WILTIMS #355-6: The other sides of GYN

This is my first week on the gynecological service within the OB/GYN rotation. To most people, gynecology means awkward, invasive exams every couple years (either for yourself, or someone close to you). We do have one week on clinic that's something like that, but the bulk of our inpatient gynecological experience turns out to actually be managing patients before, during, and after gynecological surgeries and other procedures. In just my first two days on the team, I've spent nearly 5 hours in the OR. In my opinion, this is significantly more fun than fumbling with a speculum and warning that "you might feel some pressure."

That being said, even on day-one I ran into some of the more ethically complicated aspects of this field. My first observed procedure was an elective abortion. We are always given the option to opt out of these types of procedures if it would make us uncomfortable and I respect those classmates that do just that. But the way I look at it for myself, I'm here to learn and I'm not squeamish about graphic surgeries, so, in what might be one of the only chances in my career to get this experience, I wanted to see what it really means to be a pro-choice OB/GYN doctor. I think that's as far into this topic I want to go here, but it was an interesting experience.

Next, longtime readers might remember an ethics case I discussed way back in my first year. The crux was whether it was ethically permissible to do a pelvic exam as a medical student on an anesthetized hysterectomy patient. Well, the other day, that's exactly what I did. I think the program at our hospital does a pretty good job of taking proper precautions to respect our patients. Generally, only one medical student works closely on each case and they must ask for permission from the patient to participate in the procedure beforehand. Now, do we explicitly get consent to do a pelvic exam? No. But as we are the least experienced part of the 3-4 person physician team, it seems reasonable that we might be involved in a relatively noninvasive part of the operation (and not wielding the scalpel, say). If we ever feel uncomfortable or think that the patient's autonomy has indeed been violated (e.g. many unnecessary exams are being done without any clinical indication), we are encouraged to speak up and pass on participating.

The last experience that surprised me in the past couple days was when I tagged along on an ER consult with one of the residents and a 4th year medical student (a sub-intern or "sub-I"). The resident in question mumbles a bit and was talking quietly to protect patient privacy. And since the sub-I was the real audience of his discussion, I was just happy to pick up anything that I could. We briefly looked at a pelvic ultrasound and, from the little I heard and saw, I understood that something wasn't right with this barely pregnant woman. Finally, we headed over to the patient's bed in the ER and introduced ourselves to find that she only speaks Spanish.

Lacking any foresight in high school, I never took Spanish and so, ten years later, I was immediately cut out of the conversation with this patient. The resident had a limited grasp of the language and asked a few simple questions before having the sub-I grab the three-way interpreter phone. Thanks to the phone, I suddenly had a window into the resident's half of the conversation, even if the patient's side of things remained stubbornly opaque. It dawned on me at that point that I was entering into this interaction nearly as uninformed as the patient about her diagnosis and treatment.

After clarifying some of his previous routine questions with the help of the interpreter, the doctor asked, "When did you find out that you were pregnant?"

Through context I could see that the answer was "this afternoon during this ER visit."

"Has anyone talked to you about the results of the ultrasound?" asked the doctor, hesitantly.

"No," said the patient, which thankfully translates in many languages.

"The ultrasound showed that something is wrong and the pregnancy is probably not viable." He waits for the translator to repeat his sentence over the phone, but quickly sees that she isn't understanding.

I, meanwhile, suddenly realize the impact that our seemingly innocuous little conversation is likely to have. It's like eating dinner at a new restaurant, only to find that the couple at the next table is actively going through a breakup.

"I'm sorry to tell you, but the baby is not growing," he rephrases. Now she understands and quietly starts to cry. The doctor touches her shoulder consolingly. "I'm sorry, this must be a lot to go through in one day."

This whole interaction took me by surprise. Given the awkwardness of the language barrier, I think it was handled as best as could be suspected, but it was a powerfully emotional moment for everyone nonetheless. Part of what makes medicine so captivating as a career is that our interactions with patients often happen at life-changing moments in people's lives. OB/GYN adds another layer of cultural and emotional meaning to that sentiment.

TuesdayIL: Marsupialization is the term for surgically creating a pouch - and no, not a pouch to carry your young in. We do not create human kangaroos. The technique is usually used to open up a cyst or abscess and keep it open so that it can drain freely.

TIL: The two most common causes of an enlarged uterus are adenomyosis (when the uterine lining grows into the uterine muscle layer) and leiomyomas (aka fibroids, benign tumors in or on the layers of the uterine wall). The chief difference between the presentation of the two is that adenomyosis usually causes a pretty uniform growth and fibroids cause heterogenous lumps.

WILTIMS #364: Goodbye sunshine!

Today was the first day of my new rotation on OB/GYN and my first day commuting into Manhattan from the Bronx.

We only had a brief orientation lecture (yes, even in med school, they still read us the syllabus) but no actual clinical work today. The biggest takeaway was that this is going to be my first really intense clerkship. Five weeks of 12-hour day shifts, one 24-hour shift and four 12-hour night shifts - all about an hour commute from my apartment using public transportation. Yay! I'm tired just thinking about how tired I'm about to be. On that note, I'm going to head to bed since I'm getting up at 03:45.

TIL: Chadwick's sign is an early sign of pregnancy where the cervix and vagina turn a bluish color due to increased blood flow.

WILTIMS #361-3: Outpatient round-up and peds wrap-up

Another clerkship comes to an end! Yesterday was my last day of clinical work on the pediatrics rotation. There's a study day today, a shelf exam on friday, and day-1 of OB/GYN on Monday. No rest for the wicked ...ly awesome?

The past three days were my "week" on outpatient pediatrics. Our hospital offers two types of outpatient experiences; there is a clinic at the hospital I've been working at and there are various pediatricians' offices around the county. I did my time in an office in Yonkers with an amazing pediatrician who somehow tried to tutor my classmate and I in the entirety of pediatric medicine in the three days he had with us. While trying to soak up the onslaught of knowledge I needed to wring out my brain every night and blogging went by the wayside. But below are some of the more interesting factoids.

MondayIL: A pilonidal cyst is a boil that forms on the tailbone. Usually it can be treated with antibiotics but if the infection gets too severe, a small surgical procedure can be done to drain the abscess.

TuesdayIL: If a baby turns blue after birth but turns pink again when crying, they probably have choanal atresia, the congenital blockage of the back of the nose. Normally, babies breath exclusively through their nose, but when they cry, they have to breath through their mouth. If the nose is blocked, they turn blue from essentially not breathing.

WednesdayIL: If a week-old vaginally-delivered baby has red, inflamed eyes and a cough... they probably have chlamydia. Yes, that chlamydia. Amusingly, while that may seem like a stretch at first, I'm sure any classmates of mine reading this are like, "Well, obviously." Every baby born in a US hospital gets a prophylactic dose of erythromycin squirted in their eyes right after birth. The reason for this is that chlamydia and gonorrhea are quite widespread and can transfer from the mom's birth canal to the baby's eyes during birth. In babies, the main complication of a chlamydia infection is a mild pneumonia or bronchitis.

WILTIMS #359-360: Shiny toys

Today started out pretty mild and boring in the nursery.  One of the babies I had been following was discharged yesterday. There were no new babies overnight and no scheduled C-sections for the day. But after a couple hours, a couple really interesting things happened all at once.

The first was that one of our babies routine labs came back with an alarmingly high bilirubin level and, relatedly, he developed pretty severe jaundice overnight. Bilirubin is one of the breakdown products of blood cells and is normally detoxified by the liver. The baby liver, however, is not up to the job yet during the first few weeks of life, so if anything causes more red blood cells to be recycled than normal, the bilirubin level will rise. Bilirubin's further breakdown products are what are responsible for the brown color of stool and the yellow color of urine. When bilirubin can't be converted to these products by the liver, it builds up in the blood and turns the skin yellow - a condition called jaundice.

On the left is the unit before all the lights are turned on. Above,

the blue glow from above and the green blanket in the center.

Many babies develop mild jaundice, but if the bilirubin level becomes dangerous, the treatment is phototherapy. For once, I think all of you should be able to translate that bit of jargon. The light that we use is not the sun, but a super cool looking blue and green box of medical awesomeness. Two high-intensity blue lights are placed above the nearly naked baby in a NICU baby pod to help breakdown all that excess bilirubin. What about the baby's back, you ask? They have a fiberoptics-powered light-emitting blanket that glows green under the sleeping baby. The last piece is a tiny eye-cover to keep the baby's eyes safe from the lights.

Speaking of cool medical devices, this was the first week that I got to see the video translator service in use. There is an iPad on a rolling stand that can be wheeled into a patient's room and connected to an off-sight professional translator who essentially Skypes into the room to bridge the language gap between the care team and the patient. There is an impressive selection of languages available, though the rarer ones are only available during normal business hours. Of course, over 200 languages are available 24/7 by plain old phone.

The other interesting thing today was the unscheduled delivery of a baby with a cleft lip. This is a congenital condition where two of the pieces of the upper lip don't fully merge during development. The more severe version extends backward to the palate. Though we are all taught extensively about these malformations, even the pediatric residents I was working under hadn't seen one of these in real life. A little plastic surgery next week and you'd be hard pressed to notice that this kid had anything wrong with him for the rest of his life.

YesterdayIL: Whereas high blood pressure is defined by specific pressures for adults, hypertension is adjusted according to sex, age, and height for children. Then for each group, children with blood pressure less than the 90th percentile are considered normal. 90-95 is prehypertension, 95-99 is stage 1, and >99 is stage 2.

TIL: Phototherapy is not actually done with UV light, which makes a ton of sense. Two visible wavelengths of light have been found to efficiently break down bilirubin through the skin, one blue and one green.

WILTIMS #358: Healthy advice and unhealthy nubs

One of the attendings pointed out the other day that the well baby nursery is the only place in the entire hospital where your patients are healthy. While normally the chief complaint of one of my patients is "stomach pain" or "shortness of breath," this week the chief complaint of all of my patients is "new baby." To be fair, that's one hell of a complaint; you try being ripped from your dark, warm, quiet home and being told to breath and eat and poop on your own for the first time. But existential complaints aside, all of these babies are healthy. If they weren't they would have been transferred to the neonatal ICU.

One awkward part of our job in the nursery is to provide what's known as "anticipatory guidance," which essentially means advice as to what to do and what to expect between now and the next time you see your primary pediatrician. This is super helpful and much appreciated for a first time mother. But when you have a mother of 4-now-5 as a patient, they know (or, at least, think they know) everything about babies.

The hardest part is if the mother's old habits are outdated or just plain wrong. It takes some skilled diplomacy to get them to even hear you out, much less actually follow through with your recommendations once they leave your care. Say advice without conviction and they'll tune you out; but get too preachy and they'll ignore you out of spite. Add into the mix that most of the medical students and residents don't have kids of their own yet (you know, with all that time we have) and it's amazing if anyone listens to us.

Switching gears, remember those cheap molded plastic toys like green army men or monkeys in a barrel? You know how there was always a little nub of plastic that shows you where they injected the mold? Well babies have those too. The most obvious one is, of course, the umbilical cord - the literal connection to the mom. But there are a couple other vestiges of the manufacturing process that we are very keen to check in the hours and days after birth. One such remnant is the end of the neural tube, which is like the primitive tube (for once biologists actually named something intuitively) that the spinal cord develops in.

For a good chunk of early human development, this tube is open to the fluid around the fetus. Sometimes this tube stays open on one or both sides. If the top end remains open, it's called anencephaly; if the bottom does, it is a meningocele or myelomeningocele - collectively known as spina bifida.

TIL: Diastematomyelia is when the tail end of the spinal cord is split down the middle by bone or cartilage. The symptoms often include foot or leg numbness or weakness progressing to bowel and urinary dysfunction.

WILTIMS #357: Aww, you have such a cute little nevus flammeus nuchae!

Newborn medicine has a bunch of cute names for benign medical findings on babies. The idea is that if we have a cutesy name for it, then it must not be scary and the parents can relax (a little). Here's a few:

• Stork's bite: a birthmark on the face or back of the neck that is often temporary
• Angel's kisses: reddish blotches around the eyes or on the eyelids that are temporary
• Epstein's pearls: small whitish cysts in the mouth that resolve spontaneously

TIL: You can eyeball a baby's bilirubin level by seeing how far down the body the yellow skin color of jaundice goes.

WILTIMS #356: Baby

Today was my first day in the Well Baby Nursery. This is the unit in the hospital where the brand new babies and mothers recover from the delivery and are screened for any complications. Our first patient today was born 12 minutes before we examined him. There was a stretch of time thereafter when I was the person who had spent the most time with that baby in his whole life. Weird.

One of the first things that happens after a baby is born in a hospital in the US is we take a couple drops of blood from their heel (because stabbing a needle in the vein of a 1-day-old is impossible and they can't reach their own heel yet to mess with the bandage). We then run a battery of newborn screening tests that varies from state to state. In NY, we test for over 40 different genetic or congenital diseases that might otherwise go unnoticed but require intervention to live a longer, healthier life.

I'm going to take this opportunity for a PSA: It's surprisingly common (at around 1 in every 5,000 births) for there to be ambiguous genitalia at birth. So, if you catch the parents using "it" as the pronoun for their newborn while their baby needs to stay a bit longer in the nursery or NICU, just be mindful that the parents might be going through a confusing and stressful time. Remember that there are inbetweens when it comes to a person's sex. Sometimes, the genitalia are ambiguous because of a genetic or hormonal imbalance that, once treated, will resolve; other times, it won't. The only reason these situations are difficult for the parents and eventually the kids, is the social stigma we have towards the gray areas in our false dichotomies. So, let's stop it with a little education.

TIL: When a baby is born as a presumed male their hospital name is [Last Name], Baby Boy. When born seemingly female, they are [Last Name], Baby Girl. When the gender is not immediately apparent, they are [Last Name], Baby.

WILTIMS #355: MS3 is aware

"MD aware" is a phrase used by nurses to denote in a patient's chart, often passive aggressively, that the preceding problem has been brought to the attention of the doctor (but the doctor hasn't done anything about it yet). Accordingly, the residents I work with have reappropriated the term for use with each other to mean "Got it. Thanks for letting me know!

TIL: "Skiffy" is not a thing. SCFE, on the other hand, is. It's always so hard looking up things you don't know when everything is an acronym instead of an initialism (pronounced as a word rather than as a series of letters. Anyways, a SCFE is a slipped capital femoral epiphysis which is a serious injury seen in adolescents where the growth cap of the ball part of the hip joint slips off the rest of the leg bone. If not treated quickly, the bone can die and lead to permanent disability.

If someone has a septic hip joint, they often lie in a certain way. They have their leg bent and their hip rotated outward. This position opens up the muscle joint as broadly as possible, which lowers the painful pressure on the joint.

Shenton's line is an imaginary curve that should be present if you connect the curves of the femur and pelvis.

Incentive spirometry in a young child can be achieved by having the kid blow bubbles or fire marshmallow cannons. Incentive spirometry is essentially a breathing exercise but it's boring and somewhat painful for the patients that need it. By making it into a game, you can get children to do this annoying activity willingly.

WILTIMS #354: What's going on, again?

Today was a whirlwind of updates on one of my patients. I only have one real job for inpatient shifts: write the daily progress note. Typically, all the information needed for the note is discussed in morning rounds. I can then spend an hour or so in the afternoon going through the computer to write a draft of a note that my supervising resident can edit and co-sign.

But today, my patient's condition (and even diagnosis) changed about every hour. Accordingly, his note changed several times too. Thankfully, by the time I needed to leave, my resident was willing to help write in the most current plan (of which I hadn't even heard by that point).

TIL: Growth hormone treatment is associated with rare cases of sudden death in children with Prader-Willi syndrome. Prader-Willi is a rare genetic disease caused by the loss of part of chromosome 15 that results in many developmental symptoms, including short stature. A logical treatment is growth hormone, to boost these patients' heights. But in very rare cases, patients treated with growth hormone have sudden unexplained deaths. So why don't we just not treat any of these patient's with growth hormone? Rarely, people die from one treatment for a rare disease. There is so little data on this connection, that we can't really be sure that they are linked.

WILTIMS #347-353: Catch-up mega-post

After a week of just trying to stay afloat in the sea of work, call shifts and sleep deprivation, I just didn't have it in me to post things. Getting out of town for the long weekend helped my mental health state, but prolonged my writing even longer. But through all the chaos, I did in fact save some facts to share with you when I had the time and energy. So without further ado, here's a whirlwind catch-up post!

LastMondayIL:A non-verbal infant cannot, by definition, have a sore throat. Soreness is a subjective quality and babies can't tell you what they are feeling. You can only infer that the throat hurts from their swallowing difficulty or if they cry when feeding.

Langerhans cell histiocytosis presents with osteolytic bone lesions, skin findings on the hands, and diabetes insipidus.

LastTuesdayIL: Allergic shiners are dark rings around the eyes that can occur when blood pools during an allergic reaction. The "shiner" term is because it looks like the patient has two black eyes from fighting.

LastWednesdayIL: In a pinch, you can use Coca-Cola to clean out an obstructed gastrostomy tube.

LastThursdayIL: Cerebral palsy is a lifelong diagnosis, but can be very misleading if the effect is mild. CP is when there is a brain lesion at birth that causes any sort of permanent muscle dysfunction. Whether that dysfunction is a life-altering disability or a totally benign quirk, the person with it will have the CP diagnosis for life.

Quote of the Day: "At this point in my career, if I haven't heard of a disease, it is by definition rare."

LastFridayIL: ALTE, pronounced "all-tee", stand for apparent life-threatening event and is defined as anything that happens to an infant medically that truly scares the parents. Common examples are turning blue, not breathing for extended amounts of time, not moving, etc. ALTEs are useful to group a broad, nebulous collection of symptoms into a single, generally understood category for use as a chief complaint when the child is brought into the hospital.

YesterdayIL: Arthrogryposis is a fancy term for multiple congenital contractures... which is a fancy term for not being able to move two or more joints at birth.

TIL: PDAs are more common in Denver. A patent ductus arteriosus is a congenital heart anomaly where a fetal connection between the aorta and pulmonary arteries stays open after the perinatal period. One of the environmental factors that regulates the body's drive to close this connection is the blood oxygenation status. At high altitudes, such as in the Mile High City, babies have less oxygen from the air and their ductus arterioses stay open longer and are more likely to stay open and cause problems.