital as well. This means that they take care of the babies as soon as they are out of the mom and until they leave the hospital. Thus, I've been able to see my first live birth and a csection. I always thought childbirth sounded like such a gross and horrible process, but it really is magical....to steal the British anesthesiologist at the hospital's word. Especially when you hear the first cry and see the look on the parent's faces. One of my friends was teasing me and saying "well that's just your maternal hormones acting out," and while I can't deny it, looking at the big picture, life really is a miracle. The csection baby came out with a full head of red hair which was cute and funny.

Right now in the nursery we have three preemies who are growers, so to speak. They are in incubators waiting to gain weight before we can let them go home. \5 pounds is our goal for them. We've had three sets of twins too, and lots of boys (which means I've seen tons of circumcisions).

After we're done in the nursery, we head to the clinic to see kids. Initially I didn't think I'd like seeing runny noses and well checks, but it's a lot more fun than I thought. The kids are great for the most part. The office staff is super nice, even inviting me to go out to Pizza Hut with them once. I saw once nurse give 6 shots in 10 seconds flat, it was amazing. There's so much experience in the office, which really does pay off.

I should also mention that I have a 3 minute commute to the clinic, which is one minute from the hospital. Normally I go through two tanks of gas a week; I still have over 3/4 of a tank left. Also, I get free unlimited food at the hospital cafeteria. It's not the best but it's free!

I really like the current rotation I am on a lot. I'm working with a center that does substance abuse counseling all throughout Philadelphia. Almost all of my patients have been in jail at some point, and a lot of them are court ordered. I have three roles: to sit in on group therapy sessions, to help with recovery planning, and to sit in with the psychiatrist, as a lot of these patients have concurrent psych diagnoses besides their substance abuse, such as bipolar and depression. I'm in some of the worst parts of Philadelphia, working with the population I am working with, and yet I haven't felt unsafe yet. I mean, I've been sitting next to murderers and prostitutes and drug dealers and have felt very safe and welcomed. The program has both inpatient and outpatient facilities, and I work at both.

Group therapy is amazing. Most of the time the counselor leading the group doesn't have to do much, just redirect if the conversation starts getting really off topic. The more motivated clients are really good at helping provide advice on how to recognize and avoid triggers, how to work on restoring past relationships, and helping the newer clients overcome their addictions. The stories you here are incredible. It's no wonder some of the ended up with the current struggles they have now...stories of being thrown in a trash can while an infant, being raped at young ages, suffering through incredible physical abuse. It's heartbreaking. These people are incredibly vulnerable with one another, and do a great job at keeping one another accountable. I think they reach levels of accountability and vulnerability that Jesus commands the church to have, yet I haven't been able to see yet. You can easily tell the ones who want to be there, and the ones that are court ordered. Yet the counselors say group therapy sessions really help the ones who aren't motivated. Although they come in unwilling to participate, being able to listen to people who have been where they have been is way more helpful than listening to the "educated, working class, (mostly) white people" in authority and leading groups. It's been a very encouraging experience overall.

I finished working in the nursing home last week. I loved it, it was a great learning experience. I had a week off (which is rare), and started the psych part of this rotation yesterday. I am working with a company that does substance abuse counseling and treatment. I will be spending my time between group therapy sessions, recovery planning, and sitting with a psychiatrist, as many of the clients have mental health issues besides substance abuse.

I sat in on two group therapy sessions yesterday, and it was pretty incredible. The clients are very good with one another and holding each other accountable. They're very honest, and some of the stories they share are heartbreaking. It will definitely be an interesting 3 weeks!

Emergency Medicine ended with a bang, I spent my two week holiday break traveling to NYC/Massachusetts/Maine/the Poconos, and my fourth rotation has officially started. This rotation is a combo of long term care/behavioral medicine. The first week and a half is spent in a nursing home, and the second four weeks I will be working in an outpatient substance abuse counseling program.

My first day in the nursing home was yesterday. It was very, very laid back. I'm used to only having 3-5 minutes with my patients in the ER, and we could take 20-30 minutes working with our patients yesterday. It's good that I am in the nursing home again, because it's forcing me to take a comprehensive approach to my patients. During my last two rotations, surgery and ER, you were only focused on the problem at hand that had brought the patient to see you. I was told several times "Well, we don't really care about that right now, that's their primary doc's job to manage." Now, I'm in charge of every aspect of my patients health, and it's been refreshing