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.