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 #360: Strike two!

I'm turning into a jinx for polypectomies. That's now two dilation and curettage procedures in a row where we were expecting to find and remove polyp based on prior imaging, but both times once we got in there, there was nothing to be found. In a way that seems nice for the patient, because we didn't find anything wrong. But at the same time, the patients were still symptomatic and now our presumptive cause vanished, leaving us looking for other answers. Ah well.

TIL: It takes about half an hour to walk/jog the M96 bus' route from Broadway to my hospital. Also, predawn bicycle gangs are kinda creepy. Silently their LED headlights appear over a hill along the Central Park loop and they dart past you, disappearing around the next bend in the road as suddenly and silently as they appeared.

Singultus is the medical jargon word for a hiccup.

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.