Saturday, October 3, 2015

3rd Year Chronicles: Pediatrics and OB-GYN

Third year has officially started. Well, it officially started a few months ago. I’ve actually finished two rotations so far and am currently on a week-long (and glorious) fall break.

I Finally Get to Hang Out with My Peers

The first rotation of the year was a six-week stint in Pediatrics. Some of the details of the rotation varied from student to student depending on how the lottery for the various sites worked out, but I spent two weeks in an outpatient clinic, one week on peds ER night shifts, one week on nursery, and two weeks on the peds inpatient service.

The outpatient clinic happened to fall around the tail end of summer, which meant I saw a lot of healthy kids for well-child checks and back-to-school sports physicals. Which is awesome – healthy kids are always a good thing – but it meant that the interviews and exams were getting a bit repetitive by the end of the second week. I did enjoy getting a peek into the long-term relationship that the physicians I was working with had with the families they saw – often, they had seen these kids that were now heading off to college since they had been in diapers. That was appealing to me in some ways, which is something to consider for future career choices.

The week of nights in the pediatric ER made up for the monotony of the outpatient clinic. I worked with a few different pediatrics residents overnight as they were rotating through the ER. One of the residents I worked with had a viral gastroenteritis and spent the better part of the first half of her shift hiding in the bathroom. Instead of going home, though, she grabbed a nurse that was walking by and asked him to start an IV on her so she could get some fluids. Two points for dedication, I suppose. Later, we were seeing a 17 year old male that had avulsed the nail of his right middle finger while playing hockey (it was puck vs. finger – through a glove, too). With the ER attending, she was trying to put a digital block in that finger, but was shakily heading the needle in the direction of the wrong finger. Thankfully, the ER attending smoothly redirected the needle towards its intended target without saying a word. Go home when you’re sick, folks. It was pretty cool to watch the attending complete the nail removal, suture an underlying laceration, and dermabond the nail back in place as a sort of natural bandage.

Also, I got to “fix” a patient. A 15 year old male came in with his mom complaining of a foreign body sensation in his left eye that started suddenly after he “flicked” his T shirt up at 2 am in the morning while looking at his phone (yep). I lifted his eyelid to examine him, had him move his eyes in a few different directions, and he suddenly smiled and said “It fell out!” Medical student to the rescue. Still got to do a fluorescein exam, though, which was fun.

After the ER, things slowed down a bit when I moved to the nursery. This was actually a lot of fun – what better way to spend the day than hanging out with a bunch of happy parents and new babies? We also rounded with the NICU team in the mornings, which was a bit less fun. The advancements in medical technology and our ability to keep severely preterm babies alive is remarkable, but that doesn’t make it any less difficult to see two-pound babies on CPAP machines.

The pediatrics rotation ended with two weeks on the inpatient service. I was actually surprised by how much I liked the pace of inpatient medicine (although my perspective was admittedly a bit skewed as a medical student). We actually had a pretty nice schedule – showed up around 7 am to pre-round on a few patients, write progress notes, round again with the team around 8:00-8:30 am, take care of whatever business needed to happen in the morning, have lunch, then spend most of the afternoon in an impromptu lecture, see new admissions, or study. We typically finished by 3:30 pm, which was awesome (unless we had call, in which case we stayed later into the evening).

The Verdict

Overall, I really enjoyed the rotation. I don’t see myself going into pediatrics, but I really enjoyed certain aspects of the field. The final test at the end was actually pretty difficult – since it’s such a broad field, there was a lot of information to cover. Loyola uses the MedU pediatrics final, so we had the associated cases to complete during our rotation. I did those and most of the UWorld questions, and it seemed to work out fine on the test.

The Part Where I Deliver Placentas

After peds, I jumped into OB-GYN. It was actually nice to have these two rotations back-to-back, since there is a little bit of crossover in terms of the knowledge base you need to acquire and it helps to hit the ground running in OB-GYN with the peds stuff down pat.

I started off with two weeks in Labor and Delivery. This was probably my favorite part of the rotation – I felt like I learned a lot and really enjoyed the residents that I worked with. The hours were a bit longer than peds – throughout OB-GYN, the days usually went from around 6 am to 5-6 pm – sometimes starting or ending a bit earlier or later, but that was the gist of it. This was also the part where I delivered placentas during vaginal deliveries and where I got to see my first cesarean sections up close and personal.

For the second two weeks, I moved to a service called “Benign Gynecology.” This was basically a mix of clinic, surgery for “benign” things (like hysterectomies, cystectomies, hysteroscopies, etc.), and following any general GYN patients on the inpatient side of things. It would have actually been an enjoyable part of the rotation if not for also being the rotation where I worked under a rather… interesting intern. This particular intern will one day be an excellent physician and teacher, but at the moment is still trying to find her feet and seems to be channeling a lot of that frustration towards the medical students under her. She has very high expectations of herself and others, which is awesome, but did a poor job of communicating those expectations to us. Which meant that the entire two weeks was essentially a never-ending game of “guess what I’m thinking.” We as students did the best we could, but we all were incredibly relieved to finally get off that service.

OB-GYN ended with two weeks on the Maternal-Fetal Medicine service – these are the guys and gals who manage high-risk pregnancies – those with problems with the fetus (e.g. congenital issues) or with mom (chronic diseases, diseases related to pregnancy, etc.). It was mostly clinic – three days a week were spent doing repeat visits for current patients, and two days were spent seeing new patients and consults. Honestly, the rotation itself was enjoyable but the best part was working with normal people again and being off of benign gyn.

One of the patients I was following on the MFM service was a very pleasant lady who had ruptured her membranes early at 31 weeks gestation. She was in the hospital for observation and treatment and was now coming up on 34 weeks. At that point in her scenario, the risks of staying pregnant exceed the risks of preterm delivery. The plan was to induce her right at 34 weeks, which happened to fall on a day when I wasn’t at the hospital. Another medical student on Labor and Delivery was there, though, and told me about what happened. He had followed her for the induction process and helped with the delivery. Just before the baby came out, though, he had to leave the room to take care of another issue that kept him busy for a little while. When he came back, the hallway was quiet. Blood was everywhere in the patient’s room, and the husband was standing amidst the mess, crying by himself. The student rushed back into the OR to find out what was going on – it turns out, the patient had a condition called placenta accreta.

The placenta normally implants sort of superficially into the inner layer of the uterus, but in some cases, it goes too far. It can invade into the uterine muscle or even penetrate through the uterus into surrounding structures, like the bladder. Ultrasound during pregnancy can sometimes pick it up, but not always. When it does, delivery is usually performed by cesarean section and followed by a hysterectomy – there’s no way to normally deliver the placenta without causing massive blood loss. In this case, her placenta accreta wasn’t visible on ultrasound. The patient ended up losing about 4.5 liters of blood (the human body only holds about 4-6 liters), but thankfully they were able to quickly get her back into the OR, control the bleeding, perform an unexpected hysterectomy, and replace her lost blood.

A couple of days later, I had a free moment and ran by her room to see how she was doing. She was amazingly very positive, though understandably emotional – she was overjoyed to be alive and have a healthy baby, but obviously wasn’t planning on losing her uterus or coming that close to losing her life. Other people had talked with her about what happened, but she still had some questions and really just needed someone to talk to. One of the best parts of third year is that, in some ways, you are starting to become a part of the team and can actually begin to (cautiously) answer some of those questions, but you also have the time – sometimes – to just sit with your patients and spend more time with them than some of the more senior team members can (since they are busy putting out fires that never cease to get started). This was one of those times, and she’s a patient I’ll definitely remember.

The Verdict

I don’t see myself going into OB-GYN. Once again, I enjoyed several aspects of the rotation. It really is a pretty cool mix of surgery, primary care, clinic visits, and inpatient medicine. There’s a lot to do and a lot of very distinct fellowship opportunities. I didn’t think the test was quite as brutal as the Pediatrics final exam – we took an NBME shelf and I felt like the UWorld questions and the Case Files book, along with reading Up-to-Date and various articles throughout the rotation, was sufficient.

One thing that was interesting was just the simple fact that this was the first true “specialty” I rotated in. Pediatrics is a specialty, yes, but it’s essentially medicine for little people, which means it’s a very broad field. OB-GYN, on the other hand, has a definite knowledge set that those who pursue the field become experts in. I think that appeals to a lot of people (not about OB-GYN in particular, but about niche specialties in general), but I’m think I’m the type of person who would rather know a moderate amount of information about a broad range of topics (e.g. internal medicine, emergency medicine, family medicine, some surgical fields, etc.) rather than know a lot of information about a particular slice of medicine. We shall see.

In the meantime, though, I’m thoroughly enjoying a week off with my little family. Our son is almost a year and half now and is getting into all kinds of trouble. It’s awesome to see him figure out who he is and develop his own personality, interests, and sense of humor (like sitting on dad’s face. Apparently that’s the funniest thing in the world…). This Monday, I start psychiatry. The site that I have is known to be a bit of a true crazy house and also has pretty decent hours, from what I’ve heard. Should be a nice change of pace.

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