A Day in the Life of an Intern

Obstetrics Rotation. Week Two. An eternity ahead of me.

4:10 AM: Good God. It is early. Early by anybody’s standards. Even the dairy farmers must cringe from this early hour. And yet my eyes have been open for the last twenty minutes as I fight off sleep knowing that I’ll just have to get up in twenty minutes. Now fifteen. Now ten. Now five.

4:30 AM: Holy crap it’s early. Wasn’t I just awake? Didn’t I just do this yesterday? Of course I did. But I am only two weeks into this rotation with two more weeks staring me in the face. Now is the time to suck it up. No sense getting demoralized now. The funny thing is that no matter how bad you feel about a rotation in the beginning, towards the end and once you have gotten the hang of things it never really seems that bad. I’m counting on this but OB might be the exception to the rule.

On paper the rotation doesn’t look too bad. Four weeks of 12 hour days with two full two-day weekends at the end of the second and the fourth week. Not to mention only two call days on the two Saturdays when I do not have the weekends off. Let’s just call it Q14 call which is almost like not having call. Still, if there has been one rotation that has made me regret my burning desire six years ago to become a physician this is it. It is just so wrong to be up this early. Even Persephone my faithful Black Lab seems confused.

4:35 AM: Mouthwash is my total morning hygiene package. I shower, shave, and brush my teeth the night before to save the fifteen minutes that this usually takes me. I lay out my scrubs, shoes, pager, keys, pens and my PDA the night before as well because from the time my alarm rings I have thirty minutes to get to the hospital and every second counts. I guess I could get up at 4:15 AM but this would be wrong. So wrong. So very wrong. I fantasize about my old job when I worked for myself and set my own hours. Why, I sometimes didn’t get up until eight o’clock…and once I even slept until nine.

Have I mentioned anything about OB yet? No. Here is an important philosophical point. I know that our purpose as residents is to learn medicine and that this requires a certain level of enthusiasm. If we were perfect people we would look at the long hours as just another opportunity to live our dream, something we swore we were passionate about in our AMCAS personal statement. The reality is that medical training pretty much sucks and it is endured, at least in intern year, rather than enjoyed. Naturally you learn a lot but almost any intern would cheerfully sacrifice some of his training time for more sleep and a day off here or there especially since so much of residency training is ridiculously inefficient.

5:00 AM: Post-partum intern work rounds. An exercise in inefficiency if there ever was one. I am covering half of the floor, pre-rounding on the women who have given birth and seeing how they are doing. It is inefficient because I have to transcribe vitals, lab values, and anything else pertinent from the computer to my rounding sheet. This is 2006. You’d think gathering this information could be automated. Maybe you who are still dreaming of medical school will be the first to experience the truly paperless hospital. For now we scribble away like Mesopotamian scribes. At least we don’t have to wait for the clay to dry.

Welcome to the world of abbreviations. Even in the medical profession where abbreviating is a way of life OB/Gyn carries the practice to the very limit of practicality. Here’s my note on Mrs. Smith in room 5704:

29 y.o. G4P1122 POD 2 s/p PLTCS for pre-X @ 34/3 wks EGA c/b FGR, non-reas FHT A+/RI/RPR NEG/pap neg/M/no circ/bottle/IUD/DCHD No n/v/HA/SF/VB uo 1200 ml p/MN AVSS BP 130s/80s Tmax 36.9 HR 80s ABD: NT fundus firm incision c/d/I w/o s/s inf CV: RRR 2/6 ESEM RUSB RESP: CTAB EXT: no LE edema A/P: doing well. D/C tomorrow.

Which any fool knows means “Mrs. Smith is 29 years old, has been pregnant four times, has had one term birth, one pre-term birth, two abortions (either spontaneous or “therapeutic,” and two of the births produced live children. She had her current baby at an estimated gestational age of 34 weeks and three days and was delivered by primary low-transverse ceasarian section because of preeclampsia. The baby has fetal growth restriction and the delivery was expedited because of non-reassuring fetal heart rhythms. Mrs. Smith has a blood type of A pos, is rubella immune, has a negative syphilis screen, and her last pap smear was normal. She had a boy, does not desire circumcision, would like an IUD (six weeks post-partum) for birth control. She will bottle-feed her infant and will follow up at the Durham County Health Department for her post-natal care. Denies headache, nausea, vomiting, subjective fever, and vaginal bleeding. Her urine output was 1200 ml since midnight. All vital signs stable. Blood pressure was in the 130s/70s. She was afebrile and non-tachycardic. Her abdomen was non-tender and her fundus was firm. The incision was clean, dry, and intact without signs or symptoms of infection. Her heart rate was regular but she has a mild early systolic murmer hear best in the the right upper sternal border. Her lungs were clear to auscultation bilaterally and she had no lower extremity edema. She is doing well and we will discharge her tomorrow.

0545: Data gathered, rounding sheet organized I start seeing patients. “Habla usted English? No? Not even a poquito?” Goddamnit. At least half of the patients here at Duke are illegals. Probably one in five speaks English. I understand from my Spanish PA student (from Spain and therefore not Hispanic) that their Spanish isn’t that hot either and even she has trouble communicating. Cultural competency blah blah blah. It still wears me out because I am an American and was raised speaking English. (Although we once had a Greek patient. I speak Greek. The patient spoke English so it was a bust.). I could use the blue translation phones but that takes a lot of time to get set up.

“Dolore?” Blank look. I point. “Dolore?”

“Ah, Si! Jabber jabber jibber ga-jabber dipthong jabber jabber!”

“Uh, Okay. Feivre? Nausea? Vomito? Commida?”

“No.”

“Qualle anti-contepcivo quierres?” I ask. I’m trying to find out what birth control she wants but by the look I get I think I just asked her if she wanted cheese fries with her ferret. “Pastilla? Patch? Depo?”

“Ah! Si! Pastilla.” Pill, I think, and it will be micronor because God bless illegal immigrants they at least have the sense (or lack the money) to breast feed their babies.

Well. Preliminaries out of the way I motion that I’m going to feel her abdomen and listen to her heart. The husband looks on disinterestedly. I woke him up too. Sorry Amigo, this isn’t a hotel.

Everything fine. Answer of “No” to my question of “sangre?” with pointing to region of her vagina. No vaginal bleeding. Post-partum day two so we will discharge her today.

On to the next patient, Mrs. Walsh, cradling her dead baby which died early this morning in the NICU from a congenital heart defect except I don’t know this at the time. I have never seen Mrs. Walsh before and everything I know I learned from yesterday’s progress note by another intern. The ideal they teach you in medical school of following every patient from admit to discharge is just an ideal. On a large volume, high turnover service like OB as an intern you will follow many patients who you know nothing about until you round on them for the first time. Mrs. Walsh’s note said “G2P2002 s/p RLTCS @ 33/5 for pre-X c/b fetal CHD” but since the baby died only hours ago there is no mention of this in the note.

Still, something tells me not to make the usual polite comments about the baby. The mood is somber. The mother has a puzzled look on her face as I introduce myself. The baby is wrapped in a blanket and I think to myself that he doesn’t look very healthy. (No kidding.) I ask the usual questions, complete my exam, and before I go on to the next patient look through the pediatric notes (something we almost never do on OB) to see what is going on.

More patients. The interns are responsible for post-partum patients. The upper levels round on the ante-partum. The other intern is OB/Gyn and like me is at the end of her intern year. Unlike me she has been doing nothing but OB for the last eleven months so she knows a tad more about the field than I do this being my first OB experience since the beginning of third year in medical school. She seems exasperated both at my lack of knowledge and at my unfamiliarity with her department’s procedures. This highlights one of the drawbacks of training as a generalist, namely that you jump around a lot never really getting the hang of anything. She’s nice enough but tends to talk down to me, something I tolerate because as I mentioned earlier I am starting my Emergency Medicine residency in June and I just don’t care. I have two weeks left at Duke and as much as I dislike it I have been nothing but affable and polite the whole time and I’m not going to change this winning strategy now. Still, it’s easy to be an expert on a couple of pelvic organs. I’m sure I’d be pretty handy to have around if, oh I don’t know, somebody was having a heart attack or a stroke.

0710: Formal rounds. Basically a conference where the antepartum, intrapartum, and postpartum patients are reviewed. The interns review their patients last in as an efficient manner as possible. This procedes quickly as OB is a very busy service with a lot going on and they don’t have the luxury to debate the causes of a patients hyponatremia like they do on a medicine service. The upper levels leave to scrub in on their scheduled cases. The other intern goes to clinic. I go to triage where I will spend the rest of the day.

Triage is the point of entry to the OB floor. Although there are a few direct admits, most patients come through here to be assessed. As the emergency department sends up every pregnant patient who is not spurting arterial blood, it also functions as an obstetrical emergency department. They also answer phone calls and handle telephone triage. (“Hello, I think my water just broke.”)

During the week triage is supervised by nurse-midwives. For those of you who don’t know it, nurse-midwives are nurses who undergo approximately two years of intensive obstetrics training. They are pretty well trained and qualified to handle all but the most difficult of vaginal deliveries. It’s a pretty good arrangement if you are just rotating on OB because OB/Gyn residents are notoriously clique-ish and it is very easy to get ignored during your entire rotation. Not that this would be a bad thing you understand but we are here to learn how to deliver babies and manage common obstetric problems. The midwifes are a lot friendlier and more willing to teach than the residents if only because the residents work pretty hard and don’t have time for your incompetence especially if you are not an OB/Gyn intern.

0810: 25 y.o. G1P0 @ 38/4 wks for SROM. (Spontaneous rupture of membranes) Thinks her water broke but isn’t really sure. Has some leakage of fluid but not enough to soak her panties. (Yes, this is an important part of the review of systems.) A sterile speculum exam shows no pooling of fluid. The nitrazine paper does not turn blue (amniotic fluid is acidic) and there is no “ferning” on the slide. Her cervix is one centimeter dilated, slightly effaced (I say about 10 percent but hell, what do I know?) And anterior. She can go home.

0840: 17 y.o. G3P0020 @ 36/3 wks for EOL. (Evaluation of labor.) Said she has a “boogery” discharge two days ago which was probably her mucous plug (which seals the cervix) and is now has contractions every five minutes or so. Denies ROM (rupture of membranes.) Her cervix is 5/50/-3 or five centimeters dilated, fifty percent effaced (or thinned) and I just tack on the -3 station because while I feel her membranes in the os (or mouth) of the cervix I don’t feel any baby parts. The midwife assures me that the baby is cephalic. She shows me the Leopold maneuvers to verify this and I politely nod but admit that I can’t tell the difference. I get the ultrasound machine and correctly identify the head pointing down. The midwife laughs good-naturedly and I accuse her of being a witch (which many superstitious people still believe about midwives). Five centimeters is the definition of labor so we admit her. Nice contraction on the monitor and the baby’s heart rate is normally reactive.

0920: 29 y.o. G2P1 @ 22/3 wks EGA with placenta previa for vaginal bleeding. This is a potentially serious problem so I call the upper level resident after I get a quick history. It was not much bleeding. A little less than a light period. The patient is on strict bed-rest at home and apparently this is not an alarming finding. Under no circumstances does anything get get inserted in her vagina blindly. The resident does a careful speculum exam and sees no blood at the os so she is sent home with pelvic precautions. (No sex, among other things.)

0940: Called to a delivery. The usual cheerleading for the mother. The nurses labor the patient and only call the intern when they think the baby is ready to come. Nothing to it, really, from our point of view if everything goes well. A couple of pushes, one hand on the perineum to support it and help prevent tears and one hand on the baby’s head to prevent it from popping out, also to prevent tears. The usual gush of fluids as the head appears and restitutes (or turns). Gentle traction down on the head to clear the presenting shoulder and then up to clear the posterior shoulder and the baby is out. A little bit of suction and if the baby cries put it on the mother’s chest for a few seconds so she can see it. In a normal birth there is no need to rush to cut the cord. The OB/Gyn residents are more business-like and clamp and cut immediately. The midwives often let the mothers hold the baby for several minutes (if the baby is breathing and looks good) especially if pediatrics has not arrived yet at which time they will usually demand the baby. If there are any problems the resident is paged and takes over. No lacerations so after the placenta delivers I congratulate the mother and go back to triage.

1020: 37 y.o. G1P0 @ 38/6 wks for EOL. Large woman. My fingers are either not long enough or her cervix is in some weird position. I’m not that great at cervical exams. It does take practice. The first twenty or so you do all you can really tell is that it’s warmer in there than it is outside. I can usually find the cervix and I can tell you with confidence if it is closed, long and high (or normal) but after that we get into the realm of subjectivity. Some of the time I can say with confidence the degree of dilation or effacement but if I’m not sure I ask the midwife to check behind me (which she usually does anyways).

1130: 24 y.o. G2P1000 @ 27/6 weeks EGA c/b PIH (Pregnancy induced hypertension) with bilateral lower extremity swelling and pitting edema (a finger leaves an impression). Her history is troubling as she reports a two day history of headaches, seeing spots, and swelling. Naturally the concern is for preeclampsia. Her blood pressure at presentation is 160/100. She gets a stat preeclampsia work-up which shows protein in her urine, a high serum uric acid, and a protein to creatinine ration of 426. Her liver function labs (the LFTs) are normal as are her platlets so she doesn’t have Hemolysis, elevated liver-enzyme levels, and low platelet count (or HELLP) syndrome. She is admitted and placed on a magnesium sulfate drip for siezure prophylaxis and hydralazine for blood pressure control the goal being to avoid ecclampsia, fetal death, and end-organ damage. If everything goes well she will be delivered at 30 weeks.

1240: Phone triage. G1P0 @ 12 wks EGA with spotting after intercourse. A lot of spotting? No, much less than a usual period. I fight to keep a level expression as I ask if her husband is a large fellow. Yes. Sometimes it hurts. Use a good lubricant. I think you’ll be all right. No need to come in.

1300: G11P5328 @ 24/4 wks EGA with chest pain. Yes. That’s right. Eight live births none of which she ever cared for as she is a prostitute and not a very smart one at that. Extensive and varied social history as well including most of the major illegal drugs. Now chest pain I can handle and happily work through something I am familiar with for a change. Happily, none of the midwives or residents are very good at reading an EKG so I have a chance to show that I am not a total idiot. Eventually three sets of cardiac markers will come back negative. The EKG is also negative. It is just GERD which I knew two minutes after meeting her. Still, you can’t be too careful. She signs the papers for a BTL (Bilteral Tubal Ligation) after her delivery scheduled for 40 weeks and the nurses and midwives do the wave (silently).

And so it goes until 1800 when the night float intern shows up and we find the chief resident to do our checkout. During the entire day I have also been covering the post-partum patients. As most of them are pretty healthy (because pregnancy is not a disease) this doesn’t involve too much work. The standard orders on every patient cover almost everything and I probably only get five or ten calls from the floor in the entire day. I have to do all the discharge paperwork for our mother who are going home of course which I fir in while I handle triage.

Not much to it. Like I said, technically this should be an easy rotation. It’s busy but not crazy busy most of the time. The day does go by quickly. The residents are friendly (mostly) if a little distant and the I get along very well with the nurses and midwives. But I don’t like OB in the slightest and this makes all the difference. Not to mention that by a twist of fate I haven’t had a day off in nearly three weeks (I was post-call the day before I started and had call last Saturday) and I am kind of worn out in general. I usually get out around 1830. Trust me. Two weeks of 14-hour days will wear you down.

1845: Home, finally. Obligatory Frisbee with Persephone as my kids tell me about their day and my lovely and long-suffering wife updates me on the sale of our house which is not going well. I have to be up in the great frozen tundra in five weeks and it looks like I’m going to be living alone up there until the house sells. Like most residents with families, we are living on the brink of financial disaster and we can’t afford two mortgages. Still, we just had our fourteenth wedding anniversary, our children are healthy and happy, and we have prospects for the future.