Easter Fire: In Which God has a Laugh

I notice things; maybe you do this, too. Maybe you always know where the fire exits are. Maybe you notice the elderly priest at Mass and think about what you would do if he fell or fainted. Maybe you notice the pregnant lady in the car next to you and think about what you would do if she got in an accident (maybe you even keep a scalpel in your car to do a stat C-section...).

Easter fire. (Stock photo, obviously not the situation I was in.)

I think it's neat that I can notice these things and be ready. But sometimes I think God makes fun of me for it, just to keep me humble.

I worked days this past Easter, but I had the nights off. So, after I got off on Holy Saturday I drove to an abbey not far from my city for their midnight Easter Vigil. It was going to be my rest: for just a few hours, I had no responsibilities. I didn't have to cantor, talk to people, or even stay awake! Thank God, I prayed.

This is the abbey where I made my week-long retreat before my consecration. It was an otherworldly week, partially because the abbey really lives the vow of poverty and the life of silence. Each member lives in a tiny (6x10ft) hermitage without heating or air conditioning. They also have foundations in Africa, and they live the same way on both continents. 

Given this spirit, I wasn't surprised to see a make-shift, but lovely credence table for the lighting of the paschal candle. In a broad stew pot were some coals, and this was placed on top of a cheap card table, covered with a white tablecloth.

I felt strange coming back after so many months in the world. I was then more than halfway through intern year: I was a competent, resident, I paid bills and bought stuff, and I was neck-deep in ethical questions, all far from ethereal prayer. That night, I re-entered the world of silence feeling like an outsider.

I slid in a few minutes early next to another woman. It was hot (remember: no air conditioning), and she had brought a water bottle. The plastic crackled in the monastic quiet before Mass. When the time came to light the candle, we all stood. Because I'd slid in the back, I was only a few feet away from the humble credence table. An acolyte poured some lighter fluid on the coals and clicked a lighter. My face and the faces of the whole back row were illuminated, and I felt even more exposed. Hide me, God. Please, just let me cower in the back and absorb the Mass.

All was well for a few minutes. Then the fire blew out of the pot and the tablecloth caught fire. The same sense of duty that makes me notice pregnant and elderly people was immediately awake: DO SOMETHING, it said.

What? I thought immediately. God, are you joking? 

The seraphic abbot and acolytes all stepped away in refined surprise. Inwardly, I groaned playfully at God, because it was as though He was nudging me lovingly. It had only been half a second since the fire started, and I grabbed my neighbor's water bottle, tore the cap off, and emptied it onto the table. There was just enough to put out the fire. I have residency to thank for the reflexes, and God to thank for His sense of humor.

Another July 1

Another July 1 is here, and this time I am a second year. It's bizarre to watch another cadre of interns come in, especially ones I knew as medical students.

It's a strange experience to think, after a long workday on July 30, "I'll be a second year tomorrow." I'll hold the ER pager. I'll do the crash repeats (the emergent C-sections on people who've had C-sections before) and the crash classicals. I'll run the list. I'll do the MIGS cases.

Last year, I heard people saying to the second-years, "see how much you've learned?" I know more than the new interns, but I don't know how much. I still haven't finished my Gabbe. I still haven't studied the things I missed on CREOGs (in-service exams during residency).

Before I start romanticizing a little too much, let me say: it's not as abrupt a change for me. I'm doing my ICU month first, so I'm still an acting intern this July. Even so, the difference between me and the medicine interns is dramatic. I know how to put in orders, I finished my note 15 minutes before rounds (and theirs still aren't done), I know how to present a patient. Even though I'm the off-service rotator, I was the one called to do the emergent new patient, because most of them still needed  help from the R3 for orders. (Not that big a deal though, the R3 came in to assess vitals with me...and it was even something I know how to deal with--acute anemia.)

But it's interesting.

I'm studying for STEP 3 this month. This is the last exam I will take before I have a medical license to practice independently. It's not the last exam I will take in my life, because I want to be board certified in OB/GYN, which means CREOGs and Boards (final exam at the end of residency to make sure I can start a job) and periodic recertification. STEP 3 is a two-day long multiple-choice test, with some (apparently) weird formatting in questions to simulate real-time case management of acute patients. I'm not super excited.

I think I'm a calmer person and I can now recognize when a person is really sick, and when a pregnant woman is really uncomfortable. I think I'm becoming a good doctor. I see a lot of potential in my career and the future seems bright. I still expect the day when I will make my first Big Mistake, the one that will make me look back on this time wistfully, wishing I could go back. I don't fear having adverse outcomes; I only fear causing them.

There's a very important blog post coming up, one about faithfulness to calls. And that's all for today, because the ICU attending (who is a complete genius) is expecting me to present on neuroleptic malignant syndrome in an hour.

Three Words: Rode the Bed

There's been a paucity of stuff on the blog lately because it's suddenly really tiring to blog. After the huge burst of energy that rose up in answer to the challenges of intern year, I am at an emotional, cerebral, and spiritual low tide.

But these human tides are a natural phenomenon, so this is no surprise. In the mean time, I might do some more simple blogging. Today, I'll tell you a cool story that will take no research or soul-searching. This blog was originally designed to be a story repository so that I could write a book like Danielle Ofri or Perri Klass. So here's a story.

I was in triage seeing a patient with a hypertensive disorder of pregnancy. I had some questions about her management and my chief agreed, so she came over to talk with the patient about management options. I went to the next bay to see the next patient. She was a slender woman in her late second trimester, but there wasn't much time to smile and get to know her. She was obviously in pain: she moved around the bed holding her stomach. As I introduced myself I reached for her abdomen. It was taut, like a basketball.

This shows a single loop of prolapsed cord.
My patient had a whole bunch of loops and a four centimeter cervix

She was in so much pain that I left the room and came back with an ultrasound, immediately concerned for abruption. I scanned her quickly: no abruption that I could see, but her cervix was definitely open. And there was definitely a loop of the umbilical cord going through it. I used color to highlight the cord in the cervix. (The picture on the right.)

That is a very bad situation. Luckily, my chief was closer than she'd ever been all week: right next door. (Typically, she'd be over in L&D, which is a minimum ten-second walk if you go briskly.)

Not bothering to walk out of my patient's room and knock next door, I called my chief while setting up sterile gloves and a speculum. "Gina," I said, "I have a cord next door."

This is a funic presentation. The essential difference is that cord is
not through the cervix outside of the amniotic sac.

"A cord" is a euphemism for "a prolapsed cord," which is an obstetrical emergency. My chief immediately stopped her conversation with the hypertensive patient and she was in the room the next minute. She repeated my scan. "Spec her," my chief said, "it could be a funic presentation."

My very ginger pelvic exam revealed naked loops of cord outside of the cervix. I angled the speculum towards Gina. "Elevate the presenting part," my chief said gravely. "We're going to the back."

A little background: when the cord falls out of the uterus first, the baby can asphyxiate. So, we push up the presenting part of the baby (i.e. the head if the head is down) to take pressure off the cord. Then, the person pushing up rides the bed with the patient as we go back for a C-section, which is the only way to deliver the baby without impinging on the cord in the vagina. Interestingly, my chief and I had just gone over management of obstetric emergencies like this the day before. It was all very academic and educational then; now, it was very real.


This patient was still on a triage cot. In a single motion. I raised the foot of the bed and knelt on it, my hand still elevating the fetal head. The nurse was meanwhile unplugging everything from the triage bay walls: the fetal monitor, the O2 saturation monitor, and the tocometer. She flipped the brake and the cot slowly began to roll down the hall to the operating room.

We picked up quite a speed as we approached the 90-degree turn into the OR hall. I almost fell off the cot! (Thank goodness for side-rails.) As we rolled into the OR, someone put a hat on me and stuffed a mask into my free hand. I knelt on the floor next to the OR table and continued to elevate the presenting part as the patient was placed on the OR table, as a foley catheter was placed (yes), and as general anesthesia was induced.

"Can you feel pulsations in that cord?" asked my chief.

"All I feel is her shaking right now," I shouted from underneath the drape. The patient was shaking from her general anesthesia.

"Skin!" I heard from above me. That's the signal that a C-section is starting: the surgeon calls "skin" and "uterus" so that the nurse can chart time to delivery. Within a few seconds, I felt the pressure of the baby's head disappear. "You can come out now," called my second year.

I extracted myself from underneath the drape. I discovered that someone had attempted to put shoe covers over my clogs while I was genuflecting on the floor. I fixed them awkwardly as I walked over to a computer to put in orders for a PCA for after the general anesthesia wore off.

To ride the bed is an adventure in residency, a tale you tell to lower levels like a grandfather's fishing story. And I got to do it as an intern!

Intern Year in Review

I'm on clinic this month, which means I work 40 hour work weeks (not including weekend calls, of course). That means that there's time to blog, time to reflect, and time to improve.

It's also June, which means that my intern year is basically over. In fact, in the last two weeks of June I am no longer an intern, strictly speaking, because I take 24-hour calls after the R4s leave.

These are all the hours I've logged. The months of night float show up as inverted
compared to all the day shifts. Vacations look like black barcodes across entire days.

I have myself delivered 196 babies (50 of them by C-section, with me as surgeon), and been present for many more deliveries. I've done 19 hysteroscopies, one laparoscopic hysterectomy, a small handful of laparoscopic salpingectomies and cystectomies, and five cystoscopies. I've also paid off two of my undergrad loans. (Don't get excited; in true Dave Ramsey style, I paid off the littlest ones first, and there are still eight to go.)

It was a year of lessons and losses. I lost a lot of my expectations for the way my life would go, and I also lost some battles in living my vocation to the fullest. Now that my schedule is lighter, I'm taking some time to re-evaluate how my life should be lived. The biggest items I've identified are:

1. I need to protect times for confession, spiritual direction, and spiritual reading. All of these get eroded when three out of four weekends are eaten by call and weddings, and the fourth weekend feels like Chore Festival.
2. I need to care for my body, with enough sleep and with a diet heavy in fruits and vegetables to protect myself from emotional carb-loading.
3. It takes work to prepare for good quality prayer and recreation. I need to do this work ahead of time so that I don't veg through time without real contemplation and leisure.

In short: more than limiting the extras, I need to focus on protecting the most important things.

Please pray for me: I am preparing a chapel to house the Blessed Sacrament, and am seeking the privilege of keeping my Spouse at home with me.

Objections (and New Sidebar Gadget)

"You live at a breakneck pace. It stresses me out."

"How can you be a good consecrated virgin with all this work?"

"How can you be a good doctor when you're doing these side projects?"

The first objection comes most often from my body. Ulcerative colitis and residency don't play together well. A UC colon loves a predictable schedule, well-cooked and wholesome food eaten slowly. Those things are basically impossible in OB/GYN residency, where I'm eating quickly between triage patients and deliveries and trying not to have an episode of diarrhea during a C-section.

The second and third objections come from my conscience. I work a lot, and not by choice. I worked 2430 hours in the 244 days between July 1 and February 29. That's 11.6 hours for six days a week, with a seventh day off (and includes the days I was not at work while on vacation). I'd like for things to calm down so that I can focus more time on my relationship with Christ. I could work to the bone my entire life and never get to know the man who saved me and stooped to make me his little consecrated virgin. That would be a horrible tragedy.

I am also pursuing several projects on the side, including a video (done with shooting by the time this comes out!), a set of brochures (should be done with this one completely by the time this post hits), home improvement, blogging for two sites (including this one), keeping up the scholastic life (which includes writing and submitting essays to various journals), research (don't remind me about the phone calls I have to make for my research right now...), and attempting to network with others fighting for the culture of life (which involves archdiocesan events, meeting people for dinner and coffee, and emails). How can I take care of patients when I am so tired and have to finish all these notes so quickly? How can I study and be a good learner when I'm trying to get four doctors with crazy schedules to Chicago to shoot a video?

I just thought this picture was funny.

My response to these? Part of me argues that I'm in a rare time in my life when I can spring back from fatigue after working these hours, and I can spend this much energy on things. But the other part of me completely concedes that the objections are true and I'm doing it all wrong. 

It's unrealistic to respond by promising I'll never go to another pro-life or pro-family event, or that I'll never write another paper. I need to establish a new balance of work, leisure, and prayer.

Part of being less overwhelmed is beginning to assume that the duties of adult life (taxes, car maintenance, housecleaning) are not a project and are just like brushing teeth: no big deal, just gotta do it.

The other part is limiting my projects. I used to limit myself to five active projects in medical school. This may sound like a lot, but I remember when I said "no" to eleven awesome-sounding opportunities in one week. It was a good lesson: not everything that sounds awesome is really important to a career (much less to a life). I'd like to introduce you to a new side-bar gadget: the Project Kitchen. I'm not allowed more than two active projects, with up to four on the back burners.

Intern Happenings (and four months in review)

In the past four months, I reupholstered some Craiglisted chairs (previously tiger-print), made some curtains, wrecked a car, bought another car, and survived (almost) to the end of the "dark time." This post starts silly, but concludes with big thoughts on how things are changing through my intern year.

BEFORE

When I visited the house where these tiger-print chairs were, it worked in her scheme. Some people can pull things off that I could never make work. So I reupholstered them with an on-sale green curtain fabric from JoAnn. When I bought the chairs, I knew I was taking on a Project. I thought to myself, "it's okay, I'll bang it out in a weekend and be done with it." This was a big mistake. Now that my time is more precious than it has ever been (I pulled another 90-hour week last week), I think I might have other people do my little projects so that I can focus on bigger things.  I learned that upholstery is like surgery: it's easy to do "well-enough" but much harder to do beautifully. This picture doesn't quite hide the fact that my corners look like badly made bedsheet corners. The original owner had done the tiger-print upholstery herself and it looked perfect.

AFTER

Don't let this quick succession of pictures fool you. It took at least four months from start to finish. I kept dragging my feet at the last part, which was to screw the reupholstered seats back onto the chair frames. It was so hard and I developed an almost subconscious block to doing it. I'd do everything else on my to do list, and then (oops!) I wouldn't have time to fix the chairs. The item "Screws" hung out on my iphone Tasks list for ages.

Aaaaaaand I wrecked another car. I was changing from nights to days and forgot to set an alarm. I woke up to a text from my second year asking where I was. It was a nightmare come true. In two minutes I was out the door and in the car and rushing to work. I rushed a little too much! The accident wasn't wholly my fault, but if I hadn't been stressed, I bet I could've avoided it. I ran into a tree (swerved to miss the other car, who went off). The tree won.

The story of me buying the other car is funny, because it highlights how my crazy busy schedule only permits the extreme way of doing ordinary adult things like car-buying. My dad (630 miles away) discovered that you can buy cars from rental car companies. This is nice because the car company has a vested interest in the car working and being easy to maintain, so you know you're not getting a total lemon. It's also nice because you can drive the car for a brief period before you buy it.

So they tried to find me a car from a rental car company. We failed several times because the cars they found kept being driven to unplanned locations (like Vegas) by the people who were currently renting them. It was like requesting a hold on a library book, but then you find out that the book was returned to a library in another state.

We finally had a car that showed up where it was supposed to (in the same city as I was!). The only time I could pick it up was between work (6pm leave-time) and flying out for Christmas (10pm flight). So after work I took an Uber to the rental lot, signed my life away in the typical ritual of car-buying, drove off with a new car, then left the car in my apartment lot while I took a taxi to the airport for Christmas. It was a bizarre experience.

The answer to everything.

I have now driven 42 hours in that car and am pleased with it. It's a lot of car for a person trying to live poverty (it's got a back-up camera and a fancy screen that tells you stuff), but I just hope I don't wreck it by the time I get to tell you about the next few months.

A quickie update on some things in my last blast: neither of the illustrators were interested in my children's books, but that's okay. Again, I'm constantly learning to triage my projects. One of the patent proposals didn't work, but the other is in provisional status.

I'm also flying a lot this year: a friend's wedding, home for Christmas, to Chicago to film a video for NFP-only applicants to residency, to a conference in Toronto, and to another friend's shower (and again for her wedding). Attempting to plan a bridal shower (sorry, Mom) while also planning a video and submitting a poster to two things was a lot.

In addition, I got the "dark schedule," the intern schedule with four consecutive months of L&D, then nights, then MFM, then L&D. It's aptly named, as these four hard months coincide with January and February, the peak months for burnout. I'm now on vacation and feeling a little more human. I know the second year and the third year who got this schedule, and they changed. Fatigue changes you; you get snarkier, and sometimes speak badly about patients. You complain more. You talk about other people behind their backs. You search for any comfort--in food, in entertainment....

I don't want to change, but I see myself doing it. Is my wrecked car a symbol of something destroyed in me? Is my lovely dining room a symbol of something superficially nice in me? More on this to come. For now, I'll stick with frivolous updates on chairs and cars. Yay upholstery!

Disagreeing Theologians are Doing it Right

All that fruitful disagreement is how we got
universities! This is the University
of Paris, circa the middle ages. Credit: Ex Urbe.

This is a short post to point out three key points about engaging in Catholic ethics as a faithful daughter (or son) of the Church. I am writing this in anticipation of several posts that will cover controversial territory in obstetrics. (Spoiler alert: it's not intrauterine pregnancy.)

Key points:

1. The Church does not have doctrine about every procedure and situation. And that is okay. It's actually better to legislate carefully rather than redact hastily-promulgated stuff that wasn't well thought out.
2. Faithful Catholics who have worked to form their consciences can discuss issues on which the Church has not spoken. It is even okay if they disagree!
3. New scientific data can complicate the issue and that's okay, too! We shouldn't rest until we're confident about what we know.
4. This patience, freedom, disagreement is extremely productive in the search for the truth, and often leads to the Church laying out doctrine.
5. Theologians who are truly faithful will concede when they're wrong and adopt what's true, even if they don't understand it. Sometimes, they won't know they're wrong until an official promulgation or until more science comes out, but that's okay.

That's all. I've mentioned Point #5 before when talking about St. Hildegard of Bingen and St. Thomas Aquinas.

At left is a painting of St. Thomas presenting all his works to the Church (the female figure) who wears the papal tiara and sits in the light of the Holy Spirit. Yes, the man was wrong about when life begins, but he was a faithful son of the Church and the model for all theologians.

---

Postscript on blog data for 2015: number of posts last year was not bad, considering it contained my first six months of intern year. Sure, it didn't touch the absurd 136 posts I created in 2012, when I was just out of college and living fancy free as a medical student. (Twenty-one posts during one single month...what on earth did I have to say almost every day? And that happened twice that year!) I think my most valuable posts so far have been in 2015, as I've wrestled with ethical issues.

Two months in review (7-8/2015)

In the past two months, I've been on night float and on the ultrasound service. I've worked an average of 68 hours per week and used 1-2 servings of caffeine per 24 hour period. I've delivered 35 babies, done 5 C-sections (as primary surgeon), and done about 160 ultrasounds of various types.

I'm learning how to admit patients to triage, evaluate them, "dispo" them (send them home or keep them), answer dozens of types of nurse and patient phone calls, and "update the board" (keep abreast of what every patient is doing in labor and delivery). I'm also working on ways to wash laundry only every other week, recycle in my small borough, cook only once a week, make a bed while getting out of it, and shower in the time it takes to sing a Credo. I've replaced a car battery, hung blackout curtains, and bought several loads of furniture. And most importantly, I'm trying to make space in all this work for the liturgy of the hours, meditation, the rosary, confession, and Mass. I've made a lot of mistakes, but I'm being patient with myself as I try to do better. It's been a challenge.

I enjoy the work, especially when the deliveries are beautiful or I get things right. I'm at a good hospital with excellent and friendly nurses and my upper levels and chiefs are paying it forward, being kind to me so that I can be kind to the students and the next generation of residents in the future.

Things to learn in the future are how to not miss morning meditation, how to write discharge summaries in ten minutes, how to round on a dozen people in an hour and a half, and how to do dishes only once a week without starting an impromptu microbiology lab. I am also working on having local NFP resources printed for handing to patients in clinic (which is happening in the next two months) and having my elevator speeches together for when I am doing nothing but seeing postpartum and clinic patients. Any prayers would be appreciated!

Quick Takes

In the spirit of Jen Fulweiler, I will now give you seven mini-posts on the last day of July of my intern year.

Fireworks on Call

My first call was the nights over the Independence Day weekend. It was busy (as one of my upper levels said of me, "She got slammed"), but I had fantastic support from my chief. On July 4 he let the whole team sneak through the attic and onto the roof to watch fireworks. We aren't supposed to leave the hospital, but we crouched on the tarpaper, hiding the lights of our pagers and phones as we watched the magic. They were the most beautiful fireworks I've ever seen, possibly because I was so sleep deprived. While I watched, I remembered choosing a stock image of fireworks to put next to my first ever blog post, when I was given the news that I was going to med school. It's been a long four years since then.

Triage is Stressful

Most of the intern's job is to work Triage, which is like a mini-emergency room attached to Labor and Delivery. There are only six beds in Triage, but you'd be surprised how busy it can still feel, especially with my pager going off and the phones ringing and me not knowing how to prioritize. I make mistakes a lot: misdiagnosing wet mounts, forgetting to print patient's prescriptions, not thinking to collect a certain specimen, not starting IV fluids fast enough, not writing good notes, not writing the appropriate notes, not routing the notes to the right people.... I don't like the regret that comes with these mistakes, but I'm learning quickly and I'm trying to remember to be patient with myself.

First C-Section

I did my first C-section on that call. It took me about an hour. I was only a little nervous, mostly because I was very confident that my chief couldn't let anything go wrong. I'm still in med student mode: I don't take the final responsibility, so I don't need to worry about bad things happening. It went well. The baby was cute and the closure, if you were interested, was lovely.

Nobody Likes My Choices,
But People Still Like Me

So far, I've worked with three very pro-contraceptive attendings during my clinical time. They are three different shades of displeased that I'm not prescribing (one very discrete, one very ruffled), but they have nevertheless treated me like any other resident (except for the ruffledness of the one physician). There's a little bit of ignorance about how NFP works (both how the methods work (never mind how well) and how the system works (e.g. I don't teach the method in one office visit)), but they are still treating me like a person. I admire their ability to separate someone's choices from the person herself.

Catholic Hospital, Promise.

Our hospital looks so Catholic! There's a life-sized statue of our lady with the Infant on L&D. There's an Infant of Prague on antepartum. There's a Sacred Heart in the ICU. There's a chapel with daily Mass (and I've made it half a dozen times!). But earlier this month the ethics committee (which also approves tubals) permitted an elective abortion. In response, I'm joining the ethics committee.

Look, sunlight! I forgot what it
looks like! (Only kidding.)

Project Overload

I'm currently working on two medical device studies (peon on one, PI on the other), a sociological study (peon, de facto PI), a proposal to start a half-day naprotechnology clinic in my residency, a brochure of NFP options in my new area, and two potential studies: one in student and resident mental health, and another in fetal surgery (!). I'm also joining the ethics committee (see above) and trying to be a good resident. I've commissioned two medical illustrations, I've promised my parish priest a talk on NFP to the parishioners, and I've obtained some funding (and nothing else...) for a mini-documentary on interviewing as an NFP only. It's a little too much.

Blogging in Residency

I will have less time to blog during residency, so please expect about one post a month. I'll update you with what happened that month, and perhaps tell a quick story or two. Ethics posts will continue to come as well, and so will advice/materials on how to be a Catholic in today's field of obstetrics and gynecology.