Dec 9, 2012


People have funny ideas of where miscarriages come from.  A "misconception", if you will.  I suppose it is the natural way of humans to try to assign blame for a bad outcome.  It's difficult to accept that sometimes things just happen, and we can't control them.  Whenever I counsel someone for a miscarriage, I always say that "this is not from anything that you did or did not do.  You didn't cause this."  My personal philosophy is that it is quite amazing that any pregnancy succeeds, given the complexity of things, and it's not surprising that things sometimes don't go right.  And it always breaks my heart a little when I have a woman convinced that y or z made her miscarry.  Here are a few of the things I have reassured women about:

I drank too much chamomile tea, and it made me miscarry.

I spent too long in the hot tub.  Did it cook my baby?

It's a punishment from God.

It's because my pap was abnormal from herpes (All kinds of wrong here.  Paps are not abnormal from herpes).

I ate the wrong food. 

It came out when I went in a bounce house.

I had a massage, and it caused me to start to cramp and miscarry.

I had sex.

The cat licked my belly.

To my patients and women everywhere- I hope that your doctors, and myself, continue to assure you that this is not your fault.  It happens to about half of women.  Please try to not blame yourselves. 

My Term Baby

I haven't delivered a baby who would live for six months.  It's part of the second year of residency- to hand over the term, live babies to the intern and take the more complex, sadder cases.  The little babies are so tiny, their whole body fitting in my small hands.  They are scrawny and purplish, and cool to the touch.  I feel like I've almost forgotten how a healthy baby feels. 

Today the interns were so busy.  I offered to take one of the new patients to help, and I was just tickled with my term young woman without any health problems.  Six months ago, she would have been just another lady on my long list of postpartums to see, but now- she was my reminder as to why I loved obstetrics.  She began to push, and there was a brief moment- right as the head was crowning- that I wondered if I still remembered how to deliver a big baby.  The little ones just kind of come out on their own.  I did, and it was a nice delivery with no problems.  And I held that baby in my arms just a few more seconds than I needed to, as I cut the cord and suctioned his mouth and nose, just enjoying how his weight felt in my arms, how I could tuck him under my arm rather than in my hands.  And I handed him over and I was so happy.  

A lot of the rest of my career will be these patients.  What a good job.

An L&D Story

A recent funny story from labor and delivery...

A questionable pair comes in, with the woman in labor.  She has just been released from jail earlier that day.
Due to years of drug use,  her veins are difficult to start in IV in, and the anesthesiologist has to come in to start it.  The boyfriend leans over and points "that's a good one!  I could get that one for you, if you like."

No thanks.

She delivers quickly.  The boyfriend crows "She held it in!  I'm so proud of you baby, you held it in til you got out [of jail]!" 

The next morning on postpartum rounds, the woman pulls me aside and asks "Does this baby look just a little bit black to you?  I think this might be from someone different than who I thought"   She is white.  I glance over at "Dad."  Also white. 

I tell her that I can't tell any paternity just by looking, there would need to be blood tests to confirm who the father is.

But the kid looks black. 

Oct 22, 2012

The Gallbladder

I got paged last night down to the emergency room for a patient with abdominal pain.  The ER physician was fairly sure this was gynecologic in origin, and wanted to me to come evaluate.  This is a common occurence, and one of the jobs of the second year resident.  I pull myself out of bed and head down.

The history is unrevealing.  No pelvic issues in past.  Pain aggravated by eating, particularly fatty and spicy foods.  Hmmm.

The pelvic exam is unremarkable.  But I touch her gently in her right upper quadrant of her abdomen, and she just about jumps off the bed.  She can't take a deep breath in when I push there, because the pain is so bed.

I've only seen a positive Murphy's sign once or twice in medical school.  But, I've read about it, and after seeing this lady, I really know what it looks like.  Textbook case.

I presented the case back to the ER doctor with all my findings, saying I didn't think this pain was gynecologic in origin, but had he considered the gallbladder?  Maybe an abdominal ultrasound was in order?
He stares at me.  "Wow.  I never thought about that.  I was so sure it was gynecologic that I didn't consider anything else."

Come ON.  I know I'm a gynecologist, and my expertise ends well below the belly button, but this seemed so clear.  Did he really have to drag me down for this?  There are like five things in the belly that people commonly present for, and the gallbladder is fighting for the top of the list with the appendix. 

The imaging came back a few hours later, showing cholecystitis (an infection of the gallbladder) along with gallstones.  Annoying, yes.  But I was secretly quite pleased that I could diagnose a cholecystitis on my own, just based on clinical presentation.  I guess that's why they send you to medical school.  Most of what I learned I will never use, but you never know when that textbook case will find you, even out of your specialty. 


It's two in the morning.  There is a delivery that is "unattended", meaning the attending physician isn't there.  The nurse has paged for the intern to deliver and me as (as an upper level resident) to be present.

Over the past year, I have come to find this word "unattended" fairly annoying.  I mean, I'M attending the birth in the wee hours, aren't I?  I'm the one delivering the freakin kid.  It's like my presence isn't even worth recording.  And look who's doing all the work.  Let's say the attending "attends" the birth.  Half the time he doesn't even put a pair of gloves on.  Just stands in the corner, humming to himself. 


So I have now moved up in life from being the delivering intern to the "supervising" upper level resident.  I get paged, and come to the room to find the intern in the room, quietly gowned and gloved, ready for the main event.  The nurse is furiously tapping at the computer.  "I PAGED THE INTERN?  WHERE IS SHE?  WHERE?  I PAGED HER TEN MINUTES AGO!"

The intern says "um...I'm right here."  The nurse relents.  Fine!  I didn't see you there!

I ask another nurse if the attending has been paged.  I stand there in the room, waiting for this unattended woman to start pushing.


The intern and I look at each other.

The nurse resumes her aggressive typing.

I clear my throat gently.  "I'm here"  I say.  "I've been here for awhile now.  I made sure that attending was paged."

She looks at the intern, and at me, and back at the intern, and frowns.


At this time, I hear someone come in and start humming behind me.  I turn around, irritated, and there he is.  Now, this delivery is attended. 

Can I go back to bed?

Oct 19, 2012

My Shells

My second year of residency has altered my job from delivering healthy, term babies, to preterm babies that will either not survive or babies that have died.  It's a new interpersonal skill, to give parents this life-changing news, and to support them through the process.  It's a new technical skill- the delivery of either a term fetus who has died and thus lacks the muscle tone to complete normal delivery, or the delivery of a baby so small that goal is delivery within an unruptured amniotic sac.  It's also a new intrapersonal skill for me to do this during the day (or night), and then proceed with my own life without carrying with me too much sadness or emotional fatigue. 

A resident a year ahead of me (and thus much wiser) keeps a small memorial for these children.  She told me that it helps her to cope with the job, and also is a memory of babies that parents do not acknowledge.  It seems right to her that someone would remember and honor these children.  I decided this was right for me too, and thought hard about the way I would like to do this.  I was really anxious about this task of second year, and this seemed to soothe some of the anxiety and give me more control over managing my job and emotions. 

My last night in Hawaii while on vacation early in my second year, my husband and I walked along the beach at sunset.  I had bought a little jar earlier that day from a craft fair, with a sea turtle design on it, but I wasn't sure what I was going to put in it.  Walking along the shoreline, I picked up a small shell, and then a piece of sea glass, a small piece of driftwood.  It started to come together for me, and I picked up more and more special shells, gifts from the sea.  My husband helped me find them, and held them in his pockets for me.  I wondered how many I should get.  Is twenty enough?  I wish there wasn't going to be even that many.  I pick up one and look at it, a micro-conch shell with tiny pink swirls.  What baby will you be for?  What will be my thoughts and experience that makes me drop you into my little jar? 

The jar sits on my nightstand, the sea turtle on the front of it.  About six shells so far have been dropped inside.  So far I can name each child the shell goes with, but I know this won't be forever.  Over time, the jar will fill, and I'll forget the details, but it'll serve it's purpose- a reminder and memorial of the work I do this year, and for many years to come.  And hopefully provide some closure, where I can place a shell and walk away. 

Oct 16, 2012

The Page

I hate getting paged at home.

I feel obligated to call it back, but don't really want to answer any hospital-related questions once I leave.  I'm away from the hospital computers and feel disorganized and unable to give good advice.  Just the sound of the pager in my bag at home gives me a quick palpitation and anxiety.  I would leave it in the car, but then I'm anxious about it going off in the car and me missing something important.

Like tonight.

6:03pm  Pager goes off

6:05pm  I begrudgingly call it back

6:07pm  "Oh Dr. Kennard.  I'm so glad you called back.  There was a code with your patient."

"What?  A code??  So what's going on?"

"Well we were coding I guess, but not anymore.  I really don't know.  I'm actually just helping the secretary out."

Soooo...does that mean the patient is dead?  Alive?

"Well, can I speak to somewhat that does know what's going on?"

A nurse picks up the line, and here is the story:

The patient that I operated on earlier that day was wheeled back to the recovery room after surgery.  Around this time, a nurse notices that the bathroom door has been locked shut, for an indeterminate amount of time.  They decide maintenance should open the door.  And there is the patient's boyfriend, dead on the toilet, after an overdose of heroin.

They call a code (and call me).  The ICU team comes down, and then intensivist says what everyone knows- this person has been dead for at least six hours, and there is no point in resuscitation.  He suggests to call a priest.

At this point I am imagining the transport team removing the patient from the bathroom to the morgue.  I mean, he probably has rigor mortis at this point.  Is he stuck in a seated position then, and should go down in a wheelchair because he can't lie flat on the gourney?

Meanwhile, the patient is still pretty groggy.  Another resident and I look at each other.  We weren't planning to do a full hysterectomy, but the laparoscopy was so bad that she needed it.  What should we tell her first?  "What do you think is the worse news, the boyfriend's death or the hyst?"  I ask the other resident.  (The attending is long gone by this point).

"The hyst" she says, without missing a beat.

Later that night, the patient decides to leave against medical advice, but she doesn't sign the necessary paperwork.  Security finds her padding down a major street in her hospital gown and booties.  They bring her back, not for readmission but to sign release paperwork.  And probably get the hospital gown back.

I don't really know what happened to her.  I do know that we thought this patient would be unreliable to follow up, and closed her with dissolvable stitches instead of staples for this reason.

And I will always leave my pager on at home.

Sep 24, 2012

The Bidet

I have never considered leaving a patients room before because I couldn't control the urge to laugh.  Uncontrollably. It happened today.

I stare at the dandruff on her hairline. I imagine myself in my morning commute, frustrated and stressed and tired. I cover my mouth with my hand and clench my jaw. I will not laugh, I will not laugh, I.  WILL. NOT. LAUGH. I am the doctor, the professional this woman has come to see.

And all I want to do is laugh.

She has come to see me to request a bidet toilet. She went to her primary care doctor, who told her no, she would not recommend this so the insurance would pay for it. Undeterred, the patient came to me.

"I need you to give me a bidet."  She doesn't say hello.

I fight the urge to tell her that they are in the back, along with all of our other plumbing devices, light fixtures, and home improvement hardware.  Instead, I quell my snide thoughts and already present dislike for this patient and ask "Why do you need a bidet?"

"I can't wipe my butt."

I indulge her.  "why can't you wipe your butt?"

"my arms are too short."

I clench my jaw and try to forcibly turn the corners of my mouth down.  "how long have your arms been too short to wipe your butt?"

"about four years, since I got fat."

So, I am to assume that she has been able to wipe her butt successfully for the prior 63 years?

"I can't reach my butt.  Look, I'll show you". She starts to get up.

"No, no. That's all right. You don't have to show me."

*please note, at time of this conversation she is seated with her hands below butt.

The patient narrows her eyes at me. "I'm not leaving until you give me a bidet."

I glance through her history. No recurrent infections that would suggest that she indeed cannot maintain hygiene. A note from her PCP that I completely agree with.   So what do I do? 

I pass the buck. 

I tell her that I can put in a prosthetics request form for them to evaluate her necessity, while writing all over my note that I do not think she medically needs one. I tell her that in the meantime, I can give her a pericare squeeze bottle to help clean herself. I dont have any in the clinic, but tell her I can bring one in from the hospital if she wants to come back.

No, she will wait, she says, and proceeds to sit in my waiting room for three hours until I have it. Her problem is, she doesn't have anywhere else to be.

I get back to my office, shut the door, and howl with laughter.

My Blog

This blog started for me to write down some of the things that I was learning in medical school, to share my thoughts and experiences with others, and with myself.  Anything funny, I found joy in writing down and sharing with others, laughing again to myself as I relived it by writing.  Anything sad, I found some peace and closure in finishing my essay, clicking "publish post."  And over the years I was thrilled by the feedback- family members laughing, medical students I didn't even know writing me and saying that my writing was exactly what they felt but couldn't express.  They showed it to their spouses to help them understand.  Patients- not mine, but some searching on their internet for answers- found my writing and valued the glimpse it allowed them into a young doctor's thinking.

I kept it public for all these reasons- so it could be shared freely between students, so people without email addresses to log in could still see it, and so it could find anyone that might enjoy it.  Knowing this, I was very careful to keep anonymity, to abide by patient privacy laws and confidentiality.  But, despite this, my program director would like me to take it down, despite enjoying my "creative flair."

Who told you I had this?  And how long have you been reading it?  Shit.

But, he is as free to read it as anyone else.  I had kept it that way for all the reasons I listed above, and because of this, he was able to read thoughts that I wouldn't have otherwise shared with him.

I'm disappointed to move this to a private site.  My writing has become such an important part of my life.  I write the entries in my head, in quiet moments, when I exercise or drive, or just walk and think about what I can say to make my life make sense to others, and to myself.  They never take me long to write- maybe ten minutes, limited only by the speed of typing.  And there are always others, ones that I never write down.

I loved sharing this publicly.  It has helped me tremendously not only to verbalize my own experiences, but to hear from others that my stories mirrored theirs, or that they helped someone understand their own life a little better or that people just enjoyed them, and were laughing somewhere in front of their computers.  I will continue to write, and post under a private site, but only for those not connected with my work or medicine.

It is my hope someday to put these into a book, and to finally have it "out there" for others to enjoy and relate to.  I dream of it reaching medical students that don't know me, but feel like they do after reading my book, because my stories are the same as theirs.  I hope patients can read it and know that doctors care about them, and went through a lot to be in a position to help them.  And as always, my grandmother will read these, as she does now, and enthusiastically share them with her friends and nag me to put up another post soon.


This last weekend was our resident retreat. Last year, when I heard we were going on retreat, I imagined a quiet weekend with my co-residents, in a nice location and fun activities, with time for introspection and deep conversation.

I was wrong.

The resident retreat was a wild party, an overnight trip filled with more alcohol than id ever seen in one place other than Costco. The drinking started early, during our team building activities. Which were very stupid, i.e. working as a group to pick up a bowling ball with ropes, working as a group to create a pipeline and fill a bucket, working as a group to put together a giant wooden puzzle while blindfolded.   We decompensated a little at at the end, with someone yelling "who has the corner?  Who the fuck has the motherfucking corner?", and us throwing the puzzle pieces at each other.  But i think we did well overall.

There is a party the night of the retreat, where each class comes in costume, and presents a skit. One classes' costumes this year were all the names for a vagina. We had a pussy cat, an orchid flower, a muff diver (wetsuit with English muffins taped on), a box (girl had cut a hole in a box and wore around her waist sans pants and with a t-shirt up top saying "party all night."), and so on. You get the idea.  Box girl has not worn pants for three years running.   The attending oncologist-who treats every major GYN cancer in a hundreds of miles radius-  is walking around with a blow up doll strapped to his waist.  It's that kind of party.

The skits start.  Ours is wildly racially insensitive, involving a response-type song where the girls sang "empuje!  No puedo!" and the boys employed a baseline of "all in the bottom now, push all in the bottom now."

After the skits, the karaoke machine is turned on. And I can't tell you what glee comes with watching your attending perinatologist- who has literally written the book on critical care in pregnancy- sing "when I think about you, I touch myself" into the microphone.  Off key.

Outside, the pregnant girl and the Mormon residents are hanging out.  Drinking Sprite.  The Mormons are okay with this, but the pregnant girl  takes a sip of my wine.  Her drunk friend (also her obstetrician) comes and sits on her lap.  She taps the pregnant belly and slurs,  "I'm gonna reach up in your cervix and say hey, little baby, come on out.  Come out now baby."

The night ends with the game "two truths and a lie", where you say two things about you that are true and one that isn't, and everyone else has to guess which is which. And it's amazing what's true.  Arrests. Menage a tois.  My "I've played the violin since I was five" is not an impressive Truth. 

The next morning, we are ready. There are bottles of ibuprofen and Zofran for each class. IVs are standing by.  We go outside for breakfast and our final activity, the breaking of the wooden boards. Our director thinks it symbolizes breaking through negative self assumptions and doubt. Each chief takes an intern and shows them how to do it, and we line up, with applause after each board broken. I watch as thirty two surgeon's hands- and one surgeon's head- breaks through the board, this a good idea?

And then it's over. We drive back home, with five lucky people returning to the hospital to stay overnight on call (I was one of the Chosen). Life goes on. We don't put a lot of pictures up, for liability reasons, but tease each other about our Truths, start planning our costumes for next year, and refill the Zofran.