not so good week

There have been so many upsetting things that have gone down this week. I don’t think I have ever wanted more, someone to come home to, someone to talk to or cry to, than in these past 7-10 days. It was a week that the universe not so subtly reminded me how hard it is to constantly be the recipient of someone else’s pain. It also reminded me that there is a finite pool of strategies to use to make yourself feel better in these situations. Alcohol, TV, long walks, talking with someone who gets it. But really, even when I have the option of all of these things, the hurt is still there. These “strategies” are just temporary emotional distractions. When I get home from my walk, when the ETOH wears off, when 2 episodes of The Wire are over, when I can’t seem to get a hold of anyone who may have been through the same thing…all the emotion comes rushing back in. At some point you just have to stop moving and sit with it. And I really hate those moments.

I won’t go into too much detail here but two of my prenatal patients had very bad outcomes this week. One, PPROMed at 35 weeks, was induced, there were deep variables with and without pit, she got sectioned and the baby showed no respiratory effort at birth. It was immediately intubated, and still is. He was found to have some sort of neuromuscular disease. I spoke with the pediatric attending who was taking care of the baby in the NICU and she said the baby would never live a normal life, it would never be able to breathe off of the vent…and this kind of situation would of course be devastating for anyone and every single woman deserves to have their baby be healthy but I just can’t help but think that this patent needed this baby to be perfect. She needed something to work out, she needed a miracle. And she did not get it. “My baby doesn’t cry.” She said to me, crying herself. “He just lays there. He’s so beautiful but he is so still. He just doesn’t move.” That was Tuesday.

Another pt I have been taking care of came for her routine OB appt on Thursday at 25.3 wks. She was S She went downtown for a f/u US where they have better equipment and actual OB ultrasonographers. The MD downtown called me an hour later confirming that the pt had severe oligo due to something she was calling renal tubular dysgenesis. The lungs would most likely never mature and the baby would never be able to take his first breath. Even more devastating is the fact that in my state (in most states actually) the pt is too far advanced in her pregnancy to terminate. So what are her options? Taking a trip to Kansas, carrying the baby until it dies in utero or until she aborts spontaneously. Did I mention she had a previous loss at 24 weeks? I called the pt the next day to let her know I had set up an appt for her with our high risk doc and to see how she was doing. She didn’t have any questions. She’d been through this before. She knew what this meant. Note to self: if I ever marry my first cousin, don’t have sex.

On a slightly lighter note if you don’t think about it too too hard, I had another medical school student with me this past week during a call shift. Let me just say this again. I freaking love teaching. And it kills me to watch these med students who are barely with us for 2 weeks, who have never seen a baby be born, who have never heard of a BPP, who can’t read a FHT to save their lives, I can’t stand to see them sit in our office, trying to keep themselves busy by randomly looking at things on Up to Date when the MDs have no one in labor. Do the docs discuss cases with them? No. Do they ask them what their goals are for the day? No. Do they take the time to go over some basics with these kids so they don’t waste a full 12 hours doing absolutely nothing? No, sir. Enter New CNM. I pull out strips, I quiz them, I let them write notes, I ask them if they know what something is and if the answer is no, I have them look it up and teach back to me what they’ve learned. I’m not trying to brag here but I don’t think I’ve had one med student spend the day with me who did not pull me aside afterward to say how much they appreciated my teaching. In a sea of discontent and disillusionment with my job and obstetrics in general, it feels damn good to hear that.

Anyway, I had a med student with me last week and, well, I was underwhelmed by his performance. These med students have a pretty high baseline. They are ALL self motivated. They are ALL very very curious and ask a ton of appropriate questions. They ALL seem to be fairly quick learners. But they vary in terms of their ability to create and maintain patient relationships. The particular med student I was with could not have been more than 24yo. I mean, he looked way younger but if you work out college and maybe even a post doc program and then 2 years of med school he’s probably not that much younger than 25 right? Anyway, he was just awkward. It was clear that he didn’t want to make any mistakes, that he wanted to be liked, that he wanted to do everything right. And all of those things are understandable. I think he was just a little to “right on!” for me. Like, for instance, before I’d even gotten all of my words out to critique his soap note he’d be over my shoulder saying: “Of course! Thanks! Super! Yes!” I’m like, shut up kid. We’re gonna be together for 12 hours and if you are that overzealous about everything today I may have to anesthetize you.

In short, the main things I think he’s going to need to work on are 1) his inability to just do nothing. He wanted to fix the gown and get everyone water and change the sheets on the bed when it got wet, wipe the floor dry, get me extra gloves… it was never ending. Helpful but just way too much. And my sense of things (and I like to think I have a pretty good sense of things) was that he was unconsciously attempting to avoid what was actually going on. The pain of labor, the noises of labor, the idea that sometimes you just sit and watch and encourage but mostly just let the laboring woman do her thing. And 2) when we reached second stage and the woman started pushing the only thing this kid could think to say was “beautiful”. So, you’ve got the woman, sitting on the bed, spread eagle, her husband and the nurse holding her legs back and my little male medical student watching her vagina bulge and saying “beautiful” over and over again. It was just plain gross. Unfortunately, I had to race out of there at the end of my shift and since the patient was still pushing the student stayed and I didn’t get a chance to give him this “constructive criticism”. It will definitely go into his written review…

Lastly, I was again harassed for not calling my patient a “rim” when she was actually fully dilated in order to “buy her more time”. I can’t even go into the rage I was feeling when the “team” coming on had an issue with my decision to start pushing with an unepiduralized woman who was at +1 with a spontaneous urge to push. What would they have done? Told her to breathe through another hour of contractions so the head could get to +2? Please. Our protocols say we need an MD to write a note if a laboring woman has been pushing for 2 hours. And what good would “buying her more time” have been when she has been pushing for 2 solid hours with little to know progress? I mean, maybe a doc should be involved at that point. And maybe giving her another hour only increases her risk for chorio (for instance. Not to mention wedging the baby even further into the pelvis making a possible section even harder) because, most likely, she ain’t going much further. But what do I know?