Tuesday, September 29, 2009

Stupid me

I decided that seeing patients at 6 am one day a week was a good idea.

Working patients (i.e. my insured patients who followed me to the clinic from private practice) love it.

I am not a morning person. Neither is my nurse. Every week, I bitch and moan on Tuesday morning.

Monday, September 28, 2009

Readings

So every doc tried to keep up in journals. It's an impossible task.

I skim the Green and Gray journals, but I read the "Throw-aways" cover to cover. Why? Because they are practical and summarize the research for me. Plus the malpractice columns are always interesting reads.

So today I was reading one of the throw-aways (The Female Patient, if you care to know) and there was an opinion piece on elective deliveries. Good research shows that delivering prior to 39 completed weeks increases the chances of neonatal complications. This is well known and trumpeted through OB-dom. Many OBs choose to ignore the evidence, but it is true. It's why I don't do it electively.

I honestly think the idea of elective induction being out in the community is dangerous. Women just think "oh, I'm going to get to have my baby when I chose." But I hate the idea! Sometimes, I wish patients didn't know that we can do it. The problem is, they DO know. And there is pressure.

Saturday, September 26, 2009

Preventing c-sections

Earlier in comments, someone criticized a labor with interventions. First off, I agree on trying to minimize the medicalization of pregnancy and labor. Mother nature is smarter than me and my pediatric colleagues. I try not to do elective inductions and my patients are told this AT THE FIRST APPOINTMENT. Labor works better if it comes on spontaneously. Plus the risk is lower that the baby will need my colleagues in peds.

Now, there are indications for inductions. And I have no hesitation to do them if I feel the benefits of delivery are more than the benefits of continuing the pregnancy.

I've looked at this month's stats thus far. Note that I do not do VBACs due to medmal insurance coverage. Rural areas have a more difficult time with the "suggestions" for dealing with one in labor, so I can't comply with the requirements the insurance company has. So anyone with a previous c/s gets an elective repeat c/section sometime in their 39th week. I don't want to add to risk, I work hard to prevent the c/s in the first place. I offer versions for those with breech/transverse fetuses.

For women with a planned vaginal delivery, 1 section out of 23...a 95% rate of delivering vaginally. My overall vag delivery rate (including those with planned c/sections for repeat, previa, malposition) is 81% (22/27). Most people were spontanteous labor. Several were inductions at 42 weeks, one induction for GDM, one induction for fetal anomaly with me wanting her to deliver during the week when peds would be available, two inductions for IUGR (the one failed delivery).

I have been trained to do c/sections...and they can be life-saving. But a large part of my time on L&D is being an overpriced cheerleader: "You can do this! Push! I can see head!" My value is knowing when to intervene and when to hold back. It's an art...one where I'll always be learning. Should I have called the section sooner? Did I call the section too soon? Should I have tried an operative vaginal delivery first (I admit, I do do nice vacuums)? Why do I have a bad feeling in my gut...there's nothing objectively wrong.

I readily admit, most of the time I'm kinda superfluous to the process of delivery. But those times when I'm not...that's when I earn my gray hair.

Thursday, September 24, 2009

Sunday, September 20, 2009

He's There...


Guess what I did this weekend?

I've seen Phantom several times before, all in the touring show (twice in college and once in residency). But this time, the Girl and I roadtripped to NYC and saw it on Broadway. (yes, the neon lights were bright)

Wow. Just WOW!

I've never before been to Broadway itself, despite my love of musicals. I had forgotten how romantic and seductive Phantom is in person. Yes, there is cheese galore, but I love it anyway.

And the guy playing Raoul is HAWT!

I didn't stop smiling all weekend. DD and I went to Times Square, Broadway, Central Park, and the Titanic exhibit (which was amazing, if you're in NYC go to it!). We spent Friday and today traveling, so we packed a LOT into a few short hours on Saturday.

Is it wrong to order a BLT on challah bread at a Jewish deli?

I need another vacation, a real one, not one spent at Mecca's hospital with my mother. This will do for now...I'm far more saner today that I was this time last week.

Thursday, September 17, 2009

Lucky 13

That's how many I've delivered since Friday. And there's an induction today.

Thank god I'm off this upcoming weekend!

Monday, September 14, 2009

Ahh, residents

So as part of my job, I have family practice residents in my clinic learning office GYN.

I had a patient come in recently for her postpartum check. She is a lesbian in a relationship with a great gal.

My resident was insisting that she needed birth control. I looked at the patient, smiled and winked. He just kept going deeper to my and the patient's amusement.

We finally reminded him that her partner is female...pregnancy for them requires some extra interventions.

You know it's a bad weekend...

When you have to bring in food for the nurses as an appeasement.

Every single patient on L&D was mine.
:(

Saturday, September 12, 2009

Friday night call

10 pm...delivery.

Check on the other 2 laboring. They're both fine. Head for call room at 11 pm to nap before delivering the next one.

Between 11 and 1 get 15 pages...mostly dumbass stuff. I actually asked one patient "Why ARE you calling me at midnight for this? This is for emergencies only!" She wanted to know what OTC meds she could take while pregnant. She obviously didn't read/lost the handout we give on that at the first appointment.

1 am...called for repetitive decels. Get the baby looking better than head back to sleep.

4:30 am called for delivery of baby.

6 am get back to bed after delivery.

8:43 am dumb husband calls to ask what I am doing. I might have been a little snippy to him.

10 am finish rounding. Break 3 girl's water to place internal since she isn't making much change.

Anyone would to take bets on zippering her this afternoon?

Friday, September 11, 2009

Cow story

So I'm in BFE. I can buy a cow and get it butchered pretty easily. In fact, my supplier is an L&D nurse. Many women around here work for the hospital to get insurance coverage for their farmer spouses, but I digress.

So I came home and said at the dinner table "I bought a cow."

DD's response : "It's going to live in our yard?"

"No. In our freezer." DH shot me the look.

Had DH pick up the order today. We now have about 400 pounds of beef at our home. Ummm...t-bones.

Help me


Because DD has decided that THIS is the instrument she wants to learn to play.

The violin.

Shoot me now. Please?

Wednesday, September 9, 2009

Trust

OK, we spent 45 minutes in the office discussing various options to treat your problem...both surgical and nonsurgical ( and yes, I documented and billed for that time, since BCBS will pay). And yes, I answered all of your questions there. I also remember my surgery scheduler calling you a PITA for all of your questions about stupid things.

Do NOT in the pre-op area quiz me on every detail on how I do the decided upon surgery including what SUTURE I use!

AURGH!!!!!!!!!!!

Tuesday, September 8, 2009

Stupid people, part one millionth

If you are in your first trimester of pregnancy and you fall on your back on SATURDAY...waiting until TUESDAY to get checked out is pretty stupid.

Yes, this was just a call a few minutes ago from L&D.

AURGH!!!!

Friday, September 4, 2009

Costs of obesity this week

3 D&Cs for AUB with thickened endometrial lining on ultrasound. Unable to get biopsies in the office for any of them. BMIs of all 3 are north of 50. I'm charging the insurance companies extra for the degree of difficulty - one of them I had 4 people scrubbed in with me to hold back assorted tissue. Plus you have the whole anesthesia charges. None of my normal vaginal instruments are long enough to work, so I'm Macgyvering solutions. Retractors aren't long enough, so I'm improvising there as well. My overhead lights can not be positioned so that I can see - I'm placing the hysteroscope's light source in the vagina...worked pretty well.

Induction for chronic hypertension, which would likely go away if about 100 pounds were lost.

Long discussion with a patient emphasizing her risk of post-op complications...I'm going to try and do a laparoscopic hysterectomy on her. Talked about wound infections, conversion to open procedure, blood clots. Told her it would be difficult. Her response "Is it because I'm a big girl?" Um, your BMI is higher than my age, so yeah, you're a big girl. And yes, that makes everything far more risky and complicated.

Post-op cellulitis in a c/s from last week.

Yeast infections galore.

Wednesday, September 2, 2009

Update

The meeting went as expected. Blah, blah, blah went a lot of whiny doctors. My new iPod has games on it too, which was handy since my phone's battery died.

As I was walking out of the Surgery Dept's meeting, I was with a couple other surgeons. We were commenting on another surgeon's perpetual whining and nitpicking, which was on full display at the departmental meeting.

Said the one of the others "Tom is so busy looking at the tree he doesn't realize he's in the wrong fucking FOREST!"

And so it goes.

Tuesday, September 1, 2009

Whine

The stupid quarterly med staff meeting is tonight.

I hate those damn things.

I sit in the back and play games on my phone. Much better use of my time.