You win this time, baby.

"Syncopal Event" So a couple of nights ago I ended up unconscious, on the floor, dreaming about a duck and a witch debating over who should mow their lawn. Incredibly unprofessional. But apparently these things are common on Ob-Gyn rotations. But I don't understand why these things have to be common for me. Here's my track record so far: In a week of working pure shifts I observed a c-section and helped out with a normal spontaneous vaginal delivery (NSVD). I nearly passed out in one, and definitively passed out in the other--I was on the floor dreaming about ducks. That means right now the score is: seven pound neonates 2, Elora 0.

When the scrub nurse told me I needed to leave the table during the c-section because I was leaning on the patient and I was passively crossing my eyes, I gave my retractor up and I had at the time told myself my blood sugar was probably low. Type 1 Diabetes fail! I sulked out of the room--very slowly so that I wouldn't fall onto any of the nurses standing cautiously around me. And then I had found my way to a patient fridge which are really just stock piles of assorted milks, jellos, and juice cups. One chocolate milk and one orange juice down, I found a dark, quiet unused part of the family waiting room and slowly collected the sweat pooling off of my face onto the collar of my oversized, hospital recycled scrubs. Excellent example of an acute hypoglycemic event--so perfect I didn't even think about checking my blood sugar. And then I actually passed out for real during a NSVD and upon regaining consciousness enough to check my blood glucose, I was perfectly normal--better than normal… 176 mg/dl. So now everything is in question!

DID I REALLY ALMOST PASS OUT DURING THAT C-SECTION? Even my potential as a future family practitioner should be questioned. If I can't handle pregnant people and kids, then I will have to become a… oh god… an internist? I would rather die than do something that boring. I HAD SUCH HIGH HOPES FOR OB-GYN. I've more or less "mastered" (for a third year medical student) the pelvic exam (I can find your cervix! If you have one). Vaginas don't creep me out at all! Vaginal products don't really creep me out either. Senior year of high school, as a swim team captain, I had picked up, with my bare hands, a bloodied feminine napkin that some noob had left on our locker room floor. This merited me a great gag gift at the end of the season. But it also kind of made me think that I could handle a large amount of grossness associated with the female reproductive tract. I still don't think vaginas or uteruses are my problem.

Which is why I think my real problem is… babies. When I had returned to the floor station after passing out during the NSVD, and the nurse wheeled the less than one hour old baby past me, I pointed at it and declared: "You made me pass out, baby!" What the hell is wrong with me? THEY BARELY MOVE! They are pathetic. Me and a baby in an actual fight? I would probably win, right? Gah. Maybe not.

This is the bruise left from my syncopal event.

 The midwife, the residents, and a ton of nurses have been very supportive of the fact that I am not, in fact, a very imposing six foot tall woman, but rather a pathetic, spineless, inexperienced medical student. Every one has stories of passing out and watching other people pass out. It makes me feel better to know that this isn't rare. But I don't want to feel normal. I want to actually be good at maintaining consciousness in unpleasant situations.

Talking with my friend, Cindy, who was also on shift with me, who had also watched this baby emerge into the world, who had also, like me, held the mom's legs back to flatten the pelvic floor and increase the size of the pelvic outlet, and who is a very small five feet tall, but who had NOT passed out, suggested something like, maybe it's not the actual sight of a baby entering the world--because they are pretty ugly looking in an adorable way--but maybe it's the smells of deliveries that really knock me out. Possible. The c-section lady had smelled pretty gross before the operation, and during it, she hadn't smelled that much better. And during the NSVD, I was literally holding up a thigh as the woman kept exhaling directly into my face. I shouldn't say anything. If I had been in labor for the last thirteen hours, yea… I probably wouldn't have spent time brushing my teeth, either. But then it was all I could smell and I felt like vomiting. And when the baby came out I kind of stepped out into the corner, leaning against the window sill. I was thinking to myself "hypoacousis: the thing that happens to me when I'm really happy/manic when driving and I have to turn up the radio all the way because everything sounds so quiet" because that's what was happening to me at the time. Everything was incredibly muffled. There was no longer blood in my ears, apparently. Nor was their blood in the rest of my body, because my arms and legs were moving very slowly. I managed to make it to the window sill and was just kind of waiting for the aura to subside. But it was a prodrome. And the next time I opened my eyes, I was staring at the ground and a nurse was propping me up against the wall with a blanket, and another was going out to get me orange juice. "I don't know what just happened," was my response to "Are you alright?" And Cindy was giving me a pity smile. The patient's family members were mildly freaking out, and I wondered if when the kid asked about her birth they'd tell her that she made a medical student pass out.

Later I would have to fill out an employee injury report, and although I had a small, 1-2 cm laceration ion the lateral aspect of my forearm, and my hand was really sore, I was tempted to write "ego" in the head of the anatomical model of the human body, and circle it to show where I was in fact, most hurt.

Rules and Regulations: Is Cover-Your-Ass Medicine Devaluing Healthcare?

Today was the day I realized I will have to go into family medicine. Not because I loathe internal medicine (quite the opposite--I have loved almost every day of this clerkship) but because I cannot work inside a hospital. There are many terrible things about hospitals. They are full of sick people. And because they are full of sick people they are always full of the things that accompany sick people in societies both full of resources and those that reside in the third world: the smell of disinfectant mixed with the odor of bodily excrement--almost unavoidable if you spend a day walking around on the floors; the screams... the tortured moans of patient's suffering either from a psychiatric issue (although who wouldn't be driven insane by being locked up in a hospital room for days?) or a pressing physical complaint? (I don't imagine a leg ulcer infested with maggots* can be purified without any amount of pain).

But, unfortunately... well, unfortunate for those people who find themselves confined to hospitals, and also for those people like me who have the option of working in one... the worst thing about hospitals isn't the patients or their illnesses. The worst thing about hospitals are their dumb-@$% rules.

I have a patient. He is my only patient. He is my favorite patient. He is super old and he has borderline dementia.... he reminds me of my father and so I try to be super nice to him because he, like my father in about a decade, deserves the best.

One of the things that is really hard to deal with while working as a pretend internist is how old and close to death so many of our patients are. In surgery, all of our patients had to be surgical candidates, and to be a surgical candidate you have to be able to withstand general anesthesia and someone poking around your insides. This is not so with internal medicine. Hell... one of our team's patients died the other day.

SIDE NOTE: I think surgeon's fear death way more than other physicians. While m&m's (morbidity and mortality) presentations for internal medicine (IM) are relatively tame and emotionally controlled, surgery m&m's seem to be intensely discussed, with the accusations of "who-to-blame" are hotly debated. I think this is a result of surgeon's wanting to, one some level, think of themselves as able to prevent death in their patients. I think this also makes much more timid, surprisingly, when it comes to patient care. I called both of my parents today (remember: both of my parents are surgeons) to ask them what they would have done with one of our patients: patient is an 84 year old man, with a past medical history significant for hypertension, diabetes, and two previous strokes, who was admitted to the hospital 7 days ago with slurred speech and left sided facial weakness suggestive of acute, focal cerebral ischemia, with brain CT and MRI also suggesting stroke, who know, the day before being cleared for discharge, has spiked a WBC count. Both of my parents said he should stay in the hospital. True, you should find the source of his infection. But we could almost be sure what the infection was... couldn't we just treat him for that and send him on his way? The extra care my parents seemed willing to offer might have simply been an artifact from how much more surgeons have to pay in medical malpractice. OR, they could simply hate seeing patients die from something so insidious and so simple as an infection. 

Where was I...? Yes, the incredibly stupid rules. And I'm not complaining about stupid seeming rules that are set up for the purpose of patient safety. For example, this patient, with his borderline dementia, was put on high fall precautions... essentially, he was strapped to his bed by soft handcuffs, which are called "soft restraints" in medical jargon. I understand this rule--if he falls out of bed he could easily die--although it is terrifying to think of fading in and out of orientation to a world in which you are permanently tied up against your will. No. I hate rules like the one that requires the next of kin to physically enter the hospital to sign cover-your-ass paperwork when the patient isn't at full decisional capacity. And even though a lot of terrible malpractice cases, a lot of morbidity, and a lot of mortality have arisen from the fact that things weren't explained well enough to the patient, there are some procedures that are so non-lethal it really doesn't make sense to require the patient's family member(s) to come in. Some people are busy. Most people are busy. Even I never get a weekday off work... if I was told I had to go to the hospital on a Wednesday to fill something out so that my parents could get discharged... I'd probably still take until the weekend to scrounge up enough time to liberate my parents. Doctors know what's best for the patient. We shouldn't have to explain to the patient how the procedure is done, what risks are involved... if the risks are minimal enough.

I know, I know: that wreaks of paternalism. But in all honesty, what we do now is highly inefficient. If I become an internal medicine resident, I'm going to spend my intern year writing down all the times money and/or time was wasted because we had to get paperwork down before patients could get what they needed and leave the hospital as soon as possible. Some patients love staying in the hospital... most patients don't. All doctors want to see their patients get back to baseline so that they can be discharged. But I don't think enough doctors want to put in the time necessary for analyzing why these rules and regulations are often detrimental.

Or maybe we just don't have the time. After all, I rarely see doctors taking off weekdays.

*yes. there were actual maggots in this patient's room. there were actual maggots under her skin. however, when they were finally discovered and the wound care nurse and her assistants were telling everyone outside the room about their findings within, I did not--in that moment--have enough courage to walk inside and look that hollering woman in her face while examining her wounds. I was not brave enough to examine and deduce what exact parts of her scabbed up wounds were flesh and blood and what were maggots.

I'm 23 right now so yea.

me

ermergerd

case study micro

24 year old diabetic

fungal infection

dies

that's my M3 year.