WILTIMS #511: Enemy at the gates

Fever is a very scary thing in cancer kids. In normal kids, even though the technical cut-off for fever is 100.4°F (38.0°C), we aren't really all that concerned with an otherwise asymptomatic fever until it's consistently hovering a good deal higher than that (Reminder: please don't ignore your child's fever because of my silly blog; let your doctor make the call). But if you have no immune system, like kids receiving chemo or transplant meds, then your body has a really hard time producing the signals that lead to a fever. So, if one of these kids hits 100.4°, then it means that they are likely already quite ill, but not showing the typical signs yet. It's like if you're fighting a war and you have no more troops; just because you don't hear any gunfire, doesn't mean the enemy isn't advancing right to your door.

WednesdayIL: Though ECP does stand for emergency contraceptive pill (as I learned in my OB/GYN rotation), it quickly became apparent that that is not what the pediatric oncologist was talking about in regards to treating a young boy's graft-vs-host disease. In this case, it turns out, ECP stands for extracorporeal photopheresis, a method of essentially cleaning the patient's white blood cells. The idea is to remove some of the patient's blood, separate out the immune cells, and radiate them with UV light to make them invisible to the rest of the immune system before reinfusing them into the patient. This technique is used in patients with cutaneous T-cell lymphoma and some autoimmune diseases.

I also learned that you have to be careful with dosing methotrexate (a kind of chemotherapy) in patients in renal failure, with Down's syndrome, and patients who are "third-spacing." The first case is pretty simple; your kidneys filter out the toxic medicine after it circulates through the body. When the kidneys fail, the toxic stays around longer than usual and can do damage. With Down's patients, there is thought to be overexpression of some enzymes on the multiplied chromosome 21 that interfere with the drug metabolism resulting in higher levels of active drug in the blood stream.

The last one is a bit more complicated. "Third spacing" is when a patient is collecting unusual amounts of fluid outside of the two typical fluid "spaces" in the body (inside cells and in the blood stream). Instead the fluid pools in places like the abdominal cavity or the area around the lungs. But this fluid can still absorb chemicals like methotrexate, removing active drug from circulation, so the dosage required to get a typical effect is much higher. The problem is that we are usually also trying to eliminate this "third-spacing" so if you give large doses of the drug and then pull the unused drug back into the bloodstream from the extracellular spaces, then you've now overdosed the patient with medication they already had in their body.

WILTIMS #378: OB/GYN Wrap-up

Wednesday was my last day on the floor for OB/GYN and this morning I took the shelf exam. Cancer and antibiotics; cancer and antibiotics everywhere! Man, I hate the shelf exam writers. Not personally - I'm sure they're nice enough people, but I take issue with what they stress on our tests. If you look back on all my TILs for any given clerkship, you'll get a good idea of what isn't on the self exam - namely anything practical or useful day-to-day for the field in question.

Anyways, not much interesting happened during our last shift, but apparently a lot happened the previous night. We almost lost a patient from intra- and postpartum bleeding. The story was exciting, but, for whatever reason, it feels too invasive to tell in this setting. That woman has been through enough and doesn't need her story, anonymous or not, plastered over my small corner of the internet. In any case, the result of the chaos was that by the time we arrived that morning the patient was in the surgical ICU.

A surgical ICU clear across the country is where I got my start in medicine (outside of family issues, of course) by volunteering and then working as a unit clerk. I have been trying to find out, ever since, whether intensive care or some other aspect of medicine is my calling. And by calling, I mean the specialty or subspecialty that I want to try, despite bad grades and long years of training, to be allowed to practice in 5-10 years.

And still to this literal day, I have loved getting any chance to be in an ICU. I love when things have gone horribly, horribly wrong.  I love the clarity that comes with needing to prioritize basic functions and then slowly getting to address everything else as the patient gets more stabilized. I am so jealous of the ICU doctors who got to take over our patient when she was in truly dire straits. It's fun and frightening to think that I could still do that as a career.

WednesdayIL: You can use the doppler function of the fetal ultrasound machine to see if there is an umbilical loop in a pocket of amniotic fluid. As I mentioned in a previous post, amniotic fluid pockets are one of the important signs of fetal health. The measurement of these spaces requires being sure they are empty and, as umbilical cord is nearly invisible on ultrasound, having a way to visualize it is very useful. The doppler function color-codes movement as either come towards or going away from the probe. Amniotic fluid doesn't move, but the blood through the umbilical arteries and vein does. So if you see blue and orange in your amniotic pocket, keep looking for another one.

WILTIMS #374-6: Case presentations and breech presentations

One more week of OB/GYN to go! And thanks to our city hospital having election day off, we have more study days than actual days on the unit next week.

Wednesday was very slow. It was my classmate's turn to scrub-in on the sole c-section scheduled that day, so I bided my time in the triage ward. The only potentially interesting patient turned out to have heart burn. Hey, everyday can't be thrilling!

Yesterday, we each had to do a 15 minute evidence based medicine presentation in front of the clerkship director. The presentation had to include a case presentation of a patient that inspired a clinical question and a scientific paper that attempts to answer the question. We then have to bust-out our dusty biostatistics skills to critique the study. As was to be expected, everyone over-prepared for this pass/no pass assignment and spoke for 20-25 minutes. Other than going way over on length, the presentations were all very well done.

Today I got to scrub in to another c-section. This time it was just me, one resident and an attending at the bedside. This attending is known for letting med students actually do things, and he definitely made good on that rumor. Accordingly I did my first stitch on a live person today! I got to close the outermost layer of the incision using three sutures and a dozen or so staples. I'd like to say I was a natural, but that couldn't be further from the truth. I was awkward and slow and bad at just about every step. I picked up the pick-ups (tweezers) wrong every time; I couldn't remember how to tie knots properly; I had a hard time grasping the skin with the pick-ups; I kept clamping my glove in the suture-clamps when trying to protect the needle (secure the pointy part inward, so it can't poke anyone). It was an all-around disaster. Thankfully, everyone was fairly patient with me, so I didn't run crying from the OR or anything.

WednesdayIL: ...how little we know about pain management during pregnancy. As I promised on Tuesday, I wanted to look into the options for pain management, so I chose that as my clinical topic for my evidence-based medicine presentation. What I learned while researching the topic was rather disheartening. We are so afraid of doing research on pregnant women (for good reason) that there is very little data on the dangerousness of many drugs on the pregnant population. Here is some of the little we think we know:

• NSAIDs: Animal models show early fetal formation effects. Thereafter, there is a small increase in structural defect risk. Avoid them at late-term due to effects on labor, postpartum bleeding, neonatal platelet and ductus development.
• Acetaminophen: Possible long term asthma risk for the baby, but generally safe.
• Opioids: May cause congenital heart defects and neural tube defects early on. Respiratory depression is the big risk during labor. Long term exposure can lead to addiction, which can cause many adverse effects.

YesterdayIL: ...about some studies' findings regarding OB/GYN health, thanks to the presentations from my classmates. Here's the one sentence breakdown:

• Early screening and treatment of asymptomatic bacterial vaginosis (overgrowth of bacteria in the vagina) can lead to far fewer fetal and maternal complications, including spontaneous abortions.
• Preterm premature rupture of membranes (PPROM) can either be treated with immediate delivery or expectant management, with neither posing a significantly greater risk to the fetus or mother.
• Something something preeclampsia and high blood pressure... I don't actually remember the study this person discussed, but they did a very good background presentation on preeclampsia and high blood pressure.
• There were similar outcomes in a study that compared immediate medical management of a missed or partial spontaneous abortion with one week of expectant management prior to initiating medical management.
• Though insulin is the gold standard treatment for chronic and gestational diabetics during pregnancy, metformin provides similar levels of efficacy and safety.

TIL: Delivering a placenta via c-section is very similar to delivering it vaginally: try to hold the uterus in place and pull slowly but steadily on the umbilical cord.

Also, wearing the big scrub boots instead of just the slipper-like shoe coverings is a good idea in the L&D OR. Got a giant red blob of something on me today that would have totally fallen on/in my shoe had I not been wearing the extra layer.

WILTIMS #373: Sudden realizations

This morning started out with a pretty rough case. A woman we had briefly seen yesterday and reassured that she was probably fine, came back this morning with a partially completed miscarriage. It was especially distressing because she trying for her first baby and was running out of time on her biological clock. She was pretty upset when the doctor broke the news.

It was hard being in the room as the ultrasound was being done. She and her husband were holding hands nervously and awaiting the results while the two residents and I looked at the monitor. I am not at all qualified to read one of these yet, but even I could see something was very wrong from the scan. It's weird to be standing there, hoping you're wrong, just like the patient who is sitting beside you with just a bad feeling.

As I briefly mentioned before, when women reach 35 years old, they are considered "advanced maternal age." Older age during pregnancy puts women at higher risk for complications and having a child with genetic conditions such as Down's syndrome. First trimester miscarriages are usually due to fatal chromosomal anomalies like trisomies (having three of a chromosome instead of the traditional 2 (or 1 for Y)). Trisomy 21 causes Down's, but only a few other chromosomes are able to be duplicated and produce babies that survive to birth. These are 13, 19, 21, X and Y. The general rule is that chromosomes are sorted by size with the smaller ones being higher numbers, so if you duplicate one of the lower ones, you're more likely to run into problems by overexpressing all the genes encoded by the DNA. That being said, for whatever reason, chromosome 16 is the most common defect seen in spontaneous abortions.

One of the most important things to remember when you're diagnosing a spontaneous abortion is to be very clear with the woman that there is nothing she did to cause it. There is no one to blame. The egg was simply not viable. I feel like that is an important distinction too. They did not lose a healthy baby because of their body being old; their body was doing exactly what it was supposed to do - stopping a process that would never have led to a living baby.

I had a more pleasant moment of realisation later in the day. After staring at the fetal heart rate monitor at the nurses station, I noticed that one patient had a blue line tracing on the monitor alongside the red one I am used to seeing. In the labor side of the unit, a blue line usually means that a intrauterine probe has been placed after the membranes have been ruptured. But 1) this woman was nowhere near labor, and 2) there is no need for the external line once the internal has been placed.

I was asked to bring the woman some water, so I brought her a pitcher and some glasses. After she sat up to drink, we had to wait for the monitors to re-calibrate. As the lines reappear on the screen she says, "There's baby one... and... baby two!" And then I finally get that there's two lines because she's having twins.

TIL: We are somewhat handicapped regarding providing pain management to a pregnant woman. Tylenol is totally safe, but if that's not doing enough all we have are opiates, which though not very well studied in pregnant women are generally thought to be not very good for the baby on a long term basis. Of course, if the woman is in excruciating pain then the benefit might outweigh the somewhat unknown risk. I shall be researching this more...

WILTIMS #372: Dozing through the day

Yesterday was ok... I think. I'm not actually sure, since I was dozing off at every opportunity. After a week of night shifts and a weekend of failing at readjustment, I was a mess. Then when I got home, I all but immediately passed out on the couch. But, in the little time I was conscious, I learned and saw quite a bit.

In the morning we had the first Monday conference in which we've been able to take part, thanks to a series of holidays/teaching days/night shifts. This meeting mostly consisted of the attending physicians reviewing some cases from the week and discussing what they thought the plan should be. One of the more interesting debates was about what kind(s) of doctor(s) should be in the room for a complicated delivery this week involving a fetus with a potentially cancerous cyst. Pediatric gynecologist? Gynecologic oncologist? Both?

In the afternoon, we witnessed the fastest delivery we've ever seen for someone who actually made it to L&D. We were talking to the patient one minute, she started painful contractions then next, she gave one good push, and, before any of the staff could even gown-up, the baby was out. That's the way to do it!

YesterdayIL: If a pregnant woman's water breaks early, it's a serious complication and can require an immediate delivery regardless of the fetal maturity. Sometimes, though the amniotic sac can stabilize and reseal allowing for a more mature birth. To test for this you can use indigo carmine dye, which is injected into the amniotic sac, turning the fluid there a rich blue color. Then you observe over the following hours and days. If there is no blue vaginal discharge, then the amnion is in tack and you can be more conservative and wait for a closer to full term delivery.

Vasa previa is a condition where the umbilical cord vessels separate from each other somewhere between the placenta and the fetus and then get lodge near the cervical opening. The vessels are more fragile in this state and may be punctured when the membranes are ruptured prior to delivery. This bleeding can be severe and will likely require and immediate delivery or c-section.

I you've ever seen a real umbilical cord, you'll notice that both the larger cord structure and the vessels within are extensively coiled to the point of looking like a spring. This is a purposeful design because a straight cord would be very easy to compress, cutting off the fetal circulation. All those loops allow the cord to be squished quite a bit but the loops just fold over each other and don't pinch off readily.

WILTIMS #371: Lessons for my future self

One of the skills that we are supposed to be honing during our clinical years is the ability to understand and thrive in a complex health care institution or, put more succinctly, to brave the bureaucracy. Med students, being somewhat intelligent, are generally capable of figuring out how things work in whatever setting we are thrown into. That includes straightforward things like how to use the electronic chart or the procedure for requesting blood from the blood bank, and more subtle things like who to address by first name, what work is supposed to be done by who, or where it's best to stand in a crowd based on a need-to-know hierarchy.

One of the more specific areas of this general category of learning is not explicitly part of our curriculum. Often subliminally, we are learning how to and how not to teach. Being at the very bottom of the totem poll, we have no one below us to teach yet. But in nearly every interaction with the fourth-years, residents, and attendings above us, we are finding out what styles of instruction are most and least effective.

It's actually remarkable that in a field where after a couple years you are taught, not by dedicated instructors, but by the students themselves that are ahead of you in the educational tract, we are never extensively taught to teach. Because of this, some people are great at it, others learn to be better, and still some remain stubbornly oblivious to their daily missteps. So, in what seems like a surprisingly mature response, some of my classmates and I have come to look at each poor interaction with our superiors as an opportunity to note for our future selves how we can try to consciously avoid the same pitfalls when we are in our superiors' shoes.

Here are some of the takeaways I can think of at the moment:

• Communicate better
• Be explicit- Until proven otherwise, assume that your mentee has no idea who or what you are referring to when you use pronouns or acronyms. "Go down to Dr. Mumble's office and ask her what the EP3!TX value is," is just asking to get a blank stare back from the person.
• Keep everyone in the loop - If the only interesting thing a medical student will get to do today is a surgery and that surgery has been moved up, make sure to let them know.
• Be efficient/respectful with other people's time
• Try not to make someone wait an hour for something that requires 30 seconds of your time.
• If you assign something like a presentation for a student to work on, actually bother to listen to them present it, even if briefly.
• Be nice
• If someone doesn't know the answer to your question, don't judge or berate them. Maybe ask them to look it up for tomorrow.
• Fill out forms
• Remember how important and stressful all the stupid forms that med schools make you fill out are to the students. Just because they're dumb, it doesn't mean they're not a major area of anxiety for your mentee.
• Show/explain everything
• Anything is more interesting than standing in the corner, wishing for something to do. Bring your student everywhere with you and monologue as much as possible to show them why you're doing whatever you're doing. It's much easier to learn when you're A) in the room and B) not guessing in silence about what's happening.
• Be enthusiastic
• At least occasionally, try to show why you chose to go into your field and kindle some excitement in your mentee. Being jaded is poisonous to an enjoyable learning atmosphere.

TIL: Cervidil is a prostaglandin medication (specifically dinoprostone) than can be inserted into the cervix to hurry dilation. Unlike another prostaglandin, misoprostol, which has a formulation that produces the same effect but is immediately absorbed into the tissue, Cervidil is continuously released from a string-like drug vehicle. This means that if a serious side effect occurs, the string can be removed, whereas the misoprostol version is already absorbed.

WILTIMS #370: ♫♪ In the wee small hours of the morning... ♪♫

Tonight I got to help closer than ever before with a vaginal delivery. I got to do the "put your hands on my hands" thing through most of the delivery, to get a feel for where to put pressure and how to guide the baby out while keeping the mom's anatomy intact.

Later, at around 3am, I got to scrub into my first c-section. I held some retractors and used the world's dullest scissors to cut suture thread like a champion kindergartener. I did think it was kind of funny that a c-section is the only kind of surgery, other than a conjoined twin separation, where you have a second team of doctors just waiting in the corner to take care of what you cut out. One of the poor pediatricians, who is only scrubbed because it's an OR, not because those precautions are needed around the newborn, got yelled at by the scrub tech even more than I did.

Still not really getting the appeal of delivering babies, so I'm pretty sure that OB/GYN is not going to be for me. There are other reasons too, but if the thing that is universally everyone's favorite part of this rotation is about as exciting for me as going to the grocery store, then I'll probably pass on this specialty as a career.

Blood draw update: Still more failure, but I finally had a great nurse teach me some tips, so I'm excited for the next try. I also may smuggle some needles home to practice on myself (my squeamish SO, whom I love dearly, is not helping me in this matter).

TIL: Postpartum uterine atonia is when, after delivery of the baby, the uterus fails to contract. This contraction is important for expelling any remaining products of the pregnancy, for helping the uterus return to a more normal size and, most importantly, for cutting off the blood flow that had until recently been going to the placenta so that the new mom doesn't bleed out. Risk factors for uterine atonia are, generally, anything that causes the uterus to be stretched, including a large for gestational age baby, too much amniotic fluid, and numerous prior pregnancies.

WILTIMS #369: Nighty-night

I feel like if IBM's Watson ever became sentient and chose to be a doctor it would immediately get annoyed and go Sky-net on us for being stupid patients. It would seem like programming an algorithm of questions to come to a diagnosis would be fairly simple once you had amassed the research. The problem is that people are terrible historians.

"Do you have any other medical problems?"

"No." (Are you suuuuure?)
"Do you take any medications?"

"Yes, albuterol for my asthma." (but you just said...)
"When did you start taking that medication?"

"After my surgery."
"And what was that for?"

"Taking out my spleen because of my sickle cell disease." (but that's exactly the sort of medical problem I wanted to know about!)
"And is that being successfully treated?"

"Yeah, it's gotten a lot better since I started taking my hydroxy-whatever pill." (But I already asked you about medication!)

I think a good rule of thumb might be to try to give the patient at least 2-3 opportunities to offer up any given piece of information and then you might know the correct answer to most of your questions.

I got to help deliver another baby this evening - this time while shadowing a midwife, as opposed to an OB/GYN resident. It was a very simple delivery, so I noticed absolutely no difference in technique or style between the two types of baby delivering professionals.

I also failed at drawing blood again but, as promised, I failed in new ways. So, that's a plus.

Quote of the Day: Woman explaining why her daughter's obstetrics records were only partially in our system: "She moved to New York to make a better life for herself... from Pennsylvania."

TIL: Herpes gestationis is a antenatal auto-immune condition that has nothing to do with the herpes virus.

WILTIMS #368: ♪♫ In the middle of the night... ♫♪

My body is so confused right now. After years of being a solidly night person, I finally converted back to a happily early morning person - getting up at 4am for a couple weeks will do that to you. But now I need to revert back for just one week to ultra-night person. My supposed-to-be-24-hour shift failed miserably at disrupting my schedule, with me falling asleep on the couch at around midnight. Yesterday, I managed to make it to 4am, but only by going out and doing errands at midnight.

Tonight was actually fairly eventful. I helped deliver a baby! ...if by help, you mean stood awkwardly behind the resident. Afterwards, I actually helped deliver the placenta and acted as assistant during the quick repair of some tears that formed during delivery.

When we started the night, we had two women in labor and divided them up between the other night med student and myself. Since I was the OB novice, the other student gallantly ceded the furthest along of the two to me. Of course, the other patient quickly overtook mine and delivered. Then a new admission came, that I took just to increase my chances. By 3am, neither of my patients had delivered. I was losing hope.

Then at 03:30, a woman comes in fully dilated and in active labor. By 04:00 she had already delivered and was mostly sewn back up.

TIL: There's a handy-dandy circular chart in the OB triage area for calculating any obstetrical date from any other known obstetrical date. (see above)

The biophysical profile (BPP) is a test that can be done toward the end of a pregnancy to assess the health of the fetus. Similar to the Apgar score given to newborns, there are five parts of the exam that can each be scaled from 0-2 for totals from 0-10. Unlike Apgar scores, the BPP categories are all or nothing, so you can only have even numbered values. The five categories and criteria are below.

Score	2 (good)	0 (bad)
Reactive fetal heart rate	≥2 accelerations of 15 bpm lasting ≥15 secs in 20 mins	<2
Fetal breathing movements	≥1 episode of  30 secs in 30 mins	No episodes
Gross body movements	≥3 in 30 mins	<3
Muscle tone	≥1 episode of limb/trunk movement	No movements
Amniotic fluid	≥1 vertical pocket of ≥2 cm by ≥1 cm	Largest pocket <2 cm

Total Score	Interpretation
8*-10	Normal
6*	Repeat within 24 hours or deliver if indicated
0-4	Deliver unless otherwise contraindicated

*If the 6 or 8 includes a 0 for amniotic fluid, then shift down one category

I also learned how to build tables in html (see above).

WILTIMS #367: 24 hour call - Part 2

Continued from Part 1...

13:04 - On my way down from the 16th floor, where our student lounge is, I decided to go to the bathroom. My problem: most of the hospital is closed for the weekend. I knew I couldn't get to the one bathroom on the 16th floor so I tried the 15th. No luck there; the normal one was locked and the weird secret one I found the other week was missing the trashcan that propped the door open. So I tried the 14th floor, which turns out to house the dialysis center. I was briefly excited, given that dialysis is a nearly daily medical necessity, but it seems that even that unit has scheduled Sundays off. Bathrooms locked. I finally found a place to pee in the second bathroom down the hall of the pulmonary function clinic.

It's crazy how empty this hospital is. The main bank of five elevators is normally a nightmare to snag a ride on. This afternoon, all five elevators were empty and awaiting passengers on the first floor.

14:50 - As I sink further into the abyss of boredom, I find myself pondering that it's interesting to be in one of the few fields where you are paid to wait for something to happen. Police, firefighters, EMTs, and certain types of doctors all fall into this category. Even when there's nothing going on, you need those people to be waiting. I'm not sure why you need me waiting...

At 14:00, the next resident came on board, so we did a brief sign-out again. Not much to report. The oncoming resident is in mourning because of the Michigan football game yesterday. Adding to her pain is that she "stayed up" to 5pm to watch it. Hospital schedules are weird.

To be continued...

WILTIMS #367: 24 hour call - Part 1

Today is my first 24 hour call shift and, since [knock on wood] things aren't very busy yet, I thought I'd try to multiple updates throughout the day. Though, if things continue to be this subdued [knocks again], it is likely to be a good deal less than 24 hours until someone sends me home out of pity [knocking intensifies].

05:07 - Apparently, even The City That Never Sleeps nods off at 5am on a Sunday. I never thought I'd see an empty subway car; usually there is at least a homeless person napping in the corner.

07:30 - After arriving at six, the day residents and I got report from the overnight resident. Only one woman is in L&D right now. She's still a few months preterm, but her preeclampsia (high blood pressure and usually kidney dysfunction) and past medical history have led to her being admitted under observation. There was talk overnight of doing a c-section on her today, but the residents are doubtful and are waiting for the attending to arrive to see his opinion.

The intern (1st-year resident) and I then went and did rounds on the maternity ward patients. Nothing out of the ordinary; some aches and pains, but mostly irritation at us for waking them up. It was nice to see the tiny newborns again after doing newborn nursery last month on Peds. There's always two types of doctors working on maternity wards, pediatricians and obstetricians. It's weird to now be on the latter service, where the mom is my primary concern.

One of the women needed staples removed from her c-section incision, so we grabbed some medical staple removers and popped those out. The resident showed me how to do it on the first few and then I took over. As usual, if they are letting me do something, it's because a well trained monkey could do it, but it was still cool to get to do something.

11:00 - The attending finally arrived at about 08:30 and agreed that the woman in L&D didn't need a cesarean today, unless something changes for the worse. We'll keep her overnight to make sure though. The attending was excited that the low patient count would mean he gets to watch some football later, but he warned that, since it was slow yesterday too, it was bound to pick-up today.

The peds/NICU team came down to do joint morning rounds on the L&D patient. Everyone needs to be ready in case our one patient becomes two. But that's not likely today, so it was a very quick meeting.

After just hanging out with the doctors and midwife for a while, I was given the super-exciting task of walking some discharge paperwork over to the maternity ward. After that, I studied for a while and was asked repeatedly if I wanted to take a breakfast/coffee/lunch break. I eventually gave in, muched on my lunch and started writing this.

To be continued...

WILTIMS #366: The calm before the storm

Friday was another pretty mellow day in clinic. We saw a few patients of OB check-ups and I got to take a history on one new admission. That was a lesson in discretion. The patient had a complicated past OB/GYN history including elective abortions and STIs. Normally, we want to get a good idea about what happened with either of those situations, even if it's not terribly relevant to the case. But this woman came in with her five year old son for her first prenatal visit, so, as we already knew a little about her history and it wasn't pertinent to ask about more about these things for her current visit, we just didn't bring them up. Of course, if we had any reason to think that the extra information is important, then we would have had the boy step into another room.

Sunday is my first 24 hour shift of med school kicking off a week of night shifts. Hopefully, I'll have just enough going on to both keep me awake and give me something to write about, but enough downtime to stay sane and maybe even write. See you on the other side!

FridayIL: If a patient is too obese to use a normal Doppler fetal heart rate monitor, then you can do a quick sonogram to physically see the heart beating. This has the side benefit of letting the soon-to-be mother get an extra peak at her baby, which she usually really enjoys.

Some medications are named for the frequency with which they are given. Examples are Lasix (lasts six hours) and Macrobid (BID dosing (twice daily)).

WILTIMS #364: Hanging with the big boss

Today was my first day on clinic and... not much happened. For some reason, there just weren't many patients, so we spent most of our time hanging out with the clerkship director and talking about life, med school, and administration drama. Not a bad day, overall.

TIL: A nabothian cyst is a benign, mucous-filled cyst that grows on the cervix. As a medical provider, you get nervous whenever you see something on a cervix that it might be cancerous. One simple way of determining that the cyst is not a tumor during your physical exam is to visualize it using a speculum and look at the blood vessels. The blood vessels should look normal if it's a cyst, whereas tumor vasculature often shows strange patterns like blood vessels coming straight out towards the skin or crossing each other or branching at acute angles. A pelvic sonogram is usually pretty conclusive, showing that the mass is fluid-filled and not solid.

WILTIMS #362-3: An OB and clinic preview

Yesterday was just a half-day and there were no scheduled procedures for the GYN team. So instead of leaving us to wallow in our boredom for the afternoon, the residents invited us over to the hospital's gyn clinic to shadow them. This is what I'll be doing every day next week, so I was excited for the preview.

Turns out gyn clinic (at least at this hospital) is not really my thing. A lot, but not all, of the problem is the language barrier. Normally, the best part of a clinic setting is getting to talk and connect with the patient. That connection is pretty tenuous through a phone interpreter. And as a shadowing medical student, I'm not even on the interpreter phone, but watching the resident and patient talk on a phone to each other after long pauses for translation. It's like doing a video chat with a terrible internet connection; some communication is happening, but most of your energy is being put towards the technical difficulties and no one is having a pleasant time.

I also just find it boring focussing on one area of the body. This is good to find out! A big part of third year is finding out which side of several dichotomies to fall on. Surgery or medicine? General or specialty? One body part or many? Young or old? Hospital or outpatient? Big city or little? So, my question right now is, do I dislike all specialized fields or just this one?

Today, I had my first OB experience. A nurse turned around as we were waiting for the GYN team and asked, "Can one of you med students do something for me?" I then comically looked around to see if any of the OB students were somehow hiding in the cabinet behind me.

"Sure?!" I said, with nervous enthusiasm.

"Go back into Room 1 and get the birth time, placenta time and birth weight."

"Uh... ok!" I said, having no clue where Room 1 was or who I was supposed to ask for this information.

It all worked out; I found the room and the nurse gave me the only information that she had (the birth time). It still amazes me how often med students are thrown into situations they are totally unprepared for. Nearly every week you are in a new place with new people treating patients with new problems. I think the whole process must be just trying to get us comfortable with feeling uncomfortable.

ThursdayIL: The best emergency contraceptive, commonly known as the "morning after pill," isn't actually a pill. There are pills that would work, but the most effective form is actually a copper IUD (intrauterine device).

FridayIL: If a woman is producing milk but doesn't want to, for instance her baby died shortly after birth, then wearing a tight bra, using ice packs, and controlling pain with NSAIDs will help stop the milk production. The worst thing she could do is empty the breast by pumping milk. This would alleviate the pain and fullness, but it completes the body's feedback loop and will continue milk production as long as you keep emptying.

WILTIMS #361: Hold this, exactly like this, and don't move. Ever.

Today was the first time I've ever gotten to scrub in for an OR case! And I didn't screw up too often! For those not in the know, in an OR there are two broad groups of people: those that are scrubbed in and those that are not. The scrubbed people are extensively washed, gowned and double gloved so that they are sterile and may be involved in the procedure. The unscrubbed people are just wearing a mask and aren't allowed within a foot or two of anything sterile (which is most of the room). The unscrubbed are like wallflowers; they lurk on the edges of the room watching the cool people in the middle and wishing they were invited to dance... er... tie a suture?

Today I scrubbed in on a laparotomy (exploratory abdominal surgery) and even go to hold a retractor (twice!). It's amazing how many obscure muscles you can exhaust by holding a glorified spatula for ten minutes. I also cut fancy string with a scissors. Woot!

Something I found interesting was that the scrubbed-in folk must either hold their hands to their torso (which is sterile) or they can rest their arms on the sterile dressing covering the patient. There's something reassuring about the latter because you're not just resting your arms, but you're touching the sleeping patient (through many layers of bedding and dressings). Even though s/he can't feel you due to the anesthesia, it's tempting not to pat his/her leg and say "There, there; we're taking good care of you."

The other exciting happening was that the anesthesia suddenly wore off a smidge too early and the patient started waking up just as we were finishing sewing her up. I go to hold her kicking legs as the anesthesiologist gave her something to calm her back down while we finished up. She wasn't really awake and won't remember any of it, but it was still freaky for everyone involved.

TIL: I apparently need size 8 gloves, not 7½.

When they tell you to go back to back when switching spots around the operating table, it's more normal to turn in the direction you want to go, side step behind the person you're leap frogging, and then turn back facing the same direction. If you twirl in a full 360 like a square-dancing weirdo you get laughed at.

Endometrial biopsy (scraping off a bit of the uterine lining) is only useful for diagnosing simple endometrial hyperplasia (abnormal growth of the uterine lining) if you know when the patient's last period was. This is pretty intuitive. The uterine lining grows throughout the menstrual cycle and sheds with the menses. So if you do a biopsy and it shows a thick endometrium, that could be totally normal towards the end of the cycle, but very abnormal immediately post-menstrual.

When the recommendation is to schedule a repeat test every 3-6 months, it is wise to interpret that as every 3-4 months just so that if something comes up and the test is postponed, there is still a chance that it will happen within the 6 month window.

Uterine fibroids require estrogen to grow and thus should either stop growing or even shrink after menopause. If a postmenopausal woman with a history of fibroids has new onset pain or bleeding, do not write it off as being caused by the fibroids, as that is unlikely given their postmenopausal behavior and you risk missing a far more dangerous diagnosis like cancer.

WILTIMS #359: Modern midwifery

Today was another didactic day, so we had a session on knot tying and suturing (action shot to the right!), then we had a lecture on ovarian cancer and another on midwifery, before finally having a patient panel on being diagnosed with pelvic cancers.

Midwifery has always confused me as a modern profession. I think, like most people in the US, I first heard of midwives in history class. When I began hearing of them in the present tense it confused me must as it would if someone said they were waiting for the milkman or ordering an ice block from the iceman. To my naive mind, all of these professions had become obsolete either due to safer practices or the decline of the extremely rural environment.

But midwifery has had a resurgence. After being pervasive from ancient times up to the 1800s, the practice of the midwife was ridiculed by modern medicine as being a lay-practice and not based on science, often very true claims. But in the second half of the 20th century, midwifery made a comeback. Now with proper training, midwives make a really nice addition to the obstetrics team. Contrary to popular stereotypes, 94% of midwife-supervised births take place in hospitals, not at home. Generally midwives take low risk births where the close supervision of a full obstetrician simply isn't needed. If anything goes wrong, the patient is already in a hospital and the midwife just calls one of the on-call doctors for backup.

TIL: Ephraim McDowell, a physician in Danville, KY, performed the first successful elective laparotomy (opening the abdomen to peek around and cut out any bad stuff) in 1809. That's just insane. 1809! That's before antibiotics, before anesthesia, even before aseptic surgical technique. Our lecturer today pointed out that we've done laparotomies since ancient times. If someone was dying of a giant tumor in the abdomen, it was really easy to see where the problem is. But until this random Kentucky surgeon, every patient every operated on in this way died.

"Midwife" is not actually a gendered word. It comes from the old English word for being "with the wife." Around 5% of midwives are actually men.

WILTIMS #358: Meh... But seriously, don't bend over

Yesterday was rough for all the wrong reasons. Woke up with the telltale prodrome of a head cold. Missed my 4:57 subway train because it briefly didn't exist. Missed my 5:11 subway train because I got a new credit card number three months ago. Had to beg to get on the crosstown bus because my MTA card hadn't yet realized that it now had money on it. Got to the hospital nearly on time and then tore my shoelace in half while changing into scrubs.

Then things really heated up! I spent the next couple hours standing awkwardly behind colleagues who can actually speak spanish and taking notes on what I guessed the patient might have said. Then I got to observe a procedure for the removal a polyp that turned out not to exist. Lunchbreak. Slept through a half hour of computer training. Killed an hour in the student lounge, updating my patient log and confirming that the hurricane forecast to hit us was in fact going to miss our continent. Then I doodled my way through a two hour HIPAA privacy training that was admittedly slightly entertaining. Finally, we all met back up in the labor and delivery conference room for a lesson on abnormal uterine bleeding... but the resident who was going to teach us has to run out to the clinic. About a half hour later we got a text saying we can go home.

I'm not sharing all of this to be a downer (but I'm sick and it's cold and rainy outside, so it did fit my mental state as well as this mug of hot chocolate fits in my hands [slurp]). I just wanted to share one solidly meh day. Sometimes I feel like, by only sharing all the dramatic and interesting things in med school, I am overselling it a bit. A lot of medicine is actually spectacularly boring, even ignoring med school classes like biochemistry or pharmacology. While on the inpatient service in pediatrics, I spent hours writing up notes and only 5-10 minutes a day talking with my patients.

But when it is cool, it's super cool. It just wasn't today. [shrug]

YesterdayIL: Never, ever bend down to place something in the trash in the OR. Doesn't matter if the item is a dripping piece of trash soaked in every possible bodily fluid. Drop it in the vague vicinity of a biohazard trash can. If you miss, then you miss. No biggie.

WILTIMS #357: Factoid overload!

Today was a didactic day up at our school, so I am lacking in stimulating clinical stories. But I have oodles of facts! To keep you company through the onslaught of knowledge, to the right is my classmate Caitlin successfully delivering a fake baby from a fake pelvis in our school's simulation center. Enjoy!

TIL: Pulmonary hypertension is one of the only absolute contraindications to pregnancy. There are many things that increase the risk of danger to the fetus and/or pregnant woman, but if the mother is willing to take those risks, then we are generally willing to help her through the process. But pulmonary hypertension, where the blood vessels of the lungs start down a feedback loop of constriction and loss of flow, is all but certain to kill the mother of she tries to bring the fetus to term.

35 years old is the age that we consider "advanced maternal age" because it is the year that research has shown that the risk of chromosomal abnormalities like Down's syndrome start to equal the risks from the tests like amniocentesis that we can use to test for chromosomal abnormalities.

Unlike women who develop gestational diabetes partway through their pregnancy, women who already had diabetes before being pregnant have a risk of their baby having birth defects as well as the normal complications from uncontrolled diabetes late in development. Somewhat intuitively, this is because the high blood sugar must be present during the developmentally crucial first trimester to actually cause birth defects and gestational diabetes usually begins long after that.

VDAC and TOLAC stand for vaginal delivery after cesarean and trial of labor after cesarean respectively.

The chance of uterine rupture is prohibitively high at 7-10% during VDAC if the prior cesarean was done via a vertical incision, but only 0.7% if the incision was horizontal. This accounts for part of why few VDACs where traditionally attempted - because vertical incisions used to be the norm. But the far less damaging horizontal incision has been the standard for a while now, and research has shown that VDACs can actually be quite safe in these patients.

When the first movements of the baby are felt by the mother it's called "the quickening." This may seem like a weird term for that phenomenon, but actually that usage is far older than our current meaning of the word quicken. Instead of meaning "to go faster," to quicken" meant "to come alive." Thus "the quickening" was the time when you could tell that the baby was alive in utero.

One of the tests that can be done toward the end of a pregnancy to check fetal health is called a non-stress test. This test looks at the fetal heart rate which, rather counterintuitively, we don't want to be stable. Unstable in certain ways would be bad too, but the ideal situation is for the fetal heart rate to spike upward by ~15 beats per minute for 15 seconds every minute or so. If the heartbeat is too calm or it drops downward, that is a bad sign.

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.