OB/Gyne & More

Having just taken the shelf exam on Friday, I've closed out my ob/gyne rotation. All jokes aside, I actually enjoyed the rotation. Enough that it's still on my list of possibilities. Along with most other things, as I'll touch on.

Except for the demographic restrictions, the pathologies and scope of practice are pretty diverse. Ob/gyns function as a lot of women's only interaction with the health care system. As such, this provides for a decent amount of primary care and outpatient experience. Outside of usual primary care stuff, there's obstetrics, which encompasses its own breadth of experience including prenatal care, normal births, instrument deliveries, C-sections, and conception/infertility treatment. Entwined in all of those are maternal and fetal conditions and morbidities of pregnancy with appropriate management.

Then there's the gynecological aspect, including birth control, dysfunctional uterine bleeding, cancer screening/biopsies, pelvic organ prolapse, and urinary/fetal incontinence. Gyne is a lot more surgically oriented, e.g. D&Cs, hysterectomies, LEEPs, tubal ligations, and prolapse repairs.

As a specialty, ob/gyn encompasses a lot: decent amount of clinic/primary care, inpatient medicine, and getting to operate. Not many specialties offer that combination. Of course the downers include being on call (though not as bad as gen surg), malpractice insurance (highest risk specialty), and regional litgation (Illinois is one of the worst states). Overall, I was pleasantly surprised by the specialty - especially since I was expecting to hate it and immediately rule it out. I might even say that I'm giving it some consideration.

On the "when I grow up" note, I now officially have no idea what I want to do. The first decision people traditionally make is between surgical or medical fields. I can't even decide between the two and want to do both. I know I want to be in the OR. I thought EM would quell my desire to do procedures. But it's just not the same as being in the OR and getting to operate. That said, I don't want the majority of my medical practice to be based on surgical anatomy - I also enjoy thinking and working through medical problems.

So, I've basically got a few months to realistically decide on a specialty - and I've regressed on that front since M3 year started. Score.

Rotation Highlights

Clinically Sweet Procedures
Translation: things that may not sound so hot to you, but are actually big deals to med students.
1.) D&C: dilation and curettage. Basically an ablation procedure, most commonly applicable to the uterine wall in the context of dysfunctional bleeding. As a lower end operation, why is it a big deal? Because my resident and attending let me do one of them :)

2.) Fascial closure. If you were watching an operation, closing would be the most boring part. That's because it is. Unless you're new to operating and actually get to partake. Closing fascia is basically what keeps your insides inside you. Nobody likes herniating through their incisions. The most suturing action we get is usually closing skin. So closing fascia, fat, and skin was pretty sweet. Especially getting to do it more than once :)

2b.) Digression. My other operative things were from gen surg and have a bit of a better "cool factor."
-Taking a rake out of a foot.
-Washing out a compound comminuted distal tib/fib fracture. Why is it cool? Because you could see the fractured bones outside the skin, and it was basically my hand and some soft tissue keeping the foot attached to the leg.
-Laparoscopically taking out two gall bladders, with an endocatch and a grasper. Basically like playing one of those "claw" stuffed animal games, except with a camera, a lot smaller instruments, and a gall bladder. Harder than the residents make it look, and a pretty sweet opportunity for me.

3.) LMA placement: laryngeal mask airway placement. One of the anesthesiologists and I got along pretty well, so she eventually had me place a few of these airways. I thought it was pretty cool, her letting me place airways. Especially since I'm only a third year, wasn't on an anesthesia rotation, and wasn't an anesthesia resident or CRNA student. The head is suprisingly mobile and taut at the same time when under sedation. As such, I'm a bit tentative to shove things down people's throats. Apparently that's poor technique. Regardless, it was a good learning experience :)

30 y/o G6P2032 sAB @ 16 wks
Translation: 30 y/o with six prior pregnancies, two full term births, three abortions/miscarriages, and two living children. This lady was by far the saddest patient of my six weeks on the service. This lady comes into the ER and we get called because she miscarried her 16 week fetus at home and was still bleeding. The bleeding was secondary to not having delivered the placenta and uterine atony, both of which resolved after she spontaneously delivered the placenta on the bed.

Messed up: she brought the fetus in. We ended up examining it and it was ridiculously disheartening to me. It was a lifeless miniature baby at only a few inches long. Even more fucked up is the fact that this was her fourth miscarriage. I can't imagine the pain and suffering this family has gone through over the past few years. With this many miscarriages, she's long overdue for a workup, i.e. for antiphospholipid syndrome, lupus, or something else systemic. Her lack of insurance keeps her from doing this and four miscarriages is the end result. Poverty's also keeping her from a proper burial for this fetus. She wanted to take the fetus home with her and bury it, but the hospital wouldn't allow it.

Long story short: this patient's story was immensely sad and emotionally draining. Even for someone who's grown somewhat numb to morbidity and mortality. We didn't even speak the same language, but our faces told each other what we were feeling. It was a legitimate downer to that night on call.

NSVD
Translation: normal spontaneous vaginal delivery. As opposed to complicated labor such as failure to progress, asynclitism, breech presentation, or any myriad of indications for C-section. Getting to deliver a baby is considered a rite of passage in med school, and I'd agree with that sentiment. It's not the prettiest thing, but it isn't as disgusting as I'd been led to believe either. That aside, I think it's pretty damn cool to deliver a baby and be part of bringing someone into the world. I only delivered a few babies, but it was legitimately one of the highlights of my clinical career so far.

Lost in Translation
In medicine, there can be a disconnect in communication between providers and patients. Especially when talking gynecological history in younger patients.

"Are you sexually active? Because your pregnancy test came back positive."
-asked of a teen patient with a belly bump complaining of weight gain, nausea, vomiting. And yes, belly bump is the medical term.

"No."

"..."
"How'd you get pregnant then?"

"Oh, I'm not active."
"I just lay there."

Just so not all my anecdotes from my rotation are depressing downers or med student geeky.