First Delivery!

O I just got off 24-hour call, from 7:00am Sunday to 7:00am Monday. It was very eventful: I scrubbed in to four vaginal deliveries and two C-sections. And I delivered my first baby! And guess what his name was? I can't tell you because that would be breaking the law, but it may have been remotely related to one of my favorite people, and that made me really happy. Plus, the couple was really wonderful: the wife was beautiful, and was working really hard and keeping a great attitude the entire time. And the husband was kind and supportive, and when I handed him his child, he started to sniffle (hiding it as best as he could, which was not at all) and hadn't stopped sniffling when I left the room. They were young, and this was their first baby.

Positives and negatives: I also got shoved away (literally, my hand was boxed out of the field) from an earlier delivery, which was just although a little harsh. It was one of the interns' patients, and the intern had come on her day off between rotations to deliver the patient. I'd seen the patient before, and was just trying to do what our clerkship director told us to do by holding a sterile towel to the perineum. I'm constantly trying to find the "aggressive" that's looked upon as praiseworthy in surgical subspecialties; one one side is true getting in the way or overstepping what we're allowed to do, and on the other side is not getting experiences and looking uninterested or lazy. I guess my upper-level answered that question for me this time: get out of the way, this is the intern's delivery!

I was also in on a delivery where the mother had chorioamnionitis. The mom's body was palpably hot. The baby also had other complications like meconium staining and late decelerations. But her delivery was remarkable for a really supportive family.

The last delivery I was in on last night almost moved me to tears. The mother had been laboring for days in the inactive latent phase. Suddenly, she went from 3 centimeters dilated to completely dilated, and her pushing was extremely effective. She pushed seven times, and her baby was born! She played soft country music from her iPad during her pushing, and she turned the TV off. She had one female friend with her (a friend, not a doula, but serving pretty much the same purpose). What was most remarkable was how strong and clear her emotions were about the delivery: her love for that baby struck me with awe. When the baby was born and I placed it on her chest, her expression and her quiet almost-sobbing words of love made me tear up. And then, when the baby needed a little resuscitation a few minutes later because of some complications (baby is fine now), she was anguished. She controlled her anxiety, but just barely! And she spoke to her baby across the room (where the NICU team had him under a warmer with a respirator) by name, calling out softly and encouraging him to cry. And finally, when she got to hold him again, I could see that the entire world was turned off for her, and there was only she and her son. She wanted and needed nothing else. It made me think of God's attitude toward us, and it filled me with hope and joy and admiration, both for this woman and for God who created her and who created us, and who aches for and loves us each even more desperately than this.

OB/GYN: The Hard Questions

So, this rotation makes me ask all kinds of questions. The first one is the most fundamental. When does life begin? And related to that...

• Should we be mourning miscarriages? Ectopic pregnancies? Vanishing twins? Partial molar pregnancies? Degenerated IVF blastocysts? What about blighted ova?
• Is hormonal contraception ever useable in sexually active women? In any woman of reproductive age?
• Are barriers licit to prevent STD transmission between spouses?
• Is emergency contraception ever useable in victims of rape? Which forms? (Paraguard? Which isn't currently to be given to victims of rape?)
• Is ovarian hyperstimulation licit?
• Is IVF licit?
• When is sterilization okay?
• What should we do for women who shouldn't have more children?
• What is parenthood? Genes, gestational carriers/surrogates, adoptive parents? How should men and women licitly become parents?

I need to read Dignitas Personae and Donum Vitae. Just as soon as I have some free time.

Death

I have not yet seen someone die, although many of my classmates have. I may when I am on inpatient IMED or surgery.

I have only seen little signs of death. As I was walking out of the hospital to my car, I once saw a hearse pull up to the building where I know the pathology lab is. I guess the morgue is down there, in the basement. The hearse was pulled up into a place where dumpsters were. That made me sad, that the body of the deceased person was among the trash.

My second brush with death just occured, only a few minutes ago. I'm sitting in the student lounge (I'm supposed to be studying), and a few minutes ago I heard sobbing outside the door. I debated about whether to ignore it, but I went out after a moment and found two women, one weeping and one crying loudly. I asked what was wrong.

The weeping woman wiped her eyes and said, "my brother's back there," pointing to the third-floor ICU located behind the student lounge. After I asked whether I could do anything for them and offered to pray, I went back into the lounge. Twenty or so minutes later (now) I heard new, loud cries from the same place, joined by a man. And I prayed for the man's soul. I don't know if he had died, but he may have. Please pray for the departed of this hospital and all hospitals today!

Medical Symbols

According to Aristotle, followed by the Church with St. Thomas, our bodies are the matter informed by our souls. Scott Hahn makes a similar analogy when he says "our bodies are symbols of our souls."

There are a lot of medical conditions that speak volumes about our souls. Here are just a few. (Note: this is never to say that people with these conditions have the analogous spiritual state; some conditions are heritable or acquired by actions whose objective morality no outside person can judge.)

Heterotopic heart transplant

Donor heart on left; patient's original heart on right.

Occasionally, patients with heart failure are candidates for a heterotopic graft. This means that the patient's heart is not removed and a donor heart is hooked up next to it to share the load of pumping. The person has two heartbeats. This can be done in heart failure is due to severe lung disease, or when the patient's heart might recover (at which point the donor heart would be removed, and the person would have one heartbeat again).

You know when you're trying to acquire a virtue, but your heart just isn't in it? You get up when your alarm rings not because you're excited about being disciplined for God or for others, but begrudgingly. You think to yourself, "my emotions aren't aligned with the right thing, my nature is fallen. I'm trying to become virtuous by replacing the wrong thought (snoozing) with the right one (getting up) and whipping up my emotions artificially. Boy, does this feel fake."

Eventually, virtue grows as you acquire the habit of getting up. And eventually, maybe you'll be like Mother Teresa, whose emotions and will were so aligned with God's will (who so had the virtue of charity) that it pained her not to go and help the dying.

But until then, you fake it. Your disease is so severe that your heart can't agree with the right thing to do, and you're attracted to evil. But God helps you with actual grace, pumping you up to be virtuous until your own heart is so transformed into His that it beats in synchrony, and you want the good.

There is one other symbol that I find particularly striking: syphilis. This includes graphic pictures, but no explicit images.

Happenings in OB/GYN

Inside IVF
Two weeks ago I shadowed an OB/GYN who specialized in Reproductive Endocrinology and Infertility (REI). I observed half a dozen discussions about IVF, donor eggs, and donor embryos. And I had a personal tour of the IVF lab. It was surreal and confusing and heartbreaking.

Conception and Death
Last week I was rounding on the gynecology service, and was scheduled to scrub in on a ruptured ectopic pregnancy. The same day, I saw a patient with disseminated ovarian cancer who was being "withdrawn" from aggressive ICU care (heroic measures were stopped and she was allowed to die naturally only a few minutes after I listened to her heart and lungs). The beginning and the end of life, in one day.

Numbers
I have now been to 3 vaginal births and 5 C-sections (one of which was for twins). There was one C-section for prolonged rupture of membranes and severe intrauterine infection. The amniotic fluid gushed a thick purple, like blueberry syrup at IHOP, instead of a healthy clear. The inside of the uterus was mushy and white, instead of the typical mossy red. The baby was a preemie in frank breech, and the NICU team took him and (again, not as usual) didn't bring him back to the Mom before the procedure ended. I hope they do well.

Minefield
I ended up not scrubbing on that ectopic pregnancy case, but it created a small stir for me. When I was told I was scheduled to do it, I thought, "oh great! I am especially interested in ectopic pregnancy and tubal surgery!" This is I want to save early lives and give couples with tubal factor infertility an option besides IVF! Then I realized, "oh dear. What if the surgery planned is a salpingostomy, or salpingotomy?" Quickly, I looked at the patients records and saw that she was planned for salpingectomy. I breathed a sigh of relief.

No such relief for a recent C-section with post-partum tubal ligation. I was scrubbed in on a C-section and then discovered that the patient and her surgeon were planning sterilization. Now normally, it is the medical student's job to stand at the operating table and do menial tasks, such as holding retractors, suctioning, and dabbing the field with lap sponges. Perhaps the best of these menial tasks is cutting suture. For this task, I actually need to ask for an instrument from the scrub tech. "Suture scissors," I say, and hold out a hand. She slaps the plain-jane scissors into my palm, and I proudly cut the ends of the residents' or attendings' thread. A medical student is slacking or inattentive if someone else calls for the suture scissors.

For the tubal ligation, which involves cutting of four sutures, I folded my hands and stood at the table, simply observing and listening. I pretended to be forgetful of asking for the scissors. Once that procedure was done, though, I resumed cutting, retracting, and sponging for the rest of the C-section.

Call
I had my first night call last week. I worked a typical day on gynecology (I got to work at 4:50am for rounds at 6:00), and then had a dinner break from 5:00pm to 5:45pm, at which point I worked until about 7:30 the next morning, with a 45-minute nap somewhere in between. That was exhausting. I am not sure I've stayed up for 24 hours before that. Ever. And I've got to do that again tomorrow. Merp.

Overall, OB/GYN is good.
I like the clinic, I like the surgery, and I love deliveries. I don't like all the people I'm working with, and I don't like knowing so little about what I want to do. It's a little stressful, but overall I'm enjoying it. One thing I'm struggling with is how prayer fits in to a 60-hour work week. During the past week, I've been paging the hospital chaplain and receiving communion from him on days I can (and that means I missed two days!), and I've missed parts of the Liturgy of the Hours several times. Even so, I think I am doing God's will, and I have fewer occasions of sin, and my thoughts stray to Jesus more easily.

Two quick stories

I have to go to Mass in a few minutes, but I really wanted to squeak out a post.

Story #1

At the end of my pediatrics rotation, a patient came in with a "hurt arm." I examined her and though we needed an elbow radiograph to rule out fracture (although I told the doc I thought it was a soft tissue injury, since she had so point tenderness). She got an X-ray and came back after hours (I stayed!) and we read the film. I saw something we had just learned about in radiology lectures, and said "isn't that a posterior fat pad sign?" Brownie points for that!

As the doctor was explaining the diagnosis to the parents (supracondylar fracture) the mother began to pale and she actually fainted. We laid her down on the examination table and the MA got her some cherry pedialyte and goldfish when she woke up. Then we put a splint on her daughter and the three of them went home. So, that was a terribly told story but that's what happened!

Story #2

At the beginning of my OB/GYN rotation, I was working in the private practice of a local OB/GYN and one of her patients came in for "rule out labor" (i.e. she was having contractions and wanted to know if she should go to the hospital). The answer (after we hooked her up to a fetal cardiac monitor, looked at the strip, and examined her cervic was yes, you are four centimeters and go now. The physician called the hospital ahead of time.

A few patient visits later, the phone rang for the doctor and her eyes widened as she listened. She slammed the phone down after a quick "thank you," and said to me, "that patient's complete" (meaning, she's dilated to 10 centimeters and is ready to push). The doctor said to me, "you'd better leave now, because I'm going straight there after I finish this chart, and I'm going to fly."

I raced to the hospital through the molasses of midafternoon traffic and jumped into a pair of scrubs. I didn't have appropriate shoes, but I slipped boot covers over my pumps. I helped with the delivery (at one point only I and the L&D nurse were in the room as she pushed!) and delivered the placenta. My first delivery in high heels (and hopefully the last).