Babies babies babies babies babies!

It's awfully presumptious to say that I "delivered" someone's baby. I mean really, really, really, she did all the work. So I will say that I caught a baby yesterday. All by myself for the first time!

She was 5cm dilated and her water had just broken when the midwife handed me the delivery package and told me to take over. Since she had 5cm more to go, I figured I had a fair amount of time to prepare. It took me about three minutes to find a gown that fit me: the ER had large, extra large, and extra extra large gowns placed on the shelves labeled large, medium, and small, respectively. I finally settled on large, and hurried back into the delivery cubicle (our delivery center is a teeny bit overcrowded).


Then the gloves. Now these are sterile gloves. The point of them is to open the package and put them on while touching only the insides so that the outer glove doesn't become contaminated by the amusement park for bacteria that is my hands. This is not a difficult thing to do. I however, get all shaky and weird whenever I'm being watched, and cannot seem to put the things on without contaminating them, tearing them, ending up with three fingers in the pinky hole, or all of the above at once.

So of course now, with the midwife, the nurse, the patient, and the top of the baby's head all staring at me, I had no chance. I misaligned the fingers and spent at least three minutes awkwardly squinching my fingers against each other trying to inch the glove onto my index finger as, to my horror, the baby's entire head suddenly appeared on the bed.

The nurse strongly suggested that perhaps I should stop playing with my gloves and consider delivering the baby in question.

I did as instructed, clamped and cut the cord, drew cord blood, massaged the uterus, and delivered the placenta without dropping or breaking anything (or anyone).

And it was a boy!

While I have no desire to be an obstetrician, and despite my feelings about our delivery ward (I would prefer to give birth to quadruplet porcupines alone in a rice paddy in a snowstorm than spend even part of my delivery at this hospital - another story for another time) this is definitely the most joyful thing that happens in a hospital. It's neat to have been a part of it. Today was a day that made me start feeling like maybe just meeeeeebeeeee I might be able to do this whole doctor thing.

That feeling will instantaneously dissolve the next time I have to put an IV in or take arterial blood gasses or do a pelvic exam. But it's a nice feeling.

Even better, today was free HIV test day. Negative, baby!

Chief complaint of the day

"I think my cervix is falling out."

An open letter to my golden retriever puppy

Dear Luka,

You are not tied up because I don't love you. You are not tied up because you were a bad puppy or because you poop all over the rugs every month or so.

You are tied up because you have eaten, in the past six months, five pairs of underwear, three pens, two name tags, seven socks, an entire Princess Barbie plastic medical kit, and a plastic bag.

Now I don't mind that I am currently wearing emergency back-up underwear that I bought at the drug store; and while it's not my all-time favorite pastime, I don't even mind observing your. . . outputs to make sure that everything that goes in come out the other side.

But despite the fact that I have no randomized double-blind studies to confirm this, I have a strong clinical suspicion that not pooing out household objects is much better for your digestive system than pooing out household objects.

So you are tied up for your own good. Because I love you and your intestines. Please stop looking at me like that.

Love,
mommy

Superstition

I consider myself to be about averagely superstitious. I'll walk under ladders, I've broken more mirrors than I can remember (stress makes me clumsy- not a stellar character trait for a future doctor), Friday the 13th is just a day.

But I have my little things. Like when I was a competitive kayaker, I had to do exactly the same warm-up before every race. And when I did theater, I had a very precise sequence of vocal exercises before every show/audition. I also had a lucky belly-button ring for extra-important auditions only.

I find myself playing little mind games now in the hospital. If I'm standing in a complicated surgery, I force myself to breathe evenly and slowly and pay very close attention to what's going on. This started as a little joke with myself when I got bored during operations. One of my classmates is really big on Reiki and energy healing. Inspired by him, I would amuse myself while I was standing and holding retractors for eight hours by trying to focus all my positive energy on the patient and see if I could, for example, slow down their heart rate or bring up their blood pressure. I was variably successful, as you might imagine.

But now, once in a while, we'll be operation a patient I particularly like, and I find myself playing that little game, but for real. Like if I focus hard enough on the monitors and I think positive thoughts into their room, maybe it will make a difference.

So this weekend, one of our high risk pregnancy patients lost her baby. Which obviously comes with the territory of high risk pregnancy. Now I know I had absolutely nothing to do with it. But a little part of me feels uncomfortable, because it was a surprise. She was in the ward only for observation because she'd lost a baby before at the same week; and for the week she was there everything looked fine with her pregnancy. The doctors weren't worried about her. I wasn't worried about her. And part of me feels like we let our guard down. Like we weren't sending enough mental energy her way.

Which is silliness. Stuff and nonsense. I know! You can't save someone by worrying about them or thinking about them. If that was the case, we wouldn't need doctors at all, just parents.

But I see the power that a smile has, that holding someone's hand has. A lot happens in the hospital that has a lot to do with healing and very little to do with medicine. And vice versa as well.

So I imagine I'll keep playing my little mind games as long as it makes me feel like I'm doing something when there's really nothing to be done.

Behind the curtains: gynecology

I had three patients in the same room in the gyn ward who were so thematically similar it was like a Grey's Anatomy episode.

Patient 1:

-Mrs. Fertile was in the ward for bilateral tubal ligation. The reason? She's had two children while on the pill, followed by two children with an IUD. Supereggs!! On a more serious note, she suffers from pretty major depression which she relates partially to the four "unwanted" children. We joked a lot about how we could remove all her reproductive organs and she'd probably still find a way to have three more kids. I actually do believe her tubal ligation won't even slow her down. Her fetuses find a way.

Her case was such a strange contrast to the 90% of women in the ward who were there for miscarriages, ectopic pregnancies, endometrial cancer. We're used to women who are absolutely desperate to have babies and can't. We joked about it so much because it was such a welcome relief from all the bad news, but it was also a big reminder that there's only so much we can do with medicine, sometimes the fates will just have their way.

Patient 2:

Mrs. B is a middle aged woman who's had continuous very light vaginal bleeding since menopause. All tests showed that this was just benign overgrowth of the uterine walls, and there was no need for invasive treatment. We explained that we could prescribe medication that would cut back the amount of bleeding. She did a trial of the medication and it worked, she had spotting only occasionally, no intolerable side effects.

Then, she came back with a letter from her Rabbi ordaining that she must have a hysterectomy. The reason: Religious Jews practice "T'harat habayit," literally purity of the house. The couple must refrain from contact for the entire duration of the woman's period and seven additional days after that. So every time a woman bleeds, she effectively cannot touch her husband for 12-14 days. In Mrs. B's case, because she didn't know when she was going to have spotting, she was risking "impurity" every time she was with her husband because she might have bleeding during the act.

It's actually very logical, from a religious perspective, for her to have the operation. From a medical perspective, I see a woman going through a major and unnecessary surgery for an, in my opinion, antiquated religious practice. The surgery turned out to be rather unpleasant and complicated and it felt so. . . just unnecessary to me. On the other hand, it will probably improve the quality of her life dramatically.

Summary: I'm ambiguous on this one. I suppose I have to come down in favor of treating the entire patient, so in this case, the surgical option was the one that improves her life the most and therefore the best treatment. As you, darling readers, will come to realize, I'm just generally strongly in favor of the least invasive treatment possible, so it's hard for me to endorse surgery for no real medical indication. Moving on. ..

Patient 3:

Ms. H, a 41 year old Bedouin unmarried virgin with major uterine tumors that were causing her life-threatening bleeding. The absolute best option for her was a complete hysterectomy. The complication? She still hopes to be married and an infertile woman has no chance of securing a husband. Even though she has very little hope of securing a husband, or having a healthy child if she does, at the age of 41.

Another interesting complication to her care is that it is very very important that her virginity be maintained, which means absolutely no vaginal exams of any type, including transvaginal ultrasound.

In the end we did a fertility-sparing myectomy, just removing as much of the tumors as possible without damaging the uterus. Again, a complicated surgery. Again, I feel that we did the best we could given her circumstance, but I don't know that I can say it was the best possible care from a medical perspective.


These things come up all the time, I'll write more about the prenatal diagnosis stuff we encounter later this week. The one thing this always highlights for me is the difference between a competent doctor, one who would offer the best possible medical care, and an excellent doctor, who realizes that sometimes the best medical care isn't the best patient care. It's a fine line.

Panic! In the ER

The avian flu incident:

First I need to explain the way our ER "functions." After triage, the patients wander/are wheeled over to the nurses' desk, wait for an overworked nurse to notice them standing there, inform the nurse that they are indeed patients and would like to, I don't know, lie down and be treated. The nurse then takes a glance around the ER trying to find an empty bed, gets interrupted by a dozen or so other wandering patients, disgruntled physicians, couriers on bicycles (they drive around the hospital on three-wheeled bikes), and then eventually remembers the patient and directs him or her to a bed.

So I was not surprised, as I awkwardly hovered around the desk waiting to be asked to stick needles in people, when a young man sauntered up to me, tapped me on the shoulder, and asked where he was supposed to go. A nurse intercepted when it became clear that he was a patient, and began to try to find him a bed. She casually asked him what his complaint was.

"I work with chickens and I think I have avian flu."

And then. . . chaos and despair! Three nurses converge trying to get a mask on the guy, trying to figure out if he needs to be isolated, where he should be isolated, how much isolation is necessary, whether the whole ER should be quarantined, whether we all needed to put on HAZMAT suits. The doctor I was following began frantically flipping through the avian flu protocol binder (the avian flu protocol is about 50 pages long). Then ::whoof:: all the doctors and nurses effectively disappeared for about 45 minutes leaving one resident and I alone to basically run the ER.

I actually never found out what happened in the end, I'll have to check on Sunday. I overheard the chief attending telling someone he was sure this wasn't avian flu and thought all the precautions were silliness- but who knows?

I of course, like any good medical student, have been obsessively monitoring myself for signs/symptoms of fever since I got home last night.

So far so good.

Emergency rooms. . . not just for emergencies

Our first patient's chief complaint (after her initial complaint that it had taken us too long to see her):

"Two years of painful intercourse."

Oh rrrrrrly?

Overheard on rounds:

"Mrs. F has had two live births and seven elective abortions. She uses no method of birth control."

Perks of the profession

The doctor I've been following this week, a high risk obstetrician, received a sack of just-picked tomatoes from a very satisfied Bedouin couple the other day.

He's also received, in addition to lots of yummy produce, more than fifteen chickens and ducks. (And a goat, which he politely declined). His kids are raising them in the backyard.

Yay for rural health care!

People are special

A middle aged woman with three children came in for pre-op rounds one afternoon last week. These rounds are pretty simple: we talk to the patient about why we feel they need surgery, explain the procedure to them, answer any questions, and then they sign the release forms.

This case was clear: she had had an operation a few months ago for an ovarian mass that was suspicious for cancer. During the operation they removed most of the tumor (which did turn out to be cancerous). But the lab reports showed that the surgical margins were not clear, some tumor had been left in her body.

They called her in immediately to schedule a second operation. When she arrived, her doctor explained everything to her, and told her that he wanted her to have surgery the next day.

"Oh, no." She replied, "tomorrow doesn't work for me."

We asked if the next week was better for her.

Nope, next week didn't work for her either. Couldn't we wait until April?

Her doctor explained to her beautifully how important this surgery was. That ovarian cancer can be aggressive, can spread quickly, that putting off her surgery could be really dangerous for her.

She was unmoved. This month just really wasn't convenient for her.

It took about twenty minutes of cajoling to get the reason out of her. And the reason?

She wants to lose weight and look amazing for her nephew's bar mitzva next month. And she gained weight and didn't look good after her last operation. So, long story short, there is absolutely no way to convince her to have the surgery before the bar mitzva.

Now because Israel is socialized, it's nearly impossible to schedule elective surgeries in a timely manner. This means that if she doesn't have the urgent surgery now, we might not be able to schedule it again until June.

She understood all this and still left without scheduling the surgery.

And I feel like we failed. And I feel that she let down her family, let down her body, let down the team of doctors that put a lot of thought and energy into her well-being.

It was disappointing.

But there you go.

On a side note. . .

I may or may not have just been exposed to avian flu.

Overseen in the ER

"More money is spent on breast enlargements and Viagra than on Alzheimer's research. This means that in the year 2020, much of the population will have huge breast and huge erections and be entirely unable to remember what to do with them."

I am ashamed. . .

Embarrassed. (<-- curse you extraneous consonants.) Abashed. Chagrined.
Humbled even.
I have become that which I scorned.
I have become an American who lives abroad.
And drinks. . . americanos.

What's an americano? Basically a shot of espresso diluted in a cup of hot water.

Wikipedia elaborates: One popular explanation for the name is that it was originally intended as an insult to Americans, who wanted their espresso diluted. During the Second World War, American occupational forces in Italy searched for the "cup of joe" they were accustomed to at home, which local baristas tried to emulate for them.[1] If this is the case, many American coffee drinkers are either unaware of or unfazed by the derogatory nature of the name, even in some cases going so far as to misinterpret americano as being a uniquely American way to drink espresso

Except that Wikipedia errs. I am fazed by the derogatory nature of the name. When I worked at Starbucks, I was horrified to discover that the drink named after our country was in fact basically espresso tea. I almost spit it out the first time I had a sip. It's everything that's bitter and harsh about espresso combined with everything that's boring and pointless about hot water. It nowhere near approaches the happiness that is a cup of actual coffee.

I quickly put two and two together and figured that the name probably arose from some European hotel barrista trying to approximate drip coffee for picky American tourists. And I swore that I would not perpetuate this slander, this myth that an americano bears even a passing resemblance to actual coffee. And, even worse, that my weak American taste buds can't handle real coffee unless it's diluted tenfold. And it just seems so lame, so typical to be an American ordering an americano.


And then it happened. I had been on-call the night before, delivering babies, saving lives, the usual. Okay, actually just delivering babies. I was too tired for tea. Couldn't handle the thought of another capuccino or nescafe (Israeli instant coffee) and my friend in line in front of me ordered an Americano. And against all better judgment, when it was my turn I found myself saying, "I'll have the same."

And I put a teeny bit of milk in, pretending it was normal coffee. And then, to my shock and horror. It actually kind of did taste a little bit like actual coffee. Bear in mind that I have not had actual coffee in about ten months, so my sense memory may be moderately distorted at this point. But it was kind of yummy. Not too milky, not too strong.

And this has become my drink of choice. And I cringe a bit inside every time I order it and try to use my best Israeli accent which doesn't fool anybody.

My name is T. I am an American. I am an americano drinker.
Sad.

Today was. . .

chock full of fetuses.

Which is to be expected from my obstetrics/gynecology rotation, I suppose.

We are currently 30 students rotating in two gynecology wards, two high-risk pregnancy wards, post-delivery care, multiple outpatient clinics, one emergency room, surgical day care, and labor and delivery. Each of those venues can accommodate between one and six students on a given day. We are paired with different students every day. We are also each on-call in labor and delivery or the women's ER 3-5 nights during the rotation. Our schedule approaches the complexity of most moderately sized military operation.

Today I accidentally ended up in the outpatient OR dedicated to abortions when I was scheduled to be in the gynecology ward. This led to a different kind of day than I had first anticipated.

Israel has relatively liberal abortion policies and extensive prenatal screening programs so this OR is a busy one. To be honest, I don't find it all that upsetting. Well, that's not true. I find all surgery vaguely upsetting and violent and unnatural. Especially the ones where we take internal organs out and throw them away and/or place foreign objects, such as giant plastic intestine snaps, in. I appreciate the results, ie survival, but something about it feels so wrong to me. And I didn't go through all of our clinical days, communication skills afternoons, and empathetic body language role-play weekends to poke sleeping people all day.

Moral of the story, I don't find the abortions disturbing. But it was a downer of a day anyway. Our population here is largely Bedouin, and the entire focus of their culture is children. And they're very quiet and stoic. But you can feel the desperation for a healthy pregnancy. There was a women there today, exactly my age, with six children. (What have I been doing with my life?!) This was her first pregnancy loss. She wasn't visibly upset, but right before the procedure she looked so scared, and my Arabic isn't remotely good enough to say anything comforting. Meh, it was one of those days.

I obsessively watch Scrubs to cheer myself up. I vaguely consider this time educational. Sadly, like all medical students, I tend towards the obsessive and refuse to just watch my favorite episodes. I have to watch them in order. From season 1 episode 1. This means sitting through the annoying "extra special" Scrubs(es?) where they get all serious for no justifiable reason.

So that's today. Tomorrow promises a long night of vaginal bleeding in the women's ER. Till then. . .

Overheard in the women's ER

Chief Attending to a group of students on a hospital tour: "This ER serves as the gynecologic trash can of Southern Israel."

Overseen in the gynecologic ER

The doctor pointed out the word "Virgo" written in bold across the top of an 18 year old patient's chart and asked me why it was important. I should have realized that we probably had a translation/spelling error at play, but it was the middle of the night and I wasn't thinking at my brightest, so I sat for a good ten minutes trying to figure what a zodiac sign could possibly have to do with women's health.

The answer of course is that the doctor just doesn't know how to spell virgin and he guessed. (They write it in English on the charts in order to not embarrass the patients. Despite all the other equally if not more embarrassing personal medical information also written in the chart). And the clinical significance is that we don't do transvaginal ultrasound on virgins because we'd have to break the hymen.

This is not as exciting as finding out that Virgos are more susceptible to, I don't know, ruptured ovarian cysts when the moon is in Capricorn. But reassuring to find out that my sign is not, in fact, of medical significance.

Highlights of my Israeli wedding- a cautionary tale

After explicit and vaguely violent assertions that yes he absolutely, positively had years and years of experience with American wedding cakes and he understood exactly what I wanted and I definitely, assuredly did not need to bring him pictures or check on the cake myself because he is the world expert on wedding cakes, this is what our Israeli wedding planner came up with:



My guess is that he googled "American wedding cake" about two hours before the wedding, pasted together four cakes he happened to have back in the kitchen, tried to hide the icing mistakes with ribbons, put it on the giant roll-y thing in an effort to disguise the fact that it's about 1/16th the size a wedding cake is actually supposed to be, then remembered as he was rolling it out that I had requested flowers, so he grabbed a giant pink plastic flower most likely left over from a bar mitzah the previous day and threw it on top. Very creative, actually.
(Note: this is actually the way the cake looked when it was first wheeled out. This is our wedding cake at it's very best. This is not, as it may appear, our wedding cake after a long night of drinking tequila, making out with strippers, and dancing on bars.)

And then, the ceremony itself. . .
Our actual conversation with the DJ:
DJ: When do you want the sparklers?
Husband and I: No. No sparklers. We do not want sparklers.
DJ: They're included in the price.
Husband and I: We don't want sparklers at our wedding.
DJ: I was thinking just when the bride walks in.
Me: ::As emphatically no as possible:: No no no no no no no. (I even had my husband repeat this is better Hebrew for emphasis)
DJ: Oh, so you don't want sparklers?
Us: Correct, no sparklers.