On Unrelated Symptoms & Patient Advocacy

Sometimes you think you know, but you really don't. Other times you convince yourself you don't know, but you actually do. But the moments when you're absolutely sure you know...well, those are the ones you have to hold onto and refuse to let go. Let me explain...

It was my second month of Internal Medicine, way back in September. I was in the process of admitting a new patient and I was running through the review of systems. His chief complaint was lower back pain, but as I was fresh out of second semester and the words of Bates were burned into my brain, I went down the line from head to toe uncovering any other symptoms that may have been hidden. He had mentioned a recent change in vision, a suddenly appearing red spot or floater that had started a day ago in his right eye. He didn't think it was related to the back pain, but I made a mental note of it.

I visited him everyday, assessing his back pain. I read through his chart, checked labs and radiological studies, and chatted with the nurses to see how he had been the night before. And each time I saw him, I ran through my standard questions from top to bottom. I asked him about headaches and dizziness. I inquired about his heart and lungs. We talked about belly issues and bathroom visits. And I always asked about his vision. For the first few days he continued to have the same red floater in the same eye, and I would include it in my presentation during rounds. His back pain took center stage, but there was something about his vision problem that stayed with me. And I continued to bring it up during the morning meeting.

"The patient continues to have a red spot in the center of his vision in his right eye. He described it as a lightbulb shape."

"Well, maybe he looked at the lights too long," laughed one of the other medical students at rounds. The table erupted in chuckles, and I politely smiled along with them but there was something about the patient's complaint that didn't set right with me.

The next day I saw him in the morning and I was glad to hear that his back pain had lessened with the medications. But when I asked him about his eyes he said, "Well, now the spot is black and my vision is a little blurry in that eye." Well, this can't be good I thought to myself. I ran through a vision exam, managing to track down an opthalmoscope at the nurse's station. I found the intern that was overseeing his care and reviewed the patient's status with her and my findings during the exam. She agreed that it should be mentioned during the meeting, and I headed out to update the senior resident. When my patient came up during morning rounds, I explained to the attending that the back pain was resolving but I stressed the change in his vision. He consented on obtaining an optho consult, and my intern assigned the task to me.

What seemed like way too much time on the phone, I managed to find out the opthamologist on call - Dr. Smith. Does anyone see the problem here? I think the operator hated me by the end of it because I managed to call every other Dr. Smith in the hospital. The most embarrassing moment was when the operator put me in touch with a Dr. Smith, the hospitalist on the same floor I was on sitting just a few feet away from me. He was not the doctor I was looking for.

Long story short, I finally got in touch with the correct physician, the one who looks at eyes, and I shakily ran through the patient presentation over the phone. He said he would see the patient by the end of the day, and I breathed a sigh of relief. Partly because that seemingly simple phone call was over, but mostly because the patient's vision problem would be addressed and we would find answer to this ocular mystery.

The next day I clambered up the stairwell to the top floor to find my patient's chart and read through the optho note. And there it was, the doctor's assessment in clear handwriting: retinal hemorrhage. The doctor's note explained it all, there were even drawings illustrating what he had found on his exam. The patient would be referred to a retinal specialist.

Most of the time I question myself when it comes to answering questions on the spot. I convince myself that the answer that pops into my head is wrong, it can't be as simple as that. So instead, I freeze or I say I don't know. And then I kick myself mentally when it turns out that I was correct all along. What's worse is that I continue to make that mistake, when I should be learning from it. But when it comes to my patients, I see myself as their advocate and I don't back down from that responsibility. Even though my patient had come in with low back pain, I continually (and perhaps annoyingly to my team) brought up his vision change. They were unrelated symptoms, but at the end of the day, I'm treating a person and not an isolated list of signs and lab values. I didn't care how much I was laughed at and I ignored the eye rolls during rounds. This was a case where I knew something was wrong, and I refused to let it go.

A Complicated Catch

She was young, really young. That was the first thought that popped into my head when I walked into the birthing suite on the L&D floor. The mom-to-be was laughing at a joke her boyfriend had just cracked, something about her insides being on the outside when the baby came out. That may have been an amusing punchline, but I remember thinking to myself that they will be surprised by what actually happens.

I stood next to my attending who was checking the fetal monitor. The room was full of rambunctious teenagers, squeezed tight like sardines on the couch and sharing bags of chips and gummy bears. They were laughing and squealing, as if it was just another Friday night after a long week of classes. I felt as if I was crashing a party. But here they were, two kids still in high school about to meet their child for the first time.

Her labor was progressing, and the anesthesiologist was on his way to administer the epidural. The attending announced he was about to check how dilated she was, which was the cue for the crowd to leave the room. Her boyfriend stayed back and watched with wides eyes in horror as the attending manually checked the cervix. "Oh man, that's so gross," he said out loud. His girlfriend squirmed a little as the attending assessed the diameter of the cervix and giggled in response to her boyfriend's revelation.

The next time we walked into the room, my attending and I were ready to gown up in preparation for the delivery. Swathed in sterile blue and knee-high "moon boots", we approached the end of the bed and prepped the patient for the exciting moment. She nudged herself down to the edge and placed her feet in the stirrups. Then, she started laughing. And in between the chortles and gasps for breath she repeated over and over again, "I feel so weird. I feel soooo weirdddd!" I guess the epidural had kicked in...

We urged her to push, cheering her on and encouraging each effort. After a while, it had become apparent that the forceful pushes weren't enough for the large baby to pass through without causing vaginal tearing, so the attending prepared for an episiotomy. Shortly after the attending made the incision through the perineum, the baby's head emerged. But then came issue number two: the attending felt around the head and realized the cord was wrapped around the neck.

I could feel the adrenaline rush surging in me. This delivery was unlike all the other seemingly smooth deliveries I had seen before. Anything that could go wrong was going wrong. But there was no time to worry about it. It was about getting the baby out and making sure the mom was ok.

The attending cut through the cord to relieve the pressure around the neck. Then he placed my hands on the head and directed me on how to rotate it, free the shoulders, and pull the baby out. I don't think I'll ever get over that feeling: my hands hugging the torso of a brand new life, slippery and warm, and praying that I don't drop him/her. Swoosh. That's what it feels like, looks like, sounds like when the baby is pulled out and placed on the mom's chest. Swoosh. That's what happens in the moment when the baby is born.

The nurses were at top speed drying off the newborn. Both the parents were in shock, staring at the face of their new baby girl. As the new parents uttered "whoas" under their breath", the attending instructed me to collect cord blood. Because the cord had been cut earlier, it was more of a stump I had to wrangle to drain into the tube. My gloves, slick from the vernix coating the baby, had lost its traction and I wrestled with the cord retracting back to the placenta that was still attached. And when I thought I finally had control, I released the clamp only for the cord to free from my fingers and spray a line of blood across my gown. I could have been an extra in a horror movie the way I was doused in blood, but I didn't care. I didn't care that my attending was chuckling, I just wanted to fill that darn tube. It was me against the cord.

Eventually, that task was completed and my attending told me to pull out the placenta. Using clamps, I gently eased it out, telling the new mom that she would feel a little more comfortable once the after birth was delivered. A gentle tug and the purply, webbed structure emerged, and just as with the newborn, I focused all my energy on not letting it fall anywhere else but into the collection bowl.

But our job wasn't over just yet. The attending stitched up the episiotomy he had done earlier, and I watched as his skilled hands made quick work of the sutures. But the blood, it just kept pouring out. I watched anxiously as the rich, dark red oozed out, puddling in the plastic catch-all bag. The sponges I held in place did nothing except turn maroon in seconds. I heard the attending ask for methergine as I continued to soak up the blood. And then out of the corner of my eye, my attending began to remove his gown and gloves.

"You're going to do a uterine massage," he told me. "One hand inside, one on top on the outside. Feel for the uterus, it should start to get smaller."

I nodded and did as he said, trying to remain as calm as he had been the entire time, but all the while feeling the adrenaline run rampant through my system. I began the bimanual massage, willing the uterus to relax. I locked eyes with my patient who had been groaning with the discomfort, and I was struck by how pale her face looked.

"I know this feels uncomfortable, but just a few minutes more. You did so well, you have a beautiful baby girl." And I just kept repeating the same sentiment over and over again to her as my hands tracked the slowly diminishing size of the uterus. The attending walked back over to me, after finishing the charting, and told me to remove my hands. He measured the uterine size externally as my right hand slipped out, and with it a large clot passed by my fingers. The bleeding had slowed down and I let out a huge sigh of relief. In the end, both baby and mom were fine. They were stable when my attending and I walked out of the room. But I wondered how their lives would be, parents still in high school and a newborn in their care...

It was a complicated catch, and I thought that things as scary and nerve-wracking as that would make me reconsider going into it as a profession. But it didn't. In a weird and beautiful way, it made me love ObGyn even more.

When It All Felt Right

I'm sitting on my porch, leaning back in the deck chair and draining the last dregs of tea from my mug. The air is thick with the scent of hyacinth, my lungs filling with a floral perfume with every breath. And I'm looking out onto the distant mountains, gleaming bright green in the sunlight of the afternoon. My computer is sitting on my lap and it seems I've been having some trouble finishing posts here; my draft box is piling up with fragmented thoughts and the beginnings of some potential stories. But I think I finally figured out why there's a block in my head, and it's because even though it would make sense to pick up from where I left off and continue my narratives in the order of my clinical rotations, I want to jump ahead and share what's been on my mind for quite some time. And so dear reader, what I want to tell you, what I really want to tell you, is about my ObGyn clerkship. Specifically, one unusually cold Thursday morning when it felt just right.

Now, you might think I'm going to regale with you the first time I caught a baby, and though that was an incredible, momentous experience, that will have to wait for another time. No, this story is about something entirely different. Two words - cervical cerclage.

I wasn't scheduled to work with that attending that day, but I've been waiting since my second year of medical school to work with this particular physician. So, I jumped at every chance I could to follow him. I stayed late when deliveries went long into the night. I came in early to help write notes before he rounded on his patients. And I loved every minute of it. So, when I flipped through his schedule and saw that he had a procedure, a cervical cerclage, scheduled for the next day, I asked if I could observe.

After changing into the forest green scrubs, the new material still rough and scratchy against my skin, I headed into the hall to run the board and figure out where the procedure was scheduled. As per my usual overly anxious self I was early, so I headed into the lounge to read up on what was to be done. A cervical cerclage is a series of sutures placed during pregnancy, around week 12-14, that are used to close the cervix to prevent premature birth. The stitches are then typically removed when the fetus is full term, by week 37. If you think about it, it's such a simple, elegant solution to a serious problem. Help keep the cervix intact and keep the baby protected and healthy in the uterus for as long as possible. After reading up on the different types of cervical cerclage techniques, I made my way into the OR to see if the nurses needed any help.

After introducing myself to the masked faces, I took my place at a safe enough distance from the sterile blue drapes covering the wheeled tables. I watched as people walked in and out, grabbing various plastic boxes and arranging shiny metal equipment in neat rows. There was an order, a logical sense to how things were done to set up for the procedure, and I soaked up the surgical choreography that was happening around me. As I watched the nurse pull out gowns and gloves, she turned to me and asked my size.

"Size 7 gloves please"
"Do you know how to gown up yourself?"
"I have before."
After eying me cautiously she nodded her head to me, the understood nonverbal cue to follow her and said, "Well, I'm going to show you how it's done."

She watched as I opened up the packaging and emptied the tissue packet of gloves onto the table, her eyes never leaving my hands unwrap the sterile gown from its cloth dressing. I stepped out into the hallway to scrub in, the bristly brush soaked in antiseptic soap tracking suds from my fingers to my upper arm and the cool stream of water washing my skin clean. I walked back into the room, little droplets of water collecting at my elbows as I carefully held my sterile hands clear from contamination. The nurse showed me how to properly unfold the blue paper and slip my hands into the free spaces. She demonstrated the exact technique of pulling the gloves onto my hands, the ends snapping over my cloaked arms. I've often made a note to myself how I feel safe and protected in this uniform, and this morning was no different. With my arms tucked against my belly, I watched and listened as the nurse walked me through the different instruments that would be used. She let me help set up the needles, explaining the difference between cutting and non-cutting.

The attending walked in and the atmosphere of the room shifted into full gear. It reminded me of that moment when the conductor knocks against the music stand and the discordant sounds of the orchestra settle into a unified chord. The patient was soon wheeled in and the attending began the prep. I stood off to the side, straining to get a glimpse over the physician's shoulder, but then he ushered me in next to him and instructed me to hold the speculum. He talked me through the entire procedure, explaining that he would utilize the McDonald cerclage, or a pursestring technique for the sutures. I was hunched over, willing my body to accept the uncomfortable position I was in, until the nurse instructed me to stand up straight. The attending looked up at me and firmly stated the words that have echoed in my head ever since.

"If you're going to be a surgeon, you need to have good posture so you don't hurt your knees and back."

The suturing resumed as he and the nurse continued on about statistics of surgeons who ended up needing surgery themselves from poor positioning. But as they talked, all I could think about was the image my attending had painted in my mind - me performing Gynecological surgeries, me delivering babies, me leading a C-section. He said it as if he thought I could do it. It all seemed possible. In that moment, it all seemed so tangible and real. And I wanted it.

I thanked the attending at the end and stayed back to help the nurses transport the patient. I was beaming, both inside and out. My insides were all happiness and light, and everything felt right. Nothing could touch me that day because I was in a truly happy place. And when I need to get back there, which is quite often these days, all I have to do is close my eyes and whisper to myself "cervical cerclage".

I've been interested in women's health for a long time now, I think my aunt had something to do with that. And even though I loved Family Medicine, I knew deep down, even before the actual rotation, that I would love ObGyn too. Well, I pretty much adored it. What surprised me the most was that being on the L&D floor and seeing patients in the Perinatal clinic - it felt strangely familiar. As if it was always supposed to be like that.

So there's the wrench in the plan - do a Family Med residency with a women's health focus, or go straight into ObGyn? I never thought of myself as a surgeon, I'm not even sure if I'll get into a program because it's competitive. It's a tough lifestyle, really tough, and the threat of malpractice is scary. But beyond that, it's ObGyn. It's inspiring and beautiful and challenging and exhilarating. It's being part of an incredible time in a woman's life, and it's being reminded of just how miraculous human development truly is. So, that's why I'm doing a Sub-Intern/Acting Intern rotation in ObGyn next year. I'm a little terrified of having all that responsibility as a fourth year, but I hope that my love for it will squash that fear down. I'm going to fight like heck to do it, and who knows, things just might happen that way they're supposed to.