Recognition

I went out to a wine bar this evening to celebrate the end of my Internal Medicine sub-internship. As I was looking around for a table, a woman sitting at a table behind me said, "Excuse me, are you a doctor?" She was holding a baby.

My first thought: "Oh no, is she going to ask me for medical advice?" My second thought: "Hmm, she looks familiar." I said no, I'm not a doctor.

"Are you a doctor in training?"

"Yes..."

"You delivered my baby. In fact you caught him."

I took a closer look at the woman, then at her husband sitting across the table from her, and I suddenly remembered them. I did indeed care for her when I worked on Labor and Delivery, and I did indeed catch her baby. I even cut his umbilical cord. And there he was, sitting in his mother's lap peacefully sucking away at a bottle, a healthy two-month-old boy.

"Can I see him?" I ooohed and ahhhed and ogled over this little boy who I helped bring into this world. I said my congratulations to the lucky parents, thanked them for recognizing me and saying hi, then I sat down at my table, glowing.

Finishing my Medicine sub-internship today felt pretty awesome, but this moment by far made my day.

Later in the evening, the waitress came over to say, "Your glass of chardonnay is on the little baby boy at that table." I smiled and raised my glass to them from across the room to say thank you. And I almost cried.

Code C: Emergent Cesarean Section

"Code C, room 8 to OR 3! Code C, room 8 to OR 3!"

The Labor & Deliver control room burst into activity with the overhead announcement. A quick glance at my resident, whose head nod told me to go for it, and I rushed back to OR 3 just in time to catch the patient being transported down the hall.

She smiled at me as she wheeled by. In the middle of a labor gone awry, surrounded by nurses and doctors moving and talking much faster than usual, lying in her inclined hospital bed, breaking speed limits as she flew down the hallway on her way to the operating room where she was about to undergo an emergent Cesarean section - this woman met my eyes and smiled at me. It wasn't a frightened smile or a nervous smile; she actually appeared serene, an emotion that didn't belong in this moment.

The patient was already on the operating table by the time I entered OR 3, nurses buzzing about the room as if their hive were being attacked. I stood near the patient's head, mesmerized by the serenity of her smile that was now hidden behind a face mask and then a few moments later faded with her consciousness. I moved down to the foot of the bed, out of the way but with a good view of the operating field, then stood frozen lest I get stung.

The anesthesiologist was preparing for a rapid-sequence intubation. The scrub nurse was already dressed in her sterile gown, governing her table of sterile instruments. Two Ob/Gyn doctors were already dressed in their sterile gowns and posted on either side of the operating table, one looking at the anesthesiologist expectantly and the other posed like a runner in the starting blocks, her scalpel blade millimeters from the patient's pregnant belly.

"Tell us when you have her airway!" said the first Ob/Gyn in a commanding voice that couldn't be ignored.

"Do you have her airway?" ...

"Do you have her airway?" ...

"Got it!"

Cut, a curved incision. "Cut again!" Yellow fat and gushes of blood. Scalpel down. The two doctors took a firm grip at either side of the incision and pulled with all the weight of their bodies to open the incision. Sound of ripping flesh. Underlying muscle. More blood. "Cut again!" More ripping flesh. More blood. Then the uterus appeared, large, holding a baby whose life was in danger. "Cut again!" Amniotic fluid washed away the blood. Hand inside the uterus. Some pushing, some pulling, then Baby. "Knot in the cord!" Clamp it, cut it, then Baby was whisked away to the care of NICU nurses.

No more than 30 seconds passed from first incision until Baby's birth.

With Baby out, the doctors turned their attention to controlling Mom's bleeding. I stood there planted in my out-of-the-way spot at the foot of the operating table, even as the flurry of activity around me dissipated, dumbstruck by the sheer speed and exquisite coordination of the emergent C-section I had just witnessed.

Mom recovered beautifully, and Baby was entirely healthy.

Oral presentations: The urge to keep talking

I have made amazing progress in terms of my oral presentations since the beginning of third year. I started out having literally no idea how to properly present a patient. A stellar resident taught me the basics during my Hospitalized Adult Care clerkship, and along the way other residents and attendings interested in teaching have helped to fine-tune my presentation.

Today, I was presenting to my attending an obstetric patient who was in for a regular check-up. The attending remained quiet as I went through all the pertinent subjective information about my patient's pregnancy, described the fetal heart rate and height, and gave her my assessment and plan for this patient.

I was about to talk about the patient's breastfeeding and post-partum birth control plans when my attending said, "Stop!" It's not uncommon for attendings to interrupt oral presentations of medical students. So I stopped, wondering what she was going to say. "Your presentation was perfect. You covered everything I wanted to hear, and you said it succinctly. I know your assessment and plan. You don't need to say anything else. Stop talking!"

The lesson: Part of a good oral presentation is knowing when I've said enough. I should be confident that I have covered all the pertinent details and act on that confidence by ending my presentation. For a third-year medical student who is just now starting to feel comfortable giving oral presentations, this is a valuable lesson to learn.

Nights on Labor & Delivery

This past week I worked the night shift on Labor & Delivery, from 6pm to 8am. Flip-flopping my schedule like that was disorienting to say the least. While I didn't break down and start a coffee habit, I did eat a fair amount of dark chocolate to keep me alert. In fact, I noticed that eating any food throughout the night helped me stay awake.

When there were things to do, when babies were being born, staying awake was not an issue. Rather, I had difficulty with those long stretches of early-morning quiet. I tried to use the time to study, at first, but my brain wouldn't cooperate. Preparing my progress notes during those quiet hours saved some time in the morning and didn't require too much brain power. If nothing really was happening, and my resident was feeling nice, she would send me to the call room so I could take a 1-2 hour "nap" before rounding on patients at 5am.

Generally, after a night shift, I'd get home at 9am, eat a bowl of cereal, and manage to sleep 3-4 hours in the late-morning and early afternoon. Except one day last week, I had to schedule a bunch of meetings on campus, which meant that I didn't get home until 2pm and was essentially running on no sleep for 2 days straight. I felt miserable.

Looking back, it's a wonder how I functioned at all. A week of nights on Labor & Delivery is as much a medical school hazing ritual as anything. It was definitely the most physically demanding week of medical school I have experienced yet.

I caught my first baby!

Early this morning while I was rounding on my patients, a nurse sitting behind me answered the phone. "Yeah, he's right here." I turned around, expecting the call was to tell me that one of my patients was about to deliver. "You're wanted in room 9, stat!" The nurse smirked as if she knew she were reading lines straight from a medical drama TV show. I dropped what I was doing and flew down the deserted corridor, overloaded white coat pockets flap-flap-flapping against my body.

The room was already prepared for delivery when I arrived. The bed was raised, the patient's legs up in footrests, my resident in sterile gown and gloves standing between the patient's legs, and the table of instruments and a nurse behind her. Standing room only crowd of family. A quick glance showed me that the baby's head hadn't yet crowned. "Gown and gloves!" my resident shouted at me. I gowned up quickly and stood beside my resident between the patient's legs.

"That's it, give me a good push, you're doing great!" I took cues from my resident. She was standing beside me the whole time, coaching me through each step with hand signals and a quiet but firm voice, ready to take over if necessary. After having watched so many deliveries over the past several days, the motions came surprisingly naturally.

The head crowned just a few minutes later. I held the baby's head in my left hand and followed him as he turned his head to the left. Unwrap a loop of umbilical cord from around his neck. Gentle downward pressure to deliver his top shoulder. Then with a gush of amniotic fluid and blood, he entered this world. With my right hand I supported his back and swung his body over so that I was cradling him in my left arm. Suction, suction, first breath, then a loud cry.

Remarkable. Miraculous. The whole process would seem magical if I weren't so familiar with the biology.

I clamped the umbilical cord and gave Dad scissors for the honor of cutting the cord. Then I presented Baby to Mom. She held him close on her chest, smiling down on him with tears in her eyes and that singular glowing expression of a new mother.

I could have lost myself in the emotions of that moment, but my job wasn't done yet. I collected cord blood, delivered the placenta, massaged the uterus, and inspected the vagina for tears. Under my resident's supervision, I repaired a mild tear with a single stitch. Then we cleaned up.

Dad asked my resident and me to pose for a picture with Mom and Baby. We gave our congratulations all around, I thanked Mom for inviting me to be a part of her delivery, then we left the family to celebrate.

From clinic to the operating room

A new patient was referred to the gynecology clinic from an outside community clinic that serves a low-income population. She was at the end of her rope dealing with symptoms from a condition that she allowed to progress for so long because she couldn't afford to fix it.

I was working with the chief resident, who is essentially almost a "real" doctor; even she was taken aback. "I'm going to go talk with the supervising doctor, and we'll see what we can do for you." The attending was equally impressed with the patient's history and physical exam and scheduled her for surgery the very next day.

My resident invited me to watch the surgery. "It'll give you a chance to follow a patient from start to finish." Thank you so much! This kind of continuity, as a medical student, is not the norm. I had to play hookie from afternoon clinic (with the chief's permission) in order to see my patient's surgery.

During the first two weeks of this clerkship, I saw many surgeries on women whom I had never met and never examined. The only history I knew of them is what I read in their chart and what the resident told me beforehand. Occasionally, I'd have a few minutes to chat with these patients immediately before surgery. But the whole experience felt disjointed.

That's why I'm incredibly grateful to have experienced the kind of continuity of care, from clinic to surgery, that the residents and attendings enjoy. The attending even stepped back allowing my resident to operate and leaving me to first-assist! And she invited me to accompany her to talk with the patient's family afterward! The experience felt complete.

I think more effort should be made to give medical students this kind of patient continuity. In terms of teaching and learning, I personally find that such continuity is especially effective: I will never forget this patient.

Urogynecology and gynecologic oncology

I finished my week of urogynecology and gynecologic oncology (UroGyn/GynOnc) having seen a lot of pelvic organ prolapse and transvaginal taping for stress incontinence. But I didn't see much pathology. In fact I didn't see any. No ovarian cancer, no uterine or endometrial cancer, no cervical cancer, no endometriosis. I'm disappointed, but that's the luck of the draw.

Up next: A week of gynecology clinic, then on to obstetrics (a.k.a. "baby-catching").

Anesthesiology reunion

Returning to St. Joe's for OB/Gyn has been fun because I'm seeing a bunch of people who I worked with several months ago during my surgery clerkship. One of those people is an anesthesiologist who got me so excited about anesthesiology that I seriously considered it as a possible career.

He happened to be the anesthesiologist working one of my gynecology cases, recently. We exchanged pleasantries, caught up a bit, then he asked, "So, are you going to intubate this patient for me?" This caught the attention of my resident who practically shouted, "What? You never let me intubate anyone!" My anesthesiologist friend replied, "Yeah, but I've worked with him before, and I trust him."

This was all just playful banter. My resident wasn't really upset, but the pressure was on: I hadn't intubated anyone for more than 3 months! I had a little bit of difficulty visualizing the cords, but I got them finally and successfully intubated the patient on the first try.

OB/Gyn site and schedule

I had such a good time on my surgery rotation at Exempla St. Joe's that I decided to do my OB/Gyn rotation here, too. Since the site assignments for the OB/Gyn rotation are given on a first-come-first-serve basis, I got lucky with getting my first choice. ESJ is a very popular site among medical students because it has a reputation of very nice attendings and residents. So far, its reputation has borne out to be true.

The six-week OB/Gyn block is divided into weeks on different services. My schedule:

• Week 1: Benign gynecology. Lots of surgeries. Get in early enough to pre-round on 1-3 patients and have my notes written and shared with the resident by 6:45 am. Usually leave by 5:00-6:00 pm.
• Week 2: Gynecologic oncology and urogynecology. Similar to benign gynecology but with sicker patients.
• Week 3: Gynecology clinic. Show up for educational rounds at 7:00 am and leave after the last patient, around 4:30-5:00 pm. Have to wear professional clothes, not scrubs.
• Week 4: Labor and delivery nights. Shift work from 5:00 pm to 8:30 am, starting Sunday night.
• Week 5: Obstetrics clinic. Essentially the same schedule as gynecology clinic.
• Week 6: Labor and delivery days. Not sure about this schedule, yet.

I definitely wasn't expecting that I would have most of my weekends free. I'll have to come in on the Sunday evening of my L&D nights week, and the residents may ask me to round on patients over the weekend if my patients happen to provide a particularly good learning opportunity.

Overall, I think OB/Gyn will be a good experience.

The week of hysterectomies

I saw several hysterectomies this week on the gynecology service, each a different flavor. A resident pointed me in the direction of a wonderful resource, the Atlas of Pelvic Surgery, which describes specific surgeries step-by-step with accompanying pictures. Reviewing each procedure ahead of time helped me better understand what was happening in the operating room.


One hysterectomy was a total vaginal hysterectomy, which delivers the uterus through the vagina. This patient had a prolapsed uterus, which basically means that the tissues holding the uterus in place were failing causing the uterus to sink down lower into the pelvis and out the vagina.


Another was a total abdominal hysterectomy, a procedure that removes the uterus through an incision in the lower abdomen. The abdominal approach was chosen, versus a transvaginal approach, because the uterus was burdened by several fibroids, one of them the size of a softball. Attempting to deliver such a large uterus through the vagina wouldn't have been smart.

The most interesting hysterectomy I saw was a laparoscopy assisted vaginal hysterectomy that was converted to an open procedure because of uncontrolled bleeding from the uterine arteries, which were difficult to clamp laparoscopically because of abnormal anatomy.

This turned into a true emergency. The gynecological surgeon never lost his calm, but he also started moving much more quickly than surgeons usually move. Less than 30 seconds after he called out "We're converting to open!" he and the resident made an incision across the lower abdomen and were literally tearing apart the subcutaneous tissue to gain access to the abdominal cavity. The bleeding was stopped, and the rest of the surgery went without further complications.

The attending asked me afterward, "What's the first thing you do in a Code situation?" My answer: check for airway, breathing, and circulation. Not entirely incorrect, but his answer was much more to the point: Take your own pulse.

Seeing three different surgical approaches toward the same end goal, removal of the uterus, was very helpful in terms of understanding the female pelvic anatomy. I also have a higher appreciation for how anatomic variability, both normal and abnormal, determines the course a surgery.

OB/Gyn orientation

The OB/Gyn clerkship orientation included some very practical instruction. What I found to be most useful out of the two-day orientation was a refresher course on how to do the breast and pelvic exams. We all learned these sensitive exams for the first time at the end of our second year with formal instruction from standardized patient-actors who taught the exams using their own bodies. But that was almost a year ago. Over the course of my third-year, I've had the multiple opportunities to perform breast and pelvic exams, but they were few and far between, not enough to keep those clinical skills sharp. Apparently, including this refresher session during orientation is a relatively new development and was done in response to student feedback. I'm grateful! I'm especially grateful after talking to some medical student friends at other institutions who were never taught how to perform a pelvic exam before seeing a real gynecological patient.


We also had a session with a medical mannequin in active labor. In my humble opinion, this is a much better way of preparing medical students for L&D than just throwing them in the deep end with a real patient in labor. Although this mannequin is capable of simulating labor and delivery to striking detail, the purpose of this session was really just to familiarize us with the basic steps of the birthing process. As happy as I am that I got this simulation experience, I have a feeling that it will be absolutely nothing like the real deal.

OB/Gyn prejudices

A friend recently asked me, "Are you looking forward to or dreading your OB/Gyn rotation?" I don't think either term adequately describes how I feel about this clerkship.

OB/Gyn is the one specialty that I pretty much knew 100% I didn't want to go into even before third year. But, I recognize that my OB/Gyn experience will be very educational and an opportunity that I likely won't have during the rest of my career. So I am definitely looking forward to the experience of OB/Gyn, especially the OB part that involves delivering babies. That being said, I'm also looking forward to being done with the clerkship.

Do I dread OB/Gyn? I have to admit that there are certain aspects of OB/Gyn that are slightly anxiety-provoking. I've heard disconcerting stories about some OB/Gyn residents and attendings. I'm wondering how I'll actually be received by patients, as a male medical student. I'll also be straightforward and say that I'm not looking forward to doing pelvic exam after pelvic exam for the next six weeks. But, like everything else in medical school, it's something that I just do, putting in my best effort and with a good attitude, even if I don't want to make a career out of OB/Gyn.

It'll be interesting to see how my opinions of OB/Gyn at the end of the clerkship compare to my prejudices of it now.