A Day of "Firsts" That I Could Have Gone Without

The labor process started off like most others.... slow.... but as time went on, the calm feelings in the room started to change. Nurses were moving a bit quicker from place to place. Directions were being given in a more stern tone. The midwife paged the OB on the floor. The OR nurse was sent to open up the OR "just in case" and the father had a look of sheer panic on his face. The baby wasn't ready to come out, but the fetal heart rate (FHR) was dropping steadily.

Before I knew it, the OB had her hands inside the vagina attaching a vacuum to the baby's head and pulling while mom pushed. Pop. Off came the vacuum. "Another vac, please" asked the OB in a calm voice. Attempt #2. Pop. Again, no success. "I'm gonna need a third vac." Pop. No luck.

I can feel the intensity growing in the room as I hold mom's leg up and encourage her to push like never before. Then the OB peaks at the FHR dropping and tells the mom she has one last push to get this baby out or she will need to go for an emergency C-section. Mom, exhausted, nods in agreement. Then the OB asks for the scissors and says, "I need to do an episiotomy." I cringe and thank the lucky stars that this woman rec'd an epidural. Snip, snip.... out pops the head. The cord was wrapped twice around the babies neck, but like a rockstar, the OB smoothly removes it, clamps and cuts the cord, and delivers the baby to Peds in about 5 sec.

It was dramatic. After some work by the peds team, the baby was totally fine. Now the attention turns back to mom - yikes! As the baby came out, the remaining tissue had torn and mom was left with a 4th degree laceration (4th degree means all the way through the anal sphincter). It was the first time I had seen one and I was horrified. However, knowing how it all happened - I see that the episiotomy was necessary. Time for the repair.... and that is when it happened... the second 1st of the day... my 1st (and hopefully last) sharps-stick.

As I was holding back the labia so that the OB could better visualize the field while suturing - I felt a little prick on the back of my hand. Damn. I was immediately told to remove my gloves and wash my hands. When I pulled off my glove, I was able to see that it hadn't broken the skin. Phew. But needle stick protocol still applied so I went to the ED downstairs, got my blood drawn, the patient will get her labs redrawn, and I will follow up with Occupational Health tomorrow. All and all, I'm not that worried. I was lucky that it was just a graze, no puncture wound, and that as a pregnant woman... all of her HIV/HEP screens were recent and negative.

I did learn a couple valuable lessons from the experience:
1. Don't trust anyone with sharps around you. Even the most experienced providers make mistakes. Keep your eyes on the needles and if you feel uncomfortable having your hands so close to the suturing field - ask for retractors! Your own health is your responsibility.

2. Know the protocol for your site before something like this happens. No one seemed to really know EXACTLY what to do and if it had been a random pt in the ED or an HIV+ pt I would have been much less calm during the process of figuring it all out.

Photo: http://www.acep.org/content.aspx?id=37762


My OB/GYN Rotation...

I'm tired. I am currently in my 3rd week of my OB/GYN rotation. 12hrs a day and a 26hr on-call every 4th day (including weekends). Did I mention, I'm tired? Student hours aren't super fun. I'm looking forward to my first job - and after this experience... NO q4day-call will definitely be part of my contract negotiation. Ok, enough whining... let me tell you about the cool parts of the rotation....

My first week was pretty slow. I didn't see any deliveries, but I did get to spend a couple days observing GYN surgeries -- and this is where I made my first mistake of the rotation. I was so amped up about learning every little detail about the surgeries that I was going in on (techniques, indications, complications, etc) - that I forgot to look up information on the patient. I know better, I really do... but for some reason after introducing myself to the patient before wheeling her into the OR, I never went back to read up on her chart. Big mistake.

The first thing out of the surgeon's mouth was, "Tell me about my last 2 office appointments with this patient." "Um, I don't know." "Tell me why the patient decided on this procedure instead of another option." "Um, I don't know." "What else has this patient tried before this procedure?" "Um, I don't know." The whole encounter took probably 5 minutes, but it felt like eternity. Luckily, there was a medical student in on the case with me (equally as clueless) so we were able to share the wrath of the surgeon nicely. The surgeon sternly told us never to enter her OR again without being prepared. Sweet, I thought, I guess my hours of reading up on the procedure didn't count at this very second as "preparation" and I thought better of telling her this... after all, she was right. Even though as students we feel like we need to know everything about everything... we have to remember the patients are most important. Needless to say, I haven't made that mistake again.

On a lighter note... my first weekend call on L&D (labor & delivery) was out of control. I assisted in 7 deliveries in 1 day. It was nuts. I was able to deliver the placenta for 4 of the first 6 deliveries and on the last one I delivered the baby hand-over-hand with the OB.  Since, I have been a part of 4 more vaginal births and 3 C-sections. My last vaginal birth was solo (of course the MD was close by), but I got to deliver by myself which was ridiculously amazing and intense. C-sections are fun -  as a student you will retract, cut sutures, help clean inside the uterus to be sure that there isn't placenta left behind, and assist in closing the abdomen (sutures/staples).

All and all this rotation as been good so far, but I am looking forward to Ambulatory Med (and Amb Med hours!) next. When prepping for your OB/GYN rotation.... just know that you will consume more coffee and sleep less hours than ever before. C'est la vie.


Atlas of Pelvic Surgery

Atlas of Pelvic Surgery. If you have an OB/GYN rotation coming up, I highly suggest this website to check out great surgical descriptions with pictures! As I've mentioned before, I am a visual person so pictures have been invaluable in helping me understand more about the surgery that I was going to observe or scrub in on the following day. I was introduced to this site by a classmate and fellow blogger.

The menu is along the top and there are several surgeries available to learn about.


A Little About DIC...

What is DIC (disseminated intravascular coagulation)?
-large scale clotting that uses up coagulation factors leading to hemorrhage
-it is not a disease
-it results from other conditions that cause endothelial damage or the release of thrombogenic substances into the circulation

What is the difference between acute and chronic forms?
Acute = severe, rapidly fatal, usually dominated by bleeding
Chronic = reversible, dominated by Clotting, initial clotting usually involves vessels of brain/heart/lungs which can lead to ischemia

Most common causes of DIC? (in no particular order)
1. Major Trauma 
          (Surgery, burns - causes diffuse endothelial damage)
2. Tumors 
          (Granules of leukemic cells and mucin from adenocarcinomas can directly activate the coag cascade)
3. OB complications
          (Placenta contains thrombogenic substances that induce clotting when released into circulation during OB complications)
4. Sepsis
          (Bacterial toxins can directly activate coag cascade and induce endothelial damage)

Picture source: http://images.rheumatology.org/viewphoto.php?albumId=75674&imageId=2861555
Source: Hardcore: Pathology by Wahl


What is a HSG?

Hysterosalpingogram. It doesn't roll off the tongue. Yesterday, during my OB/GYN rotation, I was able to watch two of these procedures and then perform the third. When the attending first asked me if I wanted to see a HSG with her - I have to be honest - I was thinking... "What is an HSG??"

What is a hysterosalpingogram (HSG)?

An x-ray (fluoroscopy) procedure performed to determine whether the fallopian tubes are patent and if there are uterine cavity defects. A radiographic contrast is injected into the uterine cavity via a small tube that is passed thru the vagina and cervix into the uterus. The uterine cavity is filled with dye and if the fallopian tubes are open... the dye will fill the tubes and eventually spill into the abdominal cavity (a good thing!)

What does an HSG help diagnose?

Primarily it is used as a test to determine the cause of infertility. It can also be used to evaluate the uterine cavity for the presence of congenital uterine anomalies, polyps, fibroids, tumors, and uterine scar tissue. The fallopian tubes are examined for pelvic scarring, blockages, or defects.

normal HSG

What are some of the risks to the patient?

1. Infection is the most common problem. It is recommend that the patient follow vaginal rest for 7-10 days (no sex, tampons, etc).
2. Mild discomfort during the procedure.
3. Small radiation exposure (less than a bladder or kidney study)

Images: http://www.drmalpani.com/hysterosalpingogram.htm


Menstrual Cycle. Basics.

In honor of my current OB/GYN rotation... I will talk about the menstrual cycle.

There are 3 distinctive phases: 
1. Menses
     The 1st day of bleeding from the endometrium built by the previous cycle (lasts avg of 3 days)
2. Proliferative phase
     Growth of new endometrium. Driven primarily by ESTROGEN (last avg 10 days)
3. Secretory phase
     Begins with ovulation. Driven primarily by PROGESTERONE. Mucous secretions are seen in gland lumens. Near the end of this phase - neutrophils and hemorrhage can be seen as an early sign of the next menses.

Dysfunctional Uterine Bleeding
1. Menorrhagia = heavy bleeding at menses
2. Metrorrhagia = heavy bleeding between menses
3. Menometrorrhagia = both

Common causes of Dysfunctional Uterine Bleeding
1. Anovulatory cycles 
     Happens when hormones are imbalanced. No ovulation. Endometrium stays in proliferative phase... it eventually grows too thick and outgrows its blood supply... it begins to slough off which leads to untimely bleeding. Causes to rule out: menopause, thyroid, pituitary, adrenal gland, estrogen-secreting tumor, obesity, and chronic dz.
2. Inadequate luteal phase
     Caused by insufficient production of PROGESTERONE. Pts complain of amenorrhea, excessive bleeding, and/or infertility.


Source: Hardcore: Pathology by Carter E. Wahl


Learning Radiology

LearningRadiology.com has been putting out a fantastic video podcast for a couple of years now. Dr. Herring has created a great series podcasts that teaches you how to read different types of studies, quizzes you on the "most common" diagnosis in a flashcard style, and lastly, quizzes you on "good calls and pitfalls" - essentially he will show you a film and give you the diagnosis that was originally given to the pt and asks you whether it is the right or wrong diagnosis. It is incredibly interesting and he does an amazing job at explaining and zooming in on the areas that he is talking about. I highly recommend it. I have learned a lot during my commute to work on the T thanks to this podcast. Below are some screen shots...

In addition, the LearningRadiology website also has outstanding resources such as ppt of common radiological dx, Weekly Cases, and Quizzes.

Each podcast has a brief overview 

He always points out exactly what he is referring to which makes it easy to learn

Explanation of his point
From the website


Learning More About Delivering Healthcare

As I have mentioned before I received my MPH from The Dartmouth Institute (TDI) - a program that focuses on health policy, variations in healthcare delivery, clinical quality improvement, and public health. They are in the process of re-branding and have created a 3 part video series on TDI. I was fortunate enough to be one of the interviewees. If you are interested in administration, public health, healthcare delivery, or just knowing more about the system that you work in - I'd highly recommend looking into TDI. You can get an MS or MPH in 1 year.


Staying Organized in PA School and After

I thrive on structure and organization. Without it... yikes. Two FREE services that help me stay organized in every aspect of my life are Evernote and Dropbox. The best part is that both are available in 3 locations:  online, iPhone/Droid apps, and in a downloadable version to computer so that you can work offline.

It was an invaluable tool for me during my didactic year and has continued to be crucial during my rotations. It allows for easier document sharing for group projects. For example, if multiple people are working on a paper/ppt, I used to have send multiple emails to everyone with the most updated version... not with Dropbox or Evernote. Now everyone can edit the same copy and it is updated instantly. For clinical rotations... I keep outlines, PowerPoints, anatomy pictures, and quick references in my Dropbox and Evernote so that they are easily accessible from my phone. Evernote has a great feature called WebClipper that allows you to save a URL or an entire webpage to your Evernote account with one click - this is really helpful when doing research.