For My Husband

For my husband, who has done approximately 221 loads of dishes since I started my residency
And unloads the dishwasher too.

For my husband, who installed blackout curtains during my first week of working nights
And pulls them shut each morning when I am coming home from work.

For my husband, who helped me pick out the perfect "first day of residency" outfit
And curled the back of my hair for the fancy residency banquet.

For my husband, who feeds my cats
And picks up the dog poop.

For my husband, who knows more gynecologists than I'm sure he ever thought he would
And listens and laughs to their stories and jokes at parties.

For my husband, who rubs my feet after a long shift
And puts lotion on the parts of my back that I can't reach, since it's dry from the hospital air.

For my husband, who shops at Costco instead of me
Even without a list.

For my husband, who knows more about menstruation and menopause than most women
Because he has quizzed me on every flashcard I've made.

For my husband, who turns down my bed when I'm coming home from a long night shift
And puts clean pajamas on my pillow.

For my husband, who listens to me complain
And is indignant on my behalf, even when it is undeserved.

For my husband, who iChatted me in to my family Christmas morning
Because I was at work.

For my husband, who takes care of me, and our pets, and our home
And if we can make it through residency, I think we can make it through anything.

For my husband, Ryan.

Systolic/Diastolic

120/70

Her vitals are okay to start with. Blood pressure, pulse...they aren't alarming yet. The patient, a young woman transferred from another hospital for higher-level care, looks at me but doesn't see me. Her eyes are glassy, pupils nonreactive. She is sick after an intentional overdose of Tylenol and a "handful" of other drugs. The specialists descend into the room, like flies on a picnic- toxicology, hepatology, transplant surgery, neurology, nephrology, pulmonology, intensive care.

I'm pretty sure there is some graph that directly correlates mortality with the number of specialists involved in your care.

She gets the Tyelenol overdose treatment started. She gets an ICP monitor screwed into her head, poking out like a funny antennae. We learn that she's not a liver transplant candidate, on the account that this was intentional.

She is young, and pretty. The nurse tells me she thinks she looks like Beyonce. I think to myself, maybe, if Beyonce was yellow as a canary. But I can see it too. It scares me a little that she's only a little older than me, and this sick. I don't understand how she could do this to herself. Is this outcome really what she wanted?

90/60

Her blood pressure is falling a little today. She looks the same, quiet and nonresponsive. She's not doing well, despite all the treatments and specialists. I didn't expect her to.

I find out that she's got eight kids, the youngest of which is still an infant. I clench my jaw, angry with her, forcing myself to lay my stethescope gently on her chest, and listen. I kind of want to hit her with it. She's got a stuffed bear laying in bed with her, holding a heart saying "Love You Mom." I don't understand how she's made this choice, how selfish it seems to me. I look at her own mom, lost with the idea of raising eight grandchildren. My anger grows.

50/40

She is failing, despite maximum blood pressure support. I know she might die soon, and dread the thought of performing CPR on her, dread breaking her ribs with chest compression and giving intervention to a woman that I know is already gone. She is still a full code status, and I am waiting to hear if she will be changed to a DNR when more of her family gets here. I read specialist after specialist's progress note saying "prognosis extremely grim." I know. I worry about the family. Do they know? Finally, later that day, they seem to understand. They change her to a DNR, and the tension in my stomach unknots a little as I watch her monitor.

20/10

There is a cart outside the patient's room with a large tray of muffins and cookies, and pitchers of coffee, tea, and juice. I ask the other residents what it is, since I haven't seem that before, but it looks like the hospital food service. I am informed that it is the "death cart."

What? I am stunned.

"It's the death cart" a senior resident tells me. "Once I see the muffins show up I get my death dictation ready, cuz it's gonna happen soon."

Apparently when someone is about to die, the hospital sends up a tray of food and drinks, since often a lot of family is there and they want to stay in the room with the patient instead of leaving for the cafeteria. I am touched that my hospital thought of this. But to the residents, the muffins are a herald, a sentinel sign for the events forthcoming.

I stop in the room to say hello to the patient and her family. Her mom asks me how long they can hold a body in the morgue, and if they have to pay more past a certain point? They are trying to make arrangements. I honestly don't know, so I call up the morgue myself and ask. The morgue guy tells "a few months, if we forget bout em, but most of the time, a week or so. We don't charge no rent for the fridge space."

I don't relay any information besides the fact that she can stay as long as needed. She is starting to feel cold under my touch already.

0/0

The nurse pages me, saying she has died and she needs me to come to a time of death and death declaration exam. I'm not sure what this is, and google it quickly, and find a checklist of things to do. I've never seen one before. For that matter, I haven't seen many people die before.

I hope the family is gone. I don't want them to see me do things to their daughter, their girlfriend, and mother, that just reaffirms concretely what we all know. Thankfully, they are out of the room. Some of the muffins are gone too.

I place my stethescope on her silent chest, easily gently this time. My anger for her has evaporated. My fingers don't feel a pulse on her cold wrists. I am scared by the empty look in her eyes, by her stiff tongue and blank expression. I can't unbend her fingers, and her calves are stiff and contracted under my touch. I open her eyes, look at her pupils, and touch a cotton swab to them. She doesn't blink. I shut them quickly, my fingers pulling down her lids, shutting my own eyes too. I tuck her Love You Mom bear a little closer to her in bed, and pull up the blanket. I wonder, is this really what you wanted? Somewhere, are you happy, succeeding in what you meant to do?

And somewhere, a tiny irrational part of me worries that I did it wrong. That I did something wrong, and am sending a live person down to the morgue, that there's some reason I don't know why I cant feel a pulse. That she'll sit up in the fridge and wonder how she got there. Funny, maybe. Irrational, yes. But true.

And, a tiny irrational part of me worries that there is something more I could have done when she came in. But, I know the truth. She was gone when she came to me. I guess that's what she wanted.

Time of Death: 1136.

Thank You

Here is a story of probably the nicest thing any patient has ever said to me. I wanted to write it down before I forgot, so I can look back at it on the days that I feel like my work doesn't matter, an attending berates me, the nurses undermine my work, or there is a sad outcome. I went into medicine because I wanted to help people. And I thought becoming a doctor was the best way for me to do this- to gain the technical and clinical skills to be helpful. Sometimes it is. Sometimes it feels like it isn't. But, I love what I do, and what I get the opportunity to provide. Sometimes it's easy to forget this, which is why I hold on to this memory, precious and vivid.

I admitted a young woman, pregnant with her first baby, at 34 weeks. She was feeling sick, and her baby's heart tracing was concerning. Both of them looked sicker within the hour, but the attending and I were slow to want to do a c-section on a premature baby. We gave her fluids, and I watched them both closely. Then, the baby's heart rate when down. I called a crash section, and with the help of the OR team, had delivered that baby before the attending even got to the hospital.

There are a few quiet minutes, in between initiating the crash and the quick ride to the operating room and swift delivery. They are precious, my one opportunity to sit calmly with a mother and her loved ones before the chaos begins. I take her hand, and tell her "Everything is okay. Your baby's heart rate went down, so we need to do a delivery now. But, we do this all the time, and can get your baby delivered quickly." Usually the panicked mother starts to cry about now. I let her know gently, "in just a few moments, it's going to get very busy in here, with a lot of people, but that's normal. We just need lots of hands to help. We are going to take a quick ride down the hall to the operating room, and I'll be waiting for you there."

This time was no different. Lots of nurses, a quick ride down the hall, me smiling at her with everything but my eyes covered by a mask. A few minutes later she was delivered, and I was stitching her up, just as the attending arrived.

The gem came later, two days after her delivery, during my morning postpartum rounds. I went to see how she was doing, and she grabbed my hand and squeezed it. She said "I just want you to know...that time you sat talking to me, when you told me how it was going to get busy, but not to worry, because that was normal? That was so calming, and I just wanted to tell you...when I think about my baby's birth, I think of you. My clearest memory of my delivery is you, sitting on my bed, in your flowered hat (scrub cap), holding my hand and telling me what to expect, and that it would all be okay. Thank you."

Thank you, dear patient.

The Light

This is one of my very favorite patient stories.

I am in the ICU right now, working with very sick patients. This 94 year old gentleman came in to us hypotensive and tachycardic, and needed a lot of fluids. We decided to put in an IV in the jugular vein, to allow high volume fluids to go in. I explained what we would be doing, and that he needed to have a drape over his face in order to maintain sterility during the procedure. He agreed, and masked and gowned, I covered him up with the drape and began the procedure.

It was a little dark in the room, with only the flourescent overhead lights on, so the attending reached over and turned on the bright surgical spotlight so I could see better. All of a sudden, under the drape, the old man begins screaming"I SEE THE LIGHT!! I SEE THE LIGHT! OH LORD JESUS DON'T TAKE ME I AIN'T READY TO GO YET!"

"Sir. SIR!!" I reach out and touch his shoulder. "We ALL see the light, sir. It's okay. We turned it on to see better for the procedure." He is wary. I tell him, now we are going to turn off the light, okay? He nods. I then tell him, "sir, we are going to turn the light back on. I just want you to know it's me turning on the light, and everything is okay."

He is calmer, and I place the line. He gets his fluids, and gets better. Apparently this 94 year old man's got a lot more living to do.

The Imposter

I'm still a little surprised that my name badge says Doctor. I've seen prescriptions filled that I've written, pausing momentarily to look with surprise and marvel that my name- Dr. A. Kennard- is on the label. And not as the patient. It's in the top corner; the doctor's spot on the label. I'm always surprised in the operating room when I say "knife, please" and they hand it over.

My mother laughs, and tells me I have Imposter Syndrome. She says its common in young professionals, and probably most so with a very important job, as I have. So, I looked it up. I thought she was making it up, but apparently it is actually a described and studied entity. Imposter Syndrome is described as " is a psychological phenomenon in which people are unable to internalize their accomplishments. Despite external evidence of their competence [ie, my name badge], those with the syndrome remain convinced that they are frauds and do not deserve the success they have achieved. Proof of success is dismissed as luck, timing, or as a result of deceiving others into thinking they are more intelligent and competent than they believe themselves to be. It is commonly associated with academics and is widely found among graduate students and especially in high-achieving women" (Clance, et al, 1978 and Lucas, 2008).

Huh. I wasn't aware I had given consent for researchers to observe me and exactly describe my thoughts and behavior.

I think part of my reluctance to realize my success is that I am in a group in which I am very, very average. I am definitely not the smartest. I am not the prettiest. I am not the most athletic, the thinnest, the tallest, the shortest, the hardest-studying. I am probably not the most insecure. And I'm quite sure I am not the only imposter.

I watch in awe (and jealousy) as these residents give presentations at world-class perinatal conferences. They run marathons. They have beautiful, highlighted hair, smart clothes, designer shoes and bags, toned arms, tight abs. They are mothers. They seem to effortlessly go through working twenty-four hours with a plan to go for a run afterwards, as I am blindly grabbing for my coffee, planning a workout I won't do, and stumbling towards bed. They spend hours pumping breastmilk so their babies can have the best nutrition possible while they are away at work. My dog is lucky to get his scoop of dry kibble.

What normal person wouldn't be an imposter, wouldn't be intimidated, by this group and this job? But my mother points out, I am not a normal person either. I belong here too. It would have been impossible to fool enough people for me to be here just on luck, so I must be here on my own merit, despite my veil of inadequacy. And the fact that it took a prestigious residency- one of the top in the country- to make me average is pretty un-average.

I'm back in the operating room, after reading this research. "Knife, please." They hand it over. I look at them suspiciously and with surprise. Are you really sure you want to do that?

I'll keep working on it.

The Twelve Doors of Christmas

I worked every day this Christmas holiday, 7am-7pm, sometimes longer. It was the first time I'd been away from my family during Christmas, and my first Christmas as a doctor. Here are twelve of the doors I walked into this Christmas Day.


Starting the holiday in the OR, ready to c-section twins in my Christmas scrub hat!

Door 1: The Intern Call Room (A Sad Resident)

I open the door to my call room to change and find my fellow intern sitting on the bed, crying. I asked her what was wrong? She said she had cried all the way into work, because her two small children didn't understand why she had to leave Christmas eve, why she wouldn't be there to watch for Santa and see them open stockings in the morning. I was so sad for her. It's hard to want to be with other people's babies, she explained, when you just want to be with your own.

Door 2: The Gift Shop (Good Sam)

I open the door to the gift shop. Christmas Eve, the hospital gift shop is advertising all holiday merchandise 50% off! I buy myself an ornament, to mark this first Christmas working as a doctor,. The first of many, I'm sure. I named him Sam, after Good Samaritan hospital.

Sam the Snowman

Door 3: Triage (The Reluctant Partygoer)

I open the curtain to the triage room. There is a woman I just can't get rid of. You're not in labor, I explain. You're rarely contracting, your cervix hasn't changed. She refuses to leave, insisting that she's in labor and will just come right back if I discharge her. I wonder why anyone would want to sit in triage on Christmas Day if they didn't absolutely have to. I ask her if she wants to go home, since she doesn't have to stay here? She replies that she has a large family party at her house to go to, and just really doesn't want to go...so she has presented for preterm labor. I ask her when the party ends, and discharge her home afterwards.

Door 4: The Resident Room (My Family)

We all walk into the resident room. It's a small lull in the day, so all five residents crowd into the shared resident room and turn on a tiny TV and make popcorn. National Lampoon's Christmas Vacation is on, and we share an hour and a half of watching it together, laughing, occassionally interrupting to return pages, and just enjoy being together. We are all away from our families this Christmas Day, and are grateful to enjoy our residency family.

Door 5: The Resident Room, later (Her Family)

One of the resident's kids come to visit. They have on their new Christmas PJs (see next photo), and have come for Mom to give them a hug before they get tucked into bed to wait for Santa.

Door 6: Triage, later (Santa Surgeons)

We all put on Santa hats and open the door to triage to take a picture in the emergency birth room. John, one of the second years, later tried to keep wearing it and pass off the hat as a scrub hat. Turns out Santa is not allowed in the operating room. HO HO NO.

Christmas Call Team!

Door 7: The Intern Call Room, later (My Other Family)

I open the door to my call room and open my iPad. My family has woken up in California, and are opening gifts. I have them wait until I am between deliveries, and then get on iChat with them and watch them open presents. My husband even opens a gift for me, with me "holding" it up via the screen. It was fun to feel like I was a part of it even though I was here.


Ryan and me "holding up" my new sweater!

Door 8: An Antepartum Room (Christmas Dinner)

I'm taking care of a girl that has been admitted for weeks for preterm labor. She'll likely be here until delivery, and would not be home this Christmas. I open the door to her room to round on her, and find about twenty-five people in that room, along with a Christmas tree, gifts, and even a crock pot plugged in with something delicious-smelling inside! This girl's entire family has come and brought their Christmas party to her room. I almost fall over with happiness when they invite me to sit down and eat with them.

Door 9: A Delivery Room (The Manger)

I walk through the door after being paged for delivery. I am delivering a nice Hispanic woman, Maria. She names her baby boy Jesus. I love it. How many people get to deliver Jesus on Christmas Day?
The hospital's special holiday newborn outfits, on the delivery table

Door 10: Another Antepartum Room (My Kiss)

I go into another long-term patient's room. She's been admitted with preeclampsia, and staying until she is delivered, which might be a couple more weeks. She has a few family and friends over, and they have a table full of yummy-looking sweets, and a glass jar full of Hershey's kisses. I talk to her for awhile about her baby, the plan of delivery, and ask if she has questions. She says no. I say, "well, I have a question." I point to the jar and smile. "Can I have a Kiss?" One of the guys in the back calls "So THIS is the kind of doctors we have working here. Come back here, sweetheart. I'll give you a kiss!"
I want to die. And definitely not round on her for the next few weeks!

Door 11: Another Delivery Room (Sixteen)

I walk through the door of another delivery room as a baby's heart rate drops. We put the mother her on her side, give her oxygen, and the baby's heart rate comes back up. I'm not ready to leave though. I sit in the rocking chair in her room, watching the heart rate tracing, rocking as she falls asleep. She is sixteen, and here in labor with her first baby. I rock, and think about the Christmas that I was sixteen, eleven years ago. I fell asleep excited Christmas Eve, in anticipation of my stocking. I wanted, and received, things most teenage girls would like- a new pair of cool shoes, some clothes, bubble bath, fuzzy slippers. This girl's stocking would maybe have things for her baby, or maybe no stocking at all, as she labored here Christmas Eve. I rocked and rocked, and watched her and her baby for a long time, until my pager finally pulled me away.

Door 12: Home (At Noor's)

We push the door open to the apartment. I'm staying with my dear friend and fellow intern Noor, who is working the same long Christmas days as me. She lives much closer to the hospital than I do, and offered to let me stay at her house. I am so tired. We share a piece of leftover chocolate cake, and stretch out on the couch with HGTV and a bottle of wine. I fall asleep that night, happy that I've survived my first working Christmas, and happy that it's over.

Me and Noor

Missing Grandma

Recently my grandmother was sick. I got news of a stomach bug, and didn't think much of it. Then, she was sicker. She went to the OR for a bowel resection after an obstruction was diagnosed, and had subsequent kidney failure. I anxiously pressed my parents for what the surgeon said, for a consent to send me the operative report, for information on previous kidney function, and prognosis. I asked, and asked, and they just couldn't tell me much. I desperately wanted to see her, wanted to talk to her physicians doc-to-doc, to really understand what was going on and evaluate her with my own eyes and hands, to tell her I love her. Because after all my time working in the ER, the ICU, with patients that are very sick, I know that there are no guarantees at eighty-five, that sometimes there are things we just can't fix.

And I was here. Working. Taking care of other people's families, while I just wanted to take care of my own. I would get little bits of information, and tell my parents what I knew about her illnessess, that this was a normal course for bowel obstruction, that often times kidneys can recover if it is an acute failure. I talked to my sister before she went to visit, warning her that Grandma would look sick, and have a tube coming from her stomach to her nose draining vile looking green liquid, and that this was normal and she shouldn't be alarmed by it. I was angry about being here, knowing the only time I would get off for this illness was if she died from it, and by then, what would my being there matter?

I thought about Grandma as I touched my patients, caring for them, praying that somewhere, some other doctor was taking good care of her. That some other doctor was away from his own family because he was taking care of mine.

And she got better. Not all the way yet, but better. The kidneys recovered, as I thought they would, and she was able to eat again. But this experience stuck with me, because someday, someone I love will be sick, and I won't be able to be there. I won't be there to care for my loved one, to explain to my family what is really going on, what these medical words mean, and I'll be making guesses over the phone, just like I did this time, waiting for an operative report to be faxed and feeling helpless. This is an unspoken sacrifice of becoming a physician, and one that I underestimated. Somewhere in the greater universe, it makes sense to me that this is the sacrifice of all physicians, and that we take good care of our patients because these patients could be our own loved ones, and sometimes they are.

But I still wanted to be there.

ToMAYto, ToMAHto

I work with with thirty-three different attendings. Who want patients managed, needles held, stitches thrown, lacerations repaired, knots tied thirty-three different ways. It was part of the learning curve, at first, learning which attending liked what, remembering who to call about different problems and learning to not be upset when I didn't remember who preferred what. And now, I'm starting to develop what I like. Many attendings have offered me pearls, on patient management and surgical skills, and I'm starting to develop a framework of what I want to do, what I think works well. And this is even more frustrating, because then I end up with someone new, who doesn't like the way I am doing something, and makes me do it a way that doesn't feel natural, or right. And really, no one is very wrong, but it means I am never right. It's like how some people say "toMAYto" and some say "toMAHto." No one is actually right, and everyone insists that they are.

Here are some examples:

Yesterday in the OR, an attending showed me a way to reload my needle without touching it with my fingers. Use the pickups, inch it out, and regrasp it in a way that it was ready to throw the next stitch. Better technique, he explained, it would allow me to avoid needlesticks and was a more sophisticated surgical technique. I practice, and look forward to my next c-section, where I can practice it again on a real patient. I start, expecting the attending to be impressed or at least not say anything, but she yanks the needle out of my hand and shows me how to do it....exactly like I used to. I pick up the needle, reload it using my fingers, and silently curse this frustration.

An attending that puts me on the stool in front of the mother. She does this under the assumption that this is a good position for me to deliver the baby, but I have figured out the real reason. She puts me on the stool, then waits for the crucial moment when the baby is about the deliver, then rolls me out of the way and delivers the baby herself.

Antibiotics. Some give antibiotics for GBS+ mothers at the beginning of inductions, and some only when they are actively laboring. The downside to the first option is a mother can receive fifteen doses of a medication that burns their veins and is unnecessary for that long. Alternatively, a mother can labor quickly and not get enough of a dose in and end up with a baby in observation in the NICU for 48 hours. So, I started to ask each attending, when would you like the pencillin started? They couldn't believe I was asking this, like I didn't know. Then, I would ask with one option offered, would you like this when they are in active labor? Some people then thought I was correct, and some thought I was an idiot. So, no matter what I think or what I would do, I look stupid at least half of the time, just trying to please everyone.

I am fairly ambidextrous, and can operate either right or left-handed. Some think this makes me versatile, and encourage maintaining both. Others yell at me to pick a side and stick with it. Now I don't know which side to stand on. Likewise, I can clamp and cut cords after delivery lefthanded. Usually I hold the baby in my right arm, tucking baby's feet under the crook of my elbow, and clamp and cut lefthanded. I don't know why I do this. It just feels right, to hold the baby securely in my more dominant arm, and use my left hand for the instruments. But, attendings sometimes ask me if I'm right or left handed, and when I tell them right-handed but better with fine motor skills with my left (due to violin training, I think), they frustratedly instruct me that I should only be managing scissors around a newborn with my dominant hand. Again, I'm not sure which that is.

There are probably infinite variations on how to do one surgery, one delivery, and that's what I'm learning. Even though I've never had a bad surgical outcome, somehow I am always wrong with how I do it. I'm trying to take the best of everyone's suggestions (ie yelled orders), and compile it into my own technique, but starting to realize that it will be awhile before I can really employ what I think is best. And I can't say I wouldn't be the same later, after a career's worth of doing what I decided is best...I'd probably want to hand my hard-earned knowledge along too. But it's frustrating now.

I think I'll go sit down on the roll-ey stool and practice reloading my needle.

Lessons In Cultural Competency

I'm white.

I mean, really white. Scandinavian mostly, a little Irish and Scottish, and part Sicilian. Not Sicilian enough to give me the gorgeous olive skin of my relatives, rather, just enough to turn my eyes brown and leave me with the fair and freckled skin of generations of peoples who have never seen the sun. When it comes to those "race" boxes on standardized forms, I only get to check "White" or "Caucasian." There's really nothing else there.

But, I can switch fairly fluently between English and Spanish in the exam room. I've begrudgingly completed the "cultural competency" courses of medical school and as required by my employer. I tell myself that I'm open to other cultures, I enjoy experiencing things different than what I'm used to. I really did consider myself culturally competent, at least for a white chick.

But this month, I've had a few situations that were new to me, and showed me far more culture and much less competency than I had ever seen with any of the informational videos provided by the HR department. It turns out that understanding, and respecting, another culture that is much different than your own is very difficult, especially when a pregnancy and child is involved. And sometimes that a new culture is a lot of fun, and it's a privilege to join it, at least for a little while.

Lesson #1: Las Mujeres

I come into the room to say hello to a new patient. She is ready to push, but I can't see her. There is not a word of English, and at least twenty people in the room, all female.

"Excuse me, excuse me." I jostle through the crowd. I say hello, and introduce myself, and ask, in Spanish, if she wants everyone in the room for delivery? I'm expecting most to leave, but instead, they all circle the bed, and are ready to help her push.

Who are all these people? I start to get a little irritated as they touch my delivery instruments "No, please, those are sterile", and bump me as they crowd around the bed (hello, please give the doctor some space!). But I come to find out that in this patient's culture, all of the females she loves are here for delivery. The dad is nowhere to be found, but this patient's mother, grandmother, great-grandmother, multiple tias (aunts), sisters, nieces, and even her own young daughter are here, ready for her delivery. In this culture, birthing is women's work, and all the women are here to work.

The mother cries "No, no puedo" when told to push. The tias respond with a chorus of "Si! Se puedes!" And so it goes on, until this baby- a girl- delivers, and all the women crowd over to the warmer to see the new nina, the new addition to their family.

I smile, for the small reason that they are now in the pediatrician's way instead of mine, but for the bigger reason that this is an enviable culture. I'm not even sure if I have close relationships with half as many women as this girl had at her bedside supporting her for delivery. They all were there, and knew what to do, how to support her and love her during this significant event in all of their lives. Se puedes, indeed.

Lesson #2: A Native American Preemie

There was a patient who came to our clinic from the Indian Reservation, with the complaint of bleeding. She bled off and on, and eventually went into labor, and delivered a twenty week-old nonviable baby. These are very sad situations, and we have people and programs at the hospital set up to help families cope with this. However, this family wasn't interested in the bonding time offered, or even seeing their baby. That baby needed to be out of the room as soon as possible, as it is bad luck to be around anyone who is dying, and particularly the spirit of a dying child that could affect future fertility. I came around the nurses station a few minutes later and looked suspiciously at a mound of blankets in a metal bassinette. Was that...? One of the nurses picked up the blankets, and gave them to me to hold. It was the baby, the smallest one I had ever held, with an irregular, slow heartbeart visibly fluttering under tiny ribs, with small hands and wispy eyelashes. I touched his forehead gently and pulled my hand back, startled, as I felt how cold it was. The longer that baby was cold, the more slowed-down his metabolic processes would be, and the longer he would hover somewhere in between a heartbeat and inevitable death. I wrapped him up in a swaddle and tucked him under my sweater, holding him close to my chest, sitting at the nurses station for about forty five minutes, until I couldn't see a heartbeat any longer.

And here is the cultural difference that I struggled with: His parents weren't wrong. To me it seemed wrong, to let their baby die cold and alone, but that's only because of my own learned customs of love, grief, and healing. It seemed like the right thing to do to me to bridge the gap for this baby between this earth and wherever these little ones go to, but just because I felt that was right doesn't mean his parents were wrong.

Lesson #3: An African-American Queen

It's three in the morning. At this point, I'm wondering why I went into obstetrics. There are floors above me filled with sleeping patients, sleeping residents, and yet I am running around the third floor, awake with another laboring patient. This girl is sweet, a 16 year old here with her mother, who is earnestly coaching her daughter's labor. She's ready to push and have a baby girl, so I put my gown and gloves on, and get ready to help her to push.

She doesn't need it. She pushes well, and her mom shouts "That's it! Push hard, baby! Soon we'll hear that queen holler!" And I smile. Not the absent, tired smile I feel like I usually have, but a genuine smile. For a minute, my shoulders relax away from my ears, and I remember why I loved obstetrics. I'm excited for this family. I'm ready to meet this queen, too.

Aftwerards, I congratulate mom, and grandma. As I'm leaving, I can hear grandma on the phone talking to someone, saying "Listen to that baby holler! Speaking of, you should have seen this young woman that delivered her. Not but a baby herself."

Lesson #4: A Somali Refugee

There is a fairly significant Somalian population in Phoenix, a community of refugees. Most tend to be difficult patients- mistrustful of the hospital system and Western medicine, along with a significant language barrier and cultural gap. The roles between men and women are so much different than I could have imagined based on my own experiences. In our house, my mother had a career. My husband changed careers and moved to support mine. I go to work, and he does the dishes. In their house, the husband is the decision-maker. The patients will not answer me, not acknowledge my presence or information, until their husbands are there to communicate directly with me. The mechanics of birth are challenging because of scar tissue left behind from genital mutilation. It's hard to do an exam under the many layers of robes that the patients insist on wearing. They tend to refuse medications, and epidurals, and any procedure outside of the normal vaginal delivery.

Because of all these things, when my Somali patient's baby's heart rate went down, and then came back up, I thought it was a good idea to talk to her about a c-section. She didn't need one now, I explained, it was only that I wanted to talk to her and answer her questions while everything was calm and her baby's heart rate was fine, while I had time to use the translator phone and could explain everything about the consents.

Three hours later, I'm bleary-eyed. I've tried to be sympathetic, and explain things differently. I've tried to sit back and enjoy the melodic rhythm of a language that I don't understand. But I can't. I've spent my night sitting here, instead of in bed, and I have no consent. What it came down to was the patient understood why I was talking to her about it, but said she didn't want surgery. She wanted to be healthy, and babies die every day, so if something happened, she wanted to remain healthy and not intervene for the baby.

No!! I want to scream. This is America! I can almost certainly make BOTH you and your baby healthy, even if you needed an emergency section. But, she didn't believe me. She wouldn't sign the consent, and ultimately, I can't make her. She is deemed mentally competent, and able to make decisions for herself and her unborn child.

In the end, after my shift had ended and my friend had taken over for the day, the baby's heart rate went down, and she watched them stay down- for ten minutes- as she and an attending tried to cut through genital scar tissue to deliver the baby as fast as possible vaginally, since the patient was still refusing the operating room. My hours of trying to consent her were wasted, she had more of a wound that she would have with a simple cesarean, and her baby was in the NICU.

Did it make sense to me? No. Was I angry, and worried for her and her baby? Yes. But I had to leave this situation with these frustrating conclusions, and realize that maybe that was what she wanted, because she was a culture so different than mine.

These are the real stories of cultural competence. I watched the required videos from human resources, but I didn't learn what these situations taught me- that cultures are so different. Sometimes it's fun, and sometimes its horrifying, but the "competence" isn't learning to manipulate situations to fit your own culture. It is learning to recognize other cultures and try to accept them, to try to bridge a gap for yourself in between your beliefs and these new ones, where you understand a little bit more than you did before the interaction.

As I sit here with my afternoon coffee, reflecting on these interactions, I reach for a butter spritz cookie- my grandmother's recipe- to have with my coffee. No reason other than it's 3 pm, and that's what Swedes do.

As I head for the cookie jar, I smile. At least I am competent in one culture.

A Month on Labor and Delivery

Day 1: I feel great. Excited for labor and delivery, have my lunch packed and my latte in hand. Hair is brushed, lipstick-ed mouth is smiling. Bring on the month.

Day 4: Kinda tired. Thirty-two people are now in the world that were not only a few days ago, and since it was my hands that guided them out, I am now responsible for seeing their mothers every day starting at 4:30 am.

Day 5: Hair brushing now seems like superfluous vanity. Give up in favor of extra thirty seconds of sleep.

Day 5, later: Am primary surgeon on a cesearean section for the first time. Realize that nurses do a "count" of all surgical instruments/sponges before I close the patient, to make sure nothing is left inside. Nurse reports to me "Counts are correct, Doctor." I smile. Thank you.

Day 6: How did my fridge get empty? I seriously don't remember eating all that.

Days 7&8: Don't have time to go to the grocery store.

Day 9: I am now grocery shopping in the hospital cafeteria. What do we need? Milk? Cereal? Fruit? Dinner? A recent trip to the cafeteria yielded 6 milk pints, 5 pieces of loose fruit, a box full of salad, three tins of cheerios, and a takeout box filled with cooked chicken breasts and potatoes. The cafeteria worker laughed at me, then realized I was serious and rang it all up. Swipe...and done.

Day 10: Baby count continues to climb, as does the length of my postpartum rounding list.

Day 11: Find time to go to Fresh and Easy. Please bear in mind that F&E is about 500 feet from my house. Someone with a good arm could throw a ball into their window from my front yard. Nevertheless, I feel a great sense of accomplishment and provision for my home as I drive over. Get there and realize that the coupon I have been carrying around in my scrub pocket for five days has expired yesterday. Frick. My smugness evaporates, and deflated, I buy the groceries anyways.

Day 11, later that evening: Realize I have forgotten to buy dog food. Rather than make the journey across the street again, opt to serve the dog a chicken breast mashed with potatoes, left over from aforementioned cafeteria shopping. He loves it.

Day 13: Thinking of the raw pork loin waiting for me in the fridge (it seemed like a good idea sitting there all pretty and healthy in the grocery store case), I opt to bring home dinner from the cafeteria. Chicken enchiladas- a favorite of my husband's- were being served, and I bought a plate and took it home. I slid it onto my own china, reheated it, and served it. About halfway through, he squints at me, and asked if asked if I had made these? I just laughed and asked...what do you think? He laughed too.

Day 15: I didn't have time to do my laundry, and ran out of underwear. Opted to buy a new pack from Target instead of devote time to mountain of dirty clothes. Must remember to maintain efficiency and get all other shopping done as well while I am there. Cat sand? Check. New mop? Check. Dog food! Yes! What else? I just cant remember.

Morning of Day 16: What is that smell? I turn my head. It's stronger now. I surreptitiously sniff my armpit. Oh God. That's what I forgot at Target. Deodorant.

Day 18: Deodorant still not purchased. Just when I'm about to give up and start changing my scrub tops thrice daily, I pick up a prescription for the hospital pharmacy and notice they carry deodorant. Hallelujah.

Days 20 and 21: Working both weekend days. Miss husband. He comes to hospital for lunch. I feel bad that he's driven 45 minutes each way to see me, but he insists that the Banner Bistro makes the best chicken sandwich in town, and he was hungry for a good chicken sandwich, so it's really not my fault. He also brings me and my fellow intern our favorite frozen yogurt treats, which I know is an additional 20 minutes out of his way.

Day 23: So, so tired. Realize that between the drive home and needing to come back at 4, I will spend only eight hours at home. Decide to sleep at the hospital, which allows me to sleep in until 5:30, and roll out of bed and into my patients room. Don't care that my hair isn't brushed, but realize the deodorant I've worked so hard to procure is at home. Dammit.

Day 23, later that morning: Purchase another deodorant from pharmacy. Pharmacist grins at me. "Didn't you just buy one of these?" I glare at him, and add a toothpaste to my purchase. He laughs at me.

Day 24: Baby count: 97. How is it possible that there is anyone still pregnant left in Phoenix? I must have delivered everyone by now.

Day 25: My first needlestick, while suturing a difficult vaginal laceration. Must figure out how to get to occupational health.

Day 26: Buy second pack of underwear and larger laundry basket.

Day 28: Mother, upon hearing laundry plight, mails me five pairs of Victoria's Secret panties. I'm sure the postage cost more than what I spent on Fruit of the Loom pack from Target. Gratitude for supportive family eases my tiredness and makes me smile.

Day 30: Had a slow day today. Only delivered one baby. Is it true? Did I really deliver everyone? I was kinda joking before. Hmmm...

Day 31: Never mind. Pregnancies, if not in Phoenix, have now appeared from surrounding areas, including, but not limited to: Camp Verde, Strawberry, Show Low, the Grand Canyon, Colorado City, Buckeye, Salt Lake City, and California. None of these places are within two hours drive of the hospital. Appreciate, really for the first time, that this is a true tertiary care center. Humbled by the fact that I am part of a program/medical center that people travel hundreds of miles to get to, because of what we can provide in terms of high-level care. I don't work with these patients right now- they go to the more experienced residents- but wonder how it happened, and will happen, that in a few months I will be helping to provide care that people drive hours to receive.

Final Count: Babies: 106. Husbands: 1. Supportive family members: more than I deserve. Lost hours of sleep: countless. Pairs of scrubs: 44. Hospital Meals: 61. New pairs of underwear: 17. Exhausted and humbled residents: 1.

Counts are correct, Doctor.