OB/GYN Week 4

I met a patient today who described herself as "delayed." It took me at least 5 tries to ask her if her periods are regular. Note to self: if a patient doesn't understand a question the first two times, maybe try wording it differently the third time (roll eyes at self). I've been listening to Audio Digest's OB/GYN series of lectures and one from '09 highlights some medical-legal issues, one of which is lack of patient understanding. The lecturer, a former nurse, now lawyer, mentioned an AMA study in which the researchers video recorded patient/doctor interactions, then separately interviewed patients about what they were just told by the doctor. Appatently, a surprisingly high percentage had failed to understand key components of the interaction, and they weren't all the type of patient you would expect to be "delayed," and may have seemed to comprehend perfectly. Illiteracy rates are higher than we may expect and patients will not usually be as open about it as my "delayed" patient today. The lecturer mentioned not using medical words with patients, which they have taught us from day one in med school, but being indoctrinated into the medical community, one loses one's sense of which words are common lay terms and which are medical jargon. "Appreciate" no longer refers to having a feeling of gratitude, but instead to noticing a significant finding. "Anorexia" does not necessarily conjure images of emaciated teens with anorexia nervosa, but simply indicates a loss of appetite. Are abdomen, neoplasia, laceration, analgesic used in common parlance? I just don't know anymore. Before I get too tangential, I'll sign off for the night. If I get around to posting before my next newsletter, I'll try to include more case-based info next time.

Scott

LEEP, OB/GYN Week 3

I just got sprayed in the face with cervix juice. I should back up. A patient was in clinic today for her second LEEP (loop electrosurgical excision procedure), which is a method of removing a portion of the cervix. This procedure is done when less invasive tests have shown the cervix to have certain stages of pre-cancerous cells. Practically the only way a woman gets these cells that slowly progress toward cancer is to be exposed to certain types of HPV, or human papilloma virus. The way a woman is exposed to HPV is unprotected sex, which can obviously expose her to any variety of nasty bugs. Anyway, this patient had a LEEP some time in the past, and her tests came back positive again for the late precancerous cells, so she came in to have a second LEEP. I've learned that the cervix doesn't have the same type of innervation as other parts of the body - you can hold onto it with sharp pinchers without anesthetic - but when cutting off part of it, you need to inject some anesthetic first, which is what I was doing. I had to jab a needle into the cervix, which is a firm muscle covered by mucous membrane, and inject. Because the muscle is so firm, I had to push on the syringe plunger quite hard, and I was trying to move the needle out slowly to get anesthetic both deep and shallow in the muscle. I pulled out a little too far, and all that pressurized fluid shot out straight back around the needle, and onto the most readily available surface, which happened to by my face. For things like this, I am a non-reactive person, which as a rule is a good thing whenever you have to do a procedure involving looking into the vagina. It just doesn't do to jump back and start wiping your face frantically when the patient is lying back in sturrups, speculum in place. Despite my mind working through the above concepts of nasty bug transmission, I was able to finish what I was doing and wash my face and glasses after I was out of the room. In all honesty, the incident wasn't a big deal; I was wearing glasses, so my eyes were protected, and nothing got in my nose or mouth, and all my facial skin is intact, so the risk of catching anything is somewhere around 0.00%. Still gross, though. Speaking of gross, I've noticed more random stains on my white coat this month than any previous one. I'm not sure I want to think about that.

On the obstetric side of things, I am up to catching 3 babies now. I've also helped with a few C-sections. It's amazing to me when the pale purple lump that initially is motionless starts flailing and crying. The first time I saw the baby in the warmer after a few minutes of being able to breathe on her own, I thought she was a different kid she looked so much better. They really pink up a lot even in the first minute. I may never use any of these skills or knowledge in my career, but it is quite amazing when I step out of the objective clinician's viewpoint and realize that I'm seeing a baby brought into the world.

Scott

OB/GYN Week 2

Today I helped with the tubal ligation of a one-and-done 22-year-old and the delivery of the baby of a 40-year-old who is willing to have yet a third kid if menopause doesn't get her first. Whenever I think I've acquired a sense of how varied people's views are, I get thrown another curveball.

I have been enjoying OB/GYN quite a bit. I am getting a good amount of hands-on experience. The doctors I'm working with are a married couple. Only one of the husband's patients has declined to have a male student in the room, while over half of the wife's patients have declined. We figure many of her patients sought out a female doc specifically, so more of them would have issues with a male being part of their exam. I personally am less concerned with such things in regard to my health care, which I assumed applied to males in general. However, one of my female classmates, who's working with a male doc, is asked to sit out of most men's hernia checks, so maybe men are just as sensitive about personal matters as women.

Time for bed. I'll hopefully see a twin C-section tomorrow.

Scott

Peds Wrapup and Start of OB/GYN

I enjoyed Peds a lot more than I anticipated. I thought it would be too hard for me to figure out how to communicate with the kids and I was afraid of all the crazy parents people talk about. I figured out quickly you can't direct all your attention at the little kids; it's hard to describe, but you almost talk to the little ones as if they're a side thought while you're busy with the exam or doing somehing else, otherwise they'll get all self conscious and shy. As for the parents, there was only one mom I really had any issues with. She was polite, but you could tell if I didn't stop what I was doing, she was coming across the table at me. This brings up a good point, because I was doing exactly what I should (would you expect otherwise?) but she had received poorly-explained child care directions from another doc, and she was being a very concientious parent (neurotically so) trying to follow those directions. If the other doc had taken the time to explain better, she would have had a better idea of good child care and it would have saved her and me some frustration. Also, I've seen that by far the most common avoidable cause of patient anger is poor communication. Explain to your patients what's going on and why - they'll think you're at least ten times as competent as you really are and will love you forever. Not to mention they're less likely to sue you should something untoward happen.

I just had my first day of OB/GYN today, and let me tell you I'm so glad I don't have to force a softball out of my genitalia. Even with an epidural, it's a lot of hard work and pain. It was nice getting to see a C-section and two vaginal deliveries on my first day. It should only be another day or two and I'll be catching the kids as they pop out.

Scott

February Newsletter

February was Orthopaedic Surgery month. I had confirmed in January how much I like surgery with General Surgery, and this past rotation verified that ortho is what I want to do with my life. I was sort of bummed I didn't get to see a wider variety of cases, but I know knees and to a lesser extent shoulders pretty well since those are the areas my preceptor focused on. I'm still leaning toward Orthopaedic Trauma, hoping to add Pediatrics and Hand at some point, but that's partly because I like the title "Orthopaedic Pediatric Hand Trauma Surgeon." In any case, I've just started Pediatrics for March, and I've liked the first few days a lot more than I expected to, so I think doing a Pediatric fellowship somewhere down the road would be something I would enjoy a lot. March is already another busy month, but I wanted to get out a quick update.

Scott

January Newsletter

I was very excited this past month to have finally begun surgery. I took General Surgery and liked it a lot more than I expected to. I still want to become a trauma surgeon, and have not decided between general and ortho trauma, so I'm glad that I have just today begun an Orthopedic Surgery rotation. During my General rotation, I was able to tag along for a couple ortho procedures and I was grinning the whole time. Sawing bones and popping hips out of socket is really exciting, so I have high hopes for this coming month. I'm starting to feel some pressure to decide on a specialty, since my previously undecided classmates have started deciding on specialties and others have even started setting up audition rotations. Audition rotations, or subinternships, are taken at the site at which one would like to do residency/internship in an effort to show off one's abilities and get one's name and face known. I need to start applying for these, but I need to figure out my specialty first, so it's good I'll have ortho this month to help decide.

Personally, I've been about average. My dad is living with me for three weeks, which is stressful on both of us I imagine. I guess if nothing else, it's good confirmation that not having a roommate is my ideal. In regard to my future, I'm worrying about whether I'll be able to handle residency and whether medicine was the right choice for me. Several classmates have expressed similar sentiments, so I guess it's a common doubt to have at this stage of the game. In fact, it's not the first time I or my friends have felt this way, so if you're a new medical school student or aspiring to become one, hang in there when you have nagging doubts.

Well, I've a lot of reading to do, so this newsletter will have to be pretty short.

Scott

Jaded Patient; More Splenic Issues

I was running through a history and physical on a consult before my attending got there but it was truncated to just a history. The patient was a poor historian, not giving very detailed information even when I would ask the most focused questions, and ultimately saying she was tired of questions and did not want me to examine her. Part of the problem was that she has had more operations than she cared to or was able to recall. I think the real problem, though, is probably psychiatric. She has the demeanor and body habitus of one who is poorly motivated and tends toward depression. With mental stress can come physical manifestations of that stress, i.e. somatiform or factitious disorders. It's difficult, though, because while she seems concerned with tallying up vague medical issues, she could be someone who has been dealt a poor hand medically, has needed much treatment just to live somewhat normally, and is not interested in wasting time dwelling on thoughts of an unpleasant medical history.

She insists that during her last operation (2 years ago) either something was left inside her or some other complication arose. She has had a low-grade fever since then and mild pain in the region of the procedure, both of which have been documented on a previous hospital visit. She said the pain flared to a significant level recently, so she finally sought treatment. My attending looked at her CT, asked her a few clarification questions, did a physical exam, and decided that there was no indication to do even an exploratory procedure on her. He said if something had been left in her, there would be evidence on CT: a layman could spot an instrument, and sponges have radiopaque elements in them for ease of visualization. Her symptoms and physical exam are not consistent with any process amenable to surgery. I got the feeling that even with a magic procedure that could cure her pain, she would still have a complaint up her sleeve, which is one of my red flags that there is more than just a physical medical component to a patient's presentation.

The other case mentioned in the title is a man with sharp left upper belly pain for several days. He had a low-grade fever and unproductive cough for the week prior, which he thought was unrelated. His spleen extended 2 cm below the rib cage. My attending asked me what can cause fever and unproductive cough; I couldn't think of an answer, but he said to look up Mycoplasma pneumoniae and autoimmune hemolytic anemia. M. pneumoniae causes pneumonia with a dry cough and fever, and can cause transient cold agglutinin-mediated attack of the red blood cells, leading to transient splenomegaly, which can take longer to resolve than the hemolytic anemia. My attending suspects this etiology, so he has added an M. pneumoniae test to the large battery of tests the internist has already ordered. The surgical treatment for splenomegaly with hypersplenism (overactive spleen chewing up red cells, white cells, and platelets) is splenectomy, but as my attending is fond of saying, a monkey can operate, but it takes a surgeon to know when not to operate. We should find out tomorrow whether Mycoplasma is to blame, and can hopefully give the patient a better idea of what the future holds.

Scott