Everything I Learned in Medical School: Besides All the Book Stuff (11 page)

Chapter 27

Know-It-All

There is a constant pressure in medicine to know. Those with all of the answers are respected, revered. But as science advances, it becomes clear that there is too much information for any one person to master, even in a lifetime. The focus of medical education is slowly transforming into one in which you are not expected to know everything but simply know where to find the answers. Of course, there is a basic fund of knowledge every physician must know, but the days of memorizing entire text books are long gone. There are simply too many books.

But this transition is ongoing, and we are still in the earliest phases. The attendings in the hospital were mostly trained in the older style of medicine, where knowing was everything. This not only applies to medical facts, but also an expectation with patient care. There were some physicians who told medical students they should have their patient’s information memorized, and should not use notes. A less aged physician would laugh at such an expectation. However, there is still a pressure to know answers, whether it be during pimping sessions or when asked about a patient’s lab values. It creates an uncomfortable environment for providers, and quite frankly, an unsafe environment for patients. If an answer is unknown, there is always a pressure to say something. So, in response to a resident asking, “What was this patient’s sodium value?”, the medical student may vaguely remember, and although not definitively sure, state confidently, “137.” Or, if they have no idea, say, “I think it’s 137.” The resident doesn’t have time to remember which answers were prefaced with “I think” and takes responses at face value. Surely, the medical student will go back and double check later, but patient treatment may be delayed. One would think that when dealing with people’s lives, there should be no ambiguity. Either you know, or you don’t. Imagine a conversation between a pilot and air traffic control:

“JFK, this is flight 1296, what’s our altitude?”

“Uh, 25,000 feet, I think.”

That conversation simply does not happen in air traffic control, and medicine should be no exception. Hopefully, medicine will continue to progress towards a field where it is okay not to know all the answers, and our patients will actually benefit from our ignorance, so long as we can admit it.

Chapter 28

The Delivery

Perhaps nowhere in medical school do you get a better sense of the diversity in the social fabric of your community as you get in the OB/GYN department. During this rotation, the very personal aspects of people’s lives are at the forefront, since factors such as living situation, sexual history, socioeconomic status, drug use, and family all play an important role in taking care of patients. For two months during our second year, we spent time with either the obstetrics service, in which we would take care of pregnant mothers, or in the gynecologic service, where we dealt with problems with the female reproductive system apart from child birth. The experience was particularly memorable, mostly due to a few very distinct cases.

My time on the obstetrics service started at a nearby hospital in Fayetteville, NC, hometown to Fort Bragg, a prominent army base. During the first few days on the service, we were called to evaluate a young woman that had gone into pre-term labor, and was in obvious pain and discomfort, much more than we typically see with child birth. The reason was that she had a cerclage in place. This is a device that, simply put, staples the end of your cervix together. It is used in women that have a history of multiple miscarriages with the thought that the miscarriage is due to the end of the cervix being too wide, and the uterus cannot hold the growing baby when the cervix remains open. This patient, however, had been very adamant about getting pregnant, and already had 11 miscarriages prior to this pregnancy! I could not believe what she must have gone through with the loss of each of those children. One would figure this was a woman that had been trying for a long time to get pregnant with her husband, and now was getting desperate as she was approaching middle age. But in fact, this patient was 22, single, with no job. She just simply wanted a child. Doing the math, if each of her pregnancies averaged 5 months, and if she was essentially pregnant all the time, she would have had to have started trying to get pregnant at 17. This was a conservative estimate, and chances are her attempts to conceive started years earlier.

So, the cerclage had been put in place early in the pregnancy, with hopes that if the problem was a loose cervix, the cerclage would keep things closed long enough to allow the child to be carried to term. Unfortunately, this woman was in active labor, and the baby was only about 22 weeks along. The lower limit of being able to sustain life outside of the womb is around 24 weeks. But her body was trying to squeeze out this child now, but the stitch in her cervix would not let the child out. The result was that her stitch was slowly tearing her cervix as the uterus continued to contract to get the child out. Not a good situation for the child or the mother.

Her pain and discomfort continued to worsen, and the obstetricians made every attempt possible to cut the cerclage, thereby opening her cervix and allowing her body to deliver the child. The child’s chances of living would be slim given the extent of prematurity, but nothing would stop this woman’s contractions. Her body wanted the baby out, and one way or another, her body would win. Unfortunately, her cervix had become so inflamed, they were unable to even see the cerclage, let alone cut it. So, the decision was made to put her under general anesthesia and deliver the child via C-section. A neonatal ICU doctor was called into the operating room to help with possibly resuscitating the baby if he was deemed mature enough to be able to sustain life. But when the C-section was performed, the infant that came out weighed a mere 400 grams, and was far from resembling a normal infant. The head seemed unusually large compared to a tiny, frail body. The infant’s eye lids were still fused shut, another sign of extreme prematurity. The body was placed in an incubator while the neonatologist examined him, and it took less than 5 seconds for the physician to say this child was too premature to survive. Sadly, there was nothing that could be done for him, his body simply was not ready to be out of the womb. I watched him, as he lay there lifeless, and then suddenly, his chest contracted in a desperate attempt to get oxygen. He did this again every 30 seconds or so, but it was not long before even this movement stopped.

The mother had lost a great deal of blood during this time, but overall was stable. After the child was delivered, they were able to get to the cerclage, cut it, and remove it. She was taken back to the post-partum area and told of the news when she awoke. Her child had been wrapped up in blankets so that she could at least see him. Sadly, he was already dead. However, she insisted on keeping him in her room for a while.

The next morning, I was saddened to find that she had kept the child next to her the entire night, refusing to accept the child she had so desperately wanted was once again not to be. It took some convincing to get her to finally let the child go, a true indication of just how badly she wanted to be a mother. But in my mind, I could only wonder what type of an environment such a child would have had to endure if in fact he had survived. This mother had little means for taking care of a child, and poor social support. Undoubtedly, it would have been a difficult life. And perhaps her multiple miscarriages were nature’s way of saying that motherhood was not for her. However, I doubt she took the hint.

Sadly, there is no standard in society which determines who is worthy of having a child. Those types of standards only apply to more important things like owning a gun or adopting a pet. Take for example a woman I saw not long after this last case. She was about to deliver, so the obstetrics team was called to the case. She was a single woman, with no prenatal care, and a history of drug abuse during the pregnancy. She was alone at the delivery, with no apparent family support. Despite her transgressions, the fetus seemed to have done okay, and the delivery went smoothly. Out he came, and soon gave a vigorous cry. He was cleaned off quickly, and then wrapped up and handed to his mother, who he would meet face-to-face for the very first time. She took one look at him and said, “Oh my god, look at his nose, it’s so big!” There was no motherly love, no smiles, no bonding, just simply a criticism, right from the start. Sure his nose may have been slightly generous in size, but nothing out of the norm, and otherwise, the child was beautiful. And to hear her say something negative about a newborn child just hurt me, probably because I see cases where parents try to do everything right during the pregnancy, take vitamins, go for regular check-ups, and not even drink caffeine, let alone even think about doing drugs, and the child is born with a horrendous heart or brain defect. And here she was, worried about the child’s nose! When you see these infants, who are blank slates and full of potential, and they go home with these types of mothers, it just makes me sad. I know this child will fail in life, and due to no fault of his own, but because of his surroundings.

But I quickly learned that regardless of what we as physicians think is the right way to treat a child, either before or after the birth, society often has different ideas. A few weeks into the rotation, I was working in the clinic seeing expecting mothers for their routine prenatal visits. That morning, I walked into a patient’s room to start interviewing her and see how the pregnancy was going. Inside was a young woman, appeared to be in her mid 20s, well dressed, sitting comfortably. Her husband was with the army, and had been assigned to duty in another country, so she was there alone. The visit went smoothly, with little that was out of the ordinary. She was now in her second trimester, beginning to show. As I was wrapping up, I asked her if she had any other concerns before I brought the resident to come examine her.

“Well, there is something I was wondering about.”

“Sure, what is it?” I asked.

And without any hesitation, she stated, “Well, I’m a stripper here at a local club, and my main trick is that I can climb the pole and do a split on the ceiling. Is it okay if I keep doing that while I’m pregnant?”

I wasn’t quite sure where to start. Instead, I simply said I’d ask the resident. I didn’t even want to start asking the hundreds of questions that came to mind. When I told the resident, she smiled slightly, but did not appear particularly phased. I’m sure she had heard it all. She simply went in, and told the patient that performing splits on the ceiling while pregnant was something she would advise against, and left it at that.

If this experience wasn’t enough to make me realize that expecting mothers aren’t always looking out for their unborn children, there was a couple that came in soon after our stripper friend that convinced me. They seemed like a very nice, polite couple, the type of couple I expected to see at these obstetrics appointments. The husband was very attentive to his wife, and asked insightful questions. But once again, near the end of the visit, he asked the question that made me angry.

“Is it okay if she continues to smoke marijuana during the pregnancy?”

He tried to defend his question by adding, “She has had a hard time with nausea, and marijuana really seems to be the only thing that will work for her.” He conveniently left out the fact that it was also the only thing they had tried.

The resident had to answer based on the medical facts, “Up to this point, we do not have any definitive data that smoking marijuana may be detrimental to the fetus.”

That was all they needed to hear, and I’m sure they were as happy as can be, ready to go home and smoke up with a clear conscience. And through the remainder of my rotation, I was amazed at the number of women that continued to smoke, drink alcohol, and even do drugs throughout the pregnancy.

But despite the saddening and frightening cases, the obstetrics rotation had its share of entertaining moments. Most distinctly was a case in which a woman was undergoing a simple procedure under anesthesia, and when she was ready for surgery, the surgeon noted a tattoo on the upper part of her thigh that said, “Mike’s property.” Let’s hope Mike and her are still together, since that would be a tough one to explain to the next boyfriend. After seeing this tattoo, the surgeon began discussing some of the other tattoos he had seen in this region recently. One woman had a ruler tattooed onto the inside of her upper thigh, with a message underneath that said, “Can you measure up to this?” I’ll let you decide what exactly she was measuring.

OBGYN also has the moment that is perhaps the most fulfilling throughout all of medical school – delivering your first baby. For me, this came late one night, after both myself and the resident had gone to our call rooms. The page came around 2AM from the nurse at the patient’s bedside. Since labor takes so long, the doctors are called in at the last minute when the mother is ready to finally deliver, and sometimes even get there a bit late. So, I awoke out of my stupor, and stumbled my way to the patient’s room. The resident got there soon after.

“This one’s all yours.”

I was ready. The process of childbirth is incredibly straightforward if things are going smoothly. After all, humans were delivering children long before we had obstetricians around. But when it’s your first time delivering a baby, nothing is straightforward.

I took my position at the foot of the bed, and the nurse continued to coach the mother to push with each contraction. The baby’s head was beginning to show with each push, coming out a bit further every time. My job was to hold the head, and as the baby was delivered, turn the head to the side and pull up and down on the head to allow the shoulders to come out. After the shoulders were through, I knew everything else would come shooting out quickly. The only thought running through my mind was, “Don’t drop this baby!”

The head eventually made its way completely out, and I grabbed it with both hands, turned the head to the side, and pulled down to deliver one shoulder, then pulled up to deliver the other. Tons of green fluid rushed out as I did this, which means the child had already had its first bowel movement while still inside the uterus. As expected, the rest of the body came flying out soon afterwards, and I hung onto the infant’s neck and legs as tight as possible without suffocating him. The resident helped cut the cord. He was a slippery little one, and despite my vigilance, there was still a moment where I felt him slipping, but I quickly readjusted my grip. The stimulation of the delivery was enough to get the newborn screaming, which is a sound every obstetrician loves to hear, because if the child isn’t screaming, there is a problem. I quickly handed the child over to the mother. I was probably more excited about the delivery than she was. It was difficult to get back to bed after the excitement was over.

Overall, the OBGYN experience was a rollercoaster of emotions. Not everyone in society has the same priorities in life, which became quite clear during these two months. And despite the parts that were upsetting and disappointing, the moments of exhilaration were enough to make it all worthwhile.