My First Year of Practice

Eduvacation

2009-10-24T10:13:00.000-07:00

Well, I finally went on my first eduvacation. What’s an eduvacation you ask? Simply put, it’s a vacation…plus education! The way it typically works is you spend 4 or 5 days in a warm and/or beautiful place, listen to lectures in the morning, and have free time to sit on the beach or at the pool or for exploring in the afternoon. So, you get a little break from work and life and, at the same time, you learn some new stuff about your field.
In my case, I spent last week in Cabo, Mexico right on the tip of the Baja peninsula for an OB conference at an all inclusive resort. Lecture topics ranged from preeclampsia, to primary c section to bipolar disorder in pregnancy.

I had never been to an all inclusive resort before this trip and now, I’m not sure if I would ever go back to one. In the weeks before I went, I had fantasies about all the delicious Mexican food I would eat. I imagined strong, shirtless Mexican men delivering chips and guacamole to my palapa on the white sandy beach. I imagined genius lecturers, my Spanish skills becoming Spanish skillz. I imagined breaking hearts, learning salsa, and getting a nice, even, bring-on-the-winter suntan.

Turns out, this particular eduvacation is a way people can say they are in Mexico (your passport gets stamped, you gotta go through customs, it’s ridiculously hot) but not feel as if they are actually in Mexico. The whole time I had to keep reminding myself that I was in another country. Some days, only the pesos in my wallet and my roaming cell phone service kept me aware of this. It was sort of like I was in Florida with a lot of Mexicans walking around and all speaking English. The brochure promised Mexican food. I ate Mexican food once. The literature about the hotel boasted 6 or 8 restaurants with all different kinds of cuisines but once we got there it was clear that only one or two restaurants were open at a time and it was usually a buffet. The brochure also promised beautiful sandy beaches along the lovely Sea of Cortez. However, though I was only 20 yards from the ocean, I was never able to actually go into the water because the rip tides were too dangerous. By the middle of the first day I started thinking that an all inclusive resort is equal parts nursing home and spring break in Ft Lauderdale.

Day 1 included lectures on GDM, IUGR and hemorrhage. It was nice to be in that environment again. Learning about the latest evidence based practices, taking notes, sitting cross-legged on my chair, whispering to my friend sitting next to me, seeing just how many bottles of water we could pound down, circling all the typos in the power points. (Someone actually put “strait A student” in their presentation.) It was fun.
In the afternoon we plopped ourselves down at what was apparently the activities pool. Within seconds of sitting down, an all-pool Mexican bingo game started and, after that, tequila volleyball in the pool-I did not participate in the latter. Though I was not in a palapa on the beach, I was handed a delicious strawberry margarita and I ordered multiple glasses of agua at the swim up bar. But there were no chips and guacamole in site.
The first day also included a hotel-wide “Mexican” fiesta at night. We witnessed staff setting up the stage and multiple food booths all day and when we finally arrived at dinnertime there was an unlimited supply of tamales, tacos, grilled meat and of course, alcohol. The tamales were great. The tacos and empandadas were sub par. But the “activities” were just sad. Unlucky volunteers were brought on stage to gargle water while singing La Cucaracha. A photographer came to each table donning you with a sombrero and then selling you a framed photograph of everyone at your table wearing the hat and sticking their chests out. The same guy who ran tequila volleyball, Alberto, visited each table, pouring everyone a shot of, yes, you got it tequila, and making people scream “arriba, arriba” and “coochie coochie”. Our table gave Alberto the evil eye and we all took a walk on the beach.
Tired and still let lagged, I watched a little David Letterman on American Network TV and fell into a deep sleep.

On day 2, the lectures included PROM, stillbirth and preconception care. In the afternoon the decision was made to switch home base to the kidney shaped “adult pool”. I read, I relaxed, I snooped into the beach hut where they give massages, I had a sickeningly sweet “iced tea” and some water to wash it down. The only real unfortunate outcome of that afternoon was my sunburned left armpit, tender to the touch because I didn’t spread on my sunscreen evenly.
Before dinner, my friends and I decided to go horseback riding on the beach. I had only been once before and this experience was pretty similar to my first. Super fun. Super out of control galloping. Holding onto the reigns for dear life and screaming to the riders ahead, “Coming up fast!” each time our tour guide whipped the butt of my horse.
My sister did a lot of horseback riding when she was little. Like, jumping and winning awards and being fearless horseback riding. While I was sitting on my Mexican horse I couldn’t stop thinking of her and how, when she was a teenager and I was still in elementary school she used to let me wrap a string around her waist and walk behind her around the house as I periodically yelled out commands to her as if she was my horse and I was the jockey. I’d say, walk! And she’d leisurely walk into the living room with me trailing behind. I’d say trot! And she’d start a light jog into the foyer. I’d yell: Gallop! And she’d start skipping around the kitchen. Then I’d yell: Cantor! And she’d let out a big neigh and take off running wildly around the 1st floor with me running behind her pulling tightly on her reigns and laughing hysterically.

On day 3, we had the morning off for either sleeping in and relaxing or joining in on one of the organized trips that the conference was offering. We chose to spend the morning snorkeling. This included a drive through the city of Cabo San Lucas, a lovely boat ride full of music and dancing and helping the captain drive and, of course, snorkeling. After a 15 minute swim to the coral reef which we were instructed to head towards, I was enveloped by fish of all shapes and sizes. What seemed like thousands of tiny little minnows encircled me, long eel like fish waved along the bottom, colorful flat fish fluttered against my legs. I was surrounded by them. And then, I realized, I was also surrounded by people. Since our arrival, no less than 4 other tour boats had pulled up and let out a bunch of other snorkelers. At some point I pulled my head out of the water and saw at least 60 or 70 other white people in that dead man’s float position with their little plastic breathing tubes sticking out of the water. It was a little too much for me so I swam back to the boat. As for our promised lunch time Mexican buffet? Nope! Hot dogs and hamburgers complete with Kettle Chips and, I will admit, the most delicious dill pickles.

The afternoon lectures included controversies in elective c section, preeclampsia and poly/oligo hydramnios. There was no question that the MFM who was also a DO was the absolute best speaker of the bunch. Much of the stuff she talked about wouldn’t necessarily be things I would directly manage but it didn’t matter. It was a pleasure to listen and learn and to tell her that I thought she was great afterwards.
Before dinner, everyone in the conference was given the opportunity to release baby sea turtles into that wild ocean. These little guys had been buried in the sand until they hatched and we were supposed to simulate their “run” into the water where they would then grow up and proliferate. That is, if they weren’t eaten first. An obscene amount of them die. My little turtle, I named him “Tortuga”, was covered in sand when he was handed to me and he seemed to have some motivation problems despite my coaching. Though slow and steady might win the race I can’t help but be somewhat pessimistic about his future. He did eventually make it into the water but not until someone picked him up, placed him on the wet sand and waited for a wave to pull him away.

The last day included lectures on twin deliveries, GBS and DS screening. It was an unhappy realization that in all 4 days the one CNM speaker only talked about things like mood disorders and smoking cessation. Why can’t we, as midwives, be responsible for the more science based lectures too? Now, I will not deny that my scientific education is, well, at its best, foggy. But, that doesn’t mean we can’t become experts in ANY part of OBGYN. It doesn’t mean we always have to be seen as this weirdo touchy feely part of the OB world and I can’t help but think this way of organizing the lecture topics only serves to perpetuate the unjust hierarchy among doctors and midwives.
It was boiling hot in the afternoon but we took a sweaty walk into town, bought some shit and marveled at how many Rx meds you could buy OTC here. I almost bought a few doses of diflucan and cipro, you know, just in case, but then, I only had 20 pesos left…

So, all in all, let’s see…
• Thumbs up on the lectures, but thumbs down on the fact that CNMs always seem to be pigeon holed into talking about emotions and nutrition and not the science of obstetrics.
• Thumbs up on the American Network but thumbs down on the lack of Mexican food.
• Thumbs up on being called Sarita for a week but thumbs down on Alberto our activities director.
• Thumbs up on the DO who gave a great lecture on preeclampsia but thumbs down on the 3 female MDs who were aggressively defending primary elective section
• Thumbs up on riding horses but thumbs down on tequila volley ball
• Thumbs down: All inclusive resort?? Thumbs up: eco tourism??

So, I think I would actually go on an eduvacation again. I’m just not sure I’d go to this particular all inclusive resort. Prior to going, I couldn’t stop talking about the idea of never-ending amounts of etoh but once I got there, I remembered, I’m not much of a drinker. In fact, I was more excited about the oversized bottle of water they left in our room each afternoon than the bottomless cup of Bacardi being offered 24 hours a day.

When I got back to the states, I called my father to let him know that I had arrived home safely. “Well,” he said half listening, “Back to the grind, huh?” Perhaps it was an overreaction but I took offense at his cynicism. Maybe I was still jet lagged, maybe I was even a little sad that I had to go back to work the very next day. But I’m hoping that even these few days away, regardless of how many thumbs up or thumbs down I gave the trip, will serve to soften the edges of my reality at least for a while. And when it wears off, I’ll just have to start planning for another.

Hunger

2009-09-29T13:40:00.000-07:00

Today is Yom Kippur. The Day of Atonement. Or, if you prefer At-One-Ment. As a child, I remember being dragged to temple multiple times during the year for various holidays without any real understanding of why. I remember the smell of that place, the way the voices echoed in the lobby and the back of the sanctuary. I resented having to sit and be quiet for what felt like hours. I still remember almost all of the songs, but more, the revoltingly operatic voice in which the cantor would sing them. I remember, even then, at 5 or 6 or 7 years old thinking how poorly decorated the temple was. Walls made out of different colored rugs, multicolored stained glass… Not understanding any of the Hebrew, my eyes would always wander to the walls and the ceiling and the cantor's horse-like teeth and I would think, “Why, why?”

Growing up, I never fasted for Yom Kippur. And neither did my father. My mother did but as I later found out, she made a lot of allowances for herself:

“Well, I have to have a cup of coffee in the morning. But just the one. With cream. No sugar. I have to or else I’ll get a headache! And I need gum. Just the gum though, no food. Throughout the day. Or I’ll get sick. I get so nauseas when I don’t eat! And water. I let myself have water. Just to, you know, keep my mouth from getting dry when the gum wears out. Does that count?”

As an adult, I do try to fast every year. Unfortunately, I forgot to ask for the day off today so I had a full panel of patients waiting to see me in office. So, I semi fasted, allowing myself some miso soup and a mini container of hummus so that I was not mean to my patients all day. And, I confess, midway through the day when the office manager came around handing out homemade gingerbread whoopee pies made by one of the other midwives in the office I guiltily stuffed one in my mouth right before I started my initial OB visit with yet another pregnant teen. Does that count?

So, yes, a little sustenance was needed as I welcomed 3 more teens into the world of pregnancy this week. And each story seems worse than the last.

Teen #1 has on dark eye make-up and a purple leopard skin bustier. She, like most of the teens I “take care of”, gives me one word answers to all my questions. She seems indifferent at best about…everything. She has a significant personal and family history of substance abuse and mental illness. Her parents don’t know. She doesn’t have a job. The FOB is currently incarcerated for what sounds like violent acts against the patient. She has a restraining order against him. Her neck is covered in hickies.

Teen #2 is living at home with her mother and father and is not worried that they will throw her out when she tells them that she is pregnant this afternoon. The FOB is aware of the pregnancy. He is in college but the patient does not know the name of the college or where it is.
“You don’t know where your boyfriend is right now? Like, the state or the city? You have no idea?”
“Um, I guess not.”

Teen #3 has come with her mother. The two of them are sitting in the room when I enter, the mother on a chair, the teen, slumped way over on the exam table. I shake both of their hands, ask a few initial questions and then say, “So, this pregnancy was unplanned?” and the mother says to her daughter, “Excuse me??!! You’re pregnant??!!”
“Let’s back up here.” I said. “You are here for your initial OB appt right?” I look at the pt and her mother, waiting. The mother apologizes, “I’m sorry, I’m just so sorry. It’s just that I’m in so much shock these days, with her being pregnant. My daughter, contributing to the cycle of poverty. Her grandmother was a social worker and she would be so disappointed that her granddaughter went and opened her legs like that.” She turns to her daughter. “Why would you do that? Why would you go and open your legs like that?” Her daughter shrugs and rolls her eyes. “And that ring you have on your finger? Probably out of a candy machine. Cost a nickel or a quarter. Do you even have a boyfriend? Do you even know his last name? Probably not. He’s probably with some other girl already.” Her eyes were closed and she was swaying back and forth and her hand was on her forehead.
I took a breath. I was angry. Angry at the mother, angry at the daughter. Angry for the daughter. But, I held myself back and asked the pt if she would like her mother to stay in the room. I said it was clear that everyone had a lot of emotions around the issue. I advised the mother that she might want to consider seeing a therapist herself. She didn’t respond. Just sat with her head in her hands.
“So, your last menstrual period was when?” I asked the pt.
“April I think.”
“April? It says here you told the medical assistant it was in July. Our visit here today will be very different if your last period was in April. Have you had any bleeding since April?”
“Yeah.”
“Okay, like, bleeding like a period?”
“Yeah.”
“Every month?”
“Yeah, I think.”
“Okay, when was the last time you had bleeding like a period?”
“August 21st.”
“I’m confused. So, you may not have missed your period at all?”
“I don’t know.”
“Let me understand something. What did you expect to get out of this visit today?”
“To confirm pregnancy.” She said. It was the longest sentence she had offered.
“Why do you think you might be pregnant if you’ve had bleeding every month?”
“I’m having pregnancy symptoms.”
“What symptoms?” I asked. And then, as if she had read it from the internet-
“Increased appetite. Breast tenderness. Back pain.” She paused. “And baby kicks.”
“Baby kicks? I’d be surprised.” I said. “You’d have to be pretty far along to feel your baby moving. Did you take a home pregnancy test?”
“Well, no, it was at my friends house, not at home.”
“Okay, that counts. A home pregnancy test does not mean you have to do it at your own home. Was it positive?”
“Yes.”
I stepped out of the room to run the pt’s urine through our office pregnancy test which is essentially the exact same thing as a home pregnancy test but it allowed me some time to escape the space and for some reason both the pt and her mom wanted to know what our test said. Positive of course.
We finished up the talking portion of the visit with minimal interruptions from the mother and thankfully, the pt asked her mother to leave the room for the exam. When she left, the pt and I spoke briefly about her choice to keep the pregnancy.
“I just couldn’t deal with it emotionally, y’know, having an abortion.”
“Do you think you are emotionally prepared to be a mother?” I couldn’t help but think of the shitty role model she had.
“Yeah.” She sad. I resisted the temptation to scold her. To try to change her mind. To tell her that she was wrong. To give her all of the reasons why, in fact, she was not ready for motherhood. But I told myself it wasn’t my place. Instead I promised that I would take good care of her if she promised to be honest with me, to ask questions, to let me know if she was having problems with her mom, and to take care of herself.
She lay down on the exam table and it was clear that no matter how much I had tried to convince her, it wouldn’t have mattered. This girl was very very pregnant. Her belly was huge. I hadn’t noticed it because she was so slumped over and because the gown was so baggy on her.
“You’re very pregnant, aren’t you?” I asked
She nodded.
“Let me go get my doppler.” By measurements she was 25 weeks. She certainly had been feeling baby kicks. And as soon as I put my Doppler on her belly a rushing fetal heartbeat filled the room. She looked at the ceiling.
Her chart said she had had a previous termination at 17 weeks last year. And that her mother had called the school prior to that saying that she had tried to kill herself. There was the possibility that she had been abused by a friend of the family. She is currently positive for Chlamydia. The list goes on and on and on.

And when I try to find a social worker to be involved with these patients’ care, I am again reminded that our resources are minimal. Our social worker can send me a packet of information to give to them but she can not always call them and she can never meet with them in person. Rumor has it that there is some sort of “alert list” I can get these girls’ names on so that someone will come see them in the hospital and tell them in person about the organizations that may be able to provide them with some support. They can assess their home situation, make sure it is safe for the baby and the new mom herself…But it is not enough. If I give any of these patients a packet of information about WIC and Jewish Family Services it will instantly become a coaster when they get home. They won’t make the phone calls, they won’t fill out the forms.

So even after I came home from work and broke my Yom Kippur fast with more food than was good for my shrunken belly, I was still angry and still hungry. I feel constantly torn between wanting to provide these teens with non judgmental care and wanting to convince all of them to terminate so that they don’t have to be a mother before they are even an adult. Singlehandedly, I can’t keep them from getting pregnant. I can’t keep them from wanting to have a baby. That’s of course their choice and not mine. So I’m left with this wrenched feeling in my stomach, this frustration that there isn’t even better care for these girls since they need so much more attention and education than others. I come home every day and think about how hard my job is, how difficult it is to see these girls especially, with their growing bellies and their one word answers, how I am left with this sense of hunger for easier days, more time, better resources…

But then, I think, they’ve got to be way more hungry than me.

Anniversary

2009-09-15T09:05:00.000-07:00

Last Tuesday marked my one year anniversary at my current midwifery practice. One year later I certainly feel more competent on many days. I don’t cry as much. I get slightly less panicked the day before a call shift. I know which nurses I have to sweet talk and which ones I don’t in order to feel respected. I speak up more at meetings. I started a newsletter and have precepted medical and nursing students. My leadership skills have definitely been recognized by others in my group and I am almost always nominated to head up creative endeavors and any community organizing that needs to be done. The director of a local advanced nursing program has invited me to teach an elective class to her students on literature and medicine. I guess when you write it all down like that, there’s lots to be proud of.
But to be honest, there is still something missing. And I can’t quite put my finger on it. As always, I’m not sure how to tease out the dissatisfied feelings that are coming from my life in general and which are coming directly from my job. I do think, on many days, that I would be happier if only my practice started less inductions, if less women demanded (sobbing and decompensating and pounding their fists into the mattress) epidurals in early labor, and if I was not as responsible for what feels like medical issues that are often outside of my scope of practice. On other days, I am certain I could live with a little more philosophical compromising if I felt the group of midwives I worked with was more cohesive or if my boss was more supportive. And some days I feel like none of this would make any difference at all. That I was not meant to have a full time back breaking job that demanded all of my emotional attention and where sometimes my intuition is rewarded and sometimes it is resented. I think, on those days, maybe I’m supposed to find a way to be a full time artist or videographer or dinner party holder. But then, I know myself better. And I know I am very very willing to give a lot of time and energy and emotion to work that feels right and satisfying. Plus, you’d have to do so much clean up if you were a full time dinner party holder, right? And I hate washing dishes…

I haven’t written for a while and I’ve been thinking a lot about why that might be. I certainly don’t feel nearly as compelled to come home from a call shift or a day at the office and “get it all down” as quickly as possible. Maybe it’s because, as I move further and further into the day to day experience of being a midwife the ability to break up each day into these little vignettes or anecdotes is more challenging. I mean, I still think the stories are unbelievable-I’ve had 3, yes 3, IUFDs, an inverted uterus that came all the way out of the vagina and into my hands and I was lucky enough to catch the baby of one of my best friends and watch her labor and push and make the sounds a woman is supposed to make when she is having a baby-but as time goes on, as I see more patients and deliver more babies, the stories do run together as a whole lived experience; As, my life, really. And writing it all down in a few paragraphs feels like I am compartmentalizing or trivializing it. At the start of my career (and believe me, I still think I am at the start) writing down everything that happened, telling stories, holding someone’s attention and making them laugh…It worked as such a great coping mechanism for all the emotions and hardships one has to deal with in this field. And now, I don’t know. Sometimes, writing about my day feels more like I am giving it away than doing a cathartic sharing.

It reminds me of one of the last monologues in the John Guare play Six Degrees of Separation that Stockard Channing delivers so well as she is sitting at a lunch party with her husband recounting to the other diners the last segment of the story of a homeless man who both lies to and befriends her. It dawns on her that this story she was telling was more than that, more than an anecdote. It’s her life. And as I sit down to write about pregnant teens or self-righteous nurses or unhelpful doctors I can’t help but relate.

Her character says, “…And we turn him into an anecdote, to dine out on, like we're doing right now. But it was an experience. I will not turn him into an anecdote. How do we keep what happens to us? How do we fit it into life without turning it into an anecdote, with no teeth, and a punch line you'll mouth over and over, years to come: "Oh, that reminds me of the time that impostor came into our lives. Oh, tell the one about that boy." And we become these human jukeboxes, spilling out these anecdotes. But it was an experience. How do we keep the experience?”

I’m trying to figure that out.

Babies Having Babies

2009-07-13T18:02:00.001-07:00

I can’t remember if I have already written about just how many teens I see in the office. Our practice doesn’t really serve a ton of teens in general but I do think because during my interviews I expressed an interest in them and on my “bio card” that is at our front desk it says under professional interests: “Adolescent health and prenatal care”, they just send’em all my way. 17? Unplanned pregnancy? No secure housing? More afraid of an abortion than of a baby? I got the perfect midwife for you!

And taking care of these teenagers can be very rewarding. Seeing them through their pregnancy, trying to educate and empower them, watching them become mothers and women…But when the majority of the pregnant women you see are these young girls, your ideas get skewed. And I, admittedly, get resentful and angry. These girls probably need me more than most but I often walk into their exam room with a healthy bias, thinking that they have no fucking clue what they are doing. Sometimes I am wrong, and pleasantly surprised. But sometimes, I’m dead on.

I walked into room 17 last Thursday to meet my latest soon-to-be teen mom. Crowded in the small room were three people, no one over 18. The girl I presumed was my pt was sitting hunched on the exam table, her scabbed legs dangling. The boy I predicted was the FOB was sitting on the only chair in the room and another hefty girl was sitting on the stool that I usually use during the exam. I introduced myself to my pt, her boyfriend and then to the girl in my seat.

“Hi” she said. “I’m the Godmother.” I shook her hand and wondered if she was the godmother of the pt or of the unborn. I chose not to ask because I was immediately distracted by trying to figure out if anyone was going to give up their chair for me or if I would hover over everyone the whole time. “You probably need this chair, right?” The Godmother said.

“Yes, thanks.” I said. “I do usually use that one.” The Godmother got up, moved past me and planted herself on the exam room floor, cross-legged, in the corner.

I asked my usual questions about the patient’s last menstrual period, went over her dates, asked her if the pregnancy was planned (it wasn’t) and attempted to have a conversation with her about the responsibilities of parenthood:

“So, was this pregnancy planned?”

“Um, no…”

“And you guys are certain that you are going to keep the pregnancy?”

“Yes.”

“Do you have support?”

“Kind of.”

“Do your parents know?”

“Well, my mom doesn’t know” My patient said. “But I think my dad does, I think my sister might have told him. I’m not sure.”

“How about your parents.” I looked at the FOB.

“Um, no. Not yet.”

“So you both plan on telling your parents?”

“Well…at some point I guess…”

“Are you concerned you won’t have their support if they know you are having a baby?”

“Yes. My mom told me I couldn’t live there if I was pregnant.”

“Do you think that’s just your fear or you really know that to be true?”

“Oh no, it’s definitely true. She wouldn’t want to see me.”

“So, you’re living at home right now?”

“Yes.”

“What about you? Where are you living?” I looked at the FOB again.

“With her.”

“So, you’re both living with your mom.” I look at my patient. “And at some point you think you’ll have to move out. Do you have a plan for that?”

“Oh yeah. We’re gonna get an apartment.”

“So, you have a job?”

“No.”

“So how are you going to pay for the apartment?”

“Well, I’m gonna try to get a job and plus he works for a carpentry company…”

At this point the Godmother, who had been texting up a storm and who has not lifted her head the entire time (here’s hoping she pays more attention when the baby is actually born…) stands up and politely excuses herself to make a phone call. I think she actually said something like, “um, sorry to interrupt. Is it okay if I step outside to make a brief phone call?” As if she’s taken time off from her busy CEO position downtown. Sure, sure I said. Take as long as you need. Really.

The conversation looks pretty much the same each time. Sometimes the dad isn’t involved. Sometimes the pt works at Subway. Sometimes, luckily, there is no Godmother present. But in general, it’s tough to feel hopeful for the lives of everyone involved. Myself included. There’s always a lot of nervous laughter during the exam. My patient on Thursday kept blowing kisses to the FOB while I did her pap. It was…uncomfortable.

We finished up. I gave them the emergency numbers and asked if they had any final questions.

“No.” said the patient.

“Nope.” said the FOB.

“I got one question actually.” Said the Godmother as she was hoisting herself up from the floor. (She had returned to the room just in time to text during the entire PE)

“Sure,” I said. “What’s up?”

“Um, I’m wondering if she can, like, go to 6 flags this summer.”

* * *

Another recent memorable moment with teen parents was while I was on call last Friday. There was a 17 yo in labor and she had her mom and grandmother and aunt with her. Their support was amazing. Holding her legs, wiping her down, encouraging her, telling her how strong she was, sharing their own birth stories…And then there was the FOB. He was 21 and only moderately present throughout the labor and birth. He did take many pictures of my patient’s privates while the baby’s head was making its way through but I think it was more in order to find a place to hide than genuine curiosity and awe.

“Will you be cutting the cord?” I asked him while we were pushing and he was sitting on the couch looking through the pictures he had just taken of his girlfriend’s crotch.

“Yeah.”

“I’ll be cutting it too.” My patient’s mom said looking at him out of the corner of her eye.

“What?” the FOB said. “I’m the father!” he said and pointed his thumb towards his chest.

“Well,” The pt’s mom said still not looking at him, “I’m the other father. So we’re both cutting the cord.”

After the delivery the FOB was thoroughly disgusted by the placenta and verbally convinced us of that by pointing and groaning and talking about it as “that thing”.

I cleaned up, completed all my paperwork and gave a final hug to the new mom. I spotted her boyfriend holding his new son in his arms, just staring into the eyes of the newborn. He was transfixed. I motioned for the pt to look at him so she could witness how much that new little boy was holding his attention. She rolled her eyes.

“Well,” I said, “One last thing I forgot to ask you. Are you planning on having your baby circumcised?”

“What?” The FOB shouted as he stared into his son’s eyes, “Hell yeah we’re having him cut. He not walkin’ around with no elephant trunk. Uh un. Not my kid.”

And just like that, whatever respect or hope I had gained, had vanished. I pulled out a piece of paper from my pocket and wrote down exactly what he had said because, well, it was just too fucking good to not remember forever.

And as I drove home that night and thought about my young patients I heard a song by our dearly deceased Michael Jackson whose music is now being played 24-7 on most every radio station. He sings: If you can’t feed your baby (yeah, yeah), Then don’t have a baby (yeah, yeah), And don’t think maybe (yeah, yeah), If you can’t feel your baby (yeah, yeah)

He may have been a weirdo but he sure did get that right. Hear that kids? If you can’t feed your baby? Then don’t have a baby. Got it?

Today at the office a nurse pulled me aside to tell me she just got off the phone with someone who wants to get prenatal care with our practice.

“I think she’s perfect for you.” The RN said. “She’s 16.”

Falling Into My Lap

2009-06-21T12:20:00.000-07:00

There are more than a handful of nursing schools in the city where I live. And it just so happens that the director of one of these schools is also a graduate and the president of the alumni board at the nursing school I graduated from. I was invited there to participate in a panel discussion not too long ago where some of us recent grads talked and answered the questions of the students who were about to graduate and make the transition from student to professional. This director/president was the facilitator of the panel discussion and at the end of the event she handed me her card and said simply, “Come teach for us.” I was initially sort of shocked and honored that she would think to say that to someone she had never met before that night and someone who only threw out a couple ideas and pieces of advice for the graduating students. I shoved the card into my purse and assumed she had most likely given her card to everyone at that panel. “So what?” said a friend. “You’re making excuses.” Said my therapist. “Whatever.” I said. But then, a few weeks ago, I thought, Why not? So, I dug out her card and emailed her, reminding her of who I was and basically said I was interested in teaching because my best days on the job were the ones I got to spend with students. I said it’s tough being a new professional. I said that I am always trying to expand my community of people who understand the emotional and physical and intellectual challenges of direct care. I asked if I could pick her brain sometime about how someone with a master’s degree in nursing might head in the direction of teaching. She wrote me back within the hour and proposed we have a conversation over dinner.

Two weeks later we sat a local thai food restaurant, her drinking wine and me drinking beer, discussing some alumni issues at our alma mater. I mentioned that I felt that one of the communities I found a home in during grad school was the fairly established humanities and medicine culture and that I haven’t quite been able to find the same sense of home here. I told her about the writing workshops I’d been a part of, the writing award ceremonies I’d attended and, more importantly, how the worlds of art and science felt like they were continuously feeding each other while I was in school.

“Why don’t you teach an elective class in literature and medicine for my students?” She said. “Like a 1 credit class where you’d meet like 4 or 6 times over the course of the semester…we’d pay you of course, and there’s some paper work you need to complete with your objectives and a syllabus, things like that…Every student has to take at least 4 credits of electives and there are not that many offered…”

“Are you kidding?”

“Um, no?”

“I’d do it even if you didn’t pay me. I’ll do it for sure. That would be so amazing.”

“That’s ridiculous. Of course we’d pay. It’s work, right? I’ll send you all the paper work when I get home so you can get started. I think the students will love it.”

I took a swing of beer. Why was this so so so easy? We kept talking about nursing, teaching, how she got to where she is today…and I asked her how I could start to teach actual clinical skills to students.

“Well,” she said, “You send me your CV, I forward it on to the people who do OB placements for our school and you start to precept.”

Again , shocked. So. Easy.

“Why are you being so nice to me?” I said. Yes, I said that. I actually asked her why she was being nice to me. But, in all honesty, I really could not understand why this was all going so smoothly. When every other part of my life feels like a struggle, why was this just…happening?

“Well,” she said, “We’re both alums of the same school, you’re smart and you really want to do this. Why not?”

“You are so great.” I said. Again, I’m not sure how this kind of dialogue fits in with professional interviewing strategies but hey, it was genuine, right?

“Well I think you’re so great. I wasn’t planning on coming here to recruit new teachers and I didn’t know how much of a passion you had for this. So, I think we both win.”

She walked me most of the way to my house and then she continued on to her own home. We made a plan for me to send her a description of what the class might look like, she told me to say hi to a few of the L and D nurses at my hospital that came through her program and she asked me to send her my resume.

And that was that. The process is underway. A new little path is starting to come into view, one that actually makes me excited for, not fearful of, the future. One that makes me feel totally calm about taking risks, about being wholly responsible for something and completely, completely accepting of the fact that I will certainly make mistakes. It’s true that I’ve only been a participant, not a facilitator, of a humanities and medicine class but this just feels right. Maybe all things are supposed to feel this easy. And, even if not, it’s really nice when something comes along that is.

not so good week

2009-05-31T17:35:00.000-07:00

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?

My Trip to Russia

2009-05-19T09:43:00.000-07:00

When my sister lived in New York, we used to try to go to the 10^th Street baths whenever I came to visit her. Wednesdays were women’s days. You’d go in, give your 25 bucks to a man behind the counter who had a big belly and a hairy chest. He’d hand you a key for your locker and you’d walk past a sort of “deli” with a paltry offering of unidentifiable meats and canned juices, a TV hitched to a corner of the ceiling playing sports or Russian news and into the locker room. Inside your locker there was a an oversized robe that would only fit a man weighing at least 300 lbs and some flip flops and you’d exchange those for your clothes and head downstairs to the baths. As a teenager, this experience pretty much blew my mind. There were women of all shapes and sizes getting beaten with branches, walking around with mud on their faces and grinding kosher salt into every part of their bodies. But I was with my sister and it felt safe and cool and I always slept like a baby the night after he day I’d been there.

I figured, living in an urban area now, there must be something similar in my town. A quick google search a few years ago uncovered a little known Russian bath house not too far from my neighborhood. Women’s day at this bath house is on Mondays only from 4pm to 9pm. Every other hour of every other day is men only. It’s unfair but that is the subject of another blog entirely so I won’t go into my thoughts on that now. But, I do think when there are only 5 hours every week that something is available to you, it is so much more special when you actually take advantage of it. As luck would have it, I am in clinic on Mondays and there is nothing that calls for a few hours in a sauna like a day of vaginitis and complaints of sciatica.

Yesterday was an unusually slow day at clinic. I finished each chart before I saw the next patient. Everyone’s complaints were pretty straightforward and there were very few add-ons (which I was responsible for that day). The sheer boredom made me panicky though and I raced to the bath house as soon as I got into my car.

This Russian bath house is small. You come in, walk down a long hallway and into a locker room/check in area/tv room. Everything is open and public. And very very very laid back. There’s one bathroom for everyone, the woman taking money at the counter is always calling you honey and leaning on her elbows and talking to the women sitting in the TV room who are taking a break from their steams. There is a card table set up that always seems to have pastries or egg salad sandwiches set out for people to eat, though I’m still not sure who this food is for. More investigating will have to be done…

Anyway, the place is disgustingly cheap. For 26 dollars I got a towel, plastic sandals, unlimited time (well until 9pm that is) in the sauna and steam room, a platza treatment and a bottle of spring water. I stripped down, put all my clothes in the locker they assigned me, and turned off my brain. Well, tried too. The thing about this place is that it’s a community. These woman (anywhere from 20 to 70 years old) are regulars here. They know each other from the baths, from work, from growing up. And they have A LOT to talk about. The sauna is far from a meditative place to be when you just need some peace and quiet. It’s more of a really warm gossip session. This is a slice of real life. Everyone has thick accents and drooping bodies. And last night was not the first time I overheard some of the women talking about their recent plastic surgeries:

“I just got my eyes done.” One older woman said.

“You did? I can’t tell. Lemme see. What did you have done?”

“I know. It’s still a little swollen. I had all of this pulled back.” She points to the sides of her face by her eyes. “My doctor said it might take 4 months for the swelling to go down though.”

“Hm. Nice. I’m thinking about having something done too. But, were you black and blue?”

“Nope. For 2 weeks before the surgery I ate lots and lots of pineapple.”

“Really.”

“Tons. It make you less likely to bruise. But the doctor I go to, Richardson something or other, he does’em Thursday and Friday night so everyone goes back to work, no problem on Monday morning. I had mine done on Thursday late afternoon and let me tell you something, I was at Neiman Marcus on Friday morning. I got home Thursday night from the surgery and my friend had left me a message on my voice mail. All she said was: Neiman Marcus, 20% off sale. And I was there.”

“I’m just not sure. I mean, what if I don’t like what it looks like afterwards?”

“You know what you do? If you want to see what it’s gonna look like, you lie down on your back and look at your face in a mirror. When you lie back like that gravity pulls everything away. That’s exactly what you’ll look like.”

The woman who had just gotten the surgery was very obese. And, I just couldn’t help but think, Why did you choose your eyes?

Last night was my first time getting a platza treatment. Basically what that is, if you’ve never had one or seen it done, is me, lying naked on the top bench of wooden bleachers in the sauna while receiving an “invigorating” rub down with a branch from an oak tree (supposedly hand made by one of the men that works there every other day of the week) and periodically being doused with buckets of freezing cold water to “promote circulation” by a woman wearing a bikini. The platza was good, though, I couldn’t really see any evidence of things being cleaned at all between treatments. Not that I minded all that much. The whole place sort of makes it feel like you are in a garage or an unfinished, I mean really unfinished, basement. But the truth is, if the woman who got her rub down before me had crabs, I definitely have them now too. And let me tell you something else. When I got home and took a shower in my own bathroom, I found oak leaves in body parts I didn’t even know I had.

In addition, yesterday was the second straight week I witnessed a woman in the sauna openly shaving every part of her body. I mean, not just the places you usually shave either. She was going all out. Arms, feet, neck…and from what I could tell, she didn’t have any excess hair to begin with. She used a bucket of water sitting next to her to shake her razor out and then, when she was done, just dumped it on the floor, all the water and the little hairs trying to make their way to the drain. I looked away.

So, all in all, the baths are great. I’m sure some of my readers out there will disagree with me after my description but I’ve always been attracted to those places, physically and emotionally, that make people turn their heads and cringe. Why do you think I’m a midwife? Labor and birth is full of scary, dirty, smelly things. Panic, poop, blood and total exposure. I love being a part of experiences where there is absolutely no room for pretense. Things are real with a capital R and there is nowhere to hide from it. And I like that part of my job, a big part, is about normalizing those sometimes uncomfortable experiences for others. So, thankfully, the Russain baths did not include any blood or poop (that I saw anyway) but I think it’s another place where you can let it all hang out. You can sit there and sweat and talk shit and pull leaves out of your butt and no one will think twice.

Last night was the last session of the season. The baths reopen in September. And I have a feeling I’ll be going there a lot after work come fall.

Kids these days...

2009-05-12T13:25:00.000-07:00

There was a knock on the exam room door in the middle of one of my routine OB visits. I gave my patient a confused and frustrated look as I got up to answer the door.

“This never happens,” I said. Though it has already happened more than a handful of times. “Sorry.”

When I opened the door, one of the medical assistants was standing there apologizing but letting me know that a pediatrician from downstairs asked that I be interrupted in order to consult with her over the phone regarding a 16 yo pt she had “on the table.” I excused myself and headed toward the phone thinking, Why would a pediatrician be asking for me? Like, she wants me? Me, me? Or just a clinician? My MA didn’t know. She just handed me the phone.

“Hello?”

“Hi, thanks so much for taking my call.” The female voice on the other end said.

“Well, I was told you wanted me to be interrupted.”

“Yes, yes, thanks so much. I hate to bother you during your busy day but I have a pt here, like on the exam table, and I’m not exactly sure what to do with her.”

“Okay, well, I can try to help.”

“Well, the patient is saying that during sex last night she had a “gush of blood” and now she is also having some pelvic pain. I’m just not sure what to do. You see, I’m just a floater here…”

I couldn’t help but think of her swimming in the toilet even after a flush or two…

“Well, is she bleeding now?” I asked.

“No, not really. I don’t think so.”

“Well, I’d do a pregnancy test, and I would definitely take a look inside.”

“Ok, well, but, as I said before, I am just a floater here. I’m not even sure I can do that here.”

“You mean you don’t have speculums down there?”

“No, no, of course we have speculums; it’s just that, I was hoping you could see her?”

Long story short, after being interrupted for a 2^nd time by this same “floater”, the patient was sent upstairs to see me.

It turns out, she did have a gush of blood while she was having sex. A “gush” that she describes as “filling the cup of her hand”. Then the bleeding almost immediately tapered. She reported only having brown spotting today. She had no pain before or during the episode of bleeding but now she has diffuse pain in her lower abdomen. She’s been sexually active for 2 years. She’s on the pill and has not forgotten to take her pill, ever. Her last period was normal. Her pregnancy test today is negative. This has never happened before.

I tell her that I have to take a look inside. She understands though is squirming and uncomfortable with the idea. The pt has minimal problems/discomfort with the insertion of the speculum. I can immediately see blood in the vagina and as I look around and use the speculum to push away vaginal mucosa, it’s clear that the bleeding is no longer brown but bright red. Not tremendous amounts but there is no question that something is actively bleeding. There was blood on the cervix but it wasn’t clear that the bleeding was actually coming from the cervix. I pulled my light around even more to get a better look at the sidewalls. And then I saw it. The right side of her vagina was completely intact and I could visualize the entire thing from introitus to cervix. But the left side was not right. There was a fairly large laceration that was running down the length of her insides.

“You aren’t in any pain in here?” I asked as I dabbed the gash with a q tip.

“No. I can’t feel that.” She said.

It’s true that there are less nerve endings inside the vagina. If the wound had been on the outside or up near her cervix I am certain she would have been in more pain, but presently, she was generally comfortable. Just embarrassed and anxious.

“Was there anything in your vagina besides a penis?” I asked.

“No.”

“Like, no toys? No fingers?”

“No, nothing.”

“Well you have a pretty significant cut in here.”

“I do?”

“Yes, you do. I can’t see it very well but I’m pretty sure that is where your bleeding is coming from.”

“That is so gross.”

“Well, it happens, I guess.” I had never seen this before. “But I definitely do not want you to have anything in your vagina for a while. Until this heals. And I’m going to let the doctor know what I found and see what she wants to do.”

I grabbed one of the docs who was in the office that day and let her know what was going on. We got a pelvic US to r/o any kind of hematoma (which not surprisingly was normal) and the doc told me to pack the vagina for today, give the patient good warning signs for increased bleeding and pain and to have her come back tomorrow to see if it has healed. Initially I was a little frustrated that the doctor didn’t want to see (confirm) my “diagnosis”. I mean, if she saw the extent of the laceration, maybe her plan would be different. Plus, I just didn’t trust myself. Maybe it wasn’t a gash. Maybe the blood was coming from somewhere else and I just didn’t see where…But after I packed the pt’s vagina and made her an appt for the next morning to see another clinician I checked in with the doctor.

“So, you think that packing will be enough for tonight?”

“I hope so. It might just be enough to tamponade the area. I’d like to avoid suturing the vagina of such a young girl if we can just use expectant management. And tomorrow when she comes in, I can help assess and if she’s still bleeding we’ll just have to suture her.”

That made sense to me. And since the patient’s bleeding was well under control, her CBC was normal and I could bet any amount of money she wouldn’t sticking anything inside of her for a long time, I felt better.

It turns out, she was one of the patients I thought about all night and well into my next day on call. Around noon (I knew the pt’s follow up appt was at 11am) I called the office and spoke with the midwife who saw her. It was definitely a laceration just where I had thought it was. It was still bleeding when the packing was pulled and the doc and CNM advised the patient that she would need to have the wound stitched. And she refused. She just refused. She wanted to just let it heal and bleed and not have anyone else touch her. Which, is absolutely her prerogative. I just couldn’t help but think it was the wrong decision. And I couldn’t help but think it was only embarrassment and fear that made her refuse. And I definitely couldn’t help but think that I would most likely be seeing her again. I’ll have to remember to do better education on lubricating agents the next time she makes an appointment…

Deja Vu

2009-05-03T10:02:00.001-07:00

Well friends, it happened again. Just like I told you. I was covering for my friend and fellow midwife yesterday at the hospital from 1pm until 7:30pm. She was moving to a new apartment, I was free for the afternoon and I needed some hours so I thought I would do her a favor. When I got to the hospital there was literally no one on the floor. I finished some charts from the office, chatted with another midwife friend of mine who works with another practice, hung out in jeans and open toed shoes for what seemed like hours. And then 5pm hit. Three, yes three, patients came in all at once. 1 woman at 41.3 wks who was sent in from the office for induction for an IUGR baby, not to mention post dates. Another woman who had been contracting irregularly since the morning, had a non reactive NST in the office but an 8/8 BPP who was now c/o very painful and regular contractions and the last was my own patient from the office who was a 38 yo G2P1 being induced at 41.5 wks. They ALL got to triage at the same time. Got there, in fact while I was upstairs on the postpartum floor seeing a patient that the CNM pp rounder didn’t have a chance to evaluate. One moment it was chill, the next moment it was crazy.

The IUGR induction pt got directly admitted. She was 2/75/-2, soft, midposition. She was started on pit and sat in the rocking chair while her husband knelt on a carpet and prayed over and over and over again.

The woman in spontaneous labor, yes, that’s right, I said spontaneous, was only 3cm (50% and -3) but had three elevated BPs into the 140s over 90s so we kept her. Ran labs, got her a room…her labs were normal, she had no headaches or protein in her urine, basically, she was just hypertensive. She wanted an epidural an hour later when she was 4cm/100/-2. An hour after that, she ruptured on her own to clear fluid.

My own patient from the office was a different story. She had arrived at the hospital for cervical ripening at 7:30 in the morning. But because the hospital was so busy, she got bumped till the afternoon. She had a quick NST, went home, came back a few hours later and still had to wait until 5 to get into triage to be evaluated. When I finally saw her, she looked tired, disenchanted. She’s the kind of person who was cheerful 99% of the time I saw her in the office. Today, she looked heavy. And I could see that she was trying to stay light and stay smiling but her eyes were already glassy like she was just waiting for an opportunity to let go. She was c/o irregular tightening but other than that, no real change from when I saw her in the office the day before. And her cervix hadn’t changed much either. She was a tight 2 cm, posterior and only about 25% effaced. Her last baby was an induction as well and she reported having a really hard time with the “tablet” they gave her. She remembered being sent home and starting to have frequent and painful contractions almost immediately. She was scared and in pain, and didn’t know when to come back to the hospital.

She’d been here all day, I thought. And she does need some ripening. But I didn’t want her to panic more than was necessary or relive an obviously traumatic experience. So, I went with gel. Gel, yes, gel. It’s got a reputation for not working so well. Or at all. One of my preceptors from school used to joke that she thought the gel formulation of ripening agents was just KY jelly disguised in a medical looking syringe.

“I’m gonna give her gel.” I said to another midwife who asked me what I was going to do with my patient.

“Might as well not give her anything at all.” She said back to me.

The thing was, giving this woman gel solved some problems. For one, the patient was less anxious about the ripening process and also, I was able to honestly tell her that this was a way less aggressive form of ripening agent. I was able to look her in the eyes and say, this may not do anything to you at all. You my feel crampy but it’s unlikely that you will have the same experience as you had with the cytotec.

“What if we just didn’t do the gel and we came back tomorrow for the pitocin?” She asked.

“Well,” I said, “If you just come back tomorrow and your cervix is the same, you may have to get a dose of this anyway.”

“Okay,” she said, “Let’s just do it.”

The gel went in and we started the two hours of monitoring you need on this agent at our hospital before a patient can go home. Within 5-10 minutes my patient was contracting every 3 minutes. And then she was contracting every 1 ½ minutes. And they were painful. After an hour and a half of monitoring she was shaking and asking for an epidural. This is the report I got from the triage nurse and I immediately felt disbelief and guilt. Was it really the gel making her contract so wildly? Was it my exam prior to the gel placement? Was the patient mad at me? Was she thinking I lied to her? Did I lie to her? I could barely go back into that room to confront the answers to these questions and to witness her pain. And usually, when it comes to labor pains, I’m kind of a tough guy.

“These contractions hurt!” Patients will say.

“That’s great!” I’ll say. “They are supposed to hurt. Labor is hard work. You’re doing great.”

But with this woman, I couldn’t put on the act. I wanted to immediately take away her pain. I wanted to see her smile again. I wanted to make her comfortable. I did not want her to think badly of me. I relayed her story to the oncoming midwife, who had arrived for her shift at this point.

“You know,” she said, “when you have a personal relationship with someone, when it’s someone you have seen almost every week for the past 2 or 3 months, it’s much harder to watch them be in pain.”

“I know. I know.” I said, “But these contractions…they’re like every 2 minutes…”

“So, the gel is working.” She said.

And yeah, I guess the gel was working as it was supposed to, I just didn’t care. In my head I’m thinking can we give her narcotics in triage? Turb? How can we make this go away. My head was in such a different place. The other CNM and I made a plan to admit her, get her an epidural and pit her as soon as we were able if there was no cervical change at her next exam. Armed with that plan, I was finally able to walk into her triage room. She was drenched with sweat, crying, and looked up at me with eyes that had lost every ounce of her reserves. I put my hands on her shoulders.

“Listen, I’m not going to make you go home.”

“Please, please please don’t. I can’t go home.” She said.

“I promise. You’re going to stay here. We’re going to get you a room and get you some pain relief. And I’m not going to leave until you are comfortable.”

And then the nurse told me it would be at least a half hour until she even got a room. And I bailed on her again. I just couldn’t go back in there and give her what I thought would be horrible news.

“Guess what? I know I just told you you were going to get a room and an epidural but you’re going to have to wait longer, a half hour at the very least longer, before any of that happens. I know you’re having contractions every minute but you’re doing great! Keep it up!”

I just couldn’t have that conversation with her. So the nurse went in, started her IV, drew labs, gave her fluids, basically distracted her, made her feel like things were happening before they actually were. She did get a room. And finally the anesthesiologist came in, took forever to fill out all the paper work because, I’m pretty sure, she was very new. My patient assumed the placement position with her legs dangling off the bed while her “team leader” talked her through every step of the placement. At one point my patient opened her eyes and looked at me hiding behind the curtain that separated the room from the rest of the labor floor. She just stared at me. And I couldn’t read her at all. Mad? Sad? Scared? I kept hiding.

But little by little, she started to feel relief. And her face brightened. And her shoulders softened. And she opened her eyes and looked at me again.

“You’re a saint.” She said. “Thank you so so much.” She was so sweet to say that and it made me feel so relieved. But I was also so embarrassed. A saint for what? For being a coward? For not being able to be a midwife who could sit in a room with a laboring woman who was in pain? Which part made me a saint? I wasn’t sure. But I was happy that she was comfortable. And I was happy that her husband looked like he was having a reprieve from his own stress. We all took a deep breath, they showed me photos of their first child who was 19 months old, and we joked that this labor thing would be so much more fair if the length of it could be determined by how much pain you felt.

“Well, you know what?” I said, “When you have your third child-”

“Um, no.” She said, cutting me off. “This is it. The last one. Snip Snip.” She made a scissors motion with her hand.

I wasn’t sure if she was talking about surgery for her or her husband but I looked at him and he seemed unaware. So, avoiding any more uncomfortable topics for the evening, I kissed her on the check, gave him a hug and finally left the hospital around 10pm.

I stopped in to see her today on the post partum floor. She had an 8lb 6oz baby boy at 5:46am and she was definitely NOT mad at me or disappointed in her care at all. She loved the midwife who took care of her in labor, she was happy she only pushed 3 times and she knew, without a doubt, that the gel was a much better experience than the cytotec.

She lifted her baby up from her lap so he could see me. “Look honey!” She said to him. “Is that your midwife? Who took care of you while you were inside me? Huh? Is that her?”

He just kind of stared at me with unfocused eyes and a trembling chin.

“Yeah,” I said to him as I grabbed his tiny red foot. “It’s me. Here I am. I’m your midwife.”

My Cycle

2009-05-01T09:47:00.001-07:00

Here is the cycle I go through basically every time I’m on call. I start out in a minor panic as I get report, trying to keep everyone straight in my head, and resist speaking up when I disagree with the reasons someone is being induced (for example). My shift starts and things slowly but surely get under control. On many days, not all but many, things are fairly slow, or at least manageable. I have someone “in labor” who isn’t really in labor and I baby sit her while she gets ripened or gets low dose pit and sits on a birth ball changing her cervix from 1-2 to 2-3 in 12 hours. But then, lo and behold, almost without exception around 5pm things start to pick up at a sometimes alarming pace. More triage patients come in because the office is now closed and patients are making a bee line to the hospital, someone ruptures in the lobby, a nullip calls three times freaking out that her ctx are painful and coming frequently, a patient on the pp floor can’t pee…So, after a completely in-control day, I get bombarded and things start to unravel. Suddenly it’s 7:15pm, the oncoming midwife is on her way upstairs, paper work is only half way done, there are loose ends blowing all over the place and I start to panic (ah we’ve come full circle here) that it will look like I’m just a lazy, disorganized fool who waited until the last minute to do anything. And, the woman who usually takes over for me when I work a Wednesday or a Friday shift (often the two days of the week I am in the hospital) is so hard to read. She almost never laughs at my jokes, she takes report from me without sharing eye contact, barely asks questions, just stays silent, wishes me a good night and head’s out to the floor to, I’m sure, change management plans and do her own thing.

Now, I know that one of the things I need to work on as a new practitioner (and in my life) is to chip away my stellar ability to assume that everyone else’s plan or management decision is way, way, way better than my own. I’m so good at channeling insecurity. Too good on most days. And I am constantly working on finding a balance between confidence and humility. And it is hard, hard work. Trusting yourself, sticking with your choices, knowing, and I mean really knowing, that each decision I make doesn’t directly relate to my worth as a midwife or even as a human being. Why can’t my reflex be to think that that midwife is tired, or weird, or has bad people skills. Instead I think she hates me. Yep, that’s what’s going on here. She resents that I am new, resents that I would not have done things the way she would have and now feels like she has to “clean up” my mess.

Clearly, these topics are just fodder for my weekly therapy sessions. But, in the meantime, I have 2 mantras to recite: my multip mantra as I head into the hospital and now mantra #2 which I will start to meditate on as I leave the hospital in order to quiet the judging voices in my head. I’ll take deep breaths, appreciate the fact that, if nothing else, I am walking out of the hospital and into the now soft spring air. I’ll acknowledge my insecurities but remind myself that it’s okay to be new and that patience, for my development as a midwife, is an essential virtue. And a strong gin and tonic usually helps too.

Follow Your Gut

2009-04-22T10:11:00.000-07:00

I spent the night trying to get a woman into labor who, on paper, had been augmented for post dates but who, in reality, was a TOLAC (her first was a c-section and then she had a successful VBAC a few years ago) who had started prenatal care at 19 wks and was only seen in the office 5 times since then. So, it’s been worse, right? And we actually got her GBS status (negative) somewhere in those 5 visits. Anyway, she was 41 wks by that 19 wk US and decidedly not in labor when I got to L and D.

She was reported to me as “favorable” at 2/50/-3 which I wouldn’t call supremely ripe as I gave her a bishop’s score of 5. She was “contracting” but her ctx were almost undetectable by the patient. But hey, she was on the floor, pit had been started, she was a multip and I had already prepared to be up all night. She finally changed to 3 and proceeded to an epidural. And like so many of my patients, had some rest and 4 hours later she was 8 and 100 with a BBOW.

I also ended up admitting a multip (a G6P2022 to be exact) who called me around 4am c/o irregular contractions since 3am. No bleeding, no LOF, no HA, +FM… I’m like: Call me back when the contractions are regular, like every 5-10 minutes for an hour. “Really?” She says. “But I really think I’m in labor!”

“I think you might be in labor too! That’s great. Call me back.”

I barely finished my telephone note on her when I get a phone call from our answering service. It was the same pt. Calling back less than 15 minutes later reporting 2 painful contractions since we had spoken last.

I mean, is this me? Is it my practice? Is it just people? What the fuck is up with that?

I call her back. “You didn’t make it the full hour, huh?” I said trying to mask my annoyance.

“No.”

“So, tell me what’s going on.”

“Well, it’s just these contractions! They keep coming and coming! I just keep having them! And man they hurt so much!”

I checked the number against her chart. Yep, same woman who has supposedly had 2 other children vaginally.

“Well, you’re in labor, honey.” I said a little softer. “You’re supposed to have contractions. And it’s supposed to hurt.”

“But I’m nauseous and getting all hot and these contractions keep coming!”

“All normal. You’re doing great.”

“But…”

“Are you saying you would like to come in and be evaluated?”

“Yes!”

“Okay, come on in.”

I just don’t get it. When someone has been in labor before, not once but twice (!), why do they always seem so surprised with the pain of contractions, or, actually, with just simply the contractions themselves?? What are people preparing for during those 40 weeks? No seriously, tell me! I am at a loss here. I probably get at least one report like this every night I’m on call. I understand the fear. I understand the sense of feeling out of control. I even understand the somewhat misguided feeling that the hospital is a better place for women to be than their own homes when they are in labor. But surprise? Complete and utter surprise than contractions just, well, happen? (I smell a bumper sticker here…) I do not get that. So, she got to triage, she was 5/100 and high. I admitted her and she decided she wanted an epidural before I had a chance to say anesthesia.

And then it was 7am. Glorious oh glorious 7am. This is the time I start to write my last notes, do my rounds on my patients, say goodbye, let them know who the next midwife will be…it gives me a sense that morning has broken and my own warm bed is in the very near future.

I gave report on these two patients and the CNM who was on call for the day told me she had three inductions scheduled in addition to these two patients I just left her. “Well,” I said, “I do think these two will probably go. Both are in pretty good labor now.”

“You never know.” She said back to me. “You just never know. You think these multips will go and then you are surprised. They stall or something happens…You just never know.”

“Yeah, I guess you’re right.” I said “But, I don’t know. They might.”

“You just never know.”

The on call midwife and the pp rounder started chatting as I was getting my coat on. They were talking about 2 recent IUFDs we had in our practice. Both 3^rd trimester. In one situation the MD wanted the patient to come in for a f/u NST after 1 episode of decreased fetal movement for which she had been evaluated and it was found to be benign. The doc just wanted to run another strip.

“Just because she ‘had that feeling’” The midwife said.

“Oh yes.” The other midwife said “That ‘feeling’. You have to follow your gut. You have to follow your intuition. That thing that keeps you up at night. You have to listen to it.”

Now hold on. I thought I just had a good feeling about these 2 multips headed into some nice active labor and possibly second stage. And I got shot down. I got the “you never know” response. But why sometimes, usually in hindsight I might add, do you get the “you just have to follow your gut” response. There are so many problems I have with this. Besides the glaring hypocrisy here, I think sometimes your “gut” is so wrapped up in feeling scared that it is difficult to “know” what the truth is. I also do not believe you can ever tell what the future holds. I also do not believe that because that doctor wanted the patient to have that NST and the pt refused and the baby was without a heartbeat the following week, that that doctor somehow had a 6^th sense about the fetus’ wellbeing. Or maybe it’s just that I don’t feel that I have that intuition (yet?) so I don’t even want it to exist.

But here is something I do know: I left the hospital, walked into the parking garage and just 3 cars away from mine was a blue station wagon with the license plate “BELLY”. I rolled my eyes, might have uttered a tiny “ew” as I passed and knew in an instant that that must be the car of a fellow midwife. I mean look, she followed her gut, right? And look where it got her.

Sweet 16

2009-04-17T08:34:00.001-07:00

I like to think I can relate to my teen patients. Yes I have 15 years on them, and yes, my skin isn’t as taught as theirs, and maybe I am not quite as computer literate as they are but I do like to think that I’m still sort of hip, I can still remember what it’s like to be young and not trusted and clueless about so many things. So I really make determined efforts, when young women come in for birth control or their first annual or an unwanted pregnancy, to make them feel safe and at home and like they can be honest about themselves and their situation. But sometimes, the adult in me comes out. And it surprises and actually upsets me when the adult/caretaker head rears itself at unpredictable times. I can’t tell if it’s actual caring that’s happening or just frustration and anger with the bad mistakes I see being made by some of these girls.

Yesterday I had a 16 year old girl on my panel who was coming in for her annual exam and her depo shot. Just seconds after I walked into the exam room it became clear that I would not have a huge amount of patience for this patient and that my “adult” head was starting to grow and grow and grow. She hadn’t filled out her intake form that each patient is asked to complete prior to their visit. She “lost” it. So, we filled it out together. She is a sexually active 16 year old female with NKDA currently not in a relationship but using depo for contraception who feels safe at home. She has been using depo for just about a year now but doesn’t like the “irregular” bleeding, which for her is spotting q 2 months. She’s interested in another form of birth control but can’t remember to take the pill and thinks the nuva ring is “confusing”. Her medical history is benign. She has a significant family history of alcoholism and a cancer that she does not remember the name of. She smokes ½ a pack a day but denies drug use. She uses ETOH 1-2 times a month.

She does not perform monthly self breast exams. She does not wear her seatbelt.

“You never wear it?” I ask.

“Nah…I don’t like to.”

“Why not?”

“Well, I wear it when I think I’m in a dangerous situation.”

“You should really wear your seatbelt all the time.”

“Well, I’m really good at knowing when the situation is dangerous. And basically when I’m in the car I just put my feet up on the dashboard so that would brace me if there was a crash or something.”

“Your legs would break if you were in a head on collision.”

“Well…better my legs than my head, right?”

“You should wear your seatbelt.”

“My friends and I were in a car accident and one guy got hurt pretty badly.”

“That’s too bad.”

“I saved his life.”

“uh huh”

“I did. I saved his life. There were four of us sitting in the back and I just laid right across everyone. If I hadn’t bee there he would have gotten hurt so much more. Human seatbelt!”

“…”

“So, I think about wearing my seatbelt more I guess.”

“I hope one of your friends doesn’t have to die before you start to wear your seatbelt all the time.” My “education” was devolving into scare tactics. It was terrible.

“No, I really saved his life.”

“Listen, I know when you walk out of this room you are going to do whatever you want to do. But as your care provider I have to encourage, no advise, you to wear your seatbelt.” And then it got worse. “I’m sure you and your friends are incredibly safe people and drivers.” I said. “It’s the other drivers on the road I’m concerned about. That’s where the unpredictability is.”

She didn’t buy it. She just smiled her sweet 16 smile. And started texting someone.

blogging for happiness

2009-04-09T19:03:00.000-07:00

For some reason, though I’ve had more than my fair share of scary, challenging, and memorable experiences in the past few weeks, I just haven’t been as compelled to write. Maybe I don’t need the catharsis right now. Maybe I’m sick of writing about my incompetence and insecurity. Maybe I’m just distracted by all the planning I’ve been doing for my recent Passover Seder. But I heard a story on NPR about blogging and it basically said people who blog are generally happier than those who don’t, even when they are talking about the most boring and mundane things. I’m not sure I actually believe that. But if the biggest side effect of writing this blog is boring all of the people (you) who are reading these entries, I figure it’s worth a try. So even when it feels like there is nothing to write about…I’m gonna put pen to page, or, ahem, fingers to keyboard, and get something down. So, today I have for you some choice parts of a conversation I had with one of my patients in the office today: (let it be known that this was the end of a very very very long day. And this pt was very very very late.)

CNM: So what brings you in today?

Pt: To be tested.

CNM: to be tested for anything in particular?

Pt: No. I guess not, just…everything?

CNM: So…would you like me to test you for strep throat?

Pt: um

CNM: …

Pt: I guess?

CNM: Are you here for STD testing?

Pt: Yeah, that. I want that.

CNM: Are you having any particular symptoms? Or do you think you’ve been exposed to an STD?

Pt: Yeah.

CNM: Which?

Pt: I sort of have something weird coming from down there.

CNM: From where?

Pt: From, you know, my hole.

CNM: Which hole? There are 3 of them.

Pt: Oh, I guess my…

CNM: Your vagina?

Pt: uh, yeah.

Later in the conversation:

CNM: Any other recent changes or problems with other systems of your body? Respiratory issues? Burning with urination? GI changes like constipation or diarrhea?

Pt: Well actually, now that you mention it, I have had some diarrhea for the past couple of days and I’m not sure why unless it’s the extra shot of hazelnut I’ve been getting in my coffee…

I couldn’t help myself. I laughed. Very, very loudy. And I have to admit, writing it down now is making me smile.

Women's Health Conference

2009-03-22T18:36:00.000-07:00

For some reason, I was only scheduled for one call day last week as opposed to my usual two. I noticed the extra blank space in my appointment book a couple of weeks ago and got this relief/ecstatic/criminal feeling in my body and my mind kept jumping back and forth between thoughts of, “Should I tell someone about the mistake?” to “Yes yes yes. There is no way I am not getting away with this extra day of escape from the hospital.” But then, I got an email announcing that some administrative person from my organization was going to be manning a table at a women’s health conference and she would just love it if someone else could be there with her to represent our women’s health services. In all honesty, I have to say, I was genuinely interested in this. It was a conference as opposed to a day “on” so, though I would be glad-handing a bit, I wouldn’t be responsible for anyone’s life, plus there might actually be some good info to glean about women’s health AND, most importantly (see my last entry) there would be free breakfast and lunch and coffee all day (stated clearly in the conference program that was sent along electronically with the administrator’s email.) Long story short: I said I’d do it and started thinking about what professional-casual outfit I might wear for the day…

I arrived at the conference a little late. The woman from my organization who was in charge of the table said her plan was to get there (I mean, there and ready to go and work and talk to people and be normal) at 7am. Now, when I read that, I thought, does there really need to be 2 of us putting little pamphlets and pens out on the table at 7am? Why not bring in fresh legs at around 8 or so? She never really told me when I should get there. Just mentioned what her own plans were going to be. I rolled into the hotel function room a little before 8, and let me state for the record, I decided to take the bus and it ended up either picking up or dropping off someone at every single stop. Plus, the driver gave me bad information about where to get off downtown and I ended up having to back track on foot (in a pretty mighty wind!) to get to my destination. So, I probably would have gotten there earlier if it hadn’t been for all those…situations.

Thankfully, I didn’t stop for coffee cause when I finally did arrive there was an enormous spread of starbucks coffee and pastries and bagels and all sorts of fresh juices in glass bottles stuck into buckets of ice. Had there been some lox there to go with my toasted bagel, well, the day may have turned out better.

Let me set the scene for you. This is a day-long women’s health conference with various speakers and MCs throughout the day. Women (and 1 or 2 men) have signed up for this conference, paid a fee to register, received a bag full of goodies like coupons for health clubs and travel first-aid kits and are set free to roam in a moderately sized function room with about 20 tables, each advertising a specific sleep aid or cholesterol lowering drug or boasting the attributes of a near-by mammogram screening facility etc etc. Our table had a bunch of info on our own services, specifically women’s health and midwifery related materials. The woman I was working with seemed indifferent about my being there. She barely said hello to me and definitely did not give me any directions as to what she wanted me to tell these women, the plan for the day, etc…So, I grabbed a bagel and coffee and started smiling at passersby.

The first woman I spoke with was something called a “Well Coach”. And I quickly learned that this is currently a VERY popular profession. As I kept talking with people it became clear that probably a third of the participants here were these “well coaches”. Stationed at medical centers, health clubs, resorts, or working privately they seem to be a nutritionist, a trainer and a psychologist all rolled into one. Which sort of sounds good…on paper. But it was kind of like all those people in customer service jobs who are just mean, bad communicators that make you hang up the phone and think, “Now why would that person ever want a job where they had to “service” people when they so obviously hate the species??” Similarly, many of the “well coaches” I spoke with seemed distrustful and invasive. One of them kept pushing me on some sort of wellness system she had created and that she was trying to sell to various organizations so that they could promote it to their patients. I didn’t really get what it was, plus her services aren’t covered by insurance so I can’t see that many of my patients would be interested in her “system” anyway. But I tried to give her some kind of lead.

“Well, I hear we actually just hired a wellness coach at our facilities (I overheard the admin person I was with saying this to someone else). Maybe you should speak with her about getting the word out.”

“Actually,” the Well coach said, “That is the last person I should speak with. She’d probably just take a look at the system I’ve created and say something like, ‘Wow this is great, wish I’d thought of it. I don’t know what to tell you.’ So, I don’t think that’s a great idea.”

Her response stunned me into passing her off to my right hand woman from administration. Bitch. I thought. And took another bite of my bagel. Moving on…

The participants roamed the hallway of tables until a hotel staff member (I kid you not) comes around banging on a soft but clear sounding xylophone alerting everyone that the lectures were about to begin. Everyone slowly leaves the room and takes a seat at the larger but still windowless assembly hall for 3-4 hours of power point presentations. And this was when things started to pick up downhill speed.
It is amazing how easily a women’s health conference can become a trite collection of analogies about “being present” and finding a way, in this 21^st century world, to happily balance life and kids and husband and work and pleasure. I immediately got the feeling that the population the speakers were targeting were the 50-something women who were concerned about heart health and titillated by this new funky idea of “being present”. From the outset, sitting in the very back of the room I could see an ocean of bleached, permed heads aggressively nodding in agreement with the speaker as she talked about watching her golden retriever chase birds on the beach for 45 minutes straight without tiring because he was totally and completely “in the present”. I hoped there was a barf bag in that collection of goodies all these women got when they registered cause I think I might need them all.

Someone spoke about aging gracefully, someone spoke about heart disease, someone spoke about sexual assault (after which I overheard a participant say “That was boring. I had to get out of there and come back to the tables”).

It was disappointing but I have to say, I agreed with her. I had to take a breather back at the tables a few times. I filled up my coffee cup, I drank some water, a visited the ladies room for a change of scenery. I even called my father to say hi. Any way to escape. My father, who has been an insurance salesman for over 30 years has been to a bunch of conferences about, selling life insurance I guess, in his career and his response when I told him where I was, went something like this. “Oh god. I hate those things. I used to go at the beginning of my career, thought I’d learn something, had a lot of energy to get out there, meet people. They were always so boring. I felt like I was in prison. It was hell. There was nothing worse-”

“Okay, dad-Thanks. I got it from here. Already feeling bad about being here. Thanks for the empathy, though.”

I went back into the lecture hall as the presenter was sharing stories about her family’s yearly windsurfing vacation. She was telling us how one of the most fun things to do is get on her board, catch the wind, straighten her legs and lean way back. This, apparently, makes her and her husband and her three beautiful children fly through the ocean at top speed. And it is very fun. But, there was one day when the waters were rougher than expected. And, try as she might, she just could not get her legs to straighten without losing her balance and toppling over. Again and again and again. She spoke with her husband (who is an excellent windsurfer”) about her struggles and he said this:

“When you’re riding in the chop, you have to bend your knees.” Make it stop. I wanted to say. Make her stop. But she would not. She continued.

“I looked at my husband and thought, my god, what an amazing analogy for life. When life is hard (ie when you are riding in the chop) you have to stay flexible, bend your knees, ride the waves, and you won’t get thrown off balance.” I grabbed my own goodie bag and looked for anything to regurgitate my lunch into. (Which really would have been a shame because lunch was actually the one shining moment of the day. A lovely sit down meal with fresh rolls and grilled chicken and some sort of cheesy risotto situation.) I stepped out of the room to catch my breath, went to the bathroom, and tried to concoct a way to leave early…

I made it until 2pm which I think was admirable since the thing only went until 3:30. I was sitting, “listening” to a presenter with my elbows on my knees, head in my hands, thinking of my father who thought these “educational” conferences were like jail (probably the best analogy anyone made all day) when the woman at the podium leans towards us and says into the microphone in a determined voice just over a whisper:

“Listen, the truth is, no one can start over, but you can start today and make a new ending…” Applause erupted from the audience. So, so true, I thought. I can make a new ending. Starting today, never agree to volunteer at a women’s health conference, regardless of how good the menu is …

I turned to the admin women: “How would you feel if I left now?” I asked.

“That’s fine.” She said indifferently. “You can leave whenever.”

I packed my bags, took the escalator to the ground floor and walked out into the sun. A free woman.

Drug Reps

2009-03-17T18:33:00.001-07:00

I have very few political morals at this point in my career when it comes to free dinners sponsored by drug reps that want me to prescribe their product. I like to think I have the ability to make unbiased choices regardless of how much roasted chicken and smooth tasting red wine someone else is paying for me to eat and drink. So, I rarely give up a chance to sit and listen to someone talk about the benefits of Yaz on PMDD if I can relax, eat buttery garlic mashed potatoes and flourless chocolate cake without ever having to open my wallet. It’s just, something I am okay with right now. In fact, I’m more than okay with it to be perfectly honest with you. I freaking love it. I love free food. I love free things. I am not embarrassed to say that I spent a good two years of my life gathering bread of all kinds from dumpsters and storing them in my freezer for toast, sandwiches, dinner parties…(It was because of a guy basically. Long story which I will not go into now but, just to reiterate, I am not a stranger to good deals.) So when a fellow midwife told me that there were some drug reps inviting any and all OBGYN providers to a spa last night in order to hear about the latest in HPV screening guidelines in exchange for a FREE treatment of my choice, well, I was not about to turn them down.

I arrived at the day spa around 7, was immediately served a glass of wine and multiple appetizers and had a lovely woman tell me all about the 2008 screening recommendations for HPV. She was sweet, not too overbearing, and wasn’t talking for long when it was time for my facial!

A heavyset Jamaican woman led me through a hallway to a dimly lit room that smelled like eucalyptus and had a massage table placed diagonally in the middle. She sat at the head of the bed and I wasn’t sure if I was supposed to undress in front of her, or undress at all.

“Should I take my shirt off or…” I started.

“No, honey” she said to me opening some of the bottles on the metal cart beside the table. “You’re getting the mini. You can just lie down.”

“Oh.” I said, a little disappointed that this “mini” might not provide the deep tissue massage of the neck and shoulders I was hoping for. I laid down on the table.

“So…tell me about your skin…” She said.

“I guess it’s on the drier side for the most part. Mostly right here.” I pointed to my “T zone” and might have even said “T zone” to her in the hopes that it would sound like I knew something about skin care.

“Any products?” She asked.

“Just a mild cleanser once a day, and a light moisturizer.”

“How about exfoliation?”

“Yes, I do that too. Like 2 times a month maybe.”

“Mmmmm.”

“Is that okay?” I asked.

“Well, it could be 2 times a week…Close your eyes.”

Light comes over my head and, even though my eyes are closed I can sense the woman’s face coming closer and closer to mine, examining my skin with her enormous magnifying glass.

“Hmmmm.” She says. “Hmmmm. Uh-huh. Not bad. Not bad.”

“Is everything okay?” I ask.

“Mmmmm. Well, dehydration seems to be your main issue. Lots of dehydration. You need to hydrate yourself. Dehydration causes lines. And you don’t want lines.”

I was immediately reminded of one of my midwifery school professors who interrupted me during an exam to let me know that she was distracted by how much I furrow my brow. “Well,” I said to her, disconcerted by the fact that I was still mid-exam. “I like to think that my face is just expressive.” I put my head back down but she continued to talk to me. “You know, another one of the midwives here does that. She’s been doing it all her life. And look at her now…You definitely don’t want to keep squinting like that.”

“Okay, well, thanks.” I said and kept working.

The dehydration blow was somewhat easier to digest. And, to her credit, the woman was right. I don’t drink nearly enough water. I settled in to the lotions and scrubs and hot towels laid over my face, wished there was about an hour more of the very brief neck rub and emerged from the “mini” feeling somewhat relaxed and inordinately sticky. Nonetheless, everyone still hearing about HPV screening and eating cheese said I looked like I was glowing. In addition, all of us who came to the event went home with a goodie bag including a few travel moisturizers.

So, another drug rep success. A free facial, a new HPV algorithm, party favors??!! I think I made out nicely. Listen, I voted for Obama. My politics are just fine.

No Patience for my Patients

2009-03-12T17:57:00.001-07:00

Me: Was this pregnancy planned?

Pt: Well, I was tryin’, and then I just wasn’t getting pregnant. It just wasn’t happening. And then I missed my period and I was like What is this?? And I went to the dollar store near my house (laugh) and I bought one of those test things and it was positive and I called you guys and said the test was positive and the nurse, I forget her name, but I was talkin’ to her and she was like you better come in and I was like But does it matter where you get the test like what if I got it at the dollar store or something? (laugh) and she was like, No it doesn’t matter where you got the test so I guess that was it.

Me: It says here you have no drug allergies. Is that right?

Pt: Yup. No allergies, well except lidocaine. And epinephrine.

Me: Do you have good sources of iron in your diet?

Pt: I can’t eat bananas. I just don’t like them.

Me: I wasn’t going to recommend bananas for iron.

Pt: No, you don’t understand. I just can’t eat bananas! (laugh). I just hate them. Even thinking about them, ug! I just cannot eat any bananas for the rest of my life.

Me: Listen to me. You don’t have to eat bananas. What about red meat? Do you eat red meat?

Pt: Not really. I mean, if my grandma makes something at her house and I go over there I might have some, but I don’t eat pork or anything.

Me: Pork isn’t red meat.

Pt: I eat chicken and fish but no pork. I just do not like pork.

Me…

Me: I see in your problem list that you have a history of seizures. When was the last time you had a seizure?

Pt: Oh like a long time ago, it’s not even really a problem any more. Like 2 or 3 years ago. I was hospitalized that time. I think should have my records for that. But it was like a big deal because I was like unconscious and that’s when they found out I was allergic to epinephrine.

Me: I see in your problem list that you have a history of herpes. Is that type 1 or 2?

Pt: What? I ain’t never had any kind of herpes or anything like that. We’ve been together for over 3 years now and I haven’t had anything. I had Chlamydia. Maybe that’s why my chart says that about herpes or whatever.

Me: Chlamydia and herpes are two very separate things. And you may have never had an outbreak. We just don’t want you to have an outbreak during pregnancy-when you are in labor. We wouldn’t want the baby to be exposed to a herpes lesion.

Pt: I have no idea why my chart says that. I have never had any kind of anything anywhere. I definitely don’t have herpes. That must be wrong.

Me: Do you have any concerns about your caffeine intake?

Pt: Well (laugh). I like coffee a lot. In the morning I usually have like 3 cups of coffee and then in the afternoon I usually get a Turbo.

Me: What is a Turbo?

Pt: It’s at Dunkin Donuts. It’s a coffee with a shot of espresso in it.

Me…

Pt: But I love the taste! (laugh)

Pt: So, how big is the baby now?

Me: After you get dressed, come into my office and I’ll show you some pictures I have of what your baby looks like.

Pt: Oh my god (laugh)! Okay (laugh). Cool.

A Little Bit of Everything

2009-03-08T08:42:00.000-07:00

When I'm on call, I try to take each situation and file it away in my mental filing cabinet so that I can easily recall what kind of labor management I did so, the next time I have a similar situation, I can just go back to that place in my filing cabinet and do the same thing. The problem is, every time I have a patient in labor, it feels and looks nothing like anything before it. The labor is different, my nurse is different, the entire situation is demanding new things from me. And even if there is one piece of the puzzle that looks the same as another, the rest of the story doesn’t fit. So my management decisions have to be different and my mental filing cabinet is immediately made obsolete. It's a shame actually. Because I try really hard to let one call shift inform the next. But it feels like each time, I am reminded that there are no rules, no black and white, no cookie cutter approach to labor and delivery that can get you through a non-straightforward situation. At least not yet anyway.

I had one patient in labor all day yesterday. She was a young and healthy G1P0 laboring naturally and easily, probably in more control than I had ever seen anyone. She was a role model for natural labor, and for staying on top of each contraction, asking for what she needed and staying open minded and not panicking the entire time. She had SROMed to clear fluid the night before at 10pm, labored at home until she came to the hospital at 4:30 am when she was found to be 5cm. I checked her as soon as I got to the hospital and got report in the morning and she was an anterior lip. So, she labored for another hour and I checked her again. Still an anterior lip. So I tried to reduce it. I gave her cervix a gentle push and the pt bore down at the same time. The cervix, soft and flexible, slipped back behind the baby's head. I kept my hand there and the cervix seemed to stay back. So, we started pushing. Pushing on hands and knees, pushing side-lying, pushing on the toilet. But the contractions space and the woman wasn’t feeling the spontaneous urge to push with each one. So, after 45 minutes, I checked her again. And that lip had come back.

"Well" I told her. "I can try to reduce that cervix again, but if it keeps coming back like this I have to wonder why that is. If it's not ready to stay back, it might just be trying to tell us something." Her back labor and the baby’s complete lack of descent was sort of telling me that the baby might have been in a funky position too...Either way, I did feel like her contractions just needed to be closer together and potentially stronger. But we'd already started pushing, and she originally had that ant lip, and then didn’t and now the lip was back. It just wasn’t straightforward to me. And I have to admit, when something gets "unstraighforward" I start to get “unsecure” about my decision making skills. And maybe it was completely appropriate to ask the doc what she thought at this point. But, I just started thinking, should I be doing more? Should I be more innovative? Should I know how to do sterile water papules for this woman's back labor? Would it make any difference at this point anyway? Should I seek out another practitioner who knows how to do them?

I told the pt to do nipple stim for augmenting her labor while I went to consult with the doc. I knew she needed pit but this was a pt who never got an IV, never got her initial labs drawn, had had zero interventions and minimal exams...i figured, why not let her try the least invasive option first? Plus, it bought me some consult time.

I start to page my doc to give her an update and I see another doc from my practice. "Hey," I say to her, "You have any great ideas for getting rid of a persistent cervical lip?"

"Yeah," she says, "C-section."

"Come on, really." I said

"I'm serious. C section." And she was. She was really really serious.

"Well," I said, "I don’t think her contractions have enough power."

"Well, that may be a different story." She said.

"Yeah,” I continued. “She was an anterior lip, and I reduced it so she was fully and then she pushed for a bit but now that lip is back."

"I've never heard of that." the doctor said.

"Of what?"

"Of a pt being fully and then not fully. She had a lip and then no lip an then a lip again...? That just doesn’t sound right and you’re getting into dangerous territory."

She was making it sound like I didn’t know what I was talking about. Trivializing the situation and the work we had been doing in the room to "lip, no lip, lip." She was making me second guess myself.

But, when the doctor I was on call with got back to me, she agreed that the patient could have some pit to see if that would get her into a better pattern and maybe get rid of that extra bit of cervix. So, we started pit. And though it got to 6 the patient stayed sans epidural amazingly through a wonderful contraction pattern of q 2-3 minutes. I checked her again. Ant lip. I tried to reduce it. It disapeared. But, I wanted a second opinion. The doc checked her. She felt nothing and gave us her blessing to push. So, out loud I said "Great, so maybe that lip has finally stayed back. Good news! The reduction worked! Let's push!" But inside I was crumbling and second guessing: What the hell was that that I felt?? WAS it a lip? Was it...nothing?? Was it there ever? Did I just make this woman go through tons of pit for nothing?? More second guessing.

We pushed for 2 hours. With no descent of the baby’s head. We pushed in every position we could think of, we coached and didn’t coach, and supported and did what we could but the baby just would not budge. If I could actually assess fetal position I could tell you for sure if I thought it was posterior but since I can usually only feel one fontanelle and never have much of a clue which one it is I was in the dark on that.

The doc came in and gave the "I think the best thing would be to have a section" speech and the patient agreed. She was exhausted. And though she was disappointed, she thought there was no sense in continuing.

At this point in my career, when someone disagrees with me (ie. c-section for an ant lip, if my vag exam is off from someone else's etc etc), my knee jerk response is to assume I am in the wrong. I never think, What the hell do they know? That baby was at +2 not +1! Or, A c-section for an ant lip when nothing else is concerning...??!! She is a bitch and I will get someone else's counsel. I can't wait for the day that I could care less what someone else thinks. Or, at least, keep their opinions in perspective, not let a disagreement wreak havoc on my sense of security...

So, we shut the pit off, went over the risks and benefits of section, wheeled the pt into the OR, gave her husband a set of scrubs, got her epidural placed, prepped her belly, brought her husband back to the OR to hold his wife's hand and delivered her baby. Her direct OP baby. And that whole time, before the pt got her epidural of course, she was walking and talking and not in any pain whatsoever. It was as if her labor had just stopped. As if her mind was like, Ok, well, there's no point to continuing like this so, I'm just gonna get out of the contraction mindset. And her uterus was like, Well, you know what? I'm tired anyway, and since I don’t need to help push this baby out anymore I'm just gonna take a ...little...break...zzzzzzz. The resident who was helping the doc out with the section turned to me and said "How far did she get?" "Fully and pushing." I said. "Really? She doesn’t even seem like she's in labor." "I know." I said. "As soon as she knew were going to section, things just kind of stopped."

In the end, the family was happy. I stopped by their room before I left the hospital for the night. They thanked me profusely. Though, still, I can’t put my finger on why. I was so worried the whole time that I was adding bad energy to the room by knowing deep down that there was no progress and not wanting to wait and wait and wait for hours until we were certain she couldn’t deliver vaginally and until everyone was dog tired. I know, I'm human, but I feel like I'm supposed to stay optimistic and positive and enthusiastic. And maybe it's only me that has those expectations. But clearly it's a theme for me, what can I say?

"We thought about it" the patient said, "And we're really happy about the way things turned out. We decided we definitely got our money's worth. We had all natural childbirth basically, and we also got a c-section! We had a doctor AND a midwife! We got a little of everything."

“Yeah,” her husband said. “We really wanted to be part of your “no epidural statistics” but at least the baby and my wife are healthy.”

“You’ll just have to be part of our VBAC stats!” I said. I felt a little better after talking to them but went home emotionally exhausted yet again. At some point I am hoping to quiet some of those self-doubting voices in my brain…I’m just not quite there yet…

I am on call Tuesday night with the doc who resolves anterior lips with c-sections. Already in a mini-panic.

Other Things

2009-02-28T05:53:00.000-08:00

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

2009-02-23T18:39:00.001-08:00

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

2009-02-21T09:33:00.000-08:00

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

2009-02-21T07:48:00.000-08:00

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

2009-02-18T08:07:00.001-08:00

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

2009-02-14T08:43:00.000-08:00

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

2009-02-12T18:23:00.001-08:00

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.

2009-02-08T08:59:00.001-08:00

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

2009-02-03T15:45:00.001-08:00

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…

Houston, we have a shoulder

2008-12-23T17:26:00.000-08:00

Does anyone out there actually LIKE nights? Please, if you do, tell me your secret. I spend the day of my night shift worried and down, trying to take it easy and attempting a nap in the afternoon which never seems to work. My emotions are even more sensitive at 3 in the morning. My ability to multitask is compromised. When you’re the “only one on the board” I feel like I could be the only midwife in the hospital. And if I am in the least bit busy and the beeper goes off I want to crumble. And the next day I sleep fitfully, at best, with my brow furrowed. But what can I do? It’s how I gets the moneys.

I worked a night last night. When I got to the hospital there were two women there, both at 4cm, and thinking back on it now, I realize, maybe these two patients were attempting a birthing race of some sort. Though there is no reason to believe that their labor curves should mimic each other, they went for it. Room 15 and room 17 poised…well, poised on their backs anyway, to have their baby first. They were both technically active but one was having pit started, the other just falling asleep s/p epidural placement. The doc I was on with only had one post partum person on the floor who needed a bunch of labs drawn and evaluated so she appropriately (and sweetly) said to me that she was around and to let her know what she could do for me at any time all night.

Pt#1 was Japanese speaking only. Supposedly we have translator services but no one in-house for Japanese. So. If you need a translator (I got this information from the CNM leaving for the night) you have to have the secretary page translator services, wait for someone to come up from translator services, that person will bring a special phone with them and dial a special number on the special phone and then put the phone up to the pt’s ear when a Japanese translator is on the line. Um. Is anyone thinking what I’m thinking? Downsizing! (That is supposed to be sung in the key of a doorbell ringing) Can we even just leave the special magic phone on the labor and deliver floor? Nope. Well, that process not only seemed too convoluted to me, it also seemed like when I started pushing with the multip, there would barely be time enough for me to page the secretary to call the service. So, I talked slowly, I used the FOB for translation and I ultimately explained a lot less to her than I would normally do.

Pt#2, a primip with a perfect pregnant body and a FOB that all the nurses were swooning over had made good change in 2 hours. She was 6/100/-1 when I checked her. Comfortable and nothing but a few annoying variables on her FHT. (Didn’t I say everyone had variables??)

Enter pt #3. A Grand Multip. A 38 yo G7P4015 to be exact. Her body looked tired. Her legs looked heavy. Her cervix was 5. Epidural please? (My epidural rate by the way is 100%. And just a quick aside about that. I do really believe it is about giving patient’s informed choice, not about whether or not they do what I think is “right”. I think if an epidural makes someone look back on their birth experience as something beautiful or exciting instead of something traumatic I think it’s a good thing. If an epidural can give a woman some much needed sleep after hours and hours of labor, I think that’s fine too. But I don’t even feel like there is time to do the education component around this. I think women come in to the hospital demanding the epidural. They ask about it at 20 weeks. And I think midwives are so easily looked down upon for educating women on the r/b of epidurals because it can easily be misconstrued as “keeping the epidural from the patient”. In terms of my personal learning curve with labor management, with repairs…I’m admittedly happy that so many, ahem all, of my patients get an epidural. But if I look at the big picture here, there is no question that there is an epidemic among us. Women, people in general, husbands, partners, nurses, doctors…wanting to be cut off from the intensity, the pain, the emotion, of the birth experience. Just like everything else, let’s put the TV on, watch law and order while the fucking miracle of life is happening under the sheets. It’s cool, as soon as the little guy is out we’ll come around. We’ll breastfeed, or at least try, we’ll start to really feel like parents then. And if we need a break, we’ll just put the baby in the nursery for a bit.)

Pt #3 was delivered before 11pm. It was exactly what I needed. An anesthetized multip who pushed her baby out in 10 minutes with not a laceration to speak of. And it wasn’t just what I needed because it was easy. It was what I needed to be able to stop being preoccupied by my fear of suturing in order to laugh with the patient and her family. To have a steady hand when I delivered her placenta. To actually look at and appreciate the newborn breastfeeding on her mom’s chest. Everyone in the room was mellow. Me, because it was a smooth birth where I felt like I knew what I was doing and her, because well, it’s her 6^th child for god’s sake.

By 2 am both of my other pt’s were fully and +2. I had to call the doctor, who up until this point had been sleeping all night. I let her know the situation, that both pts were ready to push, that my primip had now spiked a fever and was having deep variables. She told me to start pushing with the multip, she’d hang out with the primip and I could take her place when I finished up with the other patient. It turns out, the primip pushed her baby out in three contractions with a 1^st degree tear. “One of the most beautiful births” the doctor said. I, on the other hand, was “pushing” with the multip who squeezed her legs closed every time she pushed. It was virtually impossible to communicate with her. Impossible to help her push, impossible to explain that certain positions will keep the pelvis more open than others, impossible to tell her to bear down like she was pooping. Her baby’s head eeked along. One breathy push after another. Well, the slow progress was keeping her perineum intact at least and she felt to me as if she had tons of room in her pelvis. “Do you want some castille soap?” the nurse asked. “No, thanks. She’s moving along.” I said. “How about some jelly?” She tried again. “No.” I smiled. “You’re not into that stuff, huh?” The nurse seemed disappointed that I didn’t want to manipulate the process more. But whatever, she crowned. And crowned and crowned. And finally, the head came out. And restituted. And then pulled back in. I put my hands on the baby’s head, tried my standard maneuvers and nothing budged. No shoulder, not anteriorly or posteriorly. “Should I call it?” The nurse asked. I could already feel her anxiety. I reached my fingers under the pt’s pubic bone to see if I could dislodge something. Nothing. “Ok.” I said. “I have to call it.” And then, all of a sudden, the nurse literally drops the pt’s leg, runs out of the room and into the hallway and yells as loud as she can, “We have a shoulder! We have a shoulder!!” And then at least 7 people run into the room to “help”. Is it me or do things seem to get worse in an emergency situation when someone decides to scream at the top of their lungs? Maybe I’m crazy but I don’t think that strategy helped anyone involved. After the nurse came back to the bedside and before the stampede arrived and after McRoberts and suprapubic pressure, the shoulder was delivered along with the rest of the 9lb 6oz baby girl. Oh and did I say that the pt’s 6 year old child was “asleep’ on the chair in the room the entire time too? He was. And very annoyed (and I’m sure confused) at all the commotion. Rumor has it, they had no child care.

Her vagina looked terrible. I grabbed the doctor to help me piece things together. I started the repair with her looking over my shoulder but upon closer inspection we, well, she, discovered that this was a 3^rd degree tear. So, the doc stepped in and took over. “So, I’m gonna do some plastics right now.” She said. She was talking about muscles and capsules and sphincters and lots and lots of things that I knew nothing about. Holes were closed, tags of flesh were magically pushed back and hidden, her vagina was intact again instead of gaping. I felt incompetent of course and afraid to let her know but, in the end she agreed it was a nasty and very jagged laceration. When I asked her if a year or two from now, that repair was something I should be able to do as a midwife she basically said, I could do it but it would probably look bad. I told her that we never learned how to stage a perineal tear, that we were never taught how to find the hymenal ring. “I don’t get it.” She said What did you learn?” Note to self, keep lying about what you know so as not to feel dumb in front of people you want to have a respectful professional relationship with. She also told me it was completely fine to tell all the docs I was on with that I really want to get good at repairs and that I should just ask them to be in their with me if I can. This job is so humbling.

Oh lord. When will this be easier? I’m exhausted. Off to bed.

A Mother's Burden

2008-12-20T14:28:00.000-08:00

My mom has this fantasy she told me about a few years ago. I’m not sure if it came to her in a dream or if her mind just created a story while she was listening to the radio in the car but, in this fantasy, she is a choir teacher for a high school and one of her students is a rebellious teenage girl who happens to have a fantastic singing voice. For the “end of the year show” my mom has decided to have the choir perform the Bette Midler song “From a Distance” and in the hopes of stirring up self confidence in this young girl and creating for her some investment in the choir and the school, my mom has picked her to have the lead part in the song. But on the day of the performance, the rebel girl is no where to be found. There is no choice but for the show to go on without her. But, as my mom tells the story, she feels that this young girl won’t let her down. She assures the rest of the students that they will sing the song as best as they can and things will be ok. So, they head out on stage and start the song. As the rebel girl’s part gets closer and closer you can feel the nervousness on stage. But then, just at the last moment, the back doors to the auditorium fly open and she comes in, unable to stay away because of her belief in herself, the group and, I don’t know, the power of song?, she comes down the aisle singing her part perfectly and everyone is relieved and happy and smiling. Believe it or not, my mom actually worked this fantasy out in her head and shared it with me years ago. I often say to her when she is convinced of a downright unrealistic miracle: Mom, this is your From a Distance fantasy. This is not real. For instance, I’ll say to her, “I hate tests. The tests are too hard. I don’t know how to study. And they aren’t a good measure of my knowledge anyway.” My mom’s response would be something like: “Sarah, you just keep pushing and studying and being honest. You’ll see. In one year’s time you will be the best test taker anywhere and people will be coming to YOU for help.”

“No one likes me. I feel like I don’t have any friends and people don’t want to talk about the things I’m interested in.” My mom’s response might be: “Just stick to being yourself, do you hear me? You’ll see. You will have so many friends at this time next year you won’t know what to do with them. People will love you. They are just are too intimidated right now to actually come out and say so. You just wait. You will be the most popular person anywhere.”

So, when I mention to my mom why I feel like such a failure at perineal repairs, she gets on top of her soap box and begins: You just wait. People will be coming to YOU for help with suturing. People will pull you out of other deliveries, of other rooms where you are with patients to ask for your help. They will be saying to patients, ‘you know what? I could do this but Sarah Kleinman, the nurse midwife is right next door and this is her specialty. Why doesn’t she come in and repair this?’ You will be the very best in the practice.”

It is an almost constant conversation I have with my mom where I think I suck and she thinks I am the most amazing thing in the world. And, she insists, it is not because she is my mom but because she just knows. It’s the burden of unconditional love. It’s just a little delusional sometimes.

It was a fairly quiet day in the hospital yesterday. I got hit with the snow storm that came through so many cities and it certainly helped to keep pregnant women home and out of triage. I said to a midwife from the hospital based practice while we were watching 5 consecutive episodes of Cash Cab in the L and D lounge, while I was shaking my pager in the air which had not gone off all day long, “You see?” I said. “It just goes to show you. Women are never really in labor when they call. They just get paranoid or scared or feel alone…Now suddenly when it’s snowing they just stop being in labor? I don’t think so.”

I had one woman in labor when I got to the hospital. She was a primip (of course) with a history longer than my arm. Metformin until 12 weeks. A choley at 14 weeks. Colpo in pregnancy with CIN. GBS+. Rh Neg. An EFW putting the baby in the 90^th%. Nothing that would greatly change my management, just another experience that pushes me into believing that normal healthy pregnancies just do not exist.

The baby had been having some variables throughout labor but at this point I can’t remember the last time I was managing a labor and there were no variables. Regardless, the nurses want to page you every time they see something that veers just slightly away from normal so I was in and out of the room a number of times to look at the strip, nod my head, thank the RN for asking me to evaluate, reassuring the pt and the FOB, writing a note and basically saying “I’m fine with this strip. Let me know if it changes significantly.”

There was a 3^rd year med student there all day and I felt bad for him because the day was so slow and my patient, the only one my practice had in house, did not want a student at her labor or birth. But I let the med student know that there was still room for learning. Every time I was called in to assess the strip or every time I went in to check the pt’s progress I made sure to have a conversation with the med student about what I saw, what I did, what our options were at certain points in her labor etc etc. And man, I have to say, talking to this guy made me feel so much better about myself. No offense to any med people out there but third year med students really don’t know much of anything. Partly because they get three weeks on L and D and that’s it. OK. I get that their exposure is very, very limited but I mean labor and birth 101, man. Tell me what the different kinds of decelerations are and what they are indicative of. He didn’t know. Tell me what latent, early and active labor are. He fumbles. Ok, tell me what the definition of labor is…unsure. Let it be known that I did not make him feel bad. I did not rub in his face the fact that, well, he needs to start studying up. In fact, I told him that while he was with me there were no wrong answers, it was okay to say I don’t know. I told him that much of what we would talk about would be a conversation and oftentimes there would be many right answers to a problem. And I embraced, I mean really, got happy with the reality that I kind of know what’s up a lot more than this kid. And I felt good that he might look back on his training and say that a midwife taught him something. He had a lengthy homework list when he left that day. Hopefully, he’ll be on again Monday night.

My patient was fully dilated and ready to push at 12:30pm. But not before my finger ruptured her BBOW when I went to do a SVE an hour before. And of course not before she spiked a fever and the baby got tachy and I had to give her the dx of chorio. And not before her husband, at one point, watched his wife’s face and watched his baby crown and then looked at me and was breathing heavily, his eyes wide and just said: It’s a miracle. It’s a miracle. “Are you okay?” The nurse and I said virtually at the same time. “Are you being moved by the emotion or the sight of the baby’s head?” I asked. “The emotion I think.” He said, but I hadn’t seen him blink in almost a minute. “You know what?” I said to him, “You need to sit down. Sit down on that chair until the next contraction, ok?” “Ok.” He said sitting back slowly. “Ok. But, it is such a miracle.” It’ll be a miracle if this baby comes out with no problems and I can suture your vagina by myself, I thought. A fucking Christmas miracle.

So, she got abx in addition to the PCN she had already gotten d/t her GBS status and pushed her baby out in 19 minutes. No dystocia, no problems. Just a 2^nd degree laceration and a big crooked gash down the side of her R labia. And I really had to think. What happens with my hands when that baby comes out? I was really doing a good job of supporting the perineum, making sure the baby’s head was well flexed, that the woman was controlling her pushes…but then, after the head comes out and I want to deal with delivering the shoulders…do I neglect the perineum at that point? Is that when the tear happens? Because I didn’t feel anything give before then…It makes me think my hands could be working better. They could be positioned better, could be delivering the shoulders and protecting the woman’s tissue at the same time.

In the end, I had to call the doc in. I could not make heads or tails of the labia. But I had no shame. And the doc that came in was sweet and casual and let me stay in the suturing driver’s seat the whole time.

After all my paper work had been done, after the circ was scheduled and the baby was cooed at, I found the doctor and apologized for being so dependent for suturing help. He was confused. “Why do you feel bad?” he asked. “I just feel like we never learned how to suture really, really well in school. And learning on raw chicken is never going to be like practicing on real bleeding human tissue.”

“Well,” he said “You’ll get a lot of practice here.” He didn’t say, y’know, you’re right. Your program should add in more opportunities. He didn’t say, yeah, your skills are sub par. He didn’t say, next time you should just push yourself to do it on your own. He said you’ll get a lot of practice here. Which, for me, basically translates to, you’re in the right place. Be patient. You’ll be better soon. And right now, everything is as it should be.

Today was ok

2008-12-18T18:51:00.000-08:00

Things are getting bad, and not even related to my job. I’ve started talking to my car (i.e. Listen, Carlos, I’m gonna leave you in the hospital garage overnight, ok, cause there’s gonna be a snowstorm? So, don’t be surprised…) and my food (i.e. How we doing in there, Cous?) and I have given birth to a week-long pain in my knee that is now being evaluated for lyme and arthritis and other autoimmune origins. I got onto the elevator at work this morning, running late, annoyed at the pain in my knee and my inability to walk fast, climb stairs etc and at the 2^nd floor a man gets on. An obscenely large man. How large you say? Like, I mean, check-the-elevator-capacity-real-quick-with-your-eyes-to-make-sure-you’re-safe big. Y’know? And anyway, he was getting off at the 2^nd floor!!! He was going up 1 FLOOR! Wanted to scream. Would it have killed him to take the stairs? Well, maybe…

I had one of my first ok days at work today. A full schedule quickly turned into a few no shows and one cancellation and a fair amount of time hanging out with the MAs. But the patients I saw got good care. And they got thorough notes written in their charts. And my A neg pt who was demanding rhogam for no reason at her IOB even though she hadn’t had any bleeding and was pissed when I told her that she couldn’t have the shot just to “make her feel better” was actually bleeding (!) when I did her GYN exam so…she got what she wanted! “Isn’t it funny how the universe provides like that?” I said to her. I tried to focus on her success in acquiring the injection instead of the fact that there was a possibility that she could be having a SAB. And my 18 yo G2P0 who comes in virtually every week for abdominal pain or decreased fetal movement and who has had trich for weeks because she’s too busy to pick up her meds came in today for what basically came down to right-sided butt pain. It turns out she got her rx for the trich and has been taking the pills! And she came to the office without her mom today! And she was satisfied with non-pharmacologic comfort measures!

I think days like today are not only good ones because the patients get good care and because I feel a little less shitty about myself when I crawl into bed at night but I think more accurately because there are no awful reminders of how my skills and my limited knowledge fail the patients I am supposed to be helping. One of the stories we read for my lit and medicine class describes this perfectly I think. The author has been the doctor to a patient with depression who continues to come to the clinic over and over again for various somatic issues. She writes:

“I am not suffering. I am actually the complainer. I’m the one who can’t face this patient without immediately rolling my eyes and turning off my compassion. The reality is that I am profoundly discomfited by my inability to treat Mrs. Uddin, and she is simply the thorn that continually reminds me how limited my skills can be.”

(From the story “Torment” by Danielle Ofri)

And then, indirectly related I guess, I was listening to NPR at work and just before I shut off my computer to go home I heard a story called "After the forgetting". It was about this guy and his relationship with his 91 year old mother as she was descending into the depths of dementia. He says at the end: I can’t imagine my relationship with my mother being any better than it is now. What an amazing feeling it must be to feel that way. And what would it be like to be able to say that about your relationship with your father? Or your work? Or yourself? And why why why would you want to settle for anything less if that feeling is possible? (http://www.npr.org/templates/story/story.php?storyId=98450439)

The morning after

2008-12-14T15:50:00.001-08:00

Night call has left me exhausted and oversensitive. I was on call with a spunky young doc who, though she commonly thinks everyone who has any kind of abnormal tracing or labor curve is “getting cut”, she is extremely approachable and normal. Even better, she was up all night with two of her own patients so I never worried about waking her up or not being able to find her. The labor floor was scarily quiet. Only three patients on the east side of the unit which has about 25 rooms.

A woman who had been seen earlier in the day for decreased fetal movement, a reactive nst, a 6/8 bpp and an EFW of 9.13 called back around 11pm c/o ctx q 7 minutes. She was (surprise!) a nullip and extremely happy so I had her stay at home and call me back in 2 hours to check in. She initially called me back in about 15 minutes to tell me that she was still having contractions, still feeling the baby move but now she was having this weird blood on the toilet paper when she wiped and thought I should know. At this point it was pretty clear it was going to be a long night. I reassured her about bloody show and tried to get a couple hours of sleep. I got a call from the answering service around 1am “Guess who called back?” The telecom operator “tom” said to me annoyed when I called him back after getting the page.

She was now c/o ctx q 4-5 and they were stronger. But she literally seemed giddy while she was on the phone with me. “Well,” I said, “maybe you’re just a really happy person.”

“I am.” She said breathing hard. “I’m really, really happy. That’s exactly how I am.” After barfing in my mouth a little I invited her in because, though I think she could have stayed home, she lived an hour away and she was 3cm in the office two days ago.

She was 5cm when she got to triage and because no one wants to budge my 100% epidural rate, she got her placement and assumed the left side lying position. She was tachy, I bolused her. She got some lates, I turned her and, amazingly, they went away! I checked her at 6am and she was 7/100/-2. “You think this baby is coming out vaginally?” My nurse said. I never know how to respond to that question. How should I know? She’s 7! And yes the baby is high, and supposedly big but why is everyone so quick to be distrustful of the ability of the pelvis??

The next time I checked on her she was sound asleep. So, I passed her off to the next CNM on call and am now checking my work email incessantly to find out what happened to her. Did the baby come down? Did the lates come back? Did she in fact deliver vaginally?

The midwife who discharged the pt that I delivered on Friday did a perineum check this morning and called me to let me know that the repair was completely lopsided. As you recall, this was the repair the chief resident did for me. The partial 3rd that somehow became a 2^ndmidway through her repair.

The doctor was called in to see it, a note was written about it and sent to her primary care providers in the office. It was stated again in her discharge note that the resident’s hands, not mine, were the ones responsible for the mishap. But I can’t help but think what kind of a job I could have done if I had just pushed myself to try to repair it on my own…

I’ve been flaked on by two people tonight. And I specifically made plans on my post call night to give me a reason to get out of the house. Annoyed and feeling …annoyed. Tomorrow evening my literature and medicine class meets. And I was chosen as the lead part in this staged reading we are doing of a William Carlos Williams play. Maybe I’ll rehearse…

I hate the perineum

2008-12-13T06:22:00.000-08:00

I feel like, as a midwife there is this assumption that I am supposed to love the vagina. I’m supposed to think birth is beautiful and normal and perfect and happy. But, I just got home from call and am certain that I hate the perineum. I wait while a woman labors in constant fear of her pushing on a nulliparous perineum. I have such suture phobia that I would gladly give up all of my births to only manage labor if I just never had to repair anyone’s vagina. And now that I am finally home, out of my scrubs that were covered in blood and amniotic fluid, showered and making dinner I am still getting whiffs, from I don’t know where, of placenta and blood and vernix. It’s in my nostrils and my hair and, currently, I cannot think of a worse smell than labor and birth.

I had two patients today, both of which I was certain would not deliver on my shift.

Pt #1:

She came to triage from the office where she was seen by the CNM for her routine ob exam. She was 39 wks. But when the CNM examined her, she ruptured. Even though she was GBS neg, the head was high enough to make the CNM nervous and so she got sent in to me. She was 2cm when I checked her in triage. And writhing in pain. She got a room, took a shower and then, 2 hours later got an epidural. (2 hours because when I initially walked into her room, she was lying in bed, one fluorescent light on, not on the monitor and, no IV, no IV pole despite the fact that it was very clear she wanted an epidural. The nurse was no where to be found. When I finally did find her I have to say she was the slowest most turtle-like nurse I have ever seen in my life. Her walk was slow, her talk was slow and I would not be surprised if her brain was slow as well.) Her tracing was yet to be reactive. Good variability, no decels but no real accelerations and no scalp stim. I let her get comfy s/p her epidural, the med student wrote a note for me, which was so weirdly incomplete. There were so many things she just didn’t remark on. Decelerations, plan for reassessment, length of contractions…(I even told her to comment on these things after I read the note over and she never completely described the strip and, under UC, when I put “x” after her “q 2-3 min” she put “6 hours” instead of something like “45-60 seconds”. It was clear I should have explained better…)

At 5pm I stepped out of another labor room (see below) to check in on her. The tracing looked crummy. She now had light mec, had progressed to 5/100/-2 but her variability was minimal, no accels and these repetitive lates that I was NEVER called about. I asked the doc to come assess, (You’re gonna hate me, I said to start my report on her) and went back into my other labor room because my pt was crowning (see below). Within minutes the pt I had asked the doc to assess was rushed back to the OR for a STAT c section. Apgars 6/9. Done and done.

Pt #2:

32 yo P0 at 39.5 wks. She was being induced for mild preeclampsia which…she didn’t have. She got one dose of gel yesterday and arrived today reporting ctx all night. She was 3/80/-2 in triage which was an amazing change from the day before. We started pit and almost immediately she asked for an epidural. The next time I checked her, she was 6. And a couple hours later, I was paged to come assess her tracing. She was having variables with almost every contraction down to 90 (the notorious dipsy doodle!) so we shut off the pit (well, actually the nurse did before I could ask her to) and I checked her. Fully and +2. Meanwhile, the doctor on with me was deciding whether or not to take a morbidly obese woman back to the OR who was having lates vs variables and who hadn’t made change in over an hour with adequate ctx. He decided to wait on her and I got the go ahead to push. And for the most part her pushing was very controlled. The med student was there, with “sterile” gloves on for some reason. But she kept putting her hands on the pt’s knees and feet while she was pushing. Oh well. The head was crowning, the tissue was stretching, the FHR was reassuring, ahem, category 1. And I have to say a little midwifery thought went through my head. There is no reason to rush this, I said to myself. The nurse trusts me, I thought. The med student is watching a clinician be patient with the process of crowning and pushing and not needing the actual delivery to happen before it wants to. I imagined the ghosts of some my friends in the room proud of my confidence, my lack of fear, my ability to coach my patient, appease the nurse and teach the student all at the same time…And of course I’m thinking stay intact, stay intact, stay intact. Please. And then the heart rate went down. And stayed down. And my plan changed.

“Ok, so guess what, you are going to have a baby with your next contraction!” I said to my patient.

And she did. The baby shot out in one push. Head, shoulders, knees and toes, just slid out half on the bed, half on my arm and a liter of amniotic fluid was all at once on the bed and my thigh and in my shoe. Nuchal cord x 1 reduced and mom and dad were the first to see that they had had a baby boy. But while I was waiting for her placenta to be delivered…I got a good look at the perineum and I started to sweat. It was just a sad gaping mess of red. And there was a purple bulge on the right side and the apex of the tear was so far beyond what I was able to see…I panicked. The doc poked his head in: “Everything ok in here? Great. I’m goingback with your other pt. Stat section.”

“Oh, sure everything’s great! Sure!” I said and I have no idea why I couldn’t ask for help. I started to be angry with myself for being scared. I started to be angry with my midwifery professors for never really teaching us how to determine if someone had a 2^nd degree vs a 3^rd degree tear. My back up docs were the residents now. And I have no relationship with them at all. But they were called to help me piece this woman together. When the clipped and efficient chief resident arrived she determined initially that it was a “partial 3^rd” which made me feel somewhat validated. But then, as she basically just took over the reins she kept calling it a 2^nd and I’m like what happened to partial 3^rd? Can we please call this a partial 3^rd? Just so I don’t have to feel bad about myself? Please? “You’re ok with repairing the 2^nd right?” She asked me. “Yup. I’m good.” I said. “Well, I’ll just do it.” She said for reasons I seriously do not know. “It’ll take me 10 minutes and you’ll be all set.” I know I should have pushed her out of the way, and I have to admit I was annoyed that she just took over my suturing seat but another part of me was relieved. Another part of me didn’t want to ask her to have to come BACK in if she left. Another part of me recognizes how hard it is for me to even ask for help in the first place. How humbling it is to say, I’m new, can you help me?

I simply just have suture phobia and I hate perineums.

After all the notes were written and ordered put into the computer, I found my doc. He put his hand up in the air and gave me a high five. “Why did you say I would hate you?” he asked. “Just because I kept bugging you all day.” “You were appropriately bugging me! I’d rather you over tell me than under tell me things. You were right to get me. Anyway, apgars 6 and 9, could we have waited another 15 minutes to see what happened? Maybe. Would the apgars have been worse if we did? Maybe. Who knows? I think it was the right thing to do.” “I just hate not knowing what to do so often.” “But soon you will,” he said. “Don’t worry, soon you will.”

So. Another shift gone. Another baby born by my semi-competent hands. And back on Saturday night. This job is never-ending.

Things are just bad

2008-12-11T19:44:00.000-08:00

The problem with trying to keep the blog updated is that at the end of a busy day when I have tons to vent and gripe and ask for validation about, I just don’t have the energy to sit down and write about it. I want to come home, get into bed (before or after I have taken off my coat) and fall asleep. Remember how in Broadcast News the holly hunter character puts on such a confident, motivated, hardworking face when she is at work and then the moment she gets home, drops her bag and is by herself she sits on her bed and starts sobbing? That’s pretty much me. And I’m not doing such a good job these days of holding back the tears until I get home. Today, I closed my office door twice in the middle of the day to take a deep breath, hold back tears and tell myself it was going to be ok. My work life sucks. My personal life sucks. And it’s all I can do to hold out until I come home, sit on the couch, put my face in my hands and let go.

I feel like I never see anyone normal at work. In the past two days I saw 1 person who had no problems. And I am realizing now that I should never have blabbed about how excited I was to see teens and pts with multiple social issues. Why did I do that? I feel like the entire day I am listening to people’s shitty lives and have no way to solve their problems. In the past two days I’ve seen a teenager who just realized she was pregnant at 25 weeks and whose mom is so overbearing I want to scream. She has extensive back issues that I have no idea how to evaluate and she just got out of the hospital for pyelo which she didn’t know she had because she is so used to back pain she just shrugged off the ache in her flank for 2 weeks and popped Tylenol. I saw my return OB pt who is also a teenager and who is also 25 weeks and who has already had a total of something like 15 visits either to the hospital or office. Abdominal pain that subsides when she gets to the office, decreased FM that she starts to feel once she gets put on the monitor…she has had Chlamydia this pregnancy and trich twice in 10 weeks but assures me she has not been sexually active since she found out she was pregnant. She had trich in her urine weeks ago and she still has not been treated. The first time it was because she and her mother were “afraid” that the medicine was unsafe in pregnancy so she just didn’t take it. “Why didn’t you call me to ask?” I said. “We were busy.” She responded. I saw her yesterday and she still was untreated. Why? Because they went to the pharmacy and there was no script. “Why didn’t you call me?” We were busy, they said. “It’s really really important for you to treat this infection”, I said. “I understand it’s important” her mom said to me slowly. “I work in a hospital”, she said. “It’s just too much for us to handle right now but I don’t expect you to understand that”. I reordered the rx. Every time I asked the pt a question her mom answers. “So, you feeling the baby move every day?” I say to the pt “Oh, we’re feeling that baby move now. Now we know when that baby’s moving, don’t we? After I had to be in that hospital for hours last week…” she eyes her daughter. I wanted to say who the hell is pregnant here? Are you BOTH pregnant? If you’re pregnant too you really need to schedule something…

And I had a pt who had seen me for irregular periods and alopecia and fatigue and weight gain and terrible PMS whose labs all ca\me back normal and the MD said she thought she should have a more in-depth f/u and potentially an US and the pt basically said she couldn’t pay for any more visits. She’d try to call in February. And meanwhile she is suffering from “extreme moodiness and fatigue” 10 days before her period. And today I had a 39 yo with a history of IV drug use and alcohol addiction and her father killed her mother and himself when she was 13 and who has chronic hep c given to her by her ex husband who is now dead and she has abnormally elevated LFTs and wants OCPs and I am so at a loss for how to even begin to help her. The MD said she should f/u with her and believe me I agree, I just hate having to say to someone…I can’t do anything for you. You have to come back and see someone else who knows more than me. I’m sure she’s thinking, why did I even see you at all?? I should have just seen the doc to begin with. And I can’t say she’s entirely wrong. I feel like all I do is see patients and hold back tears and ask other people what I should do. I just don’t know how it gets better. I learn more? I just become familiar with the feelings of incompetence? I find more ways to distract myself? I fall in love and have that fill the hole in my belly when I come home at night? I just deal with the fact that this is an unbelievably hard job and there is no way around the emotional challenges?

It just seems to continue to get harder.

1st Night

2008-12-03T17:55:00.001-08:00

My first night of call off of orientation was Monday. Thankfully, it was a quiet night. (The Saturday before had been an almost perfect dry run. I was still on orientation but the midwife I was on with went to bed at 10 and didn’t wake up until I paged her at 7:15 the next morning. Though I felt terribly alone and though every time I sat down to close my eyes I was kept awake by anxiety that something would go wrong, I made it through. The MD and the other CNM had no idea that I had triaged, admitted and delivered the baby of a G2P1 at 2:45am. She arrived at 4 cm after having regular ctx for at least 3 hours at home, got her epidural finally (it only took two hours), and was tucked in for some rest. I spoke with the pt’s 2 friends during the placement. One friend was very annoyed that the baby would probably not be born until November 30^th since they had arrived just after 11pm on the 29^th. Why do you care so much? I asked. Well, she explained, “My ex husband’s birthday is November 30^th and my boyfriend’s ex wife’s birthday is November 30^th so…it’s just a bad day.”

I told them all to try to get some sleep, to turn out the lights and not to talk. But an hour later I was called to the room by the nurse for what she called “dipsy doodles”.

(“You should have told her that ‘dipsy doodles’ are not in the NICHD criteria” said a friend of mine. But I’m gonna choose to live with a dipsy doodle strip until I am certain of the nurses’ respect)

I will say though that when I saw these so-called dipsy doodles I was not impressed at all. There were three variable decels to the 100s. Three.

“These dipsy doodles just started so we figured either something’s wrong or she’s fully”. Said the nurse.

Right, I thought. First of all, what would be wrong with 3 dipsy doodles in 15 minutes? And secondly, she was 4 like 2 hours ago. But whatever. I checked her.

And I stood corrected. Fully and +3. She pushed her baby out in 2 contractions. I considered attempting to deliver in the caul since her water hadn’t broken yet but the nurse stuck her head between my patient’s legs when she saw membranes bulging out of the introitus, squinted her eyes and systematically handed me an amnihook. It would have probably gotten in my mouth anyway.)

So Monday, I was certain to get slammed. But I prayed to whatever god you want to believe in and they came through for me. I had two triage situations at the beginning of the night: one woman with decreased FM who had never heard of kick counts and who felt the baby move before, during and after a reactive NST and then a call from a term pt who was c/o flu like sx, afebrile, vomited x2, +FM, no bleeding…turned out when her husband came home he reported having the same sx all day. And the relatives they were both with all weekend for the holiday had been puking too. I told her to push fluids, brat diet, call back if she spiked a temp. And then, I babysat a cervadil pt all night long. She was a P0 being induced of course. For repeated episodes of decreased FM, a BPP of 6/10 and an AFI of 6. Now, none of these things on their own would necessarily be a good enough reason to induce but together they seemed to be enough evidence of…the clinician feeling uncomfortable? In any case, the pt was feeling the baby move the entire time she was in the hospital and her strip looked great from the moment she walked in the door. Her cervix was so closed I would actually call it sealed. The cervadil went in at 8:45pm and every time I came to the floor to write a note on her, I was sure to give the nurses some face time. I watched them look at each other’s pages on facebook and listened as they talked about their boyfriends’ bad habits. The rest of the time I let myself lie in bed and sleep. It was so quiet the rest of the night that I woke up with a start at least two or three times convinced the beeper was broken. I’d grab it, press the button that lights up the screen to see if the battery had died and even though a little skepticism remained I thought…I’m just not going to investigate. If they need me, they’ll find me.

I pulled the cervadil at 7am because the pt was contracting every minute and writhing around in a tremendous amount of pain with each one. Her exam was unchanged. I mean like a bishop’s score of 1, with 1 as a handicap because I felt bad for her. Like, sealed so tight that my fingertip barely, barely got in the external os. At that point though, the next midwife was coming on. If the tables had been turned and I was coming onto the floor with the same situation, I thought to myself, I’m actually not sure exactly what I would do. I asked the doc on call with me. Well, she said, you could just let her contract on her own, or you could start pit. Really? Start pit? Isn’t that just asking for a bad outcome? I thought.

The midwife coming on wanted to send her home. And the doc coming on agreed.

I checked her chart today. Turns out the patient was sent to c-section for FTP after 2cm and a maternal temp of 202 at midnight. It also looks like though her epidural was adequate enough to control the pain on her skin during the section, it was not enough to cover the pain of the surgery on her insides and she had to receive IV sedation for the 2^nd half of her surgery. She is 21. It was her first baby. And I just can’t help but wonder if the outcome of her labor could have looked different…

I’m back on Friday. I keep praying to all the same gods I prayed to before but I sort of have this feeling that I am due for a busy shift. And the anxiety will begin…now.