Other Things

Although I just returned home from yet another call shift that I could talk about for hours, one that was hard and busy and which, yet again, made me wish I had someone right here who could go over my patients with me to make sure I had made good decisions, to reassure me that those looks I got when I gave my change of shift report were only looks of concentration and not necessarily looks of distrust, disgust or disapproval. Even though I triaged patients for 7 hours straight, even though I sent two of them home and know I will be kept up for at least part of the night thinking about how they are doing…even though all this is true, I would like to reserve this particular blog entry for non-OB or midwifery related events.

First, my car was the victim of a middle of the night hit and run operation two nights ago. And I just have to say, with everything else going on in my life, professionally, personally, emotionally, it was a little more than I could handle. It had been one of those nights where I woke up every hour on the hour. And then, at 5am, I heard a screech and a crush and I heard a car alarm go off. “That couldn’t be mine.” I thought to myself. But my gut was telling me something else. “Of course it’s yours. It’s yours for sure. It sounds just like your alarm. And it sounds like it’s coming from right where you parked your car.” It said.

“Go back to sleep” My head said. “You have a busy day at clinic tomorrow.”

“Get up and check on your car.” My gut said. “If you at least know for sure it was your car you can start thinking about how to deal with it instead of lying in bed dreading what the car looks like.”

Well, I did get up. I looked out the window, I tried to see my car but couldn’t. And even though I crawled back into bed, I never fell back to sleep. I spent the next two hours trying to convince myself that it was possible that that crushing sound was not the metal on my car but, perhaps, someone else’s. But when I finally walked outside, it was clear. No one else had been hit but me. The front of the car looked ok. The driver’s side looked ok, even the back looked ok. I was starting to think that maybe it really wasn’t my car’s alarm that had gone off! Miracles really do happen! But as I edged around the passenger side I saw the damage. Both doors on that side had been bashed in, scraped. The part of the car over the back tire was smashed up and the door looked like it wasn’t closed completely. Was there a note? A message from someone saying, “Hey, I hit you. I’m so sorry. Let me handle all the payment/repair etc. Just give me a call. I am so so sorry.” Of course not. No note. Just some black paint left on the front of the right side of the car. Thank you. Thank you very much.

My heart and my gut and my entire body sank when I saw my car. I knew it was repairable but having to deal with the logistics of getting all the repairs done, reporting the damage to my insurance company, having to be without a car while the repairs are being done…can’t we just rewind to last night and I can promise to park on the OTHER side of the street so my car would have been unscathed this morning when I walked out to head to work? It’s times like these you can easily convince yourself that the universe is against you. And for me, it’s times like these I like to seek reassurance from mom and dad. I don’t know why. I just needed to feel sorry for myself and I felt like they, more than anyone else in the world, would just be there for me. And they were, thank god. My mom was an emotional rock. My father was a logistical hero.

“It’s going to be okay.” My mom said. “These things happen, and you can’t turn back the clock. And you will just deal with it. You will. One step at a time.”

“What’s the number of your insurance company?” My dad said. “Email that to me and also whatever kind of claim number you got from your insurance company when you reported it this morning.”

So I did. And by 10am, he had saved the day. Told me where to take my car after work, told me the name of the guy at the repair shop who he spoke with and who was expecting my call to set up an arrival time, told me who to talk to from my insurance company and what to tell them about my plans for which auto body shop I would be using for repairs. Could I have done all that on my own? Of course. Did it feel like my father, in that moment, was saving my life and my emotional sanity a little bit? No question about it. Yes.

And I had to laugh when both of my parents, during separate phone conversations that morning, offered their philosophy/advice on the situation. What each of them chose to focus on was so different from the other and it is so clear to me that I am an almost equal combination of both of their brains.

“It was probably someone high on drugs.” My mom said. Not a “drunk driver”. Not someone who may have lost control of the car for a moment. But someone “high on drugs” she thought.

My dad, on the other hand, says to me, “It’s not a problem if you can solve it with money.” And honestly, it sort of left me speechless. This statement is so utterly and completely true for my father. He really does live this philosophy. And, if you have the money, thinking about a problem this way really does take some of the pressure off. “There are so many other much worse things that could happen.” He said. “Cancer, heartbreak, things you can’t fix. Let’s just get this taken care of.” And it really did make me feel better. About the car anyway.

I brought my car to the repair shop after work (my last patient didn’t even show up so things were looking good) and things went off without a hitch. I got a rental car (that unfortunately smells like vomit) so my weekend plans are still intact. Sadly, they think the work will take at least a week which is amazing to me when my car is still drivable, no airbags were deployed and the damage honestly seems sort of superficial. Nope. It’s gonna cost over 5 freaking thousand dollars. They just called me with the estimate yesterday. I need two new doors, new paint, some new panel on the back of the car…the list goes on. I am so thankful that I recently changed my deductible. More on that as information becomes available.

Okay, the second thing I would like to speak to you about is the recent presidential address. I watched this state of the union sort of speech on tv in the comfort of my own home like many others probably did and will admit to you that, when Bush was president I rarely tuned in to similar events. I would watch for a minute or two and become so embarrassed for him, our country, myself even, that I had to change the channel. I feel like with this new administration I am making a fresh start. I am here and now committing to staying apprised and aware of the presidents opinions and decisions, because finally, I kind of care. What I would like to talk about here though, more importantly, is: did you see Nancy Pelosi???!!! Is she a complete freak or is it just me?? Mark my words, SNL will for sure do a spoof on her activities during Obama’s speech on Saturday night. It was unbelievable. There was so much uping and downing throughout the entire hour speech. Standing up and clapping, sitting down and continuing to clap. Standing up again and clapping harder! And Nancy was leading the whole thing! The crazy thing was she was just staring off into space the whole time but some part of her must have been listening because she would suddenly get emotionally moved and thrust herself out of her chair and clap like a crazy person. And then, I guess, everyone has to follow. She just looked so, so maniacally happy. Obama seemed a little annoyed actually that he couldn’t get two sentences out without her starting a mini parade behind him. And Biden, you could tell, half way through the speech he was exhausted and dumbfounded. You could almost read on his face, oh shit, Obama’s talking about our education system, fuck, he is starting to talk about green energy, that Pelosi is gonna stand up again, and I guess that means I have to also…

If you haven’t seen the address yet, or if you just listened to it on your radio, I urge you to find a clip of it on you tube. Experience my disbelief. And while you at it, answer me this question, that “middle schooler” that was there as the president’s guest? What was up with that dress? Was she in 7^th grade or was she seventy? Whatever the case, something was definitely wrong.

I’m off to a little CNM reunion this weekend. Some of the women I graduated with are headed back to the town in which we went to grad school to eat and chat and vent and share. I’ve been looking forward to this for weeks. The drive, seeing faces I haven’t seen since graduation, change of pace, change of scenery, good food…I’ve, of course, already created a game that I’m hoping to convince everyone to play but, if I get outvoted, I’ll be content to just be there.

I’m already running late.

As my therapist says: To be continued…

Wind

I woke up at least four times last night. Sometimes because I was cold, one time because I had to pee, but a number of times because of the sound of the wind whipping through my back yard, the wind chimes, the trees outside my windows, splashing water against the glass. And each time that wind woke me up I either dreamed or imagined all of my pregnant patients getting whipped around, the wind pushing them over, and my patients struggling to stand up, their bellies emptied by the force of the gusts…Every time I thought or dreamed of them I got anxious and sweaty and mad that I was awake. I’d put my head back down on the pillow hoping to drift back off but I’d just lie there, visions of pregnant women and their babies and this sick feeling inside me. So when my alarm finally went off I felt like I had never gone to sleep. My eyes were swollen, my body was tired and the last thing I wanted to do was head into the office and see patients.

Turns out, the wind had blown in a number of medically and emotionally trying people. A 41 yo at 8.4 wks came in first thing c/o abd cramping and light pink spotting. An US showed she had a 6.1 wk pregnancy with no fetal heartbeat. And here’s me, having only dealt with a handful of missed ABs and knowing that there are options for her: expectant mgt vs miso vs d and c but I’m not sure if there is a practice protocol, I’m not sure what the dosages are of miso if I choose to offer that and there are no docs in the office to ask. It’s annoying more than anything else. The CNM says D and C though I know the doc who I usually bring my questions to sometimes does miso until 8 or 9 weeks…it’s just so hard to know what is RIGHT. I find myself wanting to know things in black and white. Just, tell me what to do. Just tell me yes or no, wrong or right. Tell me the parameters. The protocols. The rules. But in so many cases there is no clear right or wrong, your mgt should depend on the patient’s issues and needs, on which doc is in the office, on so so so many things. And it just makes it so damn hard to learn sometimes. In the end, it was a moot point for this patient. The idea of any sort of expectant management made her shudder. She opted for the simple outpatient procedure and my management became clear. But still, what do I do when it happens again?

One of my teen patients came in for her first OB appt later in the morning. She had seen me last week for her first OB appt but because she was unsure at the time about whether or not she wanted to keep the pregnancy that appt turned into a “what are my options/how do I tell my parents” appt. I thought at the time that there was about a 50/50 chance she’d be back, still pregnant. I kept waiting for her appt to disappear from my roster. Kept waiting to get a phone call saying she had gone to planned parenthood for a TAB and wanted to schedule a f/u appt with me. But no, her name stayed right there. And she showed up right on time for her appt. But before she got there I received a phone call from her mother. She was very clear with me from the beginning that she knew, since her daughter was 18, that she couldn’t get any information from me about her medical care. But she wanted to…well, it honestly sounded like she wanted to warn me about her daughter. She proceeded to tell me that her daughter has significant psych issues, anger issues, run-ins with the law, she called her narcissistic and selfish. She said her younger sister hates her because of how she has acted, she told me she flunked out of college, had been living at home, has had bursts of anger so intense that her mother has had to hide from her in the basement…she asked for resources, she asked if I thought it was a good idea that her daughter have a baby. She told me that she and her husband had made it clear that if she decides to keep the pregnancy she is no longer invited to live under their roof. And I couldn’t say anything. Couldn’t share any information, couldn’t share my opinions about her daughter. Mentioned a few things I typically talk about with pregnant patients who also happen to be teenagers…but our “conversation” was one sided. She was telling me all of the reasons her daughter should not be a mother and I just sat there and listened. And while I listened I was handed a fax from her that she had sent me just before our phone call marked “Urgent” which was a 2 page list of all of the things her daughter has done “wrong” essentially. Things like: Has become accustomed to having parents who ENABLE her bad habits, Repeated episodes of ANGER, Almost FLUNKED out of high school. The list went on and on like this with words that she didn’t want me to miss capitalized and italicized. I read and I listened all at the same time. And I got sick to my stomach. Why WAS this girl having a baby? Why were her parents throwing her out? Why did all the comments on this list sound like name calling? What was I supposed to say to this woman? What was I supposed to say to her daughter when she came to see me? I definitely couldn’t tell her that I had spoken with her mom, and letting her know her mother had sent me a 2 page document convincing me how evil her daughter was would certainly only make the situation worse. I said goodbye to the patient’s mother having only been able to listen and not able to provide her with any reassurance that I could talk her daughter out of staying pregnant.

When I met with the patient she was happy and smiling, confident that she had made the right decision to keep the pregnancy. Her boyfriend, not with her today, was going to be supportive but he won’t tell his parents. She told me that her mother forbid her to stay in the house. She told me that she felt prepared to find a room for rent, that she made enough money working bussing tables at 2 different restaurants to pay for a place. She told me she had been on a bunch of psych meds but didn’t want to be taking them during her pregnancy so, once she found out, just stopped taking them cold turkey. But she was feeling good, she would f/u with her therapist, she was also considering giving the baby up for adoption. She was appropriate, respectful, happy, articulate, forthcoming and, I thought, honest. But this young woman, sitting on the exam table, was literally the exact opposite of the girl her mother had described over the phone and in the fax. Was this part of the act? Was I seeing a side of my patient that her mother couldn’t see? That the pt couldn’t show to her mother? She seemed so together. Young, yes, but together. And then I started her exam. Thyroid palpated nml. All the lymph nodes in her neck, above and bellow her collar bone, nml, non palpable. Her lungs were CTAB. And then I laid my stethoscope on her chest and told her to breathe normally. And there is was. A racing heart. Her pulse must have been in the 80s at rest. And I thought, in that moment, well, here is something real. Whether she is excited, scared, worried, panicked… whatever the emotion, there was something there.

“So, how are you doing with all this?” I asked after the exam.

“Fine.” She said smiling, waiting for the next question and kicking her heels back against the exam table she was sitting on.

“Just fine?” I asked.

“Yeah, I guess. I don’t know. I don’t know.”

At the end of the visit the patient was certain she did not want to give her consent for her mother to speak with me about her pregnancy but she said she would let me know if she changed her mind.

I finished the day with a little abdominal pain at 14 wks, intermittent vaginal itching and a wicker broom-like pattern under the microscope that I had never seen before, and one, yes one, nml return OB visit at 32 wks.

I’m hoping, as I do on so many nights, to sleep without waking up until morning. Hoping to not dream about patients, hoping to not hear the wind.

3am

Today was an extremely slow call day. But I got to help out with the interview of a new doc that we are possibly looking to hire. She’s a fourth year resident who will be finishing up her program in May. She seemed nice. Driven. Smart. But I will be completely surprised if she chooses our practice. I was so embarrassed by how her interview was run. Very informal, held in a public space, the two docs that were there were getting paged during the interview and choosing not to return the page in another room but instead, taking the opportunity to use the phone right next to where the interview was being conducted and proceed to talk louder than the interview that was continuing in the same room. They took every opportunity they could to talk about themselves instead of asking the applicant about her own passions and interests. They talked up the practice, they got distracted by the nurses, by the phones, by each other…I was devastated. And the sad part is, I think they were really interested in this woman. But they couldn’t truly show it! At least not in a way I thought would have been way more appropriate. I tried to balance them out by only asking her about her personal experiences. I asked her about her residency program, what role she plays in groups (the older sibling, of course), what she likes doing outside of work (not surprisingly she runs marathons), what her favorite parts of OB are, if she has had any experience working with midwives…

I have to admit, she was a little hard to read. But she had a healthy dose of nervousness. Not too much. And not overly proud of herself. Which was nice. Less likely she will treat me like shit.

But one comment the doc made has stuck in my head all day. At one point she pauses and looks as if she is thinking sort of nostalgically about her job (and I think she was trying to be inspirational here) and she says, “Well, if I’m going to be up at 3am, there is nothing I’d rather be doing.” And the applicant says “True. Very, very true.” And I wanted to shake them out of their trance. What??!! There are SO many things I would rather be doing if I was up at 3 in the morning. Talking with friends, making out with someone I love, at an all night dance party that’s playing really good music, looking out the window of a train and headed to a place I’d never been before….I mean the list goes on and on here. Is it me or them? Should the only thing I want to do at 3am be deliver babies? I honestly think it’s one of the LAST things I want to be doing if I am up at 3am.

Sigh. Off to bed.

Strawberries

I am seeing a patient in the office who I should not be managing. And I’ll tell you why. It’s not because I am totally incapable of handling her. It’s not because I am incapable of learning how to care for her with the help of a doc who would be co-managing her with me. It’s not because she is now 30 wks pregnant, she has a BMI of around 50, (She literally said to me at her last visit, “Do you need me to help?” and then proceeded to lift up her heavy pannus so I could wedge the Doppler against her uterus to try to find her baby’s heart beat. It consistently says in her record “unable to determine size of baby by leopold’s d/t body habitus”), not because she has GDM and her blood sugars are through the roof, (though, on a positive note, she is consistently reporting them to endocrine). It's not because the list of risk health risk goes on and on. The main issue is that her care has been thoroughly inconsistent throughout her pregnancy. She has seen a doctor twice in her entire 30 weeks and she has seen a different midwife every single time she has come for a visit. Management plans have been made for her but not followed through on. There was a plan in her problem list to see someone from MFM between 28 and 30 weeks and she is now 30 and 4 and the MFM appointment was just made for mid March. The doctor who is supposed to be co-managing her is out of the country until the end of the month and now, because I have more space in my schedule than anyone else in our office, her next 5 visits are with me. So here I am, muddling through her problem list and hoping another risk factor doesn’t pop up and wondering if anyone will listen to me and not just think I am complaining if I tell them that I think she should be taken care of by someone other than me. I did actually mention it to the chief doc today at the hospital and she asked me to send her the chart. I’m hoping she agrees with me and helps to structure this patient’s care so it is a little less…disorganized.

Even more importantly, I saw the patient yesterday for a routine visit. She told me she was feeling the baby move, hadn’t had any bleeding or headaches or leaking of fluid and then she politely lifted her tire of fat for me. And then the weirdest thing happened. She started talking about strawberries like I have never heard anyone talk about strawberries. Here is a sample of what I heard:

Me: How have your blood sugars been?

Her: They’ve been good. Pretty good. Normal I guess. But you know what I’ve noticed? Whenever I have strawberries they go up. And I don’t even like strawberries! But I eat ‘em. My husband, he love strawberries. He do. He could eat strawberries every day of the week. Me? I like grapes. All kinds of grapes. Red ones, blue ones, green ones. I could eat grapes all day long. But strawberries, I don’t like ‘em. But when I’m pregnant, I eat em. And when I was pregnant with my son…I ate ‘em then too. And now, my son loves strawberries! But I don’t like ‘em. Unless I’m pregnant. Isn’t that odd? Have you heard of that before? Eating strawberries when you don’t like’em?”

Me: I’m…not…sure.

Her: Well, I’m just so excited to see if this baby likes strawberries or doesn’t.

I just did not know what to say. She would not stop talking.

Precip

I can’t believe it, but, last night was my very first precipitous delivery. I mean, I had had very fast labors before but, nothing like this. And once again, I was taught that nothing is what it seems, one birth is nothing like the next. One woman’s symptoms do not necessarily mean the same thing as another’s. I got a call just after 8 from a 39 wk G2P1011 who SROMed to clear fluid at 8pm. No contractions yet. GBS neg. Great. Stay home, touch base with me if anything changes. An hour later I get another call from her saying that her ctx have started but they are irregular, every 10 to 20 minutes, she is walking and talking through them…I am already getting annoyed. It’s close to 10pm, I have no one else in labor, I’m wanting to lie down for at least a little while but have a feeling I’m going to be hearing from this woman all night. I tell her that everything she is reporting are great signs of labor. She should still stay home. “You know I’ve had another baby, right?” she asks. “I just want to make sure you know that.” I knew. She had a 3 day induction after a PPROM at 34 weeks. She didn’t know spontaneous labor. Stay home, I told her again.

The doc bid me farewell for the night, asks if I have anyone on the horizon, I tell him about this patient and we both chuckle and how silly people are for calling us so early in their labors. An hour and a half later the patient calls me back. I had just put my head down in the call room and was, again, annoyed that I was going to have to hear about every single shift in her labor. I could just imagine every call I would get from her…now they’re every 10-12 minutes! Now they are every, like, 8-10 minutes, but they have only been that close for like…20 minutes. I have bloody show! I’m still leaking!! Already I feel like this patient doesn’t trust her body, is too scared, too depended on medical care…

The ctx were coming more frequently now, she thinks every 2 or 3 minutes but has not been timing them, and she is very uncomfortable. I was still not impressed.

“Are you saying you would like to come in and be evaluated?” I asked her.

“yes.” She said.

“okay, well, take your time. Gather your things and really take your time. Also, I just like to manage expectations here.” I tell her. “If you come in and you’re still a centimeter or two…I’m not necessarily going to admit you. I won’t send you home but, you might not get a room right away.”

She seemed extremely disappointed with this bit of information. I’m sure I seemed nasty but when the majority of the patients you see get admitted way too soon, yes, it’s easy to get a chip on your shoulder about making sure a woman is in good active labor before they get to stay.

20 minutes later, I’m lying in a dark call room with my eyes closed and I get a page:

New pt here, pushing, please come immediately.

There was no name on the page. I thought, there is no way this is the patient I had just spoken with. First of all, she was not this active, second, she could have never even made it here in that kind of time! It must be another unannounced patient. Or worse, a patient that isn’t even mine. Even more reason to get annoyed.

I slide my feet into my shoes, put my hand on the door knob and get another page. It simply says: Delivery.

Hm. Well, now, I thought, it HAS to be another practitioner’s patient. I MUST be getting paged incorrectly.

I race upstairs and head to the room I got paged about. I have no idea if it’s my patient, if the baby delivered, if the placenta is delivered…

I walk in and it all becomes clear. It is my patient. She is yelling and crying and thrashing and her husband has his forehead pressed to hers saying that she is going to be ok and the nurse, with one glove on has her hand cupped over the woman’s vagina telling her not to push. I grab some gloves, throw them on, grab my gown and while I am struggling with the sleeves see the head of the baby emerge. I throw the gown down and vaguely remember hearing one of the nurses say something like, “so much for the gown”. The room was way more out of control than it needed to me. My favorite. Somehow, I got the patient to just listen to my voice and told her to slowly push little by little.

“But I wanted the epidural!” she cried.

“No honey.” I said. “There is no time for that. You’re going to have your baby in seconds.”

And about 10 seconds after that, she did. When the head came out she had a moment of clarity:

“Was that it??” She asked, suddenly alert. “Was that my baby?”

“Almost,” I said. She pushed once more and her baby boy was born.

Dad flipped out he was so so happy. I mean flipped and jumped and cried and kissed and told his wide she was a super woman. That she could do anything. And then he told his newborn son that his mother was amazing and that he was so proud of her. The nurses thought he was out of control. I thought he was just being real and honest in a moment of total joy. It was nice.

When he finally calmed down, just 5 minutes after the birth he looked at his wife and said, “Let’s just go home.”

And I really thought he was totally totally right. They were at home for her entire three hour labor, pushed her baby out after being in the hospital for 5 minutes, had no lacerations and a healthy 7lb 7 oz baby. Why stay? I’d go home too.

But it was late and I think the patient herself was still in shock from having gone through such a fast labor. So they stayed.

And even though things went quickly and even though the paper work involved with having to admit someone to labor and delivery and post partum at the same time was frustrating…the whole thing was normal, natural, safe. No IV, no monitoring…no time. Granted, everyone can’t have such a fast and seamless labor but it’s nice to see that babies can be born without inductions, without chorio, without an epidural, without intervention.

“You were gonna make me go walking!” the patient said quoting what I had told her on the phone.

“I know.” I said. “Well, you proved me wrong. You were certainly ready to have this baby. I’m glad you came in.”

Dayenu

FYI: I spoke with my mom about the use of the word dayenu for this blog entry asking her if she thought I could take some creative liberties with its meaning. She said no. Can’t take it out of context. It wouldn’t make sense. The word Dayenu is meant to mean “it would have sufficed” or, “It would have been enough.” And it refers to all the gifts and miracles god gave to the jews, like dividing the sea, and giving the sabbath and the torah and leading them into Israel and that even one of those things would have been enough. Dayenu. But no, the dude kept giving more and more. But after a call shift like I had today and honestly, at many moments in my life, I can’t help but think of using this word in another way. So, sorry mom (even though she doesn’t read this blog because she can’t figure out how to get onto the website) I’m taking liberties.

Tonight I hate my job. I just got home from what might have been my worst call shift so far. I don’t have nearly enough energy to write about it all but I just have to say I’m feeling like total, total crap right now. You know what? Enough tears have been shed for this job. Enough I tell you. Dayenu. There have to be other professions that suit me far better and that do not leave me gasping and crying and trying to get in touch with friends to console me and hug me and tell me I’m okay. It’s just too, too much. I had a patient who had SROMed two days ago still at the hospital after over twelve hours of pit yesterday with no cervical change and a cervidil overnight with no cervical change but contracting every 4 minutes and another 5 hours of a second cervidil before she hit a wall and broke down. And still she is at 1cm.

Dayenu.

I had another pt who made great progress. Who had her Israeli mother with her and her Palestinian husband and who said a prayer for me while she pushed because she heard that if a laboring woman prays to god, the prayer is sure to come true. And who I was paying especially close attention to during her labor course because she only conceived after her 5^th IVF cycle and because she had a history of many, many surgeries and supposedly had tons of adhesions and none of the docs wanted her to go to section. And then she pushed and pushed and pushed for over two hours and the baby’s head just didn’t come down.

Dayenu.

And the nurse for that patient, before we even started pushing and who I had never met before said to me in a snooty tone, “Let me tell you something, I am not going to stand there for hours and hours holding an anesthetized leg while a patient pushes.”

Dayenu.

And at 7pm I told the doctor that I was having problems with the nurse and asked if she would come assess the patient because it had been two hours since we started pushing and that’s our practice protocol and the doc told me she wasn’t going to do anything else before 7:30pm.

Dayenu.

And then the nurse for that patient paged us while we were giving the change of shift report and demanded to know what the plan was for the patient and again told us that she would not hold a patient’s leg for hours and said that every time I left the room no one in the family would help her hold up the patient’s leg and why was I not checking the patient more often for her progress while she was pushing and the doctor had to scold her and tell her we would both be coming to talk with her once we finished report.

Dayenu.

And when we finally finished report we went to get the nurse and the nurse in charge and an assistant coordinator and the midwife coming on, and we all go into a conference room to talk and the doc says to me, “Okay so why don’t you start by talking about how you felt unsupported during this labor.” And I had no idea I was going to be put on the spot like that.

Dayenu.

And my heart is racing and I am holding back tears the entire time while the nurse is telling me I started pushing too early and that she will not destroy her back by being expected to hold someone’s leg up for hours and that occupational health has said it was ridiculous for practitioners to expect nurses to hold up patients’ legs and that she didn’t like my attitude and she didn’t believe me when I told her that when she refuses to “push for hours” before we’ve even started pushing, that communicates some resistance to me.

Dayenu.

And the doctor said I was new.

Dayenu.

And I felt like no one was standing up for me.

Dayenu.

And when we finally got up to leave, the nurse said she was glad we talked and the doctor walked out of the hospital to start her 7 day vacation and I was still standing in the hall feeling like shit and definitely NOT happy or satisfied with that conversation (in which, honestly, the doctor did more talking than anyone and where I never felt like we reached a happy medium or made plans for how this situation could have worked better). And maybe I should have just left the hospital too at that point but I even fucking offered to stay and continue help since there was so much going on. I kept pushing with the patient until the other midwife could come in. I settled my 1 cm induction patient who finally got an epidural and was comfortable. I said goodbye to everyone I had taken care of in labor. Mostly just to make myself feel like there was some closure to the day. But before I even got in the elevator I started to cry. I can’t tell if I’m too sensitive for this job or if I happen to be working with a bunch of people who aren’t very sensitive themselves? Why didn’t someone from my practice pull me aside after that terrible “intervention” to see how I was doing? I am suppose to feel like I am part of a team but I feel so so alone so much of the time. And I can’t decide if my expectations are too high, if I should be in another line of work, another hospital, another practice? If I just need to toughen up? And I can’t seem to find that balance between not caring at all and caring too much.

And why is it always feast or famine? I think I could actually be learning and maintaining some sense of emotional and psychological security with even half of what I had to deal with today. With just one patient. Or, with all four of my patients but a little more support from my doc and a little less shit from my nurse. That would have been enough.

Dayenu. Dayenu. Dayenu.

Annual Review

I’m so tired. I can’t even go into why my day kind of sucked but I had a rotten day. I handed out diplomas at my alma mater last night and I have to say I couldn’t help but immediately feel a sense of community as soon as I arrived. I parked my car and saw familiar faces on the street. People happy to see me. Again, it was a small little responsibility I had but by the end of the evening my checks ached because I had been smiling so hard and for so long. They put my name in the freaking program for god’s sake. How sweet is that? The speeches from faculty were similar to what they had been three years ago (2 years?) when I got the same nursing diploma but I felt like each one of them was still so so genuine. It means something to those people to have students feel as if they are part of a community. A strong, solid community that cares about them and the work they do. And just sitting in that auditorium, I felt like I was once again a part of that community. Or maybe like I never left it. It was such a nice feeling. One of my favorite faculty members sat down next to me in the front row as the ceremony was starting. “So,” she said to me, “Do ya hate it?” “A little bit.” I said, matter of factly. And she just nodded and smiled. “It’s normal.” She laughed. And all I once I felt like it was just plain ok to have had a rough first 6 months. It was forgiven. It was expected. She still loved me. And that love was there on all sides, coming at me from every direction.

“So when are you moving back?” The assistant dean said. I laughed. But, I’m pretty sure he was serious.

Then, I had to begin to prepare for my call shift the next day. Though I’m now pretty resigned to never ever again being able to sleep through the night, waking up 3 or 4 times every single night does eventually take a toll. So this morning, I headed to my call shift after yet another crappy night’s sleep and had what I thought was an even crappier “annual review” after only three months of being off orientation. The general feedback was fine, supposedly I am far surpassing expectations, but there were some things that just left a really bad taste in my mouth. Little nitpicky things that colleagues had watched me do 2,3 sometimes 4 times without telling me, “Hey, that’s not the way things work here.” Instead, they waited until my boss asked for “feedback” and only then said something so she could bring it up in my eval. Things like, (just for instance) when I told a pt she’d have to reschedule because she was 14 minutes late for her 15 minute-long appointment and I had a full panel*. I’m annoyed. And disenchanted. And wondering why it is so difficult to come straight to me when you have a problem with something I am doing. So now I feel like, people are thinking mean hateful thoughts about me and then smiling when they pass me in the hall because they don’t have balls to confront me when they are uncomfortable. And maybe instead of my boss having to pull me aside and tell me I’m doing something “wrong” we need to have some sort of practice wide workshop on direct and professional communication. Have I said I was annoyed?

Just got home from call. It’s late and I’m in the office tomorrow. Having toast for dinner and going to bed. Hoping to only wake up once or twice…

*I pulled my office manager aside at the office today and asked her if there was a policy in place for how to deal with late patients. “Technically”, she said, “the policy is 10 minutes. As the clinician, you have the choice to not see them if they are ten minutes late. But,” she qualified, “that’s usually true for the docs. Most of the advanced practice clinicians will just fit them in somewhere and not send them away.” Oh. So, somehow as an advanced practice clinician I have less rights to my boundaries? Yes my visit times are a little longer than the docs’ visit times but there is just something fishy in that explanation. And it ain’t BV. So, I have to say. I’m left with a conundrum: Following the policy and maintaining healthy boundaries leaves me looked down upon by fellow clinicians. But saying yes to any straggler no matter how late they are leaves me resentful and exhausted. Again, did I say I was annoyed??

On a good note. Slept soundly last night from 11:15 to 6:30!! No ativan on board!

Okay, fine. I'm a midwife.

I had my scariest birth yet yesterday. Though I did my multip mantra before arriving at the hospital, the only two patients that were handed off to me were P0s. At this point it comes as no surprise that all I get are primips. I’m starting to feel like it’s a special higher plan that the universe has prepared for me. No matter how much I want ‘easy’, it gives me something else. No matter how much I want to glide through each call day seeing only category 1 FHTs and P2s who slide their babies out after a 10 minute second stage…the universe is powering back with something a little more challenging. And only now am I on the verge of toying with the idea of trying to stop fighting it. You want to give me a P0? Go for it. You want to throw me a completely dismantled perineum that won’t stop bleeding? Fine, I’ll just deal with it. You want to give me a nurse that doesn’t trust me and who makes me not trust myself? Good. I need the experience of building confidence and being in charge. Yesterday’s scare, though it left me with shaking hands for over an hour, taught me that, when you need help…it does come running.

My patient (a primip) was 9 cm when I got to the hospital. The baby was only at +1 and she was sitting up in bed, epiduralized of course, and generally, pretty happy and unaware that she was in labor. She was fully within the hour and had a BBOW so I AROMed her and let her labor down for another hour. I’ve gotten in trouble for laboring down for more than an hour at my practice so, even with the baby at +1, we had to start pushing around noon. And when we did, it was immediately clear that, left to her own devices, I’m really not sure if my patient would have been able to push her baby out. We had her in a sort of modified squatting position on the bed because if her head was low, she complained that she couldn’t breathe. And personally, I hate it when women are lying with the head of the bed all the way back and down and trying to push. It just seems so…hard. So the pt is upright, foot of the bed lowered and c/o a spontaneous urge to push. But each time she would get a contraction she would freak out at how much pressure she was feeling and shy away from pushing. She would windshield wiper her knees back and forth, almost clamping her pelvis closed. Her head was on the pillow and just lolling around and she was yelling and sighing and swearing but definitely NOT pushing. The nurse and I thought she was having some sort of episode. “What’s going on?” we asked her, “You need to use your words and tell us what you are feeling, what you need. Are you pushing? Are you having a contraction?” The patient could barely speak. Between each contraction we tried to do some teaching in order to anticipate the next one. “Push against the pressure you’re feeling.” We said. “Try not to be afraid of that pressure, try to use it as a guide.” We said. “If you can, keep your knees open wide, this will help to keep your pelvis open.” We said. But each time, a contraction would come she would pull her knees together and throw her head back and do a little grunting and not push. I gave her pressure in her vagina, I asked her what she needed in order to push powerfully. Nothing worked. Until I looked her in the eye, said her name sternly and literally told her to take a deep breath in, let it out, take a deep breath in again and push for 1, 2, 3, 4, 5. Let it out, take a deep breath in, let it out. Take another deep breath in and push for 1, 2, 3, 4, 5. And I was doing it with her, so if she was blocking out my words for whatever reason, she could see me and just mirror what I was doing. I hate hate hate counting with pushing but it was literally they only thing that would work for her. And there was no way that she could push longer than 5 seconds. Sometimes she would only make it through one round of this and then give up. But it was working. She was moving the baby down.

And after an hour and half of pushing like this, she delivered the head. Unfortunately, she also delivered a loop of cord and the posterior hand and the very top of the posterior shoulder. My first though was, what the hell is going on here? Do I deal with that cord? Do I try to get the rest of that nuchal hand to come out? Do I just deliver as usual and go for the anterior shoulder? No matter what I tried though, nothing worked. The baby was lodged. I tried for the anterior shoulder, not even close to coming. I tried to deliver the posterior arm by grabbing the baby’s hand but it wouldn’t budge. I hooked my finger under the posterior armpit and pulled…nothing. I went back to the anterior shoulder. And each time I tried the perineum bucked and pulled and stretched and would not give. The pt had now climbed as far back on the bed as she could without having much use of her legs. It’s as if she was trying to pull her upper body away from the experience her lower half was going through. I looked at the nurse.

“I need help.” I said. And that was all I needed to say. No less than 7 or 8 people were in the room within seconds. I have no idea why all those people come in, by the way. I feel like at least half of them are nurses and, really, what are they there for? To observe? To be able to tell the on coming shift: Oh yeah, there was an emergency today in that room. It was crazy. I was there. I mean, what are you really doing just standing by the door?? Well, thankfully, one of the people that ran in was a doctor who threw his gloves on in half a second and stuck both of his hands into the woman’s vagina to try to dislodge the kid. I put both of my hands against the woman’s perineum as he twisted and turned and pulled the baby out and handed it to me. And then, as fast as my savior had arrived, he was gone. Disappeared and I was back in the game. Baby crying immediately, both arms waving vigorously, new dad in the corner shell shocked and me, trying to hide the fact that my hands were shaking wildly. Baby was handed to peds because there had been some light mec, I don’t know, maybe, hours ago? The placenta delivered immediately, I let the woman massage her own fundus to make her bleeding stop and very, very carefully I checked her bottom. Nothing. Okay, I take that back. She had a teeny tiny hemostatic abrasion on the inside of her R labia and a small 1^st degree vaginal tear, also hemostatic. It was amazing. I’d certainly like to think it was my stellar protection of her perineum both during the pushing and the delivery that helped to maintain an intact bottom but I really don’t think I can take credit. This was a birth made of miracles. And I’m not even talking about the baby. You ask for help, and you get it. A nullip delivers an 8lb 11oz baby with a compound presentation and she walks away without any need for a repair?…the gods were with me. They really, really were. Oh, and with her too, I guess.

Yesterday was one of the few days that I walked around the halls of L and D and thought, I’m being a good midwife. I’m making good choices, I’m busy, I’m checking in with my doctor at appropriate times, the nurse respects me, I’m doing ok. And I felt like I was being a good midwife not because I think “birth is cool”. Not because I sat in a shower with someone giving them counter pressure while they endured hours of back labor. Not because I believe that the vagina is a perfect and beautiful flower and that contractions have a beginning and an end. I felt like a midwife because even though the nurse barely said hello to me when I first walked into the room, she pulled me aside after the birth and told me that I was really good with the patient. I felt like a midwife because when I finally came out of the room to write all my notes, hands still shaking, all the nurses at the nursing station told me to take a breath and be happy that was over and I felt like they really gave a shit. I felt like a midwife because even though I hate coached pushing, the patient needed a directive singular voice to take orders from and as soon as I became that voice, she started to push her baby out. I felt like I could be myself. I could make the room laugh between pushes. I could tell the pt that she was safe and mean it. I could actually access my intuition about what my patient needed and about what I needed, what the nurse needed from me, when I needed help.

And it’s too bad that things have to get to an emergency level sometimes to really see and feel the community that I work in, but it’s the truth. In those moments of panic, every single person in the room (all, um, 12? of us) had the exact same goal in mind. And I have to say, though I was shaking and scared, it felt really good. To be on a team, to have everyone taking care of the same problem, no need for explanation.

I introduced myself to the doctor who had come in to the room to save me and thanked him. Super nice and super humble about saving the day. “It was like a puzzle.” He said “Just had to figure out how to solve it. No problem.” He offered to talk to the patients, he offered to have me include him in my note…it was…cool. So, I guess, yeah, sometimes birth is cool.

Another little perk of my week was that I was asked (with just under a week’s notice) to come back to where I attended nursing school and hand out diplomas to the graduating students who have finished their 1^st year of the program. The administration had wanted to get alumni involved and, well, they thought of me. Though it probably means very little, I am so honored to have been asked and so proud to continue to be a strong part of my school community. Just the idea of ushering new students through the three year process of an advanced practice nursing degree, being there to witness all of them pass from one phase to the next…it makes me very excited. Those transitions, those scary middle places where the past might be familiar but something you know you need to leave behind, and the future is exciting but mysterious and scary…I love that. I actually hate it when I am going through it myself, but to be the Shepard, to even just be an observer of someone else’s passage…is fantastic.

Oh, and also, the test of cure results came back for my pregnant pt with trich. Yes, that’s right. She still has it.

The Story of My Pap

Well, my morning was ruined by about 10:30am. It was snowing for the millionth time and I had already spent an hour on the phone being mean to incompetent people who somehow got jobs answering phones at student loan servicing centers. I’m trying to consolidate, I’m trying to see if I paid enough interest in loans last year to declare it on my taxes, I’m trying to get my monthly payments down so I can hopefully not continue to live paycheck to paycheck…and not one person I talked to was helpful. It took A LOT of energy to not break down before lunch. I did what I could and then had to get ready for an appointment I’ve been waiting 3 months for.

Today was a day that many female gyn providers come to in their lives. Once a year usually. I got my annual pap. I’ve been going to my women’s health NP for about 7 years now and I couldn’t be happier with her care. Every time I see her I am more and more satisfied with her preventative health education, her optimism about my life and her independence in her own practice. Now that I am a professional myself, I noticed that I receive my care in a completely different way than I had in the past. First, I’m totally transparent with her about how I want her to take care of me while I’m there. That I’d just rather pretend I don’t know anything while she asks me questions, palpates my ovaries and decides what blood tests I need. I ask her if that’s ok and she reassures me that I’m free to ask as many questions as I want, no matter how crazy. I deserve to be taken care of. Plus, she’s got 25 years on me so, she’s probably picked up a few things that I haven’t seen yet. But, no matter how much of a novice I’d like to be during my exam, I can’t help but take note of her strategies to maintain efficiency, how her exam room is set up, how she hands me, not a paper “blanket” for my lap but a real, cotton sheet to cover my legs during the exam.

Here’s what I noticed:

1. The Chart and Chat. Somehow she has perfected this ability to ask me questions, type my answers, and respond to me in a totally genuine and present way. I haven’t seen her for three years but she remembered that I was going to midwifery school, some of my interests etc. She’s also, at the same time, taking notes on a piece of paper which she subsequently hands me at the end of my visit. On it she has written a brand of food she likes and that she would like to recommend to me for days when I don’t feel like cooking dinner, the amount of omega 3s and vitamin D I should be taking every day and the name of a movie she saw recently that she thinks I would like.

She did my whole history and review of systems before I even took my clothes off.

2. She has no MA. Apparently, she would rather it be like this. For one, she gets an ENTIRE hour for every GYN pt because she doesn’t have an MA. She’ll use one for colpos or endometrial biopsies but in general, she’s flying solo. So, she hands me a cup to pee in, and in the mean time, sets up the exam room with everything she needs for me (including a cup of water because I had mentioned I was dehydrated).

3. The exam room was, yes, I can say it: cozy. There were normal pictures up on the wall, as well as info posters on self breast exams and the nuva ring. There were fun little books to look at on a little metal tray next to the exam table. As I said before, there was a real sheet there to cover my body. “I bring my own sheet when I go to the dermatologist” she told me. “Otherwise I have this piece of paper on me and it barely covers me! I’m sitting there naked! I just won’t do it.” I started to think about my patients. FYI, my NP is the tiniest little thing…I can only imagine how naked my patients feel. When I leave the exam room to let them get undressed I always say jokingly, “You can leave the gown open in the front and this luxurious paper blanket we’ve provided for you can go over your lap.” I usually get a little chuckle but, regardless, that paper blanket is ripped to shreds by the time they leave the office. Wondering how much it would cost to invest in cotton…

4. She does rectal exams. Now, I can't remember if I've had this particular type of exam every time I've seen her or if this is the very first time but wowza! not an experience you have every day. I have to admit, not only was the rectal exam not a part of my training, I never do them on annual exams. Should I? Should I do them on people over a certain age? I don't even know if anyone else in my office routinely does them...something to ask about.

5. She doesn’t weigh people. If you’re pregnant, well, then that’s a different story. But for regular GYN exams, for folks who don’t have any concerns about their weight, she forgoes it. There isn’t even a scale in the office. I was interested in knowing what I weigh just cause I haven’t stepped on a scale in well over a year and she was happy to do it, but we had to walk down two hallways and use a scale in someone else’s office to take the measurement. I remember her once telling me that women are already sensitive enough about their weight. And that if there was no real medical reason for her to take it, she won’t.

6. She told me it would all be okay. And, though it’s hard for me to embrace this way of looking at life a lot of the time, especially at the present moment, I believed her.

So, after my terrible morning of dealing with people in customer service positions who didn’t know how to deal with customers, my GYN experience was a highlight of the day. I got a clean bill of health, by the way, pending all my pap results etc.

And now I will begin my multip meditation for tonight. Already tired. Off to the hospital…