Walk the plank

Today started out much as every call day day does.
Shrill alarm, cold regret, hot coffee, sullenly sulking on sofa, then mad dash to the shower, dress and to the number 48 bus in record time.

The bus lets off on a downtrodden corner of San Francisco, marked by a drug store and a restaurant better known for its rival gang shootouts than its pizza. The twenty four hour Walgreens has a steady stream of patients cashing in their pain pill prescriptions from the Emergency room. Even on days when its not foggy, the corner is gray.

Turning in at the wrought iron gate, the crumbling brick hospital buildings come into view. Cheerful construction workers holla morning greetings and trade jibes over cups of joe. Battered by budget cuts, but not beaten, the county hospital exudes a formidable presence despite its weathered exterior. Lining the entrance to the hospital is a gauntlet of smokers. Patients of all shapes and sizes loiter with IV poles and gowns fluttering in the breeze to get their nicotine fix.

Despite their wheelchairs, ostomy bags and multiple IV antibiotics many are still feisty enough to whistle a variety of unattractive offers; nevermind my sloppy attire or surly expression. Admittedly, I was curious to know how the guy in the full body cast ever thought he could good on his offer to "slap the hell out of that ass", but was certainly not about to stop and find out.

I always try to make it seem like I don't hear them and am not intimidated, but I always breathe a sigh of relief as I make it into the lobby and the Medical Marijuana clinic. Home free. Phew.

Straight to the second floor, for scrubs and my second dosing of caffeine. Now I can stay awake for rounds, and even pay attention. I've gotten much better at the attending thing- listening to the residents, letting them make the plan and asking questions about any important medical history or teaching points. The chiefs here pretty much make my job superfluous anyways, but I try to do something to contribute.

This morning however, I interrupted almost straight away. The tired intern was presenting her patients history. She had attempted a birth at home, but came in for an epidural and pain management last night. As she rattled off the patients physical exam and laboratories, she mentioned in an aside, "...and her pirate doula thinks..."

Clearly this is where I stopped for clarification. "Pirate?" I interrupt, "What do you mean?"

The chief smiled wryly as the intern innocently explained, "Oh Doula Greenbeard. That's the woman with the green dredlocks, green beard tattoo, and eye patch that's in the room. She's her doula. She self identifies as part of the pirate culture."

Shut the front door!

Ok, that's absolutely fascinating, but really just adds more questions to my list. Is she wearing nautical themed scrubs? Will there be a parrot in the room? Does she say Shiver My timbers? Will grog be used as anesthesia for any procedures?

But most importantly, when the hell did "Pirate" become a race/ethnicity designation? Did this paradigm shift occur on the last US Census? Will "Pirate sensitivity training" be a required part of the next cultural competency course the university mandates?

Tweet this

I could blame Myspace, Twitter, your haggard mother, Jerry Springer or Jersey Shore, but you know what? I blame you.

Yes you. You there, on your cell phone at the back of the number 48 bus. Yes, you, the girl with the fake Chanel bag and Hello Kitty phone cover. You.

I don’t care what you wore, that he said you’d call, or that it now burns when you pee. Neither do the rest of the hapless commuters being subjected to your inane recounting of every sordid detail from last night’s hookup. Your shrill monologue is echoing the entire bus length, polluting the entire route.

Let me be the one to tell you: he isn’t going to call, your butt does look big, and that burning? I think I can smell a new diagnosis of genital herpes even from here in the second row. Somewhere in the world, Miss Manners is delicately wiping away a tear, shed for the demise of decorum, with a lace edged hankie.

It's time to make shame a popular emotion again, and privacy a concept beyond restricting your Facebook profile. In 2010, we’re buffeted by a constant deluge of information. Status updates, Tweets, and headline news are all delivered directly to our cell phones, in an attempt to inform, entertain, and bring us closer together. It’s true, social media allows us to stay in contact with old friends and make new ones, but what is the impact on us when our lives become news? Does the desire to seem newsworthy erode privacy and encroach on intimacy?

Maybe it’s a stretch, but that’s the only reason I can think of to broadcast your breakups, hookups and meet ups to all four hundred of your closest acquaintances on Facebook. Beyond potentially netting a stalker and dashing future political ambitions, having your life on blast has important repercussions for how we interact. When the private becomes public, we sacrifice privacy and trivialize our personal lives by making it common.

Let’s conspire for a coup d’etat of courtesy and ignite a revolution of respect- turn off your cell phone and keep the details to yourself!

Tis the Season

Yours truly was recently asked by a national woman's magazine to provide some appropriate medical commentary for an article on causes of low libido. We all know Dr. Martinez has an abundance of commentary, but keeping it appropriate was a challenge.

Seriously though, they should have just had me write the damn article, because the hack that is getting paid couldnt write it all down fast enough, and tragically she got the abridged, PG13 version.

So, in the spirit of the season, I am going to provide you with the unedited version here. Take warning, its not for the faint of heart or those currently eating soft cheese.

Seriously though, as a gynecologist it is downright depressing the number of women who don't like sex. That's just not fair. Women have to deal with all of the risk of pregnancy, and a much higher risk of sexually transmitted infection. We should damn well be having an orgasm for the trouble.

The hack wanted comments from me on how birth control pills can lower your libido, and we all know that Americans like for a pill to be the answer, but she wasnt getting that out of me. Birth control makes the world a better place. I instead offered that while there are some medical reasons that sex can be painful and libido affected, that it's rarely the explanation for whats going on. At least in my practice, where admittedly women do get into fights at their baby showers, most of the sexual dysfunction has more to do with the fact that couples aren't communicating properly.

Sometimes its that women are too insecure or shy to say what they want, and sometimes it's that your new husband is a transvestite.

She was double booked into my 4pm spot on a Friday afternoon and had driven in from a small town forty five minutes away. Through sheer determination and prodding of reluctant medical assistants who'd rather be taking a smoke break, my clinic is one of the few resident clinics that actually runs on time. Its a point of pride.

So, after her vitals have been taken, I flip through her records and head into see why she's here. She tells me that she would like a "pill to fix her." I tactfully enquire as to what is broken. Brenda relates that she married her high school sweetheart just three weeks ago, and she is no longer attracted to him sexually.

They were virgins when they married, so I'm not entirely suprised the sex is lousy. I mean, it unfortunately seems to take some men a while to realize that women are not ATM machines. You don't just walk up, insert your um, card, push a couple of buttons, make your withdrawal in a matter of seconds, then end the transaction. No effing way. Unfortunately it also seems to take some women a while to realize they need to have higher standards.

Anywho, in the next five minutes I diplomatically navigate a series of questions to try and elicit whats going on. Pain? Depression? Alcohol? Insufficient foreplay? Intimacy issues in the relationship? I ask if she has thought about seeing a counselor- "Yeah, but that wasn't really helpful. She just told him to quit stealing my lingerie and makeup, because it upsets me that he looks better in them then I do, and I don't really want to wear that strappy on thing."

Its heartbreaking really. Why do women always think it's their fault?
If anything screams "not about you" louder than this, I can't for the life of me think what it would be, but she needed to hear it from a doctor.

Dr. Hernandez is known to be more decisive than most, but still she has a hard time understanding women who don't know what they like. Even more of a conundrum is those that dislike something that's supposed to be fun, but endure it silently anyways. Disliking sex is akin to silently suffering while on vacation in Hawaii.

This next gal was in her mid forties with cafeteria-lady hair and was an assistant manager at the local Mail Boxes Etc. She came in still wearing her work uniform of pleated front khakis, and psuedo denim button down shirt. She was the essence of frump and sincerity.

She plopped onto the exam table, and without further ado announced, "So, I've got this new boyfriend, and he really likes me to take it up the butt, and I don't know, I mean, it doesn't feel good, and crap keeps leaking out all over the sheets, but you know, I really like him, so that's fine, but what I can't figure out is why throat is so sore all the time and my cookie smells so bad...."

Let it be noted that Dr. Gomez wholeheartedly supports consensual adults doing whatever their thing might be, but she does NOT understand why the hell you would need to see a doctor to solve this riddle.

The second hand slowly traversed the clock as I rapidly considered how to best explain, as politely and clearly as possible the state of affairs. Inspiration struck.

I smiled and said, "Would you walk into your house, even through the back door, with muddy shoes on, then come out, muddy shoes still on, and head in through the front door before then walking upstairs?"

Bad Cop

It’s not all heartbreak and tragedy in the hospital, although it certainly feels that way sometimes. Frequently it also feels like an episode of a poorly scripted reality TV show, without the Jerry Springer style security waiting in the wings. Not that the hospital doesn’t have it’s own security trolls that they send up from the Emergency Department when a baby daddy gets out of hand. That happened last night, and trust me, their presence was far from reassuring. The tallest one barely came up to my shoulders and they were all huffing and puffing after clearing the two flights of stairs. I seriously feared they’d pop a coronary and I’d have to hope the ICU team got there in time before it became obvious I only remember the first two steps of the cardiac code algorithm. Oops.

Anyways, it’s probably my bad mood that makes the flashes of happy families and glimmers of grace seem rare in the hospital, although as a senior resident anything low risk and normal goes to an intern or a midwife. I get to be the bad cop.

One of my favorite things about my job is the insight it gives you into how other people live their lives. It never fails to amaze me what other people consider normal or acceptable, and it certainly forces me to question some of my own assumptions.

It’s incredible isn’t it? The lives we lead and the world we lead them in. That sort of sounds like it was filtered through a stoner reading “Philosophy for Dummies” that only speaks Pig Latin but I’m actually inelegantly paraphrasing Kurt Vonnegut. Mother Night, mofo.

As the gynecology consult resident, I go all over the hospital, seeing patients in the ER or on other services that have obgyn issues their physicians need advice on. Today I got called down to the ER to “provide a female presence.” That pissed me off, but it ended up being worth it just for the story.

The ER attending tried to justify calling a gynecology consult by way of saying the patient wanted to talk to a female physician, but I think it was because all the ER residents were in lecture and he didn’t feel like getting a Spanish interpreter. Yeah, I should learn to give people the benefit of the doubt. I need to work on that right after I quit swearing so much, drinking so much caffeine and actually start using my gym membership.

So I grudgingly head back down to the ER and end up talking to a teenage girl who had been treated for pelvic inflammatory disease. "But I couldn't possibly have an STD!" she exclaimed angrily. "I've only had sex four times and it wasn’t even any good!" Oh sweetie, I only wish it only worked that way. We chatted, I even had to draw some stick figures to explain a few mechanics, and she felt better. She left with some new information and antibiotics.

Sometimes its not the patients I talk to but the people I work
with that shock me. These are supposed to be well educated, high functioning professionals right? Supposedly. Sometimes you catch a glimpse into their personal life and you have to wonder how it all came together for them. I don’t except myself from this observation by the way…

I was in the locker room hurriedly changing into scrubs because our ICU patient was doing poorly and needed to go back to the OR. I returned a page from the phone in there to talk to the attending about what was going on. In walked a nurse I work with every day. She has her cell phone in hand. "2 missed calls!" she announces to me as she walks into the public toilet stall and closes the door. She then proceeds to call back her son and yell at him while heaving and straining in the litter box. Shameless.

Saved the best for last. Communication is an amazingly complicated thing sometimes. It's not always as easy as it should be to say what you mean, or to really hear what the other person is telling you. This is definitely true in the doctor's office. You're frequently discussing emotional issues complicated by educational and cultural barriers, and in oncology clinic it is also confounded by our attending's thick European accent.

This woman comes in with heavy, irregular vaginal bleeding. It had been going on for a while, but the power of denial being what it is, she had put off a doctor's visit. She had herself thoroughly convinced that the bleeding was because her boyfriend was so incredibly well endowed that this was causing her symptoms. She expounded on this theory for some time and in enough detail even I blushed.

It was a curious hypothesis, but still not as curious as our attending’s perception of events. It was explained to her there was a fungating, necrotic mass in her lady business and she likely has cervical cancer, not a porn star boyfriend. She is of course shocked, upset, sad- all 12 stages. We move through them. After leaving the room the male staff's first response to the whole interaction? Yeah, he is still obsessed with the penis theory. "Itsa like she a wanna make-a me jealous that I am not so beeg as her boyfriend!"

Whoa. I just tried to keep my mouth shut and my face devoid of expression, which is no small feat for me.

No Hablo Crazy

It was my first year in medical school, and I anxiously prepared for afternoon clinic. I nervously put on my white coat, new enough to still be free of coffee stains, carefully bundled my stethoscope into a figure of eight and loaded my pockets with pens, reflex hammer, palm pilot and hell even a flashlight for a neuro exam. The pockets strained at the seams, but I needed all the help I could get.

The first two years of medical school are pretty much brute force memorization of all the science stuff you need to learn how to apply in your last two years of medicine. When you aren’t in the classroom, you’re usually at a toga party with other med students.
One afternoon a week though is preceptor clinic, and the exception to the above rule.

They match you up with a real doctor and you work with them in clinic to try to begin to get a feel for how its all supposed to come together.

My preceptor is a family medicine doctor who works in a busy clinic in the south east part of the city. It’s a non profit clinic and takes care of the underserved with a large migrant population. I’d noted that I was fluent in Spanish on my preceptor request and that I’d like to work with the latino population. I was really excited to start.

Dr. Schwartz kindly showed me around the practice and then scanned his schedule.
“Here, why don’t you go see this new patient? He’s just here for a medication refill, but why don’t you practice getting a complete history, and then we can do the exam together.” He disappeared into the exam room next door to the one I was supposed to enter.

Faking an air of confidence and clutching my bulging white coat pockets for moral support, I opened the door and nobly sallied forth.

According to the medical assistant’s notes, Ricardo was a forty two year old laborer who needed his prescription refilled. Ricardo wore paint stained overalls and fingers colored by nicotine. His eyes were tired, but he had a sweet smile and was holding a Safeway bag of empty containers.

I introduced myself, and then asked “Prefiere hablar en ingles o espanol?’ He gave a sigh of relief and said “Oh espanol, porfavor.”

Ok, no problem. I used to be a Spanish translator at a clinic in college, I can totally do this without getting the clinic interpreter.

I try to remember the acronym I learned last week to remember the order of a proper clinical history. BADHITS? ADCVANDISMALS? Thank god for the Maxwells in my pocket. Chief complaint, that’s right.

“Pues senor, como podemos ayudarle?” What can we help you with today, sir? Somehow medical school seems to have erased all of my previously existing common sense.
In Spanish he begins to explain to me. This is what I understand.

That he has always been in very good health without any problems but two years ago, well maybe last month his stomach began to hurt. When the pain started he was driving a truck all night from Jalisco to Guadalajara, and the moon was very bright and the sky with stars. Suddenly a cat, an orange cat, ran across the road and he swerved. The window became the door. A woman all in blue appeared and motioned him towards a hill. He was very tired, but summoning all his fuerza he made it up to the hill where he found a well. He is not sick, but the water from that well helps him.

I listen and nod sympathetically, but am wondering what the hell happened to my Spanish! I used to be so fluent, and I really have no clue what this guy is telling me. What the hell else could well mean in Spanish? Antacids? An herbal tea? I better go get the interpreter because this is totally hopeless. Ricardo smiles cheerfully and hands me his empty prescription containers.
*********

“What the fuck does that mean?” Ivy explodes. A gaggle of girls have gathered to celebrate finishing our final exam of the semester. It’s a beautiful fall evening and we are laughing at the swimmers out in the bay. Sure, they may have only 2% body fat, but its much nicer in here. The embers from the fire reflect off the dark wood paneling, there’s soft cheese, sparkling wine and an adorably flamboyant waiter who keeps the wine and outrageous compliments flowing.

We’ve discussed health care policy, advanced calculus, the hidden symbolism of War and Peace, and now we’re onto updating each on other on our romantic relationships, or lack there of. Ok fine, we mainly just talked about boys and shopping.

Ramona has just finished telling us about the great guy she thought she was dating. They had been going out together for a couple of months, spending weekends in wine country, and getting along fabulously. She got jealous “Ooooohs” when she described the sweet voice mails he’d leave at night when they couldn’t be together. Not from me of course, I tried to not roll my eyes and signaled to the waiter for another drink. I knew there had to be a punch line.

Yeah. Yesterday, as they basked in the afterglow, wrapped only in the bedsheets he said, “You know Ramona, what I like best about you is that we don’t have to be in a relationship, we can just have fun. I’m just in such a selfish place right now….”

Ouch. Where the eff did that come from? We all have our own theories of male behavior, but few of us would have guessed that was coming. I did, but would have thought he’d have the common decency to not say it while naked.

I think that Francine managed to one up her however, and Ivy can barely contain herself.
“Is he gay?” she asks. “Does he have a girlfriend? Maybe an STD? Oooohh. Erectile dysfunction?” Ivy is also a gynecology resident, so she paused, thought for a second and then queried suspiciously, “Are you sure he isn’t really a woman?”

“Oh stop it Ivy, I think it’s kind of sweet. He just wants to take things slow,” Kat, the married friend interjects. Ramona nods in agreement and takes another slug of her mojito.

Francine sighs. “Yeah, that’s what I thought at first, but it’s been two months now. And I swear I’m so sick of just making out and it not going anywhere further. Besides, kissing him is not my favorite thing. He’s so great in so many ways, but he kisses me like his tongue is a fish gasping for oxygen on the bottom of a boat. Except it’s the back of my throat.” She forlornly swilled her wine and looked to the bottom of the glass for answers.

Ew. Good on paper, but not so bueno in the bedroom. Francine really needs to walk away from this, or hell simply run, but as a friend we’re required to tactfully filter the message with as much positive spin as possible.

“Well, it doesn’t sound like you’re really that into him anyways,” I say.

“No, not really, I guess, but I am starting to think its something about me!”, Francine responds. This elicits a chorus of “Oh honey, it’s not you!”

And it really probably isn’t. Francine is the complete package: brains, beauty and boobs.

“Well, that’s definitely NOT it, and if he doesn’t do it for you, just move on. Who knows what’s going on with him? Man-glish is impossible to translate.”
We all laugh and order another round.

**********

I leave the room exactly as Dr. Schwartz exits his.
“Wow”, he exclaimed, “You’re fast! Normally I can see three patients while the student sees one, but we finished at the same time. Why don’t you go ahead and present him to me.”

Embarrassed, I start off as Maxwell’s instructs.
“Ricardo is a 42 year old truck driver presenting today to establish care and get his medications refilled. He is generally in good health, as long as he takes his medicine every day.” I pause, unsure how to phrase the next part. “Um, his history is a little confusing, as he says he has nothing wrong with him, he just needs all these medicines refilled. Maybe I didn’t understand his Spanish as well as I thought?”

Dr. Schwartz has been busily sorting through the bag of empty containers and writing prescriptions as I talk. “Great, great!” he heartily replies. “So concise! And very professional too. I like your sensitivity to his disease. Of course he doesn’t think anything is wrong with him.”

Even more confused, and blushing like a debutante at the Folsolm street fair, I am still an experienced enough medical student one month in to know better than to ask questions that reveal my ignorance when I can just look them up myself.
I walk back into the room to give Ricardo his prescriptions for haloperidol, fluoxetine and lorazepam. After he leaves I stealthily turn on my Palm Pilot and check out the pharmacy manual.

“Haloperidol: an atypical antipsychotic useful in the management
of delusional szhizophrenics. Side effects include….”

Krystal Ball

I love personality quizzes. Whether it's the latest issue of Cosmo, the Meyers-Briggs odyssey or the back of a box of cereal, I'm right there with my number 2 pencil. It always amuses me to see my diagnosis. I read my horoscope for the same reason, although I only believe the good parts. Classic Leo, right?

It's truly staggering in a profoundly sarcastic sort of way of course, the deep insight that can be gained from answering questions like what color I would choose to be and analyzing the shape of my used lipstick. It's a novel way to try and make sense of choices, and sweeping generalizations are always fun.
I’d love to see the personality test that could make sense of some of the patients I see. How would you classify someone who’s water broke when they were:
a) In da club
b) In court on child abuse charges
c) Performing as an exotic dancer

You think I am making that up, don’t you? Sadly I don’t even need to. And yes, I know that the playing field isn’t level, and I know that many of these women were born into heartbreaking circumstances themselves. But it’s hard to not be judgmental when they are bringing another baby into their mess. It’s hard to not be disgusted when it’s 5 am and your forearm has just been swallowed by the Vagina that Ate Detroit. It’s hard to not get angry when you’ve been awake for thirty hours. It just seems senseless and hopeless.

Obsetrics is full of superstitions, many of which seem to be eeriely accurate. Ask any resident- we all know that a birth plan or more than four people in a delivery room guarantees a complication. I start preparing for the worst the second I catch site of “Amy and Don’s Birth Plan” double sided and laminated (“…the room will be absolutely silent. We will chant in between contractions. Amy is NOT to be exhorted to push. If Amy asks for pain medications, you will not let her have them the first two times she asks. On the third time, ask her husband’s permission to administer pain medications…”). It’s a classic set up. If you are determined to control something inherently unpredictable fate is obligated to step in and administer a smack down. It’s better to accept that we never really know what’s going to happen, but it takes inhuman discipline to let go of the illusion of control. I suck at it too, just look at my day planner.

Some of it’s patient profiling, that’s true. Woman with a husband, a boom box and Jack Johnson CD? Faculty patient. Woman with braids, earnest husband, incense and her own pillow? Nurse midwife! Woman that’s not actually pregnant but still brought half of her family in the ambulance to witness her fight/guilt trip her boyfriend? Family practice god bless them. Woman in handcuffs with four officers? Resident patient.

I’ll never forget a resident patient I delivered early in my second year. Second year is a journey into the heart of darkness without a map, and this particular patient still figures in my nightmares.

Did you know that crack cocaine induces labor? It does. She had been picked up on a parole violation and was out of her effing mind. She was snarling, screaming and kept trying to run out of the room. The length of chain that kept her affixed to the labor bed kept jerking her back and she’d howl with rage. It looked like she was in active labor, but it was hard to say for sure- she tried to bite me when I got close enough to her to examine her. The officers helpfully mentioned that she was positive for Hepatitis C and that this was her 6th or 9th pregnancy according to her last arrest records. They were in the room with one eye on the TV and the other watching us and the ensuing drama.

A group of us gowned in full space age protective latex encircled her, trying to establish some rapport. Our staff was convinced she could be reasoned with. I wasn’t. I’d seen her feral eyes; there was nothing human left. We couldn’t get close enough to place an IV or to give her pain medications. I knew her body was in control and she’d deliver the baby eventually, I just had no idea how I would get close enough to catch the baby and keep it from hitting the floor and not catch Hep C in the process myself. A few minutes later, I had my answer.

She grabbed the handrails of the bed, and I could tell from her face that she was pushing. I darted in. The baby exploded out of her perineum and I caught it. Her eyes opened as her son entered this world. I’ll never forget the mask of terror her face froze into- she had no idea what had just happened.

Take my breath away...

No, this isn't going to be an 80's soft rock tribute blog.
Yours truly is at a medical conference, an exercise in academic frumpiness, research promotion, and small talk. I know, I know, I really should have something better to do.

Anyways, my not so secret pathology is that I *hate* being late. Really hate it. It gives me a lump in my stomach and makes me fret like no ones business. So I did my best to be nonchalant when my flight was delayed, even though it meant I got into town too late to register for the meeting and drop off my research project for display. Oops.

So of course, this morning, the third day of the conference (the first two being devoted to golfing and birding, which as it turns out is tax deductible for any private practice attendings) I show up ten minutes early to make my apologies, register, and drop off my research poster.

Of course I'm the first one there, except for a large contingent of companions (98% wives) who are in charge of organizing and reorganizing the reception table. I am alarmed- I don't see any coffee.

The nice lady at the table is joined by two of her friends, but they could all pass as triplets. Frosted blond hair, coordinated pants suits, and rocks on fingers that looked like they would need slings to support their sheer weight. Big smiles, very kind.

I say hello, and that I'm checking in for the conference, and that I'm here as a guest to present my research. They ask my name, and I reply.

"Hernandez?", one inquires skeptically.

The other grabs my left hand and the third one inspects my left ring finger to confirm accuracy. Yep, they confer, confabulate and configure the data. No ring.

"Is that your first husband's name?" one chirps sympathetically.

"No", I respond sweetly, "It's my father's."

"WOW!" she responds, "You're the tallest MEXICAN I've ever seen."

(Editors note- for those who have not met Dr. Alvarez, she's a charming conglomeration of race/ethnicities, none of which involve Mexico, or Mexicans).

I am not sure what I looked like as I vacillated between uncontrollable giggles and an unrestrained need for more coffee, but I'm sure it was damn funny cause it's always pretty obvious what I'm thinking.

Her friend must have registered something from my emotional Richter scale, cause she leaned over the table and cooed, "Oh,honey, that's great! We have the most beautiful vacation home in Mexico, and we have LOTS of Mexican friends...."

Gibberish is Genius

I just love that comfortable level of drunk, where the buzz is warm and friendly and everything you have to say is insightful and oh so profound. Soft backlighting envelops the world and new acquaintances are old buddies.

Today?

Its sober enantiomer. It was the effed up kind of day where you run around in well intentioned circles accomplishing nothing more than miscommunication and escalating crankiness for all involved. And no booze was involved, just for any legal types who didnt appreciate the inept analogy. Like I said, it has been that kind of day.

There were red flags from the beginning.

At midnight came the SOS text message from a friend stuck on a date that had devolved from repeated references to his genitalia to an indepth discussion of his pornography collection and deep affection for Debbie Gibson. Oh, I'm sorry, Deborah. Did you know she's Deborah now? She's past the prime of her Electric Youth pop star days but apparently still within her Playboy window. He had it downloaded on his Iphone and was nose to screen.

I'm no Miss Manners, but I think at that point in time it's ok to just call a cab and leave without an explanation. Or fake appendicitis. Whatever. I mean life is short, and there may be a Law and Order marathon on at home.

So I packed an extra energy drink and set off for clinic. As I headed in through the waiting room, I heard one baby daddy angrily berating his pregnant gf. "Girl, you so fat your legs be lookin like two seals fightin each other!"

His imitation of a barking seal was pretty goddamned funny, I'm not gonna lie, but really? She countered with threatening to not go through with the abortion they were scheduled to have that morning and "stickin his skinny ass with child support."
Love is a many splendored thing.

Crankiness is highly contagious. Pagers screaming, IV pumps beeping, anesthesia delaying, patients hollering, med students slacking combine to make the perfect shite storm. The most irritating part of all if it, is that none of it is that really big of a deal. I mean, no one's dying. It's just a bunch of small bs that keeps eroding morale and sucking you in to a cycle of inefficiency that is just going to make it that much longer till you get the hell out of the hospital.

As summer circles the drain, the whole hospital seems seeped in nostalgic disgruntlement. Too few of the grand plans for summer have materialized and too many calls from the ER have. The senior residents are ready to be done. The novelty for the interns has worn off but the frustrations are just beginning. Even the hum of the florescent lights sounds discontented. It’s been far too long since the last vacation, and winter is just around the corner.

It’s easy to get peevish and snatchy. I am definitely not immune. Exasperation courses unchecked, and the simple act of a pager going off can cause an explosion of expletives. It’s always somebody that wants something from you or of you, and it is difficult to explain how draining it is to have that be the basis for all of your interactions with others.

I always try to regain perspective as I dial the number back and return the page. I know I signed up for this and it is a privilege to be here. But it is still really fucking annoying to be interrupted when half of the pages seem to be wrong numbers from nurses who aren’t all that sure why they called you in the first place but expect you to solve their woes. Complaining is an art form honed to perfection by residents.

This particular page was a quick slap in the face of reality. Peds residents are always so damn nice that they automatically make me feel guilty about not being a better person. Half the time I'm not entirely sure what they're saying. It's true that obgyns have their own language of acronyms and random Spanglish, but so do the pediatricians. Peds pidgin is full of words like "kiddo" and "punky."

They had just admitted a fourteen year old girl who was undergoing treatment for cancer. The cancer was in her blood, which means she was weak from not having enough oxygen circulating to tissues and that her blood wasnt clotting properly. This is why I was called- she was having her period, but way heavier than normal and they wanted help slowing it down.

I always feel out of place in the Children's Hospital, but I went to talk to her and see what I could do. This kid was pretty amazing. Despite the fact that she had cancer and was admitted to the hospital instead of out enjoying summer break, she was articulate and polite. She was also continuing to train with her cross country team throughout her chemo.

She was really hoping to get out of the hospital for a run that weekend. I couldnt believe she was still running with blood counts that low, and asked her how she did it. She gave me the look a typical teenager does when you ask something so stupidly obvious that it seems like, hella retarded to even answer.

She did though. She matter of factly replied, "Um, you just keep going. The first mile is always the hardest."

It's true. The first mile is always the worst. Just keep going.

Never turn your back on a laboring multip.

That lesson was imprinted on me as an innocent intern by an esteemed chief, and they've remained words to live by to this day. Embroider it on a pillow, tattoo it on your arm, embrace it as a meditative mantra, but do not ever forget it. Ever.
For those of you about to wikipedia multip, it's short for multipara, which is Latin for "had too many babies." Or something like that, I mean there's a reason it's a dead language after all. Nulliparas, first delivery.

With a nullipara, you can reasonably assume her labor course will take longer than your last vacation. A multipara's labor on the other hand? Well, that's probably only going to last a little bit longer than your ex boyfriend....

No, seriously. A woman who has never had a baby and has no epidural will likely push for about an hour. If she has an epidural, she'll push a little longer, but three hours is the outside limit of normal. A woman who's had a delivery before and has an epidural, will maybe push for anywhere from 15 minutes to an hour, max.
But a woman who's had nine deliveries, has no epidural and is telling you she needs to push? That's the express train coming through Chicago. I recoiled from the force of the ten pound baby she launched into my arms and staggered back.
Ergo, NEVER turn your back on a laboring multip.

I make it a point to try to scar or scare all new interns with this policy, but alas, not all of them are as apt of pupils as I was. As a result I've delivered more than my share of babies one handed, one gloved, diving across the room. Yuck, I shudder just thinking of it. So listen up interns; keep your chief happy and when a multip is huffing and puffing into the station, do not turn to adjust your instruments, avert your eyes to your pager or leave the room to go to the bathroom.
On a related note, dads to be; think carefully before scheduling an out of town business trip within a month of your due date. Guaranteed trouble.

This lack of foresight on one dad's part led directly to one of my favorite births of all time. In the poor guy's defense, the due date was a month away, it was their third child, it was an emergency work trip, and there is a recession going on. As soon as his plane landed in Vegas his wife's contractions started. She thought they'd go away, but they didnt. In fact, they got quite a bit stronger.

By the time she arrived on Labor and Delivery, she was just about ready to actually have the baby, but you wouldnt have guessed it from when she walked in. She was a petite woman, immaculately done up. Cute outfit, coordinating accessories and nails done. In a sweet, quiet voice she asked to see a doctor, saying she thought she was having contractions. A second later one hit, and she was roaring like she'd been posessed by all the demons in hell, or Republicans in Congress. Her eyes rolled back in her head, she clawed at the nurse's station, and frothed just a little bit at the mouth. After the contraction passed and her head stopped spinning, she delicately wiped away the foam with a monogrammed handkerchief and in dulcet tones asked to be checked. We hurried to oblige.

Minutes later, she was tucked into a labor room, ready to deliver and her husband was on speaker phone. The poor guy was shouting into his Blackberry from a conference outside of the Rainforest cafe at the MGM Grand.

"Oh honey, I love you so much!" she sweetly uttered into the receiver in response to his abject apologies intermingled with excited pride. "ROOOOOOOOOOOOAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAARRRRRRRRRRGHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!!!!"
Her next contraction ricocheted off of the pyramid at Caeser's palace and was heard at the far end of the Vegas strip. Without skipping a beat she returned to cooing with her husband. Until the next contraction. It was hilarious and pretty adorable- the pattern repeated for a good fifteen minutes until she delivered one of the cutest babies I've ever seen.

Vacaciones

I guess it's been a vacay of sorts, but not the kind I'd like. Sunny beaches, umbrella drinks, trashy novels, and surfboard type of vacation I mean. This summer has been more along the lines of biostats, research papers and assorted other character building activities.
I'm in grade 25 now, and I've got character oozing out of an assortment of bodily orifices.
TMI, I know. Well, welcome to the theme of this blog. The musings of a surly obgyn are inherently TMI. Read on at your own risk or click over to the next episode of "Jon and Kate plus 8." Wait, that actually might be more offensive then vagina talk, depending on your values.
Anyways, I'm trying out some new things here as I work on the book. Honest commentary always appreciated. And by "honest" I mean compliments.

Christmas Morning

It’s my own fault. I knew better and I had fair warning when she told me “he’s a really nice guy”, but I have a hard time saying no to Brittany, so here I am on a blind date with her family friend. I sensed it was a mission of pity from the fact that he started all of his sentences with either “My therapist thinks…” or “My girlfriend, I mean ex,”
Before self righteous accusations start getting lobbed at my head, let me explain why “nice” men irritate me, and no, it’s not because I like douche bags. I don’t waste my time on jerks. Well, not anymore anyways. I like considerate. Nice is generic and is frequently passive aggressive. Nice is also frequently a cover for boring and insipid. You thought I was going to say ugly, didn’t you?
Anyways, he is as advertised, nice. And trying really hard to not be heartbroken. Chad has the forlorn appeal of a puppy dog out in the rain, and so I’m being nice too. It’s a stretch, but I’ve always got the pager as an emergency exit. That’s another good thing about my job- it’s a great excuse for arriving late or leaving early. I’m never late, but I’ve been known to set the pager’s timer to go off conveniently and make my excuses sooner rather than later.
We’ve covered the weather, what he does, and what I do. As a brief public service announcement, the general public seems convinced that all doctors like watching medical dramas and talking about medicine. I haven’t met any who do, with the exception of Scrubs. Scrubs is damn funny, and surprisingly accurate.
Chad is telling me all about his recent medical drama of his own; a kidney stone. And yes, passing a kidney stone is supposed to be the male equivalent of labor, but that’s not sexy or particularly interesting. Except maybe to Chad. He is becoming very animated as he goes into colorful detail about how the nurse had trouble placing his IV, and how his veins are very unique. I am smiling sympathetically and nodding with interest in all the right places.
He stops all of a sudden; he’s going to run out to his car to get an audiovisual device to better illustrate his medical mishap. I wait with bated breath.
Chad returns with the KUB film taken in the ER. KUB stands for kidney, ureter, bladder and basically it’s just a black and white x-ray of those areas. Kidney stones frequently have calcium in them so that like bone, they look white. Fluid or air looks black and muscle and fat tissue is a shade of grey.
I have enough close guy friends that I’ve heard many a bitter man complain about the fraud perpetuated on their half of the species known as the Wonder bra. Lately new technology has been introduced in the form of “cutlets.” Cutlets are silicone inserts women can pop right into any old bra and beguile many an innocent man astray into thinking an A cup is a C cup.
‘Oh cruel world!’ is my standard insincere response as I point out that women never know what they are going to unwrap until they’ve committed to undoing the zipper as well. It’s like Christmas morning when you’re not sure what Santa left you underneath the tree. Does that package contain the electric train set of your dreams, or just a lump of nasty coal?
Chad is now holding up to the light, for the entire bar to see, the x-ray from his hospital stay. As he is gesticulating wildly and relating his tale, keep in mind that a KUB shows the kidney, ureter and bladder. It shows the bones, fluids and the soft tissue beneath… Pretty much he showed the whole bar a picture of his lump of coal.
Can’t wait to thank Brittany for this evening.

Things Fall Apart

We all make choices and have to accept their consequences, but there’s so much we can’t control. The patients I’ve taken care of that I admire the most are those that accept uncertainty with courage and grace. The patients that I sympathize with the most are those who have been deprived of the opportunity to have a choice.
Marie was a beautiful thirteen year old girl. Perfect chocolate skin, big brown eyes, and hair carefully braided into neat braids. She clutched a teddy bear to her side. and stared at me anxiously. For the first time I could remember, I wished I spoke French, Marie’s only language. She had fled the violence with her family in the French Congo five months ago, and they had immigrated here, where members of their devout church would help them assimilate. Not Marie though.
A physical examination is a required part of Customs, and Marie’s secret was discovered. As so many other women and girls in her country, she had been viciously attacked and gang raped before they were able to get permission to leave the country.
Marie was pregnant. She had never even had her period and had no idea how her body had betrayed her.
Ashamed of Marie, her family had hidden her and her pregnancy away from their religious community by separating her from her family. She was sent to a foster home for teen moms while the rest of the family established a home in the northeast corner of our city. They told church members she was ill, and had to be quarantined by U.S customs.
As Marie told the nurse they didn’t want her near her little sister, worried that “she might be a bad influence.” I felt a surge of hate for her parents when I heard that. Who could do that to their daughter? Is it her fault some asshole monsters raped her, tortured her, stole her childhood and saddled her with a pregnancy?
She was so heartbreakingly vulnerable as she sat in the Labor and Delivery bed clutching her teddy bear. Marie looked terrified, and remembering the violence she’d been put through, I struggled to think of how I could possibly make this ok for her. Again, I wished I could at least speak to her in her language, instead of through the telephone interpreter. But what could you say? What could make any of this ok?
There are some things that just can’t be fixed, but at least I wouldn’t make this worse.
I tried anyways. We got an in person interpreter. Social work was called, and the nuns from her group home arrived. They convinced her mother to come in. A dense epidural was placed. We limited exams, and asked her carefully about how she wanted the birth to go. The baby was to go up for adoption, and when I asked her if she wanted to see the baby she spoke the only word I heard her say; “NO.”
How do you survive pain and violence like that? Marie was having to learn how to do this alone at the age of thirteen. I have no idea how she found the resilience, and her strength made me ashamed of my own weakness. I knew my problems were trivial in comparison, but they weren’t feelings I could easily set aside. When you don’t have a choice you just have to keep going and do the best you can at that point in time.

Imma letcha finish

I probably need to cut back on the diet energy drinks and actually sleep some. I think my external filter is completely gone, but it’s hard to tell because Labor and Delivery is such a circus. One of our patient’s just informed the intern that he was too young to be a doctor, announcing that he “still smelled of his mama’s titty milk.” At least they thought the male intern was a doctor. I got a thank you card yesterday from a woman who came in hemorrhaging. I met her in the Emergency Room, did her surgery, delivered her baby and cared for her afterwards. Her card told me I was the best nurse she’d ever had… I appreciate the sentiment, but when are we going to leave the 1950s and realize that women are allowed into medical school these days?
Because seriously, explaining that I’m not a nurse is one of three questions that I have over and over and over yet again. I’m not sure what I hate the most, explaining that yes, I’m really a doctor, or answering one of the other two.
Option b) “How tall is you? Girl, you’re big!”
Option c) “Gonzalez? How’d you get to be a Gonzalez? Is you married to a Mexican? You sure don’t look Mexican.”
I have a hard time answering either of these patiently even when I’m not sleepy or cranky. I mean really, both are just rude. But enough tangents and back to my original digression. I need to think about cutting back on caffeine.
The scene: Labor and Delivery. One of my clinic patients is in preterm labor, and the room is a total circus. Several small toddlers are squabbling and trying to put Cheetos up their noses while the adults watch football and leave for smoke breaks. My patient’s mother is a thin woman who reeks of Charlie perfume and stale tobacco. Her younger sister is 16, pregnant and has eyeliner smeared down her cheeks.
Intro:
"Hi there, I am on the doctor on call tonight..."
Patient’s mom: "Oh are you the new nurse."
The clincher:
Trying to discuss the non reassuring fetal heart tracing with the patient in the midst of all the baby mama drama when her mother from across the room interrupts me with "How old are you anyways honey?"
Without thinking my reply "How much do you weigh?"
Fortunately the whole room cracked up, although the nurse was trying to give me a stern look, she couldn’t quite keep her face straight. A knock on the door announced the next crisis. “Is Dr Rodriguez in there? Family practice needs an OB consult in room 64 right now.” And I’m off.
Room 64 contains five family practice doctors, a Spanish speaking woman in active labor, and a nurse, my friend Robin. The patient is on her hands and knees with an oxygen mask on and fetal heart tones have been in the eighties for about eight minutes now. Babies heart rates drop and come back up during labor all the time, but if the heart rate falls below ninety then they aren’t getting enough oxygen. And sometimes the heart tones don’t come back up, which is why after three minutes of a low heart rate, I like to head to the operating room where we can do a stat cesarean if necessary. When a baby has been without oxygen for ten minutes, the risk of brain injury is high. Robin knows this and agrees, so she’s antsy as heck, but the family medicine team is in charge and they are debating whether or not a vacuum assisted delivery would be possible.
That’s where you use a device to help pull as the woman pushes and deliver a baby expeditiously. The baby has to be low enough though, the mom consented and in the right position, and now we’re at eight and a half minutes and still nothing’s happening. The family practice team is hopeful that their attending who does vacuum deliveries can get there in time to do it, instead of having to consult us for help.
Well, that doctor is fifteen minutes away, and this is getting ridiculous. As the family practice team debates the fetal position, the OB intern gets ready to resuscitate the baby, nurses prepare a delivery cart. I grab gloves and asked Robin- “Is this her first baby? Has she even pushed yet?” I’ve been in the room for forty seconds now, and seconds matter, and thank god Robin looked at the clock when I walked in, cause I sure as hell don’t want it charted I’ve been here all along…
Robin is pushing IV fluids and answers “No, it’s her fifth and she hasn’t pushed yet.” What the fuck? It’s hard getting called in to assist in an emergency on a patient you don’t even know. The patient is wracked with painful contractions and looks terrified. I lean over and quickly explain in Spanish who I am and that I’m going to check her cervix.
Guess what? She’s completely dilated, the baby is right there, and the whole time we’ve been discussing a vacuum delivery to assist her, no one thought to actually talk to the patient. She doesn’t understand much English, and it hurts so much she’s been afraid to push.
I look her in the eyes and say firmly, “Senora! Esto es una emergencia! Empuja ahora! Se puede hacerlo!” These are words all OB residents know; labor Spanish. “This is an emergency! You need to push now- you can do it!” I add a few other phrases of encouragement for dramatic flourish that I learned in an aerobics class I took in Mexico. The patient nodded, gave a little yelp, and our intern delivered her fifth baby fifteen seconds later.
Robin is relieved, but is never without a smart ass retort. “Rodriguez,” she quipped, “I don’t know what you did, I just heard you shout “Nachos! Chimichangas y burritos!, but we had a baby, so muchas gracias!”

Construction

Work on the blog is stalled for a bit- I'm working on a draft of the book.
Stay tuned...

Please don't urinate in the sink.

I'm giving up on reason, and trying to understand people. It's just not worth the effort. And yes, for someone who has spent way too many years in school learning logic and the scientific process, that is grounds for crucifixation; at least in effigy.

But you know what? I just got off an elevator where a guy was taking a dump. There is no earthly reason for that, ever. That alone isn't enough to make me abandon all attempts to fit the world around me into a rational paradigm of course, but the encounter I just had in the Emergency Room was the final straw.

Mind you, it's 9 pm at night and I haven't had a chance to pee today, let alone eat, and I'm now sixteen hours into putting out fires on Labor and Delivery. Patient phone calls for percocet, and more percocet, hemorrhage here, angry baby daddy there, crash section, another section, then forceps and a mountain of paperwork to document it all that hasn't yet been started. Fortunately there's still another ten hours left in my day to catch up, and it looks like things are starting to slow down.

Bleep! The bleepin' bleepedy bleep medical student actually said that out loud. That's something you NEVER say on Labor and Delivery. Think it if you must, but saying it condemns you to the exact opposite. Call me superstitious, but my pager went off the exact second I was delivering that clinical pearl to the naive medical student.

Another round of bleeps. It's a Level 3 trauma page from the ER. This means there is a pregnant patient in the ER who just had a severe accident, and they are activating a hospital wide code to get all of the necessary players there. NOW. Uh-oh. Adrenaline kicks in.

I fly down five flights of stairs, past the people shooting up, into the ER, past the patient urinating in the sink, and head straight to trauma bay 3. The patient is surrounded by the entire trauma team- an assortment of general surgeons, emergency room doctors, paramedics, nurses, medical students and nursing students. And now me.

This could be anything from a post mortem cesarean (a pregnant woman dies and her baby needs a cesarean to live, and you do it in the ER or the ICU, or wherever you need to) or it could be a woman who got into an argument at HER BABY SHOWER and tripped when she tried to bitch slap her bff and sat down hard on her rump.
Guess which this is?
Yeah. She was re-enacting it for the surgery chief with her neckbrace on while the RN popped in an IV.
I breathed a sigh of relief, and did a quick ultrasound to make sure the baby was ok. And it was. My heart rate returns to normal.

The excitement's died down a bit, and I admit it. I'm totally curious as to what on earth happened, at a baby shower, to provoke a pregnant woman into such a rage that she jeopardized her health, her baby's life, and activated a state wide trauma alert.
So I ask her.

She looks at me and then explains matter of factly "Bitch got in my FACE. I mean, I ain't talkin' about no little thang, bitch got in my FACE."

Really? That's what led to all this? I must have looked incredulous, or more likely, irritated, because the guy with her chimed in, "Doc can you prescribe an attitude adjustment? Cuz thats what she needs!"

Oh, ok. So where were you when your friend/girlfriend/baby mama/partner was getting into it with her bff? Since you're such an oasis of reason, why didn't you intervene before it came to five squad cars and an ambulance arriving at her BABY SHOWER.

He looked me up and down then said, "Dude be lookin' at my woman!"

Yeah. He was simultaneously beating up some guy who he thought was checking out his pregnant friend/girlfriend/baby mama/partner.

This little piggy went to market

I get pangs of conscience from time to time, accompanied by a fleeting desire to try to be one of those just genuinely nice people, but I have enough insight to realize it ain't gonna happen. That's not an excuse, it actually ups the charges from a misdemeanor. I mean, if I know I'm being a jerk, but still keep making the same mistake, well then I'm definitely going to hell.

On a somewhat related tangent, this applies equally well to men who think that acknowledging their bad behavior excuses it. No, that actually makes you a bigger asshat, because you do know better but aren't doing anything about it. And of course ladies, that should be seen as a red card (Yooooou're OUT!) not a matador's red cape (an irresistible challenge).

So since I am going to hell anyways, let me tell you the unadulterated, undiluted story about a woman I'm pretty sure I'll see on the other side of the River Styx.

It's Thanksgiving, so of course I'm on call. I don't really care much actually, it's not my favorite holiday (my birthday and Halloween are of course) but it's busy as hell in the baby factory. They are popping out left and right and the ER keeps blowin' up my pager.

I'm coming back to Labor and Delivery from one of these adventures to the 5th circle of hell, and as I turned the corner, I felt the ground shake. Another earthquake? No, this was another force of nature that was storming down the hall towards me.

It wasn't just her super sized girth, but this woman's attitude could have filled a cathedral, and her volume knob had broken at 11. I got but a glimpse of her "I'm not fat, I'm pregnant" T-shirt as she thundered past me, hands waving, weave flapping, complaints flying. I looked over my shoulder, jaw agape. From behind it appeared that two hogs were wrestling under her stretch pants as she irately paraded past hurling insults and threats of lawsuits. And yes, it's the hog comment that is sending me to hell. I can't resist the simile, even though I've been the chubby girl and know that fat jokes wound. But damn, each step was registering on the Richter scale.

I walk up to the nurse's station. "What was that all about?" I enquire. Replies the beleagured intern, "She's upset because all of our labor rooms are full and I told her we couldn't induce her labor today, just because her horoscope said today marked an auspicious beginning. What-ever!"
"Did the fetal monitoring look ok?" I ask.
"Yeah, she was in the triage unit- also full by the way- and her baby looks fine." sez the intern wearily.
"Cool", I reply. "I never understand why patients think it's such a threat when they say they'll go to another hospital."
"Seriously," replied the intern, as she rolled her eyes. "This sure as hell isn't Nordstroms."

I should explain. Our triage unit is a room with six beds separated by curtains. It's where women are seen when they first come to labor and delivery and the intital evaluation is done. That's where this woman had been waiting, and five other women were in there right now. In fact, just then we heard one of them say something that caught our attention.

"Heeey. Where's my purse?" patient behind curtain one enquired. Silence. Curtains 2-6 in chorus "I can't find mine either!"

Clearly it wasn't hogs our patient was smuggling amongst her fat rolls. She had absconded with the purses and wallets of all of the other patients here in labor ON THANKSGIVING.
Now that is a one way ticket to hell.

What lies beneath

Surgeon General's Warning: This entry contains graphic gynecologic details. Read at your own risk.

4-7551.
Those five numbers never fail to make my blood pressure go up and an expletive to erupt. It's the Emergency Room paging. And yes, I know plenty of nice people that work in the ER, but it's still hard not to hate them. The pages and consults always come at the least convenient moment, and always seem to be cloaked in a veneer of arrogance with a dusting of laziness. Or maybe it's just in residency you're always one hairs breadth away from snapping.

Three minutes before sign out and my pager goes off. Triple fuck. It had been 24 hours of constant pages, baby mama drama and a whole lot of hemorrhage in the operating room. I just wanted to go home, wash the hospital off of me, have a glass of wine and pass out until I had to get up and do it again.

But now there's one more bleeping thing to do first. The ER attending is on the line, and she's telling me she's never seen anything like this. Trying to temper my impatience (is this more or less important than the fetal bradycardia in room 24? Is it an unstable ectopic who needs to go to the OR five minutes ago or a pelvic pain patient that the next chief can give narcotics to?) but she tells me "You just really need to come see this. She had it all packed and dressed herself. I'm giving her 2 units of blood and then admitting her to psych."

WTF? She's an attending so I can't really argue with her. I stomp down the five flights of stairs and head to the gyn exam room. Hunched on the edge of the table is a frail woman whose very presence exudes embarassment. She sat on the edge of the table taking her own blood pressure. “I just thought I’d help the nurse out,” she said apologetically. “I don’t want to be a trouble to anyone. My ulcers are just really bothering me.” Her skin and hair were the same pale, frazzled color.

Ulcers? Call medicine. Call GI. To paraphrase Tina Turner, what's gynecology got to do with it? I flip through the nurse's notes as I listen to her talk about her health. Antidepressants, Ambien and acid reflux agents.

I found out that she had been a caretaker for her mother who had Alzheimer’s until recently, when her mother had passed away from pneumonia. She had devoted her life to raising her children, then caring for her mother, and now she worked taking care of animals at the vet school. She'd been brought in by ambulance after one of the veternarians found her passed out in a pool of blood in the barn according to the ambulance notes. That explained why her blood count was half of normal, but why the hell did they call gynecology? And why the hell don't the ER doctors ever put any notes in the chart or do a history and physical before calling an effing consult?

I'm exhausted and a little surly, but this is a sweet woman who obviously needs help, I'm just not sure what I can do for her. I've been amazed to realize how well being direct can work. So I sat down next to her and said gently, 'I'm not sure it's your ulcers that would have caused you to lose all this blood. I'm a gynecologist. Can you think of a reason why the ER doctor thought you might want to talk to me?"

“ Well,” she finally said, “Maybe it’s because of this.” She bit her lip and looked at the wall. Well damn. The ER doctor was right; I'd never seen anything like this. She had dug a crater in her vulva that extended down all the way to the pubic bone. Oozing and raw, the jagged wound was huge- large enough that an orange would have fit in it. She had a matching one on the opposite side that looked infected. I wasn't sure what to say, so I just waited. Silence sometimes works even better then being blunt.

'I think maybe a nerve got cut or something, because it just itches and itches to the point where it's all I can think about,' she started to explain. "It started after my husband had an affair and left. At first I thought I had an infection, but the doctor said I didn't. Its like the only thing that will make me relax is if I get in there with tweezers and try to find it, and then suddenly hours will have passed and I'll still be in the bathroom and I'll realize my leg is covered with blood. Maybe if you could find the nerve and sew it together, it would stop itching?" Her voice trailed off as she met my eyes.

I'd seen patients on my psych rotation as a med student that had cut themselves or pulled out their hair as part of their anxiety disorder or depression, but I'd never seen anyone mutilate themselves to this degree. There was nothing wrong with her vulva beyond what she'd inflicted on herself. It wasn't an infection that could be treated or a nerve that could be sewn together, it was deeper than that, and it was incredibly sad; that this woman who devoted her life so completely to caring for others could find no value in herself.

I'm not sure what she saw in my face but she shook her head and said "I'm just not sure how I got this lost..."

The moment of insight was poignant and crushing. Change can happen quickly or slowly, but we all have moments where we stop, and wonder how the fuck we ended up where we are right now.

How did it come to this?

Fantastic voyage

Sometimes when I'm on the MUNI, I like to imagine I'm an anthropologist collecting material for an oversized coffee table book. "The Frumpasaurus Horriblus" as observed in its natural habitat, by Anonymous, MD.

Instead of being swathed in comfortable, yet unattractive khaki and orthopedic foot wear, I've donned my oversize sunglasses and Ipod to maintain anonymity. I've also eschewed the pith helmet in favor of a Blackberry and the enticing Brickbreaker game. And yes, I know confusing anthropology with archaeology is akin to mixing up astrology and astronomy, but dammit, the opportunity to use 'pith helmit" was irresistible.

The juvenile delinquent plays a prominent role in the MUNI society, as does the hustler and the loud talker on the cell phone who needs to have TMI tattooed permanently on their forehead in penance for their sins.

Whether it's the young thug sniffing our intrepid scientist's hair and complaining about the injustice of his prison sentence (or is it jail? I always get those two confused- one's federal, one's state, right?) because "the damn bitch be askin' to be knifed" or the gaggle of pregnant teens demonstrating oral sex techniques by the preschool on the field trip, the MUNI is an unpleasant window into the heartache of adolescence. Although it was damn funny when the wannabe freestyle rapper's ridiculously low slung pants actually fell off and nearly tripped him as he tried to kick it old school. Yes, I know I'm going to hell. It was funny.

The extra loud cell phone conversations are among some of the most painful, mainly because it's hard to keep the internal monologue from becoming external. Some of my fellow passengers don't feel so obliged. This morning's exhibit.

A middleaged woman with short fuchsia hair sporting a bedazzled T and overworked stretch pants is loudly talking into her cell phone as she munches on Cheetos at 730 in the morning. Particle of orange dust spray from her lips as she recounts last nights adventures and the speedy exit of her amour. "And I said, oh hell to the no! If you tryin' to hit it and quit it then go home to her, that ain't right. We gots a baby together too, and well, if you be likin some young skinny girl best than a real woman, well then I'll pray for your soul." This is the abridged version; she went on for about 15 blocks about her many attributes and his sinfulness for not being able to "bear witness to her glory." The entire back section was hearing her testimony, and I was close to giggles- the woman had some excellent descriptives. All of a sudden, the woman next to me leaned forward and said "Girl, if I were you I'd shut my mouth and start prayin' to lose some weight instead of save his soul. You be looking like a big ol boulder with no legs and a mouth that just keeps rollin' downhill."
Ouch! Tough crowd.

A Rose by any other name...

..probably will still smell sweet, but if you name your daughter Kuhlymidia, she's going to end up as a toothless, chubby stripper doing the bump and grind in an anonymous club that reeks of sordid desperation. How can I be so certain? It's because I'm an obstetrician.
I want to believe in free will, but the more women I meet named Krystal (or Kuhrystahl, Crystal, Kristal) the less I do.
Let me explain.

Some parents pore over family trees and multiple purchases from amazon.com, but other parents name their baby after the first billboard they see on the way to the hospital. Really.

The excited teenagers saddled their progeny with the moniker "Diesel." It could have been worse, he could been ridiculed on the playground as Walmart, but fortunately they took a wrong turn as they backed into their neighbor's car before speeding to the hospital and thus saw the gas station first. Now Diesel certainly doesn't rank as the worst baby name I've ever heard, but following the logic of Johnny Cash in "A Boy Named Sue", Diesel is in for a future with a lot of scars and empty bottles of whiskey.

My favorite all time baby name ever is also going to end up toothless and stripping in an exotic club near the airport, but it's kind of a sweet story none the less. It's 3 am and complete pandemonium in room 64. A woman is screaming obscenities and pushing as several frowsy blondes with smeared eyeliner hoot and call each other "Sissy" and "Momma." They use the terms interchangably with each other, so it's not entirely clear who is related and how, but they are all busy trying to check her cervix....

I'm too busy restraining myself from slapping the baby daddy to care much. He's been hollerin' in my ear for the last five hours, his acne bespattered face aglow. "Coooome on JAKE! Jake the snake man Jake! Woo-hoo push Momma!" He'd slap his woman's thigh and repeat his refrain again. And again. And again.

As I have deduced from his tshirt, WWF limited edition jacket and mesh ball cap, Jake the SnakeMan is his favorite professional wrestler and soon to be the name of his son. Fast forward. Baby is finally delivered and placed in the exhausted mom's arms. A sudden silence falls over the room as we all realize that Jake the Snake Man.... has no snake! It's a squalling little girl. Everyone turns to look at the dad who has been so vocal and so excited to have a son. His face briefly falls, but then he looks at his daughter and his wife, smiles and says awestruck, "Ain't she beautiful Momma? Just like a Hollywood Star..."
And so their daughter was dubbed "Hollywood Star."

Another proud father, so overcome with testosterone driven pride at having spawned a son named the fruit of his loins after his loins "Mahwillie."
Perhaps Mahwillie can take solace in the company of twins born by crash csection after a failed attempt at being delivered at home under less than auspicious circumstances. "Wolfgang Racecar" and his sister "Flannery Centrifuge" are also going to need years of therapy.

Any derivation of Crystal? The odds that the urine drug screen are positive for something beyond a prenatal vitamin? Betting odds.

Misty or Destiny? That's a high risk name that almost certainly guarantees a preterm delivery with a fetal anomaly.

Brianna? Do not pass go, do not collect $200, direct admission to the NICU with an intestinal malformation.

Lovely? Precious? The ER is paging to rule out pelvic inflammatory disease. Their name just ruled it in! Ain't nothing lovely or precious about pus. Start antibiotics for all 4 collectible sexually transmitted diseases...
Oops gotta run. Family Practice is paging with a consult. They just admitted a "Laqueishiah" with a threatened miscarriage. Bet you a drink it's her period and she's having a fight with her baby daddy.

Soundbites

Soundbites

Bumper stickers grind my gears. Deep down, they just outright offend or irritate me with their smug vinyl proclamations. The occasional political bumper sticker is the exception to the rule, but much like rabbits and viruses, bumper stickers turn out progeny faster than you can say “Back off, I’m a goddess” or “My other car is a broom.”
Really? Is that all you’ve got? What are you trying to prove by plastering these tacky nothings all over the bumper of your dusty Subaru? We got the point from your tie dye tshirt and socks with Birkenstocks. Enough said.
Tattoos are a step up from bumper stickers, there are far more of them that I tolerate and actually downright approve of. Especially a nice forearm tattoo on a cute boy, or a well thought out elbow design. If they’re lame tattoos, then I can only hope they are lame enough to be remarkable, instead of trite and mundane. I remain un-inked however, largely due to being exposed to countless “No Fear” and Grateful Dead dancing bear tattoos on sorority girls at an impressionable age.
However, the tattoos uncovered in gynecology clinic never fail to amuse and amaze me. Old time classics are the lawnmower inked at the pubic hair line, Daddy’s girl inked on a pendulous adolescent breast (Father’s Day present of course), and “Spank that ass!” screaming for oxygen deep in the folds above an obese woman’s ass. And yes, you could most definitely rest a cup on that booty. The current winner however is one I uncovered during a vaginal surgery as I attempted to tape up the pannus (fold of fat for the layperson) that was draping down over her perineum (taint for the layperson) to create a sterile field. What’s that I spy? Right above the hair line was the NASCAR racing logo and the tasteful phrase “Faster Daddy, Faster!” Ma’am, I am not sure the laws of physics would permit that possibility.
I’m including pickup lines in this blog, because it’s the most overt example of someone throwing something out there in a desperate attempt to attract attention from the universe. Or maybe it’s because I spent my whole bus ride home today wedged in a MUNI seat with a young thug trying to smell my hair and tell me all about his prison sentence. I think he was bringing it up as a not so subtle way to let me know he could hook me up with an assortment of drugs if I’d “be his mujer”, but I’d already guessed that from his breath that was redolent of marijuana and Olde English. The smells of my youth. Nonetheless, I informed him he had nothing on the kind homeless gentleman who had accosted me with his cane as I disembarked the bus that very same morning, cackling “Zam little mama! Youse lookin’ tastier than some KFC!”

POLST form

I am dying from the common cold and have multiple deadlines, so this will be short.
I hereby wish to state that if I am ever inclined to wear tacky jewelery with matching sweatsuits bedazzled with puffy paint to a "funvention", that whichever of my friends that is closest to me should grab me by the shoulders and slap me firmly to my senses. If this should fail to acheive the desired results, admit me to the Mother Baby Unit (aka hospice) for a morphine PCA with a high basal rate. I already have Do Not Resuscitate/Do Not Intubate tattooed on my chest.
Shopping for "successories" would also be grounds for the above action.
Thank you for your consideration.

Disclaimer

Our attorney advises us to note that that this blog has been sufficiently fictionalized to protect the innocent and not so innocent, as well as satisfy a variety of regulatory acronyms such as JCAHO, HIPPA and the FBI.
Furthermore, in case you wonder how our intrepid reporter is able to complete a ridiculously rigorous residency while encountering an assortment of cretins, please be advised that not all of the dating debacles have occurred to our fair author personally. Thank god.
Rest assured, all of the stories are true however, identities have just been changed to protect the somewhat innocent.

Yikes

Wow.
I thought I'd get more work done on my research project if I went into the hospital today, instead of working from home. Admittedly I'm easily distracted from working on a paper I don't really want to write, but my office with its windowless drab interior offers zero in the way of distractions. It's part of the glamorous benefits package of working at a bankrupt county hospital.
Turns out I forgot one key distraction: the overhead paging system.
A bored nasal voice just came on the loudspeaker to announce that the deputies (yes, there is a prison ward within the hospital- see glamorous benefits package above) had LOST a gun in the PSYCH UNIT.
So many thoughts run through my mind.
First, who entrusts those cretins with guns? I'm scared enough to ride in the elevators with them! The deputies that is, not so much the prisoners. The prisoners are so broken down and dispirited in their all orange outfits, including neon orange Keds they are a minor threat when compared to the insecure deputies with their leering mustaches and billy clubs.
Secondly, how the hell do you lose a gun? In the psych unit?
Thirdly, what the hell is an overhead announcement going to accomplish other than a novel type of Easter Egg hunt in the psych unit?
I think I will work from home today...

Call schizophrenia

I slammed the car door shut. It made a satisfyingly loud thunk, which made me feel a little better. I was facing down the barrel of another long call night and was super size cranky. I was half way through my residency in obstetrics and gynecology, and as much as I loved my job, the sleep deprivation was starting to get to me. No matter how I would try to rationalize it or prepare for it, the truth is call just really sucks. Especially at St Vincent’s where there is the sweet promise of a call room with cable TV but the harsh probability that you wont have time to pee let alone watch Chuck Norris movies.Oh well.

Most of the time I enjoy knowing that absolutely anything could happen, and I’d have to deal with it. Baby mama drama comes in a lot of different flavors. A woman pregnant with twins, hemorrhaging in triage. Heart tones in the sixties. A pregnant prostitute high on crack. A done up society lady losing her shit and throwing a temper tantrum because she can’t be induced tonight. Annoying doulas who think Standing Dog pose is a reasonable answer to a fetal bradycardia. A sweet, elderly woman in the Emergency Room with a bowel obstruction due to advanced ovarian cancer.You can intersect with so many different lives at critical points in the course of one shift. You have to oscillate between celebrating in room nineteen, grieving in room twenty one, and preparing for the worst in twenty three. Throw that in with sleep deprivation and I frequently start to feel like I’m having an out of body experience.

Life becomes surreal. People need so many different things from you; authority, compassion, decisiveness, encouragement. It’s exhausting and at times I really resent it; I only have so much to give and the need seems to be endless. At other moments I am struck by the grace of a particular moment and patient..At the most inopportune moments I will be struck by exactly how strange the moment is. The sensation is akin to déjà vu and kissing cousins with acid flashbacks- goose bumps, altered sensation of time, intrusive thoughts. Something I do fifty times a day suddenly will seem totally inappropriate. Like a cervical exam.It’s three am, why is my hand in someone’s vagina? I can never think of a good answer for that annoying little voice. Uh, geez, I don’t know, but it took four years of college, four years of grad school, and one hundred and fifty thousand dollars of debtIts as if my internal monologue has Tourette’s syndrome. Your baby’s heart rate is dangerously low and we “cause Ice Cube had more amps, get in bitch” need to perform an emergency c-section now. Risks include… If your contractions are getting stronger,if you have any bleeding or think “I'm Tony Montana! You fuck wit me, you fuckin' wit da best!" you’ve broken your bag of water its important you call us right away.I always hope that my other personality has the common sense to wait until I’ve secured the uterine artery before interrupting the fucking liar! but I never know when the mental tick will occur.

At times I realize I am speaking but am so disconnected from the words that it vaguely amuses me to realize I don’t know what will come out next. Fortunately it always seems to work out ok.I am not sure if that’s because what is going on beneath the surface is so well concealed or if it has more to do with our own inherent self absorption. I suspect it is the later- no one is ever as interested in our actions as we think they are. We see what we need to in others and hear what we want. It makes for a relationship of mutual parasitism. Although it serves both parties well enough, it’s alarmingly impersonal. You could really be anyone and it would satisfy their need.

Again, the education I received from Kinko’s is proving more useful than my college diploma- if you can teach a stoned hippie to make double sided color copies on hemp stock in self serve you can master any customer service situation.

Chief Complaint

Some things never fail to amuse me. At the age of twenty nine I still giggle uncontrollably when a patient with the name “DeBollz” is presented in pathology conference. Dissecting the rectum off of the posterior vagina always cracks me up too. “Rectum? Damn near killed him.” I have no idea why those jokes haven’t gotten old- I must have a short circuit somewhere in my wiring and my sense of humor has been frozen at an infantile state.

My clinic schedule never ceases to amuse me. Not so much the four o’clock add-ons with chronic pelvic pain or the double booked ER follow ups but the actual printout the secretaries post. It’s supposed to be a practical guide for the afternoon- all of the pertinent information we need to take care of the patients coming in to be seen.

Emphasis on the supposed to be. What with the revolutionary new computer system and the brand new state of the art building, the entire clinic has been revamped into a fully modernized state of chaos. The schedule is really more of an article of faith than anything else. For the chronically skeptical, such as myself it’s a source of amusement.

Besides listing the patient’s name, age and appointment time the schedulers have also entered their chief complaint. The chief complaint is the reason the patient gives that they are asking to be seen by a doctor. It’s the issue that brought them in today. It’s frequently in their exact words, and it is frequently hilarious.

Sometimes it’s funny in a ridiculous sort of way. Sometimes it’s funny because it’s taboo, gross, or involves “down there.” Sometimes it’s funny because it’s better to laugh than cry.
“My boyfriend thinks it tastes different.” It is truly amazing the things people will tell you if you wear a long, white coat and introduce yourself as a doctor. I tactfully redirected her monologue of unnecessary personal information and made the diagnosis of bacterial vaginosis. Flagyl, 500 mg po bid times 7 days.

“It’s like a wind tunnel down there.” The joys of natural childbirth- what they don’t show on the Discovery channel is how the female pelvis gets completely reorganized after delivering a couple of these little miracles. We booked her time in the OR a couple of weeks later to revamp the wind tunnel into the tunnel of love. Take it out, lift it up, pull it in. Repeat.

“Who be my baby daddy?” Holy shit. Clearly today is not going to be the day I stop drinking. Twelve years of post graduate education is not enough to answer this question. Even Jerry Springer might need more than an hour to unravel all of the intricate social complexities of this one.

“I was hooking up with my ex boyfriend and he lost the condom.” Oops. I start to review emergency contraception when she interrupts me. “He lost it five days ago.” Oh, damn. I have been known to procrastinate errands, cleaning, and working out but foreign body retrieval? Wow.

“I was in da club and I think my water broke.” Fuck. The hidden dangers behind teenagers having a fake I.D. Not only are they going to get drunk and knocked up, their babies will be exposed to the teratogenic effects of alcohol and house music. Thank god I escaped that destiny- I just used my fake ID to buy liqour and day dream about setting up a secret identity. We all have our moments of being ridiculous, neurotic, lazy or just totally f’ed up. I’ve been that girl one way or another, and I am sure you have too, although it might take some persuasion to get you to admit it.

We all have times that we just want to move on from. Usually these moments are private enough or well concealed by the remainder of our normal lives to pass in a pleasant haze of obscurity.

A real friend will be complicit in this; we all tacitly agree without actually speaking to never mention it. And thank god for people who know you well enough to recognize these moments for the aberration that they hopefully are. We all have our flaws but when you know who someone truly is they seem superficial and irrelevant. Or, you just realize they’re a jackass and walk away.
I’ve never been good at shades of gray; it’s a challenge to learn how to comment without passing judgment. Even when I let my imagination run wild, it is hard to envision a parallel universe where I might find myself living out some of these realities. Jesus Cristo, I’d like to think I’ll always know who the baby daddy is without having to assemble a forensics task force to decide.

Courage

“It hurts a lot,” is what she told me. She twisted the hospital sheets into a knot and glanced at me anxiously before her gaze darted back to the wall.
We were in the pre-op area and she was scheduled for surgery. I was to help with her case, and part of my job is to make sure all the paper work is filled out, including a current history and physical exam. Hers wasn’t. I went in to say hello, see if she needed anything, and to complete all of the forms.

I glanced down at her chart and her current medication list. Methadone 160 mg three times a day. Oxycodone 5 mg, eight times a day. Vicodin prn. Hell, that much narcotics could take down an elephant on a wild rampage mid stride. I believed her. Something had to be hurting.
I started to ask her a question and she interrupted me. “Can you open the door please? I don’t like the door being closed.”

She was fifty four years old, but looked a generation older. She had ill fitting dentures that left her mouth agape. Her skin was lined by tobacco. Her roots were embarrassed, trying to over grow a dye job that never should have been. If you met her on the street she would have been easy to over look.

She haltingly began to tell me about her medical history. Depression. Stomach ulcers. Anxiety. I asked her if she’d ever had surgeries before. “At least ten,” she replied. “They took out all of my female parts, part of my stomach, some of my guts, my spleen, and maybe one of my kidneys.” I must have looked incredulous, because she pulled up her hospital gown and showed me her belly. It was a mess of twisted scars. “I was in the ICU longer than anybody else,” she said, with a faint hint of pride.

Her story started with a chance meeting in a bar. It ended with him abducting her. He raped her so viciously she couldn’t have children. He beat her and knocked out all of her teeth. He set her on fire and burned off most of her hair. It ended with him attempting to disembowel her and then dumping her in an alley. She would have died except the frigid air caused her heart to slow, her blood to clot and kept her almost alive until she was found by a horrified husband taking out the trash.

She was in the ICU for months, eating through a tube, and having breaths taken for her by a machine. Surgery after surgery was done to try and repair the damage. Weeks passed and small battles were won. She was weaned off of the ventilator. She was able to drink a liquid diet. She took a few steps on her own. Months after the chance meeting in the bar, she finally left the hospital. They showed her a line up of suspects but she couldn’t be certain, and didn’t want to name the wrong man. They never did identify him.
She found a way to keep going and to move on as best she could, but some scars never heal.

Circle of Life

I can't write creative fiction to save my life. The very thought of it paralyzes me with embarrassment. Like many modern day tragedies, the origin of this trauma stems from early high school, where I endured Mrs. Beekman's poetry class with all the other ninth graders, alternately bored and resentful. That really doesn't distinguish it from the other seven periods in a day, let alone cause permanent psychological trauma. No, the true torture came on the days when we would have to read our work out loud to the class and provide constructive feed back for each other.

I never minded reading mine out loud. Knowing full well I was the only Spanish speaker in the class, I would simply spend lunch in the smoking section writing my poetry by rearranging practice sentences from my advanced Spanish grammar workbook in an artistic fashion. No capitalization, random indentations, and staccato phrases. Voila, a poem is born. Everyone always smiled and nodded politely, while Mrs Beekman would murmur something complimentary about the inherent rhythm and beauty of the Spanish language. Silly gringos.

The pain came when it was Kevin's turn to read out loud. Kevin lived in the trailer park and rode the same bus to school as me on the days I decided to attend. He had a mullet, a penchant for Skid Row, and a Trapper Keeper full of epic ballads for his girlfriend, Christine. Kevin gave the same verve and emotion to his performance as Axl Rose belting out "Sweet Child of Mine" in the Palace Arena. He also wore the same flag bandana.

"In the darkness of my fifteenth year, a light, a light, Christine. Eyes of green, be my queen…" He'd go on for nearly the whole period, pumping his fist in the air for punctuation, and grinding up against the desk for emphasis.

I'd nearly herniate valuable organs trying to not giggle while maintaining a respectful demeanor. The interplay of emotions on Mrs Beekman's face was priceless. You could see her internal dilemma- not wanting to stifle a student's creative muse at war with discomfort at watching him perform pelvic thrusts against the potted plant on her desk.

Anyways, that's why I can't write creatively. I live in fear of sounding as ridiculous as Kevin. That said, it amuses me that my daily life is now so melodramatic, I can't figure out how to write about it without sounding like a histrionic drunk. Or like Kevin. Oh well, here goes.

Beep! Beeeeep! Beep! I eyed my pager with suspicion and glanced around warily.
"4-7551 Pt delivering in ER, come now.” Now ordinarily, that sort of page would have me on a run to the Emergency Room four floors down, but it had been a busy week on L&D. Busy with deliveries, surgeries, and prank pages. Yep, that's right. The anonymity of the text paging system provides all kinds of opportunities to harass your fellow residents.

Classics include pages to the sperm bank, the public health STD reporting line, pages from "Oxslong, Mike M.D holding" or "Dr Clea Taurus, gynecology" but fake pages to the floor or the Emergency Room are perennial favorites as well. So I looked around carefully to see if anyone was laughing. Hmm. The second year was in evaluating a 23 weeker with post coital bleeding, our fellow was in ultrasound and the intern was being harangued by an obese diabetic who wanted her methadone refilled a month early. Oops. This might be real.

I hurried off to the emergency room, snapping on a pair of gloves as I careened down the stair well. I always like a nice barrier of latex between me and anything I might encounter in the ER. Safety first.

It was easy enough to figure out where I was needed as I pushed open the doors to the ER. I could hear the screams and curses from the nurse's station. Like Hansel and Gretel, I followed the trail of profanity and opened the curtain to the room. It was total chaos.

This feral eyed creature with no teeth was clawing at the bed and screaming with rage as she was delivering. About twenty doctors, nurses, paramedics and students were bustling about all pushing each other nervously to get away from the patient who was crowning. Between the woman's screams, the barked orders and the cacophony of pagers, phones and machines I could only hear part of what the ER doctor had to tell me as he nervously backed away from the patient. It was enough. "No prenatal care…used meth this morning… Hep C positive." The woman looked up, made eye contact with me and screamed "Get this fucker out of me!"

I sometimes think of moments like these when people talk about how “much fun it must be” to deliver babies or discuss the immorality and tragedy of abortion. There is a lot of grey in life.

Seconds later I delivered her baby, a healthy little girl whose first cries did nothing to calm the pandemonium in the room. I cut and clamped the cord and handed the infant off to the loving arms of the state foster care system.
.

John Hinckley

Or why I cancelled my myspace account...

Email One January 9th

]Isabel-
You have the most transfixing eyes. I feel sure I have known you before, not in this life maybe, but my soul recognizes yours. I’m new to myspace, will you be my friend?
Peter

Email Two, January 9th.
You might have seen my profile. Cause I sent you a message. ok, maybe I'm not handsome, or smart or tall. But I wanted to offer you this tidbit. I went to open the door at a shop today, and tried to push it open, but it wouldn't budge. I did the ol classic. Pushed and pushed, people waving at me inside and stuff... and finally got it that I should pull, and then noticed the hidden door handle. donkIf a door says "push" on it... though I can read just fine... I often can't figure out what to do if there is no very visible cue of handle for pulling or place to push the door open. I'm a design dork.My point is that my world is almost entirely dominated by feel and energy. And rely on it almost entirely. I'm not saying cues I've read about you are from your pictures or words. I can't really explain what those are precisely, because I haven't the faintest clue of who you are. But I am curious, and following orders. Can I interest you in a coffee or tea sometime

Email 2 January 9th
Peter then lists three phone numbers and two separate emails where I can reach him.

Email 3 January 9th
Hi Isabel: I am so sun deprived right now, I can't tell you how I'd like to go someplace warm... But instead I'm heading to a meditation intensive to look at the inside of my eyelids.I also wanted to say that if we meet, I'd like to do it in the spirit of low intensity, and casualness. Start with an hour or something... we've got warm places to go to!

Email 4 January 9th
I just got the idea in my head that I'm not going to hear from you.
That's alright if you want it that way. But just, a little nudge, I don't think you should. You've witnessed a few of my ramblings and blunders, which I hope you can take with a grain of salt.Truth be told, I just started my space about two weeks ago, and have been having a blast. I've never really had a lot of friends and it's been very interesting. Anyway, I have 20 friends now, many are very beautiful and interesting women \And not saying this to be over flatterous, if thats a word, but you are the only person I would like to hear from. Really.And you should write me. I would like to hear whatever you have in your head, and promiss to lighten you day.


Email 5 January 9th
Why not?I'm trying a few new pictures on my profile, for your curiousity's pleasure, and gotten more precise on my words. My description is far too verbose, but will keep it another week, as I really want to know all of those details about a person too. Not sure if this is normal MO, should I keep writing you? Are you sitting back patiently watching?Ever see someone... and say that's the only person I want to meet out of all of this life? I'm happy to have found that at all... with you.Not into games, I am a busy person, so if I'm just not your type AND you're sure of that, then please let me know... easy enough and done... I assure you of that... .AND I can completely understand caution, and wanting to see more before you commit to anything. Can I send photo? I am an uninhibited sole.I was at Albina Press yesterday, and think I witnessed a first date.There was a guy, who for some reason, I noticed... His energy was high and intense, and he was kind of pimped out, so I could tell something interesting was going to happen. He also, looked like he'd be a very attractive guy... in a picture.... so I naturally think, maybe he's waiting for a first meeting. So I looked at him, or into him, to see what his date is going to see...And oh my.... it didn't look good for whomever he was meeting. He had a ton of ego, resentment, and anger.... that's all that was being projected from the inside, he was tormented and very ugly actually... slap a nice smile on and he's open for business, as long as you never meet him. His date comes. It IS a first meeting.She's cute, they're well matched in photos. I tune them out, busy with other stuff, and they should have their privacy.Not 5 minutes goes by, and I see the woman walk by outside... what?... he's following her... they speak intensely for a bit.... she leaves... he sits there with more monsters... shaking his head etc. He was thinking at that moment, "Why does this crap continuously happen to me?" Which it will, over an over, until he clues in. I bet there's alot of people alone because their energy sucks in person. Glad she got out of there that quickly.... and can see why people might be a little leary, and cautiousSo I understand, that you might want to get a good idea of a person, before you even decide to start talking with him, to avoid people and situations like that. And you may have not gotten a clear picture of me yet either. Would you be interested in spying on me sometime?So I continue to write you, and not sure where you are about it. In your shoes, I'd probably do the same... nothing, but wait and see... it all unfolds in the way it naturally would anyway. And perhaps you've got things you're currently juggling.I'm actually, and totally for real. Not juggling anything in the form of love relationship. The most significant relationsip of my life is coming next, or soon. We are ALL one of a kinds, I'm a particularly magical one, which I hold kind of in secret, and way more attractive in person, which is probably why I want you to meet me...BUTHere's the funny part... I'm in the same shoes as you. You could be totally psycho... and now that I look into your transfixing eyes once more, realize that perhaps you are really dark and evil at the core. So... don't know about you either, and have little to go on but every word of your page. I bet that if you met me somewhere else, you probably would want to talk to me, perhaps even fidget around. Warmly.I can tell alot about you, but I think my oddly favorite of carefully crafted phrases on your page, was "trail running".Anyway... off to Vipassana.Do you know Morse Code?If you want me to write you, will you respond with one blast, means yes, Two = no, and three means send helpAnd last question. Do you work in the field of Law? If not you should.bye bye

Superstitious

I guess I'm superstitious, but I always take the elevators as a portent of what the day holds. I've spent some of the best years of my life waiting for an elevator at OHSU, so if one is waiting when I'm ready to leave in the evening, well then, I know it's going to be a good night. I'm a lot more flexible with my omens in the morning though- I'd just as soon sip my coffee and zone out on the first floor, then arrive on Labor and Delivery, twelve floors up, before my caffeine levels are titrated appropriately.So there I am innocently mainlining caffeine when I have one of those moments. No, not a Kodak moment. Not a Cafe Vienna moment either. More of a "the mass murderer is outside of the cabin you idiot, why are you headed out in a tubetop with a dying flash light" kind of moment.I'm standing there. He's standing there. It's 5 am and we're in the hospital's barren subbasement waiting for an elevator to deliver us from the parking garage. His mulleted hair blows gently in the breeze from the hospital ventilation system, and he has the wracking cough of a emphysematous leper. His tuberculoid hacking is really interfering with my pleasant self delusion that the whirring of the pneumatic tube system is waves crashing on the beach in Bali. What can I say, I have a vivid imagination. Regardless, I think good manners are important, so when he leans in to wheeze a question, I listen politely."Say hon," his spittle spatters. "I gots a question fer ya. My old lady well her (insert your socially acceptable term for the gynecological centerpiece here) tastes different. You think she's steppin' out on me?"What bizarre universe is this? Am I awake? Is this really happening? How did I arrive at a point in my life where this could happen to me? I thought I had the polite but impenetrable facade mastered! After all, I've deflected marriage proposals in Cuba, deterred panhandlers in Kuta and navigated happy hour at Duke's. What on earth gave him the idea that I, a perfect stranger, would be the appropriate person to discuss this with?Oh. I was wearing my white coat. Somehow the embroidered "Obstetrics and Gynecology" is perceived as an open invitation to discuss any old thing. In gruesome, graphic detail. In a public elevator. And worst of all, before I've had my coffee. Damn, was this in the Hippocratic oath?As I recomended a course of Flagyl for his missus, I thought about all of the other random ass questions I've gotten in public over the years. And really, I wonder, is the free advice really worth the shame of braying your secrets to the entire elevator?Some of the questions are fairly benign. "Is hormone replacement therapy totally evil?" No, no it's not. Most are more personal, such as the Orange County housewife who recounted the entire tale of her ex-husband's infidelity and her infertility issues to me in the LAX bar. At least I had a martini in hand for that one. She got my sympathy and attention, but the martini was necessary to cope with her repeated use of the words "cookie" and "peepee." With her volume knob broken...Many are questions I would be embarassed to tell a close friend, let alone announce to a perfect stranger. But then, with Jerry Springer in his eleventh season why would I be suprised that multiple women have consulted me in the coffee line, at the elevators, or at my high school reunion to determine who their baby daddy be? A brief public service announcement. If your period was normal, the baby daddy is probably the winner you done been creepin' with after onset of menses. For my gentleman readers, condoms, condoms, condoms.It's endlessly fascinating to me how people live their lives, and the choices they make. Sometimes it's frustrating and sometimes I wonder if I am the last bulwark of sanity in the free world, but it's always interesting and there are unexpected moments of grace and courage.And at the very least, you have carte blanche to ask people why they thought it was a good idea to get "Da" tattooed on the inner aspect of their left thigh and "Bomb" tattooed on the right.Like I said, you can learn a lot!

NC-17

She was grostesque. A swollen toad, puffed up with the liters and liters of fluid, that they had tried to resuscitate her with at the small community hospital where she had delivered her baby, but hours into her death they realized they were in over their heads. Life Flight was called to transport her to a larger hospital.
She arrived by helicopter at our hospital on a lazy Sunday afternoon. The page I received was so incongruous with the late summer sun it took a second to register.

The trauma surgeon spoke in clipped tones. “She had a baby three days ago, and two days ago she started to bleed. She’s gotten 24 units of blood and her liver and kidney have both shut down. They did a D&C, tried to embolize an artery, and even did a hysterotomy. They packed her and sent her to us. She’s still bleeding. We need you in OR 15.”
A hysterotomy? What the hell? Only half of that made sense, and what came through was the urgency. I may not know a lot, but I know when to not fuck around. I called staff and ran to the OR.

She lay there pallid and sedated, with a labyrinth of tubes tethering her to machines. One was breathing for her. One was pumping blood in to replace what was streaming out. Another was acting for her kidneys, which had already quit in disgust. One more drained her bladder. I could see no trace of the nineteen year old she had been three days before. She barely appeared human. It was frightening and repulsive.

As they transferred her to the OR table, I hurriedly flipped open her chart to try and make sense of her story. First baby. Forceps assist. Labs wildly abnormal- liver in shock, kidneys gone, blood counts way too low. A line hurriedly scrawled into her history and physical caught my eye.
“Social History: Nineteen year old, hispanic female. Spanish speaking only. Father of baby not involved. Mother in Mexico, her father lives in Reno. He is driving here as fast as he can.” I caught a glimpse of the nineteen year old and my heart broke. It can happen that fast.

I snapped the chart shut and went to scrub. Emotion is dangerous and best avoided. There isn’t room for it. In the OR it’s irrelevant and can cause lethal mistakes. Outside of the OR it’s unpleasant, upsetting, and unfamiliar. None of us like to be reminded of the transitory nature of life. We want to believe that the center will hold.
You know what? Sometimes it just doesn’t. I want you to see her purple face, swollen and distorted with slack jaw. I’ll see it when I close my eyes tonight. Do you see the bloody fluid that pours out of her belly, running onto the floor when we open her fascia? The trauma surgeon had to throw his shoes out because her blood soaked through layers that covered them. Do you see it now?

Her uterus was swollen with clots and blackened with infection. Her ovaries were edematous, hanging limply off of the withered vines of her fallopian tubes. It all had to be removed. It was cruel, vicious, and unfair; but it might save her life. It might.
The circulator nurse answered the phone in the OR. The lab was calling to let us know that preliminary blood cultures had returned positive on the patient and her baby for Group A Strep. It explained the wasteland of her abdomen. The infection was unusual but not that exotic. It was bad fucking luck, but not headline news. Another commonplace tragedy.

Where Did I Leave My Keys?

So at 3 am, after having been in the OR all bleeping day, it can be hard to stay awake. Unless you happen to have a urologist also scrubbed in. In that case the conversation always evolves or devolves (depending on your perspective), to one of my favorite topics: the various objects that as doctors we have discovered in patients bodies.
I start with the story that impressed me most as a med student in the ER. Obese woman, skinny ass husband come in because she is complaining of severe abdominal pain. I meticulously take her history and begin the physical. As I methodically shift rolls of fat from side to side to thoroughly evaluate her pain, I hear a soft "plop" as something hits the floor. We all look down. It's a twinkie, smooshed, but still in it's wrapper with a shelf life of several more years. My jaw drops. The patient yells "Goddamit it George, I told you to quit hiding food on me when I'm sleepin'!" She vainly tries to swat him as he dances back laughing. The joys of marriage.
The urologist counters with a story from his intern days in Georgia. Large, crazy county hospital where no one came unless the police brought them in, orthey passed out in the parking lot or they had no other choice. He is the senior resident in the ER. A nurse tells him he needs to come evaluate the patient in room 18. He walks in and there is a beautiful peroxide blonde in a short skirt with a long fur jacket. "Doctor", she says in all earnestness "I'm on fire." He maintains a professional demeanor. She hikes up her skirt and jumps onto the exam table. With a nurse to assist with the light he begins the pelvic exam. What he encounters astonishes him so much that he blurts out the truth: "Ma'am there is a PICKLE in your vagina!"
"Well, take it out then," she cooly replies. He does and sits there on his stool staring at the large, Kosher dill clamped in his forceps. She hops down from the table and smoothes her skirt back over my legs. "Can I have my pickle back please?" He mutely hands it back and she sashays out.
The staff gynecologist joins in. A menopausal patient was referred to him for evaluation of recurrent urinary tract infections that had been going on now for years. She had been worked up by multiple specialists with no diagnosis. He did a pelvic exam (this is where the male readers are going to freak out, so skip ahead if you must) and encountered a horrifyingly stinky, fungating, necrotic mass. It looked like the worst case of cervical cancer that he had ever seen. He prepared to biopsy it and break the bad news to the patient. He inserted the punch biopsy and squeezed. He then carefully extracted the specimen and plopped it into a bottle of formalin. It didnt need to be sent to pathology to be identified as the last tampon she had used with her last period- ten years before!
Now the anesthesiologist chimes in from behind his blue drape. He tells the story of having been on call for night float one week last month. Monday night he had to provide anesthetic for the colorectal surgeons as they removed two apples from a man's sigmoid colon where they had "accidentally" gotten lodged. One granny smith, one golden delicious. Wednesday night, he did it again. The guy had tried to masturbate with the apples again, but this time had put them in a Safeway plastic shopping bag so that he would be easily able to retrieve them. Alas, his ingenuity was to no avail. I guess an apple a day does not keep the doctor away.
Back to the urologist- they always have the best supply of these stories.He tells the tale of getting called to consult after a CT scan done on a patient in the ER shows a large mass in the bladder. She was having recurrent blood in her urine and is incontinent at age thirty. As he scrolls through the images on the viewer he realized the shape is strangely familiar, but totally out of place on a woman's body. It looks like there is a glans penis floating in her bladder! No way. He gets out the cystoscope and with proper analgesia puts the camera through her urethra into her bladder. Sure enough, there floating in urine, having eroded through the wall of her vagina is a wind up toy shaped like a penis. "So that's where I left Hopalong Petey!" she exclaimed. She had apparently been unable to retrieve him several years back and had somehow thought he could find his own way home...
to be continued...

Week in Review

Yikes, it’s been a long weird, week. Here are a few of the more bizarre moments that left me wondering if perhaps my life has become a bad sitcom that is due to be cancelled midseason….

Monday morning clinic.
I spent the morning in a busy clinic seeing women with high risk pregnancies. The attending that staffs the clinic is brilliant and the head of the division. He also has the incredibly awkward bedside manner of the night janitor who still lives at home at age 40.
So here goes.
The patient is a cute, very petite 17 year old girl. It's her third pregnancy and English is her second language. I've already chatted with her for awhile and then I bring staff into the room to say "Hi there, any questions? No? Great!" He typically says that and then leaves in under10 seconds so that he can legitimately bill for it, but I provide the care. This patient interrupts his standard routine with a question though.
She tells us that she is worried that her baby is too small.
The attending gets suddenly quite animated, the only other time I have seen him exhibit so much interest in anything is when he is discussing the research he does in the sheep laboratory.
"No, no your baby is fine!" sez he. "How much do you weigh?
112 lbs, 93 before pregnancy.
"Oh that's fine! It's just like horse breeding! If you mate a large stallion with a large mare, the foal will be quite large, but if a small mare mates with a large stallion then the foal will be small. A small foal isn't a bad bloodline, size just depends on the mare!" The patient looks completely bewildered and lost. I am politely silent. He looks at her and says "So it makes sense your baby is small."
She still is lost. Her husband’s English isn’t as good as hers and he is equally confused but also somewhat unnerved by the hand gestures Dr. Davis has been making to illustrate his points. Some signals translate universally. I see him looking uneasily at their children wondering if he should perhaps cover their ears, eyes or both.
Dr. Davis senses their confusion and actually gets a note pad out of his pocket to try and Pictionary what he means. I am breathless with anticipation to see what on earth he is going to come up with.
Instead he comes up with another inspiration. He neatly summarizes by turning to me and stating "Now if this doctor here were mated with a large stallion, well then the foal would be quite large." I am completely amused that staff, MD, Phd and Division Chair is discussing me in the context of animal husbandry. What is there really to say to that? How on earth can I end this conversation before our patient loses all faith in us?
I turn to him and doing my best impersonation of horrified indignation say "Dr Davis, are you calling me FAT???!” HE turns beet red and exclaims "No, no! You look quite nice. I mean, um, you're tall! No, no, not fat. Your baby will be fine."
He then flees the room, visions of sexual harassment lawsuits clearly dancing through his mind. It took me an extra 15 minutes to try and convince the patient we are not insane and are in fact licensed physicians.
Stick with the sheep Dr. Davis.

Tuesday afternoon, covering Labor and Delivery.
The 400 lb, 5'4" black woman here to get induced because her diabetes was out of control. It was pretty cute, she was so excited to be there and have her baby. She was very determined to have her self a "real natural birthin' " That desire lasted about five minutes into early labor.
Anywho, there was some serious drama with the baby daddy- history of substance abuse and mutual domestic violence. She wanted to be admitted under an alias to try and avoid him. She asked if she could use "Black Butterfly." as her nom de guerre. Perfect! First of all, no one looking at a list of patient names "Amy Smith, Maria Gonzalez, Hortenica Rodriguez, Black Butterfly, Monica Jones" would suspect that the Black Butterfly was an alias! And secondly, Butterfly? Seriously?

Wednesday night, on call
My all star patient came in at the busiest point of the day when all of the rooms are full, many with seriously ill patients that need close watching. A flustered nurse comes tearing down the hall and grabs me. She tells me that I am needed right now in room 74 because “there is a situation.” I head down there with her to be confronted by an irate woman.
This is her eleventh pregnancy (other kids in foster care cause she's been in jail till a couple weeks ago) and she just wants me to “cut the baby out of her." True, its a few months early, but she's tired of being pregnant, her diabetes is "totally crazy" (perhaps because she does not take her insulin and loses all of the medical supplies she is given) and she has gained 130lbs this pregnancy. She screams at me that this is all my fault because I am a bad doctor and have caused her to do these things.
“Man is a rationalizing animal, not a rational animal.” I love that quote! Although I recognize that reason plays no role in our conversation, I take perverse delight in refusing to allow her to provoke me. I stay calm and logically try to address the many insults, complaints and demands she barrages us with. I imagine she has spent her life getting what she wants by being belligerent and threatening.
Interspersed with some colorful profanity she demands that I operate on her now or admit her to wait on her hand and foot because she is too tired to do these things for herself. If I won’t do this she will transfer care to another hospital. What a threat! I tell her it is my medical opinion that we not deliver her baby before it is old enough to survive and offer to photocopy her records for her to facilitate her transfer of care.
This was apparently not the response she expected. The best moment came when she ripped the sheet off of her corpulent, bloated, nekkid self and screamed "You dont know my pain bitch! Why dontcha climb up in my cooch and try and tell me ain’t nothing wrong!"
Wow. No Thank you.

Thursday
I am having lunch in the cafeteria. One of the family practice residents I am sitting with gets paged. He reads the message, starts to laugh and hands the pager to me to read the message. It’s from a nurse at the VA. It reads.
“Mr Jones is masturbating in front of staff and will not stop. Please advise.”

Friday I am going to leave to your imagination!

The New 20

"It's amazing the pain the human mind is capable of forgetting," the anesthesiologist was solemnly lecturing me as we stood in the pre-op area getting ready for the case. I smiled and nodded politely. That’s the true job of a resident; generalized obseqiousness. I have the formula down- I can maintain a deferential and pleasant façade while I freely ponder any old thing. Mainly I was wondering what the heck he was talking about and why was he being so pompous this early in the morning...
I assumed he was referring to the amnestic qualities of the Versed he had just given our patient. She had been wailing like a baby coyote as he had attempted to find a vein to place an IV. 350 is the new 150 you know, and that makes even the simplest of tasks challenging. For both of them.
Hours later, as our one hour case stretched into five, and my back started to seize, I hoped he meant it in a more general, philosophical sense. Perhaps he was saying that pain is an inevitable part of reality, and that we all delude ourselves otherwise to keep going. Was he saying that humans selectively forget unpleasant experiences out of cowardice? Is it an evolutionary adaptation, or are we just self centered and spiritually stunted?
Or maybe he was just saying he would save some Versed for me too. That would be rad. I am pretty sure I'm out of olives and it always makes me feel like an alcoholic to just drink the vodka. It was definitely going to take a lot of something to make me forget the pain of my months at St Vincent’s. Hmm. I’ve been looking for an excuse to rationalize a pair of Rock & Republic jeans, but even that probably won’t do it. Damn!
Anyways, whining is a fine art form, but I am really just doing it out of habit. Even if I wasn’t fully aware that there are worse ways than operating to spend Christmas, the case following ours would have reminded me. It was an emergent add on for a penile fracture. Triple ouch. I hadn’t even realized that was possible. I think I'll choose to forget it. I'm a gynecologist for a reason- I hate to mix business with pleasure.
I do love observing the selectiveness of human memory. Nowhere is the true inventiveness or creativity of the human mind seen more clearly. It’s phenomenal what we can remember- or forget- if given sufficient time and motivation. Present company definitely included.
Whether it's balancing a checkbook, explaining a fifty yard fake out, or justifying whatever it is you want but know you shouldn't, different accounting styles are always entertaining. Sometimes it's a collaborative collusion between friends. "He was cuter in the bar." "You definitely need another black top." "She probably would have had that heart attack anyways..."
It's a tacit acknowledgement that we'll both ignore what we know to be true. Personally, I get more joy out of breaking rules than making them, but I excel at helping better intentioned friends find loopholes in their own commandments.
Life is short and fun is transitory. No one will notice. It fits you perfectly! He seems like fun. You can dictate that tomorrow. Why not? And of course, “20 is the new 10.”

Haiku Kung Fu

Oncology:
Clamp, clamp, CUT! tie, CLIP!
Guttural roar of ennui.
Beautiful, beautiful.

Oh uh ma god!
Shave her to ze clee taurus.
Ees she a beeg gurl?

OB:
Cheap linoleum, no sunlight.
FHR overall reassuring.
Fucking triage.

REI:
Visa, Mastercard.
Follicles wax and wane.
Payable in advance.

Vanessa

It was 3 am and I was slumped against the wall in a back corridor of the hospital. I was ass tired, and wanted nothing more than to crawl into bed and pull the covers over my head.
The doors to Labor & Delivery had been thrown open an hour previously by the ambulance crew, but we had all heard her coming well before then. “Fuck, fuck you, fuck!” her shrill, young voice carried far down the hall ahead of her.
She was sixteen and hadn’t even known she was pregnant. Meth has a way of stripping a person down to the bare essentials and after a year of using, this girl didn’t have much left of herself. She fought us like a cornered animal as we tried to stabilize her, snarling and spitting in between contractions. She cursed out the nurse who was trying to place her IV with a fluency that would have impressed even Tony Soprano. The young student nurse stood in the corner, eyes as wide as saucers. It was total chaos.
An older woman who had accompanied her fluttered around helplessly in the background, tugging on her half shirt and wiping her hands on her ripped cutoffs. Her face was lined with years of hard drinking, smoking, and too much waterproof mascara. “Are you her family?” I asked. She looked surprised to be addressed. “Well, yeah, I’m her aunt kinda”, she slurred, her voice thick with whiskey. “Can you talk to her and try and help her calm down so we can help her?” I said curtly. She looked nervous but listed over to the bedside. “Vanessa, honey, why don’t you let the doctor check your baby?” she said feebly. “FUCK, FUCK YOU!” Vanessa screamed. Her nurse and I glanced at each other.
Chaos reigned; something had to be done before the situation escalated out of control. With some kind words and an authoritative air she let me examine her in between contractions. She was almost completely dilated and the baby’s head was low in her pelvis.
I did a quick ultrasound to try and get an idea of how far along she was. As I turned on the machine, her aunt piped up with excitement, “Can you tell if it’s a boy or a girl? I want a boy cause she’s already got a little girl at home!” Oh help me jeebus. I told her I didn’t have time to check for gender right then, and she quickly lost interest. She went back to playing with her cigarette and staring out the window.
It looked like she would be able to see for herself soon enough if it was a boy or a girl. Judging from her exam, Vanessa was about to deliver a very preterm baby. If this baby survived to leave the hospital, it was going to have problems a lot worse than the family it would have to spend Christmas with. “Call the NICU team now,” I told the nurse. She nodded and hit the code button.
The anesthesiologist was struggling to place an epidural as Vanessa writhed with pain and frustration. I leaned in close to her to try and get through to her. I spoke calmly and quietly trying to soothe her and regain our rapport. The ceasefire lasted for all of two contractions, and then she tried to punch me. That was it, I was done. There wasn’t anything human enough left to connect with her through kindness or empathy.
I said coldly, “Vanessa you need to get a hold of yourself right now. We all want to help you, but you can not treat us that way. Try that again and we’ll leave.” She hissed and cursed gutturally, but responded to the authority in my voice and calmed down. Her second baby.
Eight minutes later she started to scream and didn’t stop. Her son was ushered into this world, greeted by her rage and a team of pediatricians. I quickly glanced at his tiny, twisted face and wished him luck silently before I handed him off to the NICU team.
Moments later he was intubated and in an incubator in the intensive care unit. Minutes later his mom was signing out against medical advice so she could go have a smoke.
I looked in on her son that night before I went home. All preemies look a little eerie. You can see vessels and organs through their translucent skin. They have tubes entering and exiting their throats, nose, and umbilical veins. Their lungs are so fragile they have to breathe with the help of a machine that rattles their chest like a washing machine in spin cycle.
As I looked at him, I realized why his face registered so strongly with me in the moment I had first seen him. His ears were low set, at the level of his jaw. His eyes were spaced far apart, and his nose sloped into his forehead without a discernable pause. His head was also very, very small. The medical term is “microcephalic” but the Farside cartoon of the pinhead family explains a lot more. I picked up his chart and saw the third strike against him. A rare syndrome named after three dead white guys. Anytime three people have their name on your disease you know it’s obscure and probably lethal, although you might have to endure several months in the ICU before they let you die.
And so it went. On day one, his family left. On day two, a feeding tube was placed into his stomach. On day three, he had his first massive bleed into his brain. On day four he got transfused. On day five, they added a third IV drug to help him maintain his blood pressure. On day six, he got a horrible infection in his lungs. He continued on for the rest of the summer that way, struggling to live in his incubator with only the changing guard of the nurses for company.
It was hard to not hate his mother, although I knew she was an addict and sick herself. But she wasn’t there watching him suffer, and I was. How could she forget her own baby? Did she remember him at all? She never came back after she left for a cigarette. She’d probably gotten high again and thought it was just a bad dream.
*********
Fast forward ten months. I am finishing up one of my last calls of the year at a community hospital, covering their high risk obstetrical service. It’s five thirty in the morning, and I am mainlining caffeine while trying to finish rounds after a busy night.
The charge nurse stops me in the hall. “We just got a call that Life Flight is bringing in a mom and her baby. Apparently she just delivered a preterm baby at home. No prenatal care and she is high on something- she attacked one of the paramedics on the helicopter.”
Life Flight is the helicopter ambulance that air lifts in critically ill patients from remote parts of the state. It sounded like it would be more of a job for the pediatricians, but I still went to meet the helicopter. The sun was just coming up as the helicopter touched down on the landing pad outside the hospital.
From the first screamed obscenity that was audible over the helicopter’s roar, I knew who it was. It seemed impossible that it could be her with another baby already, but I felt it with a cold certainty. They brought her out of the helicopter on a stretcher, arms and legs restrained, screaming her bloody head off. Her face had aged years in the months since I had seen her last. Most of her teeth were gone now.
She got pain medication and a room in the Family Birth Center. I waited till the morphine had had its’ effect before I got within hitting or spitting range.
“Hi Vanessa. You probably don’t remember me, but I delivered your son at University Hospital this summer.” She opened one eye and glanced at me warily. “How is he doing?”
“Who?” she asked in complete confusion.

Throbbing Vaginas.

Yep you heard right.
I thought I had misheard the gum snapping, vacuous unit clerk on the other end of the line too. I had been talking with one of the medical students about managing obstetrical emergencies when the pager went off.
We had just finished discussing umbilical cord prolapse. That's when the bag of water breaks and the cord sneaks down in front of the baby. "What's the first sign that you have a problem?" I asked. He correctly answered, "The fetal heart rate drops to below normal." And normal is? Batting two for two he answered, "120-160 beats per minute is normal for a fetus."
"It's a surgical emergency," I explained. "If the cord gets compressed, the baby isn't getting any oxygen and you have minutes to act before they will be riding the short bus to preschool. You have to put your hand in and elevate the baby's head off the cord. You keep your hand in there as you consent her for an emergent csection, you keep your hand in as you roll to the operating room, you keep your hand in as they prep and drape her for surgery, and you can finally take your hand out of her vagina, when they pull the baby out of her abominal incision."
He nods his head, suitably impressed.
Beep beep goes my pager. I sigh and pick up the phone to dial. The Family Birth Center is notorious for ridiculous pages about absolutely nothing important. They usually reserve those until 2am when they like to call you with normal vital signs.
Bubbalicious Barbie answers. "Um, the patient in room eleven says that there is something throbbing in her vagina, and her nurse wants you to come check it out." She cracks her gum efficiently.
This is a patient with very preterm triplets.
I pause. There are SO many ways to respond, few of which seem like my responsibility and none of which seem professional, but who can resist? "Something's throbbing in her vagina?" I query. "And she's complaining? Isn't that how she got pregnant in the first place?"
Barbie doesn't think I'm funny. The medical student does and jokes, "Should we give them a few minutes?"
"Is she contracting? Bleeding? Leaking fluid? Are the babies not moving?"
"I don't know," Barbie replies. "Well, the nurse looked and couldn't find anything but says you should come look too."
Great. Thanks for all the information.
I turn to the med student. "It's probably nothing, maybe a varicosity, but this patient is super preterm, is ruptured with triplets and has the additional risk factor of being really nice so we better go check it out."
We head into the room where Oprah is on TV and the nurse and parents are looking through baby name books. It's a calm Tuesday afternoon. For about another 90 seconds.
The med student starts to ask the patient a few questions. The nurse chipper as can be informs me "I just spot checked heart tones, and two of the babies are in the 140s and the third is in the 80s."
"In the 80s?" oh shit. "And you're just standing there? Grab the monitor so we can confirm that." I whisper so the patient won't be scared. Oprah covers for me as she asks Diane Keaton about a particularly hideous outfit she wore to the Oscars. The nurse looks startled and slowly starts to move out the door. "Look, we aren't going for 2 out of 3 here, this is an emergency."
My heart rate is climbing. I interupt the med student. "Mrs X do you feel pressure in your vagina?"
"Why yes! It's like something just fell out!" she answers nonchalantly. "It's just the wierdest thing."
Oh fuck. I grab a glove and tell the medical student. "Have them overhead page staff stat to the room and tell anesthesia we need to open an OR."
He looks suprised at being interupted so rudely.
I explain we need to do a pelvic and I check her. I feel one little leg and a very tiny behind hanging almost all the way out. Great. I push it back up, smile and say "How do you feel about Memorial Day as a birthday for the triplets? It's a three day weekend so they could each have their own day."
A code gets called. 5 million people rush into the room. I consent her for a section as we roll down the hallways of the hospital, my hand still in her vagina.
Her husband is stunned. Oprah and Diane keep chatting. The patient is amazingly calm.
They throw the prep on her abdomen and drape us both. This is likely the most compromising postion I've been in for some time. It smells pretty bad. Anesthesia gets induced.
Staff had paged his partner out of clinic because he needed an assistant.
The staff doctor has already made his incision with the scalpel and is rapidly cutting down to the uterus. Thunk! He drops a heavy metal retractor on the drape right above my head.
I wince.
His partner is pissed. "Where is the ob resident?" he angrily exclaims. "Shouldn't she be doing this case?"
"I am scrubbed in Dr Jenkins," I cooly announce from beneath the drape. "I'm down here!"

Icarus

She was a tiny woman; all deep brown eyes and fragile sorrow. Her husband tenderly helped her sit as if she was made of porcelain. This was their fourth pregnancy, but their house was silent. I sat on the stool in the exam room with them.
“Senora, estamos aqui para ayudarle en cualquier manera que sea necesario. Me da tanta pena escuchar de su perdida…”
She nodded her head in acceptance. Her first three miscarriages had occurred in Mexico, where the anomalies were discovered on ultrasound after she had begun to cramp and spot in her twentieth week. In antiseptic rooms she had been separated from her pregnancy and denied the right to see her child. The doctors and her husband thought she wouldn’t be able to handle the truth of their malformed faces and twisted bodies. She would always wonder what they would have been, but would never know them as they were.
They had traveled to Oregon to be close to family and in the hopes that doctors here would be able to help. We had not. Again late in her second trimester, ultrasonic waves showed a severely malformed fetus without a heart beat. She had come into the hospital tonight to say goodbye.
I had done any number of first trimester abortions of unwanted pregnancies, and I was comfortable with that role. This was different and I was anxious. As I haltingly began to explain the process of induction to her I felt enormously inadequate and rude; an unwelcome intrusion on their grief.
When I discussed her options for pain management she looked surprised and whispered with her husband before conferring with me. She had not been offered any analgesia for her births in Mexico and was uncertain if she deserved it here. Another fissure appeared in my heart.
A point of contention between her and her husband arose. Part of the history and physical had involved a discussion of their birth plan. Did they want to see the fetus? Hold it? Burial plans? Autopsy? Genetic studies? She looked directly at me and said, “Quiero llevar mi bebe en mis brazos.” I want to hold my baby. I nodded in agreement and her husband became upset. “Mi amor,” he cooed protectively, “no quieres hacer eso.” You don’t want to do that.
He had seen their last baby after it was born and hissed at me that “habia parecido como hecho de gelatina negra.” It had looked like it was made of black jello. I winced. She looked at me pleadingly and I saw her vulnerability. It would certainly be easier now for me and her husband to keep the baby hidden and maintain a polite façade. Could I do that? Why did I even have to care? It would be so much easier to ignore the truth. Bullshit. I told her husband it was her choice to make, not ours.
I did wonder if she would regret it though. I had seen the lab reports of maimed chromosomes and had looked at the distorted ultrasound pictures. A normal twenty week pregnancy looks like alien enough, and I could only imagine the details of this one.
Would it really be better to never know? It was a choice I hoped I would never have to make, but a truth I couldn’t imagine living without knowing. I knew she deserved the same respect I would demand, so I let it go. There is a certain liberty in acknowledging events are beyond your control.
Hours passed. I delivered several babies to happy families, checked my email, staunched hemorrhage, had grilled cheese, and fielded annoying calls from the ER. Twenty hours into my shift I was called urgently to their room. I ran down the hall, heart pounding in trepidation.
“She just delivered,” the nurse announced calmly, “She felt a little bit of pressure and the baby came right out.”
Mother and father looked at me expectantly, holding hands. She was partially sitting up and there was a pool of blood with an indistinct mass between her legs. She remained tethered to her child by a frail umbilical cord. I bent down, hesitant. There was a faint smell of damp licorice in the air.
The baby was a quivering, gelatinous form with barely recognizable features. The skin was black and mottled. I could see its chest rippling with a faint heart beat. I didn’t know what to do; it was worse than I had anticipated. There was almost nothing present that I could recognize. Its translucent skin looked as if my fingers would pass right through it if I tried to touch it.
“Pick up the baby” the nurse whispered to me. I nervously picked up the baby and wrapped it in a blanket. The nurse tenderly placed a hat upon its head. The knit cap looked incongruous with its twisted features, but it lent the affair a semblance of normalcy. I was shaking. I gingerly placed the baby in its mother’s eager arms; I had no idea what her reaction would be.
She looked down at the baby in her arms and burst into tears. She rocked back and forth, consumed by sorrow. “Mira, mi amor, mi bebe, mi bebe! Mira sus dedos perfectos, ay mi corazon…”
I sat there quietly, the early hour and lack of sleep lending a surreal air to the affair. Out of the whole fucked up situation she had clung to the one normal thing about her child; its perfectly formed hands. She was focusing on that and grieving the loss of the family she had envisioned, while I had been fixated on the bizarre and unnatural.
When you are totally lost, begin with what you know to be true. We see what we want to, and our reality is largely our own creation. We can discover unsuspected strength if we simply acknowledge what is. It may be cruel, beautiful, vicious, unfair, hilarious, maddening or totally ridiculous: but there you have it.

Rivers and Earthquakes

Rivers and Earthquakes
She was a grotesque, middle aged buddha, whose bulk kept her confined to a wheelchair and whose dark glasses protected her from prying eyes, even here in the oncology clinic. Her weary daughter was with her, and she explained that they had driven all the way from Eastern Oregon this morning to be seen. Her mother, who refused to meet my gaze, had been having postmenopausal vaginal bleeding for the last decade. She had collapsed the week before and her family had discovered her secret. In the tiny Emergency Room on the Idaho border, they confirmed the diagnosis of endometrial cancer and sent her to our care.
As we discussed surgery and radiation with her daughter, the patient remained silent, her thoughts concealed behind her sunglasses, her hands idly picking at her lap blanket; she was removed from the discussion of her five year survival rate. We assured her and her daughter that with proper treatment, her chances of complete recovery were very good. As the attending consented her for surgery I mentally ran through the list of complications she would likely have based on her size alone. Blood clots. Aspiration pneumonia. Wound infection. Post operative myocardial infarction. Wound dehiscence. Jesus Christ, this was going to be a mess. I couldn’t believe we were going in.
I was both fascinated and repulsed by her sheer enormity. Her bulk spilled over the edges of the hospital issue wheel chair, and I needed a running start to get enough momentum to propel her chair down the hall to the exam room. I felt something in my lower back pop as we creaked along down the hallway.
It took four of us to help her stand, and two to help dislodge her clothing from her various crevices so she could be examined. She swayed unsteadily on her feet the entire time, worrying me that she would fall and I would be trapped underneath the avalanche of her abdomen. “I’ve fallen and I can’t get up!” Oh fuck. I tried to clear that image from my mind and attend to the task at hand. Two nurses helped lift her belly from down below her knees, so that the attending and I could find her vagina and do a pelvic exam. I was buried in rolls of soft tissue to my elbow before I found the cancerous mass near her cervix. I tried to hide my disgust, but I don’t know how successful I was; her face betrayed nothing.
This woman had been slowly growing her cancer with years of gluttony and neglect. Obesity is correlated with endometrial cancer; the fat cells produce exogenous hormones that cause the lining to proliferate rapidly, and dramatically increase the risk of neoplastic conversion. Her weight had not only caused her cancer, but was going to make her surgery very difficult, and her recovery prolonged. Her apathy would be the hardest obstacle to overcome.
We took her to the operating room three days later. We taped and prepped her abdomen, attempting to find the most direct route amongst all the fat tissue to her pelvis. Parts of her body that hadn’t seen daylight in years were subjected to the florescent glare of the bright OR lights and the unyielding scrubbing of the circulating nurse. We cut and bovied through inches and inches of fat, tunneling our way to her uterus.
When we arrived, it was at the bottom of a very deep well. Even with our longest instruments the depth was such that we couldn’t safely secure the blood supply to the uterus. We had to close without completing the surgery- she was too fat to safely remove the tissue with cancer. We marked the uterus with clips in the hope that radiation therapy, a distant second to surgical management would do her some good. Perhaps the ionized electrons would have enough energy to penetrate the foot of subcutaneous tissue that was guarding and nourishing her cancer. We sent her to the recovery room frustrated and defeated.
Over the next several days, she would pretend to be asleep every time I came in the room to check on her. We had talked in clinic about the different things she needed to do after surgery to help her get better. It had been thoroughly emphasized to her that her prognosis was very good if she would follow medical recommendations. She refused to do any of them, saying she was “too tired” or simply ignoring me and staring at the wall above my head. Every morning and afternoon I would encourage her to try and do some of the activities we had talked about and remind her of the risks to her health if she did not.
On postoperative day five, she had still refused to use her breathing machine, hadn’t gotten out of bed with physical therapy, and had her Foley catheter in so that she didn’t have to walk to the bathroom 3 feet away. She had refused to let the nurse help bathe her, and her room stunk of yeast and apathy when I walked in. I looked at her gelatinous form, prone and silent in bed. She was unresponsive to my usual questions and I stood there and looked at her silently for awhile, just waiting. Nothing. I was exhausted from being up all night and felt reckless. Sympathy and understanding had yielded nothing. I said exactly what I was thinking. “Nancy?” I said. “Nancy!” I repeated more firmly. “We need your help if you want to get better. We are doing everything we can, and you will get better if you try. But you need to walk, you need to clean yourself up, and you have to do your exercises. Your catheter is coming out, we’re turning off the tv and your IV pain meds and giving you the choice. You have work to do. ”
How had she let herself come to this point where she was being literally suffocated and destroyed by her bad decisions?
How do any of our lives end up being shaped or defined? When I was younger and filled with the wisdom of made for TV movies, I thought they had it right, and it was the result of one obviously horrible decision made in high school. While we all had at least one friend we can think of who couldn’t avoid one of the adolescent sand traps, most of us felt smugly self righteous that the smart or right thing to do was lit up in neon, blinking. Don’t get in the car with Billy after he kicks back that six pack of beer, don’t take the candy from the stranger on the bus, go to Planned Parenthood and get on the pill, and when in doubt, remember Nancy Reagan and “Just say No.” If only it were that simple. There would be a direct road map to success and happiness that most of us could read.
As I became older and met people with dramatically different upbringings and experiences than mine, I took a more fatalistic view. So much of our lives seemed predetermined based on the time, people and place we were born into. There was no way we could pretend the playing field was level. By birth and thus by chance, some of us were propelled forward to college and a suburban home outfitted by Crate & Barrel. Others were destined for a parallel reality where love was shown with fists, drugs were a logical escape, and life past next week wasn’t planned for.
I no longer think destiny is that obvious. It is far more insidious, with change happening when we aren’t paying attention. Oversight can be enough to change the course of a life, and what seems to be an inconsequential triviality can become the driving force in our lives and characters. We do have the ability to choose our lives, but often lack the insight to recognize the pivotal moments when small decisions loom large. While volcanoes, earthquakes, and other violent acts can change geography in minutes, the slow erosion of a calm wind can have an equally profound impact over years. It can’t all be blamed on the one time use of a “gateway drug” or our parents, regardless of what a high priced therapist will say.
A series of small decisions can over time cause us to become lost beyond recognition of who we once were or what we valued. It can start with something as simple as not defending the acne-laden, fat girl on the bus when insults and spit wads are flying fast and furious. Fast forward ten years and you are the type of asshole that feebly laughs at wetback jokes and doesn’t stop to help even though you know her “No” didn’t mean “Yes.” Or maybe it begins with a stupid mistake- a drunken kiss in a bar. You know it doesn’t mean anything and so you spin a series of lies to protect the person you love and yourself. Your cowardice backfires and in a year, you can’t be honest with yourself or them. Maybe it is simply thirty years of an extra slice of pizza or a third helping of mac and cheese, overeating for solace, until you are literally trapped beneath the weight of your depression and pain. Any moment can be life altering. The question is will we recognize it?

Sweltering Rosebuds

I followed the advice of a good friend recently. In an attempt to exorcise some personal demons, I followed her prescription of drinking a fifth of whiskey, eating a whole Caramello bar and spending the weekend reading trashy romance novels. It was therapeutic in some unexpected ways, although it will be some time before I can look Jim Beam in the eye again. Her theory was that ingestion of all of the above toxic ingredients in one sitting would have a purgative effect. It sounded at least as valid as anything I have heard on Oprah, and being congenitally impatient I hate to wait for anything. Years of therapy just don’t fit into my schedule. Her accelerated plan takes you right through the whole range of human emotions in under 12 hours. Anyways, I will skip right over the first eight circles of hell that I traveled through and take you directly to the gates of Mordor- the romance novel.
Have you ever actually read a romance novel? A surreptitious glance in the grocery line doesn’t count. These priceless gems discover your full attention and careful perusal. They are hilarious! I laughed so hard, I think I nearly ruptured some key visceral organs
as well as discovered a potential new career my high school guidance counselor
neglected to mention.
As the bathroom ceiling spun above me, I had fun contemplating what the authors of these books were like. At first I was envisioning myself attending conferences with frumptastic, plump women who would earnestly comb their thesauruses to find synonyms for “rigid.” Then as I hit page 10, I solved the romance novel equation. Tempestuous heroine with violet eyes arrogant misunderstood male = semblance of plot. It of course follows that one party is poor, and the other rich to add an intriguing element of social consciousness to the drama. By page 11, I was pretty much convinced that I had already missed my window of opportunity at being a romance author. Clearly these novellas were so formulaic a computer is already writing them and has rendered those poor virginal matrons obsolete. Crap. Another good idea down the drain.
It wasn’t until the whiskey was nearly gone and I was several chapters in that I finally discovered the true value of the romance novel. It lies in their subtlety. Much like Rorschach ink blot tests, the bizarre euphemisms employed can really mean anything the reader cares to make of them. I was pretty sure they were reinventing oral sex in every chapter, but really you could make of it what you want. Doubtlessly someone with more character would have interpreted the same passage as describing a world free of war and famine.
Some of these literary constructions are pretty phenomenal in both their lack of direct meaning but clarity of implication. Poetical ambiguity. Sarcastic double entendre. I can do that! Now I am picturing jaded, vodka swilling iconoclasts carefully constructing every trite euphemism with some hidden, subversive meaning. Excellent, I will dust off
my beret and find the nearest sidewalk café to join them.
Only one problem, now that I think of it: what the hell is the hidden political meaning of “sweltering rosebud of femininity?” I guess I will never be that subtle.

Tuesday Morning

Tuesday Morning
I took a cursory glance at her chart before walking in the exam room. Bipolar disorder. History of alcoholism. History of sexual assault. Five previous pregnancies and vaginal deliveries, with all of her children in foster care. She was here for her first visit for a new pregnancy. Her name was Tawnya.
A strand of unwashed, mousy brown hair was stuck to her fat, placid cheek. Her clothes were dirty and disheveled; her t-shirt proclaimed “Watch out I’ve got PMS and a gun!” Her face was bovine in its passivity.
I started with my standard new obstetric visit questions: How did she feel about the pregnancy? Was this a planned pregnancy? Tell me about the father of the baby…?
“Oh Earl and I are just thrilled to be having us a baby! We’ve been wanting one to keep for ever so long.” We continued with the rest of the history and the physical exam. As we neared the end of the appointment, I could tell something was bothering her. Deep beneath the still waters, something was bubbling up. She was picking nervously at her fingers refusing to meet my gaze.
“Tawyna, we will send off those labs and have you come back in a couple of weeks for another check up and ultrasound. Any last questions?”I asked with one hand on the door. It’s always when you have one hand on the door.
It erupted out of her: “I need you to write a letter to my husband!”
I sat back down. “Well of course, but why?”
Now that the train had left the station, it picked up speed. “Because I need you to tell him it’s normal for me to have more discharge down there now that I’m having a baby! He keeps checking my panties and accusing me of being with another man! He is going through the laundry and everything, and is calling me all sorts of names.” She gulped and continued, “ We went to his brothers for Thanksgiving, and he got so mad he ripped my panties off underneath my dress and showed them to his brother, and now they both think I am cheating! And I ain’t! I told him it’s like this with all my babies, but he don’t believe me.” Her broad face shone with sincerity.
I tried not to stare in fascination as a plump tear meandered through her heavy foundation, creating river beds as it journeyed to her chin, where it hung quivering. This particular situation I hadn’t encountered before. “Well, uh, Tawyna, of course you’re right, and it’s normal and healthy. But I am really worried that Earl would treat you that way. Do you feel safe with him?”
She was puzzled by my response. “Well of course, he loves me. And he only acts that way when he’s drinking.” I was equally puzzled by her reply, and we went around and around the same point, neither of us really understanding the other. Finally, convinced that it was her choice to stay with him and she knew where to find help, I left the room to do what she asked.
I sat down at the computer to compose an official sounding letter, but the topic was just so ridiculous and offensive I didn’t even know where to start. I got out a piece of letterhead on formal cream colored cardstock and stared at the computer screen awaiting inspiration.
“To Whom It May Concern:
Please be advised that the increased vaginal discharge in Ms. Smith’s underpants is physiologic, and does not constitute proof of infidelity. It is termed “leucorrhea of pregnancy” and is normal. Please desist in your unwarranted searches of her person….”
I hit the delete key. I doubted that a person of Earl’s intellectual stature would understand that. I tried again.
“Dear Jackass,
What kind of sick jerk humiliates his wife that way? You must be a complete toad to treat her with such a total lack of respect. You deserve to be publicly humiliated and slapped upside the head for the total fool you are…”
Backspace. That particular version, while much more satisfying, would at best cost me my job and at worse net me a violent stalker. I thought of the woman waiting anxiously in the exam room for her doctor’s note for her husband; how could such a fucked up situation possibly seem normal to her? I thought back to those brief comments in her chart that said so much about her life “History of sex abuse. History of alcoholism. Bipolar disorder.”
Had she ever known that she deserved to be treated with dignity and respect? Had anyone ever loved her and thought her opinions mattered? Maybe she had once known all that, but life with all of its challenges and cruel twists had taken it from her. Is it possible that if I was given the same circumstances to deal with that she had, that I would find myself in a clinic nervously asking a doctor to write a note to my psychotic husband? I sincerely hoped not, but I really didn’t know. We all have shitty stuff happen to us along the way, but I couldn’t pretend that where we started from didn’t impact our ability to overcome those obstacles. She was doing the best she could with what she had been dealt, and it was my job to help her where she was now, not judge her for it.
“Dear Earl,
Your wife is pregnant, and this causes lots of changes in their bodies. The discharge she is having is perfectly normal for a pregnant woman. Her exam today was totally normal. I am sending a book home with her about some of the common changes in pregnancy. Please call me with any questions.”

Anniversary

It's 11 pm- do you know where your hand is? It was our eighth major surgery of the day and I wanted to cry I was so tired. My feet were more swollen than the Elephant Man's nuts. Our eighth, sweet, lovely, middle aged woman with perfectly coiffed hair who had felt fine until a month ago. Their faces and stories were so similar.
Four weeks ago she was swimming and shopping in Palm Springs with cocktails at the golf course. Three weeks ago she realized her pants had become too tight to wear and she took some tums for indigestion. Two weeks ago she started having bad constipation and abdominal pain. One week ago she came into the ER for nausea and vomiting. Two days ago she learned she had widely metastatic cancer. Today she was filleted open under the fluorescent glare of the OR lights and I was up to my elbow in her abdomen searching for cancerous implants. It was eleven pm and my hand was systematically evaluating the lymph nodes nestled at the bifurcation of her aorta searching for the answer to the question: How likely is it that I will be alive in 5 years?
When I cut into her fascia, past the skin, past the fat, past Scarpa's, green goo exploded out of her abdomen. Total Ghostbusters, and I had been thoroughly slimed. Her abdomen was a mess. Liters of mucousy drainage swirled away down the suction.This was a woman who apologized for crying out in pain when we moved her. Who asked about my mother every day. Who wanted to set me up with her grandson. But this was nothing personal. It's me, not you. Her bowel was so matted with metastases that it appeared that super glue had been introduced to a game of Twister with disasterous results. A necrotic mass of cancerous cells hunkered down on her ascending colon refusing passage through. It was a bloody mess.
As we sorted through the necrotic labyrinth, searching for any normal landmarks, the discrepancy between what was on her inside and outside was truly amazing. It brought me back to my freshman year in college, sitting in dorm rooms listening to stoned trust fund kids with their deep thoughts about alternate realities and Jerry Garcia conspiracies. They did have one thing right- there are levels to truth. Parallel realities exist that intersect, diverge and contradict. Dude, it's like blowing my mind man! Pass the bong.
No one would have guessed at what was hidden beneath her surface. A lot of nasty ass shit can be concealed in our depths, both from ourselves and from others. Sometimes it is a conscious act to ignore what we know is lurking below, other times it is a betrayal of our trust. Either way it sucks to be confronted with what it is.
It's a test of character, how we deal with uncertainty and grief. I don't think we know who we are until we have had to face what we fear the most. The first thing this woman had said to me was "Oh doctor, I am so glad to meet you. I want to have surgery as soon as possible. I am not going to go through what Frank did." She had lost her husband to metastatic lung cancer last year and was determined that she would not die a lingering death as he had. She looked me in the eye and firmly said "You are going to let me go if it's bad. I've had a good life." Her voice rang with certainty, but she spoke with the easy confidence of denial. She had always been healthy.
I dreaded having to talk to her about what we had seen. Her pelvis was so full of rotting, bleeding tumor that it was difficult to identify anything normal. Her bladder, bowel and blood vessels were encased in a snarl of blackened cells. Green mucus from the tumor coated every surface. It was a war zone. We took out what we could and closed.
The first day after her surgery she was groggy from narcotics. The discussion of prognosis was delayed until we had the final pathology read and thus the definitive diagnosis. On postoperative day 2, the pathology reports were available from all eight of our cases. It was like report card day, when you aren't sure how well you did on a critical final. We went from room to room giving the results. Sometimes I felt like the tooth fairy leaving an unexpected present for our patients. "Stage 1 Mrs Smith, with chemo you are going to do very well. We caught it just in time." Mainly though I felt like a harbinger of death. "Lo siento Sra, desfortunadamente habia un pedazito del cansur por su intestino. Es un tumor bien agresivo y advanzado."
Mrs. Carlisle's was the worst. It was a particularly aggressive form of colon cancer that was resistant to most chemotherapies. This would be her last spring in Oregon. I think she knew before we told her that the diagnosis was as bad as we had feared. The light faded from her eyes and she turned to the wall. Her voice was flat. "Then I don't want anything more done."
Tragedy is lonely. It leaves a void within us where previously we had been whole. Well meaning friends try and offer advice to fill the vacuum it creates. "You'll feel better soon. You are a fighter! I know you can beat this. Focus on the positive. You'll forget about him and move on. You need to distract yourself with other things." It says more about the other person's needs than the patient's, but it is easier than being silent.
They teach that grieving involves a prescribed series of steps, but I don't buy it. Tragedy is uniquely personal. Only the individual can define it's meaning in their life. It's their right to interpret their loss for themselves and manage it as they see fit.
A variety of approaches exist to deal with the void. Denial is a perennial favorite that comes with a brand of desperate optimism. For obvious reasons depression and apathy can become close friends as well. Others choose hollow relationships, or the retrograde amnesia of alcohol. Filling schedules with meaningless errands to avoid acknowledging what's lacking. You do what it takes to get through, and you hope you like yourself at the end of it.

The Boy is Mine

This was totally ridiculous. It had already been a little bit ridiculous upon her arrival to Labor & Delivery. Twenty- two years old and her fifth baby? Damn. It progressed quickly from sad-ridiculous to outright Jerry Springer. She came in at 1 am by ambulance because “My baby ‘bout to fall right out!” Her gold tooth sparkled with sincerity as she moaned and grabbed at her belly. Her cousin who was with her, frantically started dialing numbers on her cell phone. The paramedic muttered “Good luck,” as he headed for the door. Interesting.

We quickly got her on the monitors, checked the baby’s heart rate and did an exam. Huh. By all objective measures, she was nowhere close to being in labor and her baby looked just fine on monitoring.

Lets call her “Beatrice.” Beatrice had calmed down considerably since her arrival and was in fact comfortably interrogating the nurse about the dinner menu. Beatrice had been here several times over the last week and knew the menu by heart. She had more than one special request as to how her midnight snack should be prepared.

Her cousin piped up “I got Norbert on speaker phone!” The baby mama drama kicked back into high gear. The nurse and I tried to continue with our jobs but the barrage of cursing, accusations, and static flying through the phone was way too distracting. I wish I could do the scene full justice, but I was too overcome at the moment to record it all.

Anyways, here is what the nurse and I figured out. “Norbert” the baby daddy was out with Beatrice’s coworker “Mildred.” Apparently Norbert was also baby daddy to a forthcoming progeny of Mildred. Mildred was at another hospital, also in labor. This upset Beatrice to no end, so she came in to our hospital with the express goal of making Norbert upset. “You out with that dirty ho and I be having your son tonight! What I gonna tell my baby? Your daddy out with some ho when you was born!” Norbert’s reply involved a colorful and novel suggestion involving who be the baby daddy and a storage spot for Beatrice’s cell phone.

“Oh no you didn’t!” Beatrice fired back. “You know Edward just my
other baby daddy, this one is your baby!” Her cousin was an excellent back up singer, chorusing in with an astounding array of expletives. “But T-Bird, ah love you!” Beatrice proclaimed.
Will the real baby daddy please stand up?

Your tax dollars at work folks. As much as I hated the waste of limited health care dollars, I have to say it was far better than anything on TV. How is it that Beatrice, unemployed, sans insurance can get a free ride in the middle of the night to a free “hotel” where they will custom order her meal for her, also gratis, while the only damn channel the TV in the call room gets is the lactation channel? Seriously if I have to hear any more flute music from the human dairy channel I will not be responsible for my actions. I mean “breast is best” and all, but HBO has at least as much T&A as the Family Birth Center.

Beatrice was damned clever. I gave her full points for ingenuity and the verbal orchiectomy she performed, but had to mark her down a point for her outfit. Of course, there are always multiple sides to the story, and for all I know Beatrice was the side dish to Mildred’s entrée. Whatever, I still love revenge, and this was certainly a new twist.

Suddenly, I thought of yet another way to pay off my med school loans. Forget finishing residency. Forget the plan to write a cockamamie diet book. Forget the lottery ticket plan. And never mind the plan involving Kobe Bryant.

The patent is pending on this idea instead: a new reality TV show for the USA network. Forget “A Wedding Story”, “A Baby Story” and of course “The Proposal.” Why not a show called “A Break up Story?” That would be way cooler. Perhaps Bob Saget, or better yet, Jenny McCarthy could host. We would have some cute tag line the audience would chorus. Maybe “It’s you not me” or “Can we be friends?” Bring back the coliseum and the lions, our modern gladiators could battle out the sordid details of their betrayal in the privacy of a cable TV show! The winner would receive a free divorce and a year’s supply of Pampers. I bet you wish you had thought of it first.