(Another) Day in the Life
When I posted my last "Day in the Life" post, I had at least 1 or 2 requests for a post about a day on clinical rotation. So, I picked yesterday/today, a call day. Here it goes.
6:45am: Wake up. No exercise today because I'm on call, so I planned to sleep in. Pat my back for not hitting the snooze button.
7:00am: Shower. I love showers. They're my favorite, next to baths.
7:30am (long shower): Rush out. Running Late.
8:15am: Arrive at work, 15 minutes late. Go to teaching conference for residents. Realize the residents aren't there. Go to office to check email and stuff.
9:00am: Wander down to ultrasound, my rotation for the month. Say hi to J, ultrasound secretary.
9:30am: Scan patient... routine anatomy scan. Baby is in such a weird position that I can't find the head. I felt fairly confident the baby has a head, I just couldn't see it well on ultrasound. Find sonographer... have patient walk around, empty bladder. Baby then is in a better position to scan, still can't complete the anatomy, but at least confirmed the presence of a head and brain.
10:00am: Perform genetic amniocentesis.
10:30am: Scan another patient. This time, it's a routine viability scan (early pregnancy scan used to establish that the pregnancy is still alive, often done for patients with bleeding, histories of multiple miscarriages or ectopic pregnancies)
1045am: Chat with attending of the day.
11:00am: Chat with sonographers.
11:30am: Wander down to labor and delivery to cause trouble. Decide they have enough trouble on their own. Seriously, I was trying to figure out how the call night was going to go.
12:00pm: Lunch. Chicken salad from the deli downstairs. I am so in love with their chicken salad.
1:00pm: Back to ultrasound. I'm covering for the attending now.
1:15pm: Counsel patient about an echogenic intracardiac focus (a bright spot in the heart that with an otherwise normal pregnancy changes this patient's risk of Downs Syndrome from 1/1000 to about 1/500. It's really difficult to explain risk to patients.)
1:20pm: Slow afternoon in ultrasound. Hunker down at desk to work on growth restriction paper. Still working on the literature review.
2:00pm: Assist with intracardiac KCL injection to end a specific kind of ectopic pregnancy that, if the patient had surgery for it, would likely lead to a hysterectomy, and the patient desires future fertility.
3:00pm: Another anatomy scan. Diagnose another EIF, and counsel patient about it. Again, it's very difficult for our patients to understand risk.
3:30pm: Another amniocentesis.
4:30pm: Ultrasound day is done, but my day has just begun. Sneak up to office for nap, and wonder how lazy that makes me.
5:30pm: On call responsibilities start. Discuss the patients with attending from the daytime.
6:00pm: Check in with the chief resident who runs the maternal special care unit (kind of like an ICU for pregnant women.). Realize that they're some really sick patients tonight, including a patient with periodic runs of ventricular tachycardia (kind of a bad arrythmia) and a patient with a pulmonary embolus (big blood clot in her lung), post partum cardiomyopathy (a kind of heart failure people can get from being pregnant) and Sheehan's syndrome (when the pituitary gland in the brain basically dies because of low blood pressure and bad perfusion, it causes failure of most of the important endocrine hormones).
7:00pm: Get called stat to a patient's room. The patient has a bleeding previa, and just lost >1 Liter of blood, and is continuing to actively bleed. Decide she needs to be delivered before she and the baby decompensate. Move to emergency C-section. The thing about previas is that in patients with previous c-sections (like this one) they put the patient at a high risk of uncontrollable hemorrhage and needing to have a hysterectomy. Fortunately, this patient didn't have any problems and didn't need a hysterectomy. The baby was 34 weeks, had to be intubated and transfused in the neonatal intensive care unit (NICU).
8:00pm: The residents sign out to the oncoming resident team. I try to teach them.
9:00pm: I wander around meeting all of the patients in the maternal special care unit and documenting the plan for the night, and discussing the plan with the chief resident.
10:00pm: Maternal-Fetal medicine consult on a woman with a short cervix at 23 weeks, which puts her at a nearly 40% risk of delivering in the next 14 days. When born at 23 weeks, very few babies survive and the survivors have severe handicaps. When born at 24 weeks, 25% of the babies survive and 33% have severe handicaps. After that point, the survival increases daily, but the risk of handicaps doesn't improve until 28 weeks.
11:00pm: Wander around L&D meeting patients and documenting the plan of care.
**WEDNESDAY ENDS THURSDAY BEGINS***
12:00am: Pull residents aside for a little teaching session on the care of asthma during pregnancy (since we admitted a woman with a severe asthma exacerbation)
1:00am: Ran into attending. Chat about patients.
1:30am: Run down to Wendy's for dinner. Run into the gynecology team (for whom I'm also responsible) and discuss the care of a gyn-onc patient. I have gone out of my way to be approachable to the residents. The good part of this is that they rarely lie to me when they mess up. The bad part is that they would rather discuss things with me than with their actual attendings (the one covering gyn-oncology) because they know I'll teach them without yelling at them. Or maybe that's also the good part.
2:00am: Long line. Eat dinner. Sit down for the first time since the nap at 4:30pm.
230am: Talk to a doc from some hospital in Canada who wants to transfer a patient. Rapidly realize that the doc cares much more about getting back to his bed than taking care of the patient, and then accept the patient despite the fact that our hospital doesn't really represent a higher level of care. It's just that someone has to take care of the patient who will care enough to get out of bed at 3am to figure out what's going on and take care of her. (A separate post will be coming)
3:00am: Patient with twins arrives in labor. Teach resident how to counsel patients with twins about labor versus cesarean section. Patient decides for a vaginal delivery with a breech extraction. YAY!
3:30am: Lie down in call room. I'm starting to get the post call jitters... that anxious weird feeling I get when I'm post call that I think is related to exhaustion.
5:00am: Resident from labor and delivery calls. She needs help with the Canadian patient.
5:05am: Wander out of call room, talk to resident about Canadian patient, examine her. Realize that she's 25 weeks and has had her water broken since 18 weeks and now has an infection around her baby. Call neonatology fellow over to discuss the situation with the patient.
5:30am: Revisiting the Canadian patient. Discuss with her the options, including the option for non-intervention for fetal distress, because the prognosis for this baby is so poor. Patient wants everything done, including a c-section for delivery because the baby's breech. Because there's an infection around the baby, the baby has to be delivered reasonably quickly (within hours) or it will get infected (if it isn't already) and it's prognosis will be worse.
6:00am: The twins are delivering! Vertex breech twins. Deliver first twin, the resident is unable to do the breech extraction, and so I do it, but I'm almost unable to do it. Seconds seem like hours when you're trying to deliver the baby, and it is so hard to push the panic away so I can concentrate and get the baby out. The baby had a nuchal arm and it was difficult to reduce. The time to delivery was only 2 minutes, and the baby was a little stunned at first, but did really well. No injury to the arm, which is good, because I thought I might have broken the clavicles.
6:30am: Canadian patient moves to the OR for a c-section. The spinal was complicated, and took a little while.
7:00am: Actually get to start the c-section, baby born at 7:10.
7:25am: Realize I'm supposed to be at Random Community Hospital (RCH) at 7:30 to teach their residents. The residents are doing a great job on the c-section, and I'm really just day dreaming anyway, so I scrub out and briefly sign out to the day-attending.
7:45am: Arrive at RCH 15 minutes late and apologetic. Teach the residents for an hour.
8:45am: Drive back to Massive Academic Hospital (MAH).
9:00am: Go up to labor and delivery.
9:15am: Go to NICU and realize that the baby from the c-section is going to die. I really hate doing c-sections for babies that die. Stand by the baby's bedside and watch the NICU team fight the inevitable.
9:45am: Wander back to check on c-section mom. She's still too out of it to talk. Arrange for her to go to a room separate from the postpartum floor.
10:15am: Realize I'm running late to ultrasound. I take a quick shower.
1030am: Go to ultrasound. Counsel some patients about abruptions, vaginal bleeding and those EIFs from before.
12:00pm: 3-d ultrasound clinic. Do 3-d scans of patients for 1 hour.
1:00pm: Ultrasound patients start again.
1:30pm: Realize that my feet really hurt. And I'm suddenly starving. Decide to step out for lunch. On leaving, I realied they probably didn't need me for the afternoon, so I stopped by a little cafe type place for a sandwich and headed home.
2:00pm: Ate sandwich and watched tivo'd shows.
3:00pm: Decided to take a nap. I told myself it was just going to be for 2 hours, and set my alarm for 5pm.
7:00pm: Got up. I have some work I need to do, but sometimes being exhausted makes me feel ill, which is how I feel right now. I think I'll put the stuff off until another day.
It's now a little after 8pm. I think I'm going to feed the cats and try to go back to bed. I'm on call again tomorrow, and tomorrow will likely look like yesterday. I'm also on call again on Sunday.
Whatever doesn't kill you, right?
posted by Midwife with a Knife @ 6/21/2007 07:34:00 PM
20 comments
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20 Comments:
Wow! What a schedule. Thanks for sharing this...
Much better than my day.
0550: Drag ass out of bed
0700: Sign out from night team. Only one new kid on service.
0730: Done seeing all three patients I have.
0800: Need. Coffee. Stat.
0900-1200: Talk with attendings, teach students, yadda yadda yadda.
1200-1245: Lunch. More caffeine.
1300-1630: Continuity clinic (made up when I missed Tuesday's when I was post call).
1700: Get home, change, water lawn.
1745: Head out to newbie intern picnic.
1800: Realize I'm lost. Call friend who doesn't answer.
1815-2000: Find my way on my own, eat hot dogs, drink beer, and play with babies (all my fellow residents/attendings brought their kids and it was grand).
2000-2130: Get treated to ice cream by program director (post-picnic tradition).
2150: Get home, do dishes, make lunch.
As soon as I'm done typing this: bed, for I am on call tomorrow (my last 24 hours of intern-ness!!!! I have a week off and then I start July 2 as a PL-2 on night float for two weeks. Hooray!)
Though that sounded incredibly busy (which it was), it also sounded so interesting to me! It really makes me excited to work with people. Sure I have two years before clinical, but what you did sounds so interesting and you are obviously really good at what you do. You are a fine online example :)
Is this a typical shift? I am guessing it can be even busier.
The MAH here told me they no longer consider the intracardiac focus to be a strong indicator.
What is it about risk that people have trouble understanding? Or is it just that they are not happy with you not being able to tell them the baby is fine?
whoa... that was enlightening... umm if I may be so bold, what was a fellow Canuck doing getting transferred to your side of the boarder? I'm going to assume that she was visiting/living in your country when everything went to hell in a handbasket? Because I have yet to see anyone head South to deliver a baby in a hospital (midwives, just over the boarder doing hotel births for vbac mama's yes... hospital no)
Just curious... one Canadian thinking of another... and feeling sad that she has to recover from surgery and grieve at the same time... heartbreaking... have friend who is doing that at the moment. Crash sections don't always have a happy outcome =(
Wow, that sounds like a really tough day. Pat on the back for making sure the C-section woman gets a room in a different area. That sounds important, but I bet it gets missed.
Wow, what a day+. Who are all these people in line at Wendy's at 2am?
Fascinating - thanks for posting that.
Wow, sounds like fun. Maybe its time for a new profession. I hope that baby whose head you finally found in the scan, has all its other parts. Keep wandering.
You say it is hard for your patients to understand risk. Do you mean your patients specifically, or patients in general? Why do you think that is? It isn't so complicated a concept and I don't feel like my clients have particular problems understanding risk when I explain it to them (but I am not in the obstetrics or human medical field).
Wow, what a crazy day!
Dr. A: My schedule is particularly crazy this week!
doctor bee: Heh! Your day sounds better to me!
aggie: Thank you. I don't know how good I am at what I do, but I generally really enjoy what I do, and I usually feel lucky to have the kind of job that I do. :)
lisa b: The echogenic intracardiac focus is what's called a "soft sign", meaning that it can increase your risk for Down's Syndrome a little bit. 20% of T21 babies have an EIF, and 1% of normal babies have an EIF. So, when it's isolated, it's not something we'd suggest an amnio for or anything, but if it's combined with other things, it can be a little concerning. People used to think that EIFs increase your risk for heart defects, but that doesn't seem to be true.
anon: It's a long story, I'll write a longer post on it, but basically, we're on the border with Canada, so we're probably the nearest tertiary care hospital.
bardiac: I don't know if it gets missed. I do think it's important to not make women who have just lost their babies stay on the postpartum floor and hear everybody else's babies.
brewgal: Mostly people who work in the hospital.
magpie: my pleasure.
echo: Yeah, the baby was a normal baby in a very inconvenient position.
webhill: I think it's hard because when you're talking about something like, "Your baby may die." or "Your baby may have [insert random horrible birth defect]"; I think that that's so scary for people that even when it's just a 1/500 chance or a 1/100 chance, it makes it too hard for people to translate an abstract risk into something that they can use to make a decision. Also, many patients ask me, "So, are you saying my baby has Down Syndrome?" after I explain that their risk for Down Syndrome has gone from 1/1000 to 1/100. Part of it may be that my patients tend to be undereducated.
Yay for delivering twins vaginally. I had twins (after two vaginal deliveries). I did my best to find an ob-gyn who would try to deliver vaginally. We ended up with a planned c-section because the presenting twin was breech (as it was explained to me) which made it dangerous to have a vaginal delivery.
I always wondered if that were so, but I'll never know for sure. I did end up with two healthy 7 lb babies so thats what matters most.
This the first time I have every heard of somebody else having post partum cardiomyopathy. I am a twice survivor of it. All the info I can find usually focuses on peri partum cardiomyopathy.
How is the lady doing? I feel for her. I'd love to hear updates on her progress if you can give them.
Your blog is great. Tuesday's conversation with yourself sounds like the conversations I have every morning too!
Have a wonderful week.
Girls Galore
I should have mentioned it was the cardiologist who did the fetal echo who said they don't worry anymore but the Dr who does the ultrasounds (no idea what his actual field is - he only does ultrasounds. The geneticist told me he was an ultrasonographer) was very worried about it because of my daughters short femurs and large head. He found her ventriculomegaly and sent me for a fetal MRI. The neurologist was not concerned about her brain structure, even after she did an MRI when she was four weeks old. The high risk OB and Neonatologist I met were both relatively unconcered with the ultrasound findings.
Turns out my daughter has a rare genetic growth disorder so the ultrasonographer was right. There was something "wrong" but it took until she was five weeks old for genetics to figure out what it was.
I'm not sure how much education plays a role in the decision making regarding risk.
Knowing that I could have no signs and end up with a baby with any number of problems I could not terminate a baby with a "soft" sign?
I think it is difficult to make these decisions. I think someone with less education might not understand why you cannot tell them for sure if there is something wrong but understanding that really didn't help me in my decision making.
In fact, much of the time I feel like having less education, and just believing whatever a Dr told me would make my life easier.
srr: we don't usually deliver twins vagainally when the first one's breech because we worry about breech deliveries in general, and if the second twin is vertex,the heads can lock, and that's a really bad problem.
girls: peripartum cardiomyopathy is probably the same as postpartum cardiomyopathy (in terms of the cause of it). My patient who had it is doing well and went home several days ago! :) I'm glad you like the blog.
lisa b: Ah! It's a method of different perspectives. They used to think that EIFs were markers for congenital heart disease, although that doesn't seem to be true. They are markers of risk for chromosome problems, but really only soft signs. I'm sorry your daughter has problems, but it just kinda goes to show you that there's so much we can't diagnose on ultrasound.
I don't know what the deal with risk is. i'm not sure it's completely an education issue, although it certainly is at least partly that. Just out of curiosity, was there anything that did help you in your decision making?
I have been thinking about this a lot.
The decision to do the CVS with an NT of 7.5 was an easy one for me. My risk of having a baby with a genetic problem was far, far greater than the risk of miscarriage. I was told that many people terminate based on the increased NT alone. I was not willing to do that.
My husband wanted someone to tell him the baby was fine. This is a very different thing from understanding risk (he sells deriviatives for petes sake).
I think you have to ask patients what decisions they are trying to make and what information will help them make that decision. I understand why genetic counselling explains to people what the genes are and how they work and what their risk is but really I think the only question is are you going to continue the pregnancy or not.
I knew there could be something wrong with my baby but I know that babies with no indicators are born with problems. So I could not terminate the pregnancy. I would always have thought the baby would be fine. I don't regret that decision.
After my baby was born the Genetics Fellow came to examine her. I had not met her before. We ended up chatting and she told me she has trouble figuring out what people want from her. I don't think the geneticist thinks about this. He seems to be in butt covering mode all the time. It lead me to distrust his opinion somewhat but I don't think it really affected my overall decision making.
I think you focus on what decision your patients need to make and the information they need to make the decision.
I suspect that what people really want from you is what my husband wanted. You can't give that to them. They have to accept the risks and all possible outcomes of having children.
Perhaps a list of risks in life such as being struck by lightning or run over by a bus would help people put things in perspective?
I also know one of the OBs equates womens risk to their age. As in they are 33 but with the risk of a 45 year old.
Wow, that made me tired just reading it!
mwwak:
THanks for your response to my twins delivery comment. My presenting twin was breech and the other was vertex. My OB said there was a risk of heads locking. It is nice to have verification.
I borrowed your idea without asking. Thanks a lot. Hope you don't mind.
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