Rants from the Crib

An Ob/Gyn gone mad

Archive for the tag “physicians”

Take Your Vitamins

Most of you are familiar, I believe, with the concept of vitamins. They are compounds that are essential (or at least damn useful) to the physical well-being and development of the organism taking them. Many of us take vitamins. Some take them religiously. They have been seen as possible cure-alls for almost everything. My husband superstitiously takes magadoses of Vitamin C whenever he feels like he is getting sick, which I think is a crock, but it probably won’t hurt him. The problem is, when I feel like I might be getting sick, he tries to foist them upon me too, and he becomes indignant when I refuse to take them. My dad, in the past, has dabbled with mega-doses of various vitamins and minerals. Usually when you take hyperdoses of vitamins, your body takes out what it needs, and dumps the rest into the toilet, wasting your investment

I will stand on my Doctor Soapbox for a moment, and remind my gentle readers that it is actually dangerous to take excessive doses of the ADEK vitamins (a mnemnotic for vitamins A, D, E, and K), which are the fat soluble vitamins, and they can actually hurt you in excess. It has been discovered that Vitamin E, taken in dosages higher than recommended, can cause heart problems.

Among other things, excessive vitamin A can cause birth defects in a fetus who is conceived when Mom is on megadoses. The acne medicine Accutane is actually a form of extremely high-dose Vitamin A, and they medically recommend abortion if you become pregnant while taking it – it often results in babies born without brains, which, needless to say, is an extremely undesirable outcome. Physicians are required not to prescribe Accutane for a female of childbearing age unless it is verified that she is on a reliable form of birth control. Accutane has been linked to suicide in some users. I don’t like Accutane. It is nasty stuff.

Then there are “medical vitamins”. These are not actually vitamins, but are very useful medications. Anything we medical types jokingly call “Vitamin” is usually a drug that gives immediate results, typically for a patient who is anxious, in need of immediate intervention, or a pain in the ass.

Vitamin K is a good one. There is an anesthetic drug out there called ketamine. Some of you may know of it. It was initially used as a veterinary anesthetic, because when they tested it on humans, it caused pretty intense hallucinations. It is seeing more widespread use now in people. My specialty uses it frequently to boost pain control in an awake patient who is having some discomfort during her c-section with a poorly functioning epidural. This results in the patient saying some pretty darn amusing things. I was actually given it during my c-section, because I had a hot spot in my epidural and was in a lot of pain. I watched the anesthesiologist squeeze something into my IV really fast and then I was out. When I awoke a few minutes later, the pain was gone, but all I could see were blue brains. Fortunately, I am not easily rattled and pretty much realized they had just dosed me with ketamine. The blue brains turned into blue triangles, and then I realized it was just the blue surgical drape that was placed over me. I couldn’t remember what I was doing for a minute. “Oh,” I thought, “I’m having a baby. Is it a normal delivery? No. It’s a c-section. What’s a c-section?” We also use it to quickly sedate uncooperative patients who need to undergo anesthesia. We hit them with something called a ketamine dart, usually in a sneak attack on the shoulder. Most typically this is used for patients who are unable to understand or cooperate, or who may be outright combative. I have a fairly large group of patients in a state facility who need annual pelvic and breast exams, but they may be violent or scared and unable to be awake for them. They are brought in, given a ketamine dart, and then their IV is placed after they are asleep. In one particularly funny episode, we were sedating a large and dangerous mentally handicapped female patient who struck fear and respect into everyone she came into contact with. She is missing one eye, and legend has it that she is so mean, she removed it herself. At any rate, she bites, spits, and hits anyone who comes near her, and she packs a mean wallop. Our anesthesiologist danced around her like a prizefighter, trying to sneak up on the side of the missing eye to administer the ketamine dart. She caught sight of him anyway, and administered a massive blow before he could duck away. She was finally successfully sedated, but not without a lot of expletives from the nurses and the anesthesiologist. Ketamine is also a street drug, prized for both its general anesthetic and its hallucinatory properties. On the street it is known as Special K.

Vitamin A is Ativan, which is a drug in the same class as valium and it works great on addled little old ladies who are in the hospital and causing a fuss. Typically the anxious patients are placed on this medication, or others in its class, as outpatients, to calm nervousness and the bad habit of calling the office daily with imaginary problems.

Vitamin H is Haldol, which is less commonly used, but extremely useful in the case of a violent or psychotic patient as it is a rapid acting antipsychotic and has an almost immediate sedating effect. We will frequently call for “a butt full of Haldol” for an out-of-control patient, because they aren’t going to cooperate with any pills given them, and pills wouldn’t act fast enough anyway. The key is to, well, corral them enough to pin them down and administer the aforementioned Haldol Butt Shot.

Vitamin V, or Versed, is also an antianxiety drug that is extremely potent. It is used for situations where a patient needs to remain conscious but sedated for a procedure, and combined with a good pain med, it keeps them calm and comfortable. Vitamin V is used routinely in the OR holding area, where the patients waiting for their surgery are almost certainly anxious, whether they seem so or not. Versed also has a powerful amnestic effect – that is to say, once you are given it, you will almost certainly not remember what transpires in the next few hours. This is handy, because the patients will not remember the ride back to the cold OR, the positioning on the table or preliminary and potentially frightening discussions about instruments or other such. Best of all, should a patient have an extremely rare consciousness experience under general anesthetia, which I understand is terrifying, they will probably not remember it. Having been given Versed myself, I can testify that the stuff is AWESOME.

Watching a patient being given Versed is a wonderful thing to see. At the bedside, in preop holding, your patient is trying to hold it together but it is obvious that they are tense and aprehensive. After your preop chat, where you address any final questions or concerns, it is nice to be able to then say to the patient, “Anesthesia is going to be coming in a couple of minutes, and they will be giving you the equivalent of at least 3 margueritas in your IV. Once you get that stuff, you will be grinning and telling me that you’re so psyched, you’re having surgery!” They look at you skeptically, and you hang around because it is so merciful and fun to see that stuff kick in. When anesthesia arrives with the syringe of Versed, you tell the patient, “Here come your margueritas!” They will eye their arm apprehensively and watch as the needle pushes the medicine into the IV. Then, about 30 seconds later, you can see them visibly relax, and almost sink into the bed. A lot of times they will look at you out of stoned eyes and slur, “Thish shtuff is AWESOME! I’m having Shurgery! YAY!” Gives me a kick every time! And a lot of times, they will tell you some REALLY funny things. One patient, after her Vitamin V, became convinced that the handsome CRNA was a doctor whom she needed to seduce and make her sugar daddy immediately. She pinched his ass repeatedly, making him yelp and jump every time he tried to check her vital signs. She kept offering him fascinating sexual favors, some of which are only available online, and he was so embarassed that he turned bright red, which was hysterical because he is normally an obnoxious and non-embarassable person.

My husband has a very funny history with Versed. After we married, for the first several years, he seemed to need a surgery almost every year, usually in November. For his first ever surgery, I accompanied him to the holding area because I am a doctor and I can. I also had some concerns. My husband, in his right mind, is a blabbermouth who cannot keep a secret even if he really means to, and has very little internal filter regarding whether something might be inappropriate to say. He has mortified me on numerous occasions. Rarely, I have seen him drunk, and am surprised he has not been arrested (or at least had the shit beat out of him) for some of the things he says. He loves women and doesn’t have any problems with discrimination against women, near as I can tell, but what he thinks is subtle sexual innuendo, out of his mouth, can be freaking AWFUL. No filter. Then he brightly looks around and says, “Oopsie! Was that my out loud voice?” I maintain that it is his out loud OINK.

At any rate, I had concerns about his behavior under the influence of Versed. It was entirely possible that he would began to disseminate details of our intimate personal lives, or the last awesome video he saw on YouTube, all of which would render me humiliated and my colleagues confused as to what kind of person would marry someone this awful. So I was there to police him, at least until he was wheeled back to the OR. Well, Vitamin V knocked him on his ass. I somehow kept him on track until they wheeled him back, but I am still worried about what he may have said on arrival to the operating room. The problem is, it may have been embarassing enough that my colleagues would not report it to me. I will never know.

After the surgery, my husband waxed lyrical about the amazing stuff they gave him on the way back to the OR. “I never understood how anybody could crave or be addicted to drugs, but I could sure see wanting more of THAT stuff!” He did remark, however, that he found it extremely disarming that he could remember nothing after the injection was given. That could be disturbing for a bona fide control freak, which he most certainly is. At any rate, despite that, he found the stuff quite enjoyable.

A year later, we were back in the holding area, getting ready for another surgery. My husband had told me that he was psyched, because he was looking forward to the Vitamin V, but that this time, he was DETERMINED not to forget events that followed its administration. I told him that was probably not possible. He insisted that his superior intellect would absolutely make memory of the event possible. I found this immensely reassuring, because, distracted by the work of recalling all events with his “superior intellect”, he would be unlikely to say anything inappropriate, because he would be focused on remembering everything around him. I also found this extremely amusing, because a fiendish plot was forming in my mind.

Prior to the administration of the Versed in the holding area, I pulled the CRNA, who is a friend of mine, aside. I explained to him the whole dislike of forgetfulness and loss of control thing, and about my husband’s determination to use his “superior intellect” to beat the amnesia. My friend, who is my friend because he catches onto things very quickly, smiled a sneaky Grinch-like smile at me. “I’m doubling the dose.” he told me. This did not concern me as it would not harm him – he was about to be put all the way to sleep. It would, however, be wicked funny as hell.

Sure enough, my friend loaded up enough Versed to drop a rhino and pushed it through my husband’s IV. He was WHACKED. I watched him ride back to the OR, pointing at objects on the way back to the operating room and slurring, “I’ll remember you DOOR and I’ll remember you WINNOW and I’ll remember you LADY and I’ll remember you DESK…”. Awesomesauce. Never laughed so damn hard in my whole life.

After the surgery, I asked him how his memory was. He was indignant, because somehow, the drug had overcome his superior intellect. He couldn’t understand it. Of course, at that point, the final stop in my plot arrived – I told him I had arranged to have him DOSED and he couldn’t have remembered his name if someone had asked for it at that point. He was downright incensed. And then he laughed. And laughed. Because he loves a good joke, even if it is on him.

So as a medical person, I must say, it is essential to remember your vitamins! And not just the ones that come in expensive bottles at the GNC…

Medical Coding Made Easy

Many of you may wonder, how is medical billing done?  How are your unique ailments translated into standardized format, to be recognized as payable by the insurance company?  Or, more likely, NOT recognized as payable to the insurance company.

The first coding category is ICD-10 code.  Translated into English, this category encompasses Shit That Is Wrong With You.  For example, gonorrhea is 098.0, which encompasses the following conditions and more:  acute gonorrhea, gonorrhea of the vagina, gonorrhea penis, gonococcal urethritis and acute Bartholin’s gland gonorrhea.  However, something slightly different (and you may be provided hours of entertainment trying to visualize how this was transmitted), gonococcal infection of eye is 098.4.  There are codes for every possible disease, illness, deformity, even one for High Risk Sexual Behavior.  I have this one memorized.  The digits in front of the decimal point usually delineate the main category of the disease, whereas the 2 digits after the decimal point delineate more specific details.  That fifth digit (the second one after the decimal point) is added only where extreme differentiation is required, say as in 607.83 (edema of penis) and 607.84 (impotence of organic origin).  In my opinion, many codes for Shit That Is Wrong With You have been excluded.  It would be very useful, for example, to have an ICD-10 code for Skank Ass Ho.  This would immediately trigger payment by insurance for things such as testing for STDs, multiple pregnancies, and chain smoking.  You could add a fourth digit, after the decimal point for Skank Ass Ho Who Lives In A Trailer Park, and a fifth digit to delineate Skank Ass Ho Who Lived In A Trailer Park But Got Thrown Out On Her Ass For Screwing The Guy In The Trailer Next Door.  See how useful this would be?  Also there could be one for Neurotic Middle Aged Woman, which would cover any number of ills, which I will not go into here for fear of being lynched.  Another highly useful code would be for PITA (which physicians all know stands for Pain In The Ass).  That code should cover all sorts of tests that the patient demands for ailments that he doesn’t really have, and allow higher billing, because the visit will be interminable because of all the whining and complaining.  The ICD-10 codes are changed almost annually, to numbers that are frequently completely different, by the Powers That Be,which are most likely owned by Big Insurance Companies.  The changing of the codes occurs in hopes that some hapless doctor will accidentally use last year’s code, which is now obsolete, and then they can weasel out of paying. 

The second category is the E Codes, which in English mean Bad Shit That Can Happen To You, basically from an external force.  These are numerous and extremely specific, such as Slipped On Deck Of Yacht While Walking In Swim Fins.  I believe this one actually exists, although I seldom have cause to use it.  The ones I use are usually tragic, things like Spousal Abuse, or Rape, Alleged.  You gotta love it.  Even medicine is biased against the sexual assault of women.  There is no Rape.  There is only Rape, Alleged.  I am totally surprised that they don’t have an E Code for:  Rape, But The Bitch Totally Had It Coming.  They have numerals that differentiate between Jumped and Was Pushed.  I shit you not.  There are some E Codes that would be extremely useful but do NOT exist, such as Had His Ass Kicked In A Bar Parking Lot After Talking Smack To Some Gangsta Guy.  Now THAT would be useful.

Then there are CPT codes, which translated into English are Shit That The Doctor Does To You, which covers most surgeries, treatments, and other medical interventions, or a badly needed bitch slapping.  We use these to cover Normal Spontaneous Vaginal Delivery, Primary Cesarean Section, Total Abdominal Hysterectomy, and Oopherectomy (removal of the ovaries), just to name a VERY few.  The insurance companies like to “bundle” these codes, which is to ensure that we are paid as little as possible.  For example, you are paid so much for just a Total Abdominal Hysterectomy.  If you remove the ovaries at the same time, these two codes are bundled, because they are frequently done together.  If you had removed only the ovaries, you would have been paid for that, but for both together, you just get paid the one reimbursement, usually the lower of the two costs.  They bundle some rather unlikely things, to make sure that we don’t get too big for our britches and do “unrelated” stuff.  Also, let’s say you do two procedures, with two different surgeons.  The specialist OB/Gyn does a hysterectomy, and a sub-specialist Urogynecologist does a bladder lift procedure, during the same surgical episode.  Typically only the sub-specialist is reimbursed, for both procedures, because they are considered capable of doing both, and sub-specialist outranks specialist.  I consider this outrageous, because it deters physicians from seeking specialized care for their patients, because if we bring in a sub-specialist, we don’t get paid for anything.  Thus, patients may be subjected to two different procedures at two different times, so that reimbursement will be given to both parties.  Now tell me how that optimizes patient care?

There is another coding system, for psychiatrists, which I believe is now DSM-4.  They change that up a lot, just like the CPT codes.  New diseases are added and removed with each revision.  For example, Female Hysteria was finally fortunately removed .  See?  We are making progress.  Psychiatrists code things on Axes (plural for Axis), in which one axis might be physical (like psychosis induced by lack of sleep), or biochemically induced bipolar disorder.  Another axis might be external, such as psychosis triggered by drug ingestion.  My friend, with a PhD in psychiatry insists that they should add a whole other axis, “The Axis of Evil.”  She also states they should be better reimbursed if it is invoked.

So let’s see how all this works.  A patient presents to the ER, bashed up and ranting and raving.  ICD-10 codes might be Acute Alcohol Intoxication, Chronic Alcoholism, Oppositional Defiant Disorder, Nausea and Vomiting and Opioid Addiction, Other.  E-codes might be assigned for Had His Ass Kicked In The Parking Lot Of A Bar After Antagonizing Some Dude Named Vinnie and Blunt Force Trauma To The Head, .  CPT codes for Shit The Doctor Did might include codes for Gastroesophageal Lavage (stomach pumping), four-point leather restraints, skin suturing, CT scan of the Head, and Adminstration Of A Rapid Paralytic Agent To Settle The Guy Down And Shut Him The Hell Up.  See how neatly that works?

I hope that this quick guide has helped you to a deeper understanding of the inner workings of the world of medicine.  If it does, I’ll send you a bill.  ICD-10:  Eyestrain, and Complete Incomprehension of Medical Procedures, E-Code:  Spending Too Much Time Reading Blog Posts, and CPT code:  Administration of basic information needed to comprehend the complexities of the medical world.  That’ll be $1,349.53, of which your insurance will cover $135.  Any further questions will cost you extra.

Flu Shots

I am adamantly and passionately pro-flu shot since my own run-in with the flu.  I remember the exact year and the place:  1992 and Bethesda, at the National Institutes of Health.  I was working there on a Howard Hughes fellowship for the year, and in the early spring I contracted a most virulent strain of influenza.  I was sick as a DOG.  I literally did not leave my bed for three days, except to go to the bathroom, which I barely remember.  I did not eat or drink.  My fever cranked upwards of 104 degrees and there was no one there to take care of me; my folks lived in Alabama and I did not dare ask anyone else to get near me for fears I would get them sick too.  Not only that, but the flu left me drained, weak and unable to work for nearly a week afterward.  For someone who hardly ever gets sick, that is saying something.  It also left me horribly depressed, a known side effect of influenza.  I called my mother crying every day for a week during my recuperation.  She was terribly concerned about me, as well she should have been.  The next year when the flu shot was made available, I took it.

I got the flu shot every year since then.  I have already gotten my flu shot this year.  I have gotten them for twenty years in a row and have not missed a year.  I have never again had the flu and I pray I never do.  I got my flu shot the year the H1N1 strain of flu got out, and I doctored plenty of sick pregnant women without ever catching it.  The flu shot is recommended for women in all three trimesters of pregnancy, and I highly suggest they get it.  Pregnant women with the flu are highly susceptible to influenza pneumonia, and we had pregnant women that year who were on ventilators for it. 

What people don’t understand is that the flu is lethal.  There are several thousand deaths from flu each year in the United States alone, but people dismiss it as “just the flu”.  If some new disease killed that many people, we would all be freaking out.  If you want to read a shocking description of a flu pandemic, read “The Great Flu”.  It describes the great flu pandemic of the early 1900s and it basically states that one out of ten citizens who were stricken with it died.  An eye witness described riding on a streetcar and one of the passengers and the driver being dead by the end of the run.  Very few people take the flu seriously but when I see a new strain described I get very afraid.

I did witness the funniest thing today.  One of the nurse practioners works for a physician hospitalist who has a great sense of humor.  Apparently she refused to get her flu shot when the infectious disease personnel came around with them.  Her physician boss was quite put out with her for refusing her vaccine and he was not going to take no for an answer.  He and she and I were all sitting around the physician dining room today when suddenly two nurses wheeled in with a tray containing flu shots.  He had had them come to the physician’s lunchroom to get her!  She couldn’t say no and she got her flu shot on the spot.  She vowed revenge and told him he would not get a Christmas gift from her THIS year!  He tried to give her a piece of cake but she turned her back on him and pretended to give him the cold shoulder.  We were all laughing at his insistence but I totally agreed with him.  Got to get that flu shot!

As for those who claim they get “flu-like symptoms” when they get their flu shot, I say this:  There is a whole lot of difference between “flu-like symptoms” and the flu.  As in, the real flu is about a hundred times worse.  A little stuffy nose and an achy arm from the flu shot is NOTHING compared to the real flu.  I strongly advise people of every age and walk of life to get their flu vaccines this year and every year.

Things Your Ob/Gyn Never Tells You

1.  We don’t care if you didn’t shave your legs.  We don’t even notice that you didn’t shave your legs, unless you apologize to us for not shaving them, which we think is really funny.  With all the weird things we see, you would pretty much have to have live hedgehogs growing in your nether regions to get our attention.

2.  You can prevent razor rash from shaving your nether parts by applying deodorant stick to the shaved areas immediately after you are done shaving.  Why do you think you never get razor rash under your arms?

3.  It’s your feet that stink.  The things that really get to your Ob/Gyn are stinky feet.  Nothing else is that bad.  Please don’t wear leather shoes without socks.  That smell can clear a room for an hour.

4.  If you scrub at your bottom with toilet paper prior to your appointment in an attempt to thoroughly clean the area, the toilet paper rolls up into little balls that stick to your crotch that you can’t see.  But we can.  And it looks funny.  And we have to try not to poke the little toilet paper balls up into your cootchie when we put the speculum in because we don’t want to embarass you by telling you they are there. 

5.  We are really not being evil and nosy when we ask you questions about your sex life.  We really need to know if you are heterosexual or homosexual, because that changes areas of care that we need to address.  We need to know how many partners you have had because if you exceed a certain number, you are a high risk patient and your insurance company will be more likely to cover your exams and tests when we bill them.

6.  We know how that object got stuck up in there.  We do not judge.  However, please do not LIE to us and tell us that you fell on the squash from your living room stairs.  We know when you are lying to us, and we don’t like that.  It doesn’t improve the doctor/patient relationship.  And it makes it more likely that the squash scenario becomes a funny story, if we are lied to.

7.  You can get that stuck tampon out on your own.  They really cannot go far.  You can reach them and get them out without difficulty.  They will not disappear up inside of you.  And if you can’t get it out, please don’t wait DAYS before you call us to help you.  Those things stink SO BAD we have to close that exam room for the rest of the day.

7.  It really doesn’t matter if you wipe from front to back or from back to front.  Studies have shown this.  Cranberry juice really does help though, if you are getting a bladder infection.

8.  Hemorrhoids are really just varicose veins around your rectum.  No need to be embarassed about that.

9.  No matter how weird and embarassing it sounds to you, we have heard weirder.  Just take a deep breath and tell us the truth and we will help you to the best of our ability.  We fuss more about being lied to than being told the truth.

10. Cleaning products such as lysol, listerine, etc, have no place in your cootchie.  Do not put them there.  You will burn up and have to come see us.  Also, strong deodorant soaps such as Lever or Dial will burn you up.  You should use unscented Dove or Oil of Olay for your nether regions.  Washing too many times a day will mess you up.  More is not necessarily better.  That part of your body was not meant to take that kind of abuse.

11. It does not count as infertility if your husband is out on an oil rig somewhere or deployed overseas.  There is a definite reason you are not getting pregnant.  If you do get pregnant, we will wonder how that happened.

12. Pregnancy is a sexually transmitted disease.  If you “caught” a pregnancy, don’t be surprised if you caught other things too. 

13. Just because they fathered your child, live in your house, fight with your family and sometimes show up for doctor’s visits does NOT make them your fiance.  Just discussing marriage does not make them your fiance.  A RING and a DATE make them your fiance.  Otherwise, the word is woefully overused and we are unimpressed.

14. Getting married after you find out you are pregnant is like closing the barn door after you find out the horse is gone.  Getting married in a maternity dress looks really silly.

15. Please don’t set your baby shower for the week of your due date.  You will go into labor early and you will miss it.  Then for some reason, you will be upset with us.

16. There is no reason to become pregnant if you don’t want to.  Either talk to us or the health department.  We don’t want you to have a baby if you can’t afford it.  We will give you the birth control, free if we have to.

17. Hysterectomies are not hereditary, as one patient asked me.  They do not run in families.  Just because your mother had one, and your sister had one, does not mean that you need one.  That does not constitute a diagnosis that your insurance company will cover.

18. There is really no reason to bring your husband, your boyfriend or your giggling best friend to your appointment, unless you have an unholy phobia of visits to the Ob/Gyn.  Even so, their presence may not help much.  Our nurse usually makes a better companion.

19. Please don’t bring your small children if you are having a vaginal exam.  It is very distracting and disturbing to have a small child hovering “down there” asking questions like, “It hurt, Mommy?” or “What is that?” or “It tickles?”  How can you consider exposing a little kid to something like that?  They will be in therapy for years.  And maybe so will I.

20. When the nurse tells you to put on the gown so that it opens in the front, put it on so it opens in the front.  There is no excuse for not paying attention to simple instructions.  Did you ever try to examine someone’s breasts through a gown that they are lying on that opens in the back?  Seriously.  Follow your instructions.

 

 

Things I Learned At Work

1.  If you carry keys in your pockets everyday, they will make holes in your clothes.  Most women don’t realize this, because they typically keep their keys in their purses, but I keep a set of mine in my work hoodie in case I need to get into the call room or the doctor’s lounge.  I have holes all in both pockets now and the keys poke through them embarassingly.  I guess I’d better get another hoodie, so I can make holes in it too.

2.  No one will replace the toilet paper, the pillow cases or the hand soap in the call room but you.  That’s right.  I have put more rolls of paper on the spool, bought more hand soap from Bath & Body Works and replaced the pillow cases on the call room bed more times than I can count.

3.  People will cheerfully take/use your stuff.  I am constantly running out of paper clips and people steal whole Post-It note pads off of my desk.  They also steal my pens.  Since we no longer get these free from the drug reps, replacing them becomes annoying.

4.  Dried yogurt looks exceptionally bad on scrubs.  Enough said.  It just does.  It looks disgusting.  I guess dried yogurt looks pretty bad on all clothes, when it gets right down to it.

5.  If you have an opportunity to put your scrubs on backwards, you will.  Especially if it is three o’clock in the morning and you are rushing to put them on.  Your patients and nurses will cheerfully point this out to you.

6.  You can persuade yourself that you do not have a weight problem if you wear scrubs all the time.  Scrubs are loose and forgiving, except for when they become tight and unforgiving and you have to go up a size.  Reality sinks in when you attempt to put on normal clothes at home, which doesn’t really happen all that often.  Especially when you know your clothes aren’t fitting well, you will tend to stick with the scrubs at all times in an attempt to lie to yourself.

7.  More babies are born at four AM than at any other time.  This is a cortisol and circadian rhythm thing, and the babies cannot be persuaded to help you out and be born at some other time.  Neither can the moms, who have no interest in waiting. 

8.  Your phone will always ring at the least convenient time.  Especially when you are at work and being bombarded with problems from six different directions and dealing with demanding patients.  Or especially when it is your husband, who ALWAYS calls at the worst possible time.  Like when you are peeing.  Or in a room with a patient.  Or doing a delivery.

9.  Your computer will always fail just after you have entered in about an hour’s worth of data.  Even if you hit save frequently.  Somehow the save button is rendered useless by the evil computer.  You will have to type everything in again.

10. You will never find your nurse when you need her.  She will always be in another room with another patient when you need her to bring you something, or when you need her to help you with a patient who is passing out.  No one will have any idea where she is. 

11. You will always be on call when there is an event that you want to attend.  Without fail.  If there is something fun going on on a weekend, you will always be on call on that weekend.  And if you try to plan something on a call day, something will always happen so that the activity is canceled.

12.  The elevator is always on the wrong floor.  And you will run into that problem patient, who, while they have you on the elevator, wants to ask you “just a few more questions”.  They even ride the staff elevators.

13. Your patients will always start early and end late on those days when you are already running behind.  Everyone shows up on the day where you’ve been stuck doing a c-section in the middle of clinic.  And they all want to wait to see you; no one wants to reschedule.  You will have a relentlessly heavy schedule on days where you have been in surgery all morning and are exhausted, are post call and are exhausted, or on days where just waking up in the morning requires more coping skills than you have.

14. The patient you have been strenuously avoiding throughout her entire pregnancy will find you and be in labor on your call day.  You will have to do a c-section alone on a three hundred pound woman.

15. Medical professions breed negativity.

How To Be Sybil: On Being an Ob/Gyn

I don’t think people realize the heart-stopping shifts in mood that this profession requires.  In a standard day:

A woman is sobbing in Room 1.  She has just found out she has miscarried again.  You feel terrible.  You try to comfort her.  There is no way to comfort her.  You are fighting back tears when you leave the room.  Sometimes you don’t fight them.

A woman is exultant in Room 2.  She has just found out she is having a boy.  She already has 3 girls.  You slap hands with the husband, and hug the patient.  He is already madly texting to tell everyone he knows that he finally has his boy!  You feel so happy for them.

The woman in Room 3 is sullen.  She is having another boy.  Her third one.  She is actually angry at us for telling her she is having a boy.  She does not want to believe it.  She has already yelled at the ultrasound tech and slammed the door.  You attempt to persuade her not to be angry.  She yells at you.

The next woman in Room 1 is quiet.  She finally admits that she has caught her husband cheating on her with a woman who is known to use drugs.  She is scared that she has caught something bad.  She is crying because her marriage is over.  How do you comfort her?  You can’t.  You sure can feel bad for her though.  And you feel deep anger.  This woman didn’t deserve this.  This irresponsible man has put her at risk for diseases, some of which are not curable.  Some of which are fatal.

Back to Room 2.  The new patient in there is radiant.  She is here for her pre-wedding physical, and to get on birth control.  She goes on and on about the wedding, how nervous she is and how excited, and where she will spend her honeymoon.  You have carried the bitter cynicism in from Room 1 and wonder how long it will take the guy to cheat on her.  You instruct her on how to use the birth control pills.  You muster up some excitement for her.

The woman in Room 3 is a pregnant drug abuser.  She spends all her visits complaining of pain and trying to wheedle Lortab out of you.  She has tested positive for THC, barbiturates, opiates and cocaine during the pregnancy.  You feel intense anger and disgust.  You want to throw her out of the office.  You don’t understand how she can do this to a baby at all.  You want to yell at her that you are on to her little game and you know she is a drug addict and to STOP ASKING FOR FREAKING DRUGS.

Back to Room 1.  In there is a teenager whose mom has caught her having sex.  She has been dragged in for birth control and STD testing.  You can tell the girl is lying when she answers questions in front of the mom, but the mom refuses to leave the room.  She will control this or else.  You wish you had a chance to talk to the girl alone.  You feel like you could help her better if you knew what was really going on.

Back to Room 2.  A stunned teenager has just had a positive pregnancy test.  Her mom is in the waiting room and does not know.  There is going to be a huge scene in a minute when she finds out.

The pregnant girl in Room 3 is screaming hysterical curse words into her cell phone.  She is yelling at her boyfriend about being a stupid sonofabitch who is going to jail.  Her baby’s daddy will be in jail.  She doesn’t bother to get off the phone when you go into the room.  You feel angry at being disrespected, and angry that the other patients can hear that language.  You also feel angry that she has a nicer cell phone than you do.

Back to Room 1.  The elderly woman in there has not been to see you in two and a half years.  Her husband has had a stroke and has dementia and she is spending all her waking hours trying to keep him from wandering away from home or setting the house on fire.  She could barely find a caretaker for him long enough to come in for her appointment.  And she is afraid to drive alone in town.  She is grieving the loss of her husband even though he is still alive, and grieving the loss of her autonomy since she is shackled to caring for him.  The ironic thing is, once he passes away she won’t know what to do with herself.

Room 2 is a woman with multiple physical complaints.  She seems perfectly healthy and her use of office time complaining about every little thing is really annoying.  You wonder what is really going on that she is so unhappy.  She won’t let you out of the room.

Room 3:  a giggling teen here for her yearly exam.  She has her best friend with her who is giggling too.  They are ANNOYING.

Room 1:  A pregnant woman complaining because she is uncomfortable.  Really?  Pregnant much?

Room 2:  A young couple upset because their fertility treatments aren’t working and they are desperate for a baby.

Room 3:  get the general idea?  By the end of the day my emotions have spun so many 180/360 degree turns that my brain hurts.  Do all Ob/Gyns get bothered by this?  I think they must.  If we aren’t psychotic when we start this profession, we will be when we finish.

On Circumcisions

During my residency, I was trained to do circumcisions.  Circumcisions are a barbaric practice in which perfectly good skin is removed from a helpless infant who is too young to consent.  We feel perfectly good about this, but I am sure there are other civilizations who are criticizing or who will criticize us for our mutilation of our children.  Now, here is my question:  if Ob/Gyns spend their whole training on learning female anatomy, how is it that we are expected to do surgery on MALES?  Very important surgery, as any man will tell you.  We did the circs when I lived in Atlanta.  We do them here in Alabama.  Why do the pediatricians not do these?  Why do the urologists not do these?  The urologists do circs on older children and adults; why can they not do the newborns?  Is it that they just can’t be bothered?  Ask any Ob/Gyn and they’ll tell you that circs are among their most hated procedures.  The whole thing is just disturbing.  First there is the ridiculousness of the preop “Time Out”.  On adults, this makes sense.  You verify the patient’s identity by asking them.  You then ask them if they know what procedure they are having done and the name of the doctor that is doing it.  A typical Time Out for an infant circumcison might go like this:  “What is your name?”  Baby:  “waaah”.  What procedure are you having done today?  Baby:  “waaah”.  Who is your doctor today?”  Baby:  waaah.  Great time out guys, I feel so reassured that the baby is OK with this.  The baby’s arms and legs are strapped down tightly to something called a “circ board.”  The babies hate that as much as anything, and they start to yowl and cry as soon as they are strapped down.  They are numbed with a cream or with a needle into the foreskin, which really must hurt.  Then they are painted with cold iodine prep, and the cold shocks them and makes them cry again.  Then the foreskin is grasped with two mosquito forceps at the upper outer corners, and another mosquito forcep is spread open repeatedly under the foreskin to break down any adhesions between it and the penis.  This is not a hit with the baby.  The third forcep is then clamped up the middle anterior third of the foreskin to create a pinched bloodless area where a scissor cut will be made.  Again, not a hit with the baby.  The foreskin is then peeled back, something one of my colleagues refers to as “skinning the grape”.  A metal bell with a handle is then selected to be the correct size to just cover and protect the penis.  This is placed on the head of the penis and the foreskin is pulled back up over it.  A safety pin is used to perforate and hold the two edges of skin together around the bell.  Essentially, the baby gets his first body piercing.  Then the bell is locked into a mechanism that cranks a plate tightly in a circle around the foreskin, with the penis protected underneath.  A knife is then used to cut off the newly isolated foreskin.  The gadget is then removed and the foreskin arranged and wrapped with vaseline gauze to prevent sticking.  May I just say that the infants are not pleased with this arrangement.  They are given sugar water to suck on during the procedure because apparently studies were done that show that the baby’s pain response is blunted by the pleasure of sucking on the sweet stuff.  I’m not convinced.  How did they find out that the baby’s pain response is blunted?  Did they ask the baby?  Because I think the baby would say differently.  The babies don’t pee for several hours afterward, we think because they fear the burning afterwards.  We may be overly reading in to this.  Anyway, the whole procedure is a bit disconcerting for everyone involved.  I know the studies show decreased penile cancer and decreased transmission of sexually transmitted diseases, but I bet some day another culture will be looking at us and wondering what the heck we thought we were doing.

Things Patients Do

Things patients do, with a capital Things.  It is unreal how many completely inappropriate things can be done in a small exam room.  Where to start?  Shoes.  Patients wear leather shoes without socks and their feet STINK.  Any gynecologist will tell you, it’s not the crotch smells that get you, it’s the FEET.  Also, patients put their shoes right on the little step at the bottom of the exam table.  Well, that’s great, people, but I can’t open my bottom drawer and get to my pap brushes because your shoes are sitting there.  Why would that be a good place for shoes?  Clothes are also placed on the floor, despite having a large seat cushion to put them on and hangers on the back of the door.  Would you put your clothes and underwear on a dirty old floor in a doctor’s office?  People in doctor’s offices have GERMS.  In particular, shoes and purses are placed directly between my seat and my lamp.  Just how do I pull the lamp up to the table to use it, people, if you have all your clothes tangled up in my wheels and blocking the lamp on the floor?  Another area of poor parking involves BABIES.  People bring their babies, which I understand, because they are new, and they want to show them off, and they may not have a sitter, but why put the infant carrier on the floor EXACTLY where my chair needs to go, at the bottom of the table?  Then you wind up having to move a purse, or a sleeping baby, and the patient is giving you irritated looks, despite the fact that their stuff is on the floor right where you NEED to be.  Then there is the issue of bringing entire FAMILIES.  A woman will come in for her checkup after having a baby, and she will bring her infant, the older sibling, the boyfriend, and maybe the mother-in-law.  Then the baby will be screaming, the toddler will be babbling and dragging the baby carrier toward the garbage can, the boyfriend will be on the phone and the MIL will be saying, “What about THIS?  And THIS?”  Meanwhile, the patient, instead of being appropriately ashamed of having brought this monstrous collection of human beings, will be trying to discuss her ENTIRE LIFE HISTORY with you, over the screaming baby, the yelling toddler, the distracted boyfriend making drug deals on the phone, and the MIL trying to get your attention to try to discuss what SHE thinks is more important, like, when can the patient have sex with her son?  Then there are the telephone people.  People are supposed to have their cell phones turned off when they come in.  Well, they don’t.  I come in and the patient is yacking on the phone.  Instead of apologetically turning it off, they keep on blathering.  On several occasions I have told the patient, “I’ll come back when you’re ready,” and they’ve STILL kept on talking.  So I leave the room, and go see another patient.  Then, even weirder, are the ones who talk on their phones THROUGH their exams.  In Atlanta, I was examining a stockbroker, who, during her pap smear was yelling, “Sell!  For God’s sake, sell!”  She still had on the top part of her power suit, which was even more disconcerting.  Then there are the stealers.  The worst offenders are often the boyfriends.  I once had one steal the toilet paper key from the bathroom.  His girlfriend made him give it back.  I catch them squeezing their zits in the mirror, stealing the q-tips, and looking for needles.  One of our patients stole the nurse’s cell phone.  Then there are diapers.  This should perhaps be organized under babies.  A ripe poopy diaper can ruin an exam room for the better part of the day.  So do old tampons.  Then the patients refuse to follow instructions.  My nurse tells them to put the blue thing on open in the front, they put it on backwards.  My nurse tells them to spread the white thing over their laps, they sit on it.  The worst part is, I reiterate these instructions before I leave the room to have them undress.  So they’ve heard it twice.  Then there is the big old sign that says PLEASE DO NOT CLOSE THE DOOR WHEN YOU LEAVE.  This is to prevent mystery patients.  If we see a closed door, we think there’s a patient there.  We can waste an hour on an empty room if we don’t figure it out.  I think most folks can read.  So why do they close the freakin’ door?  Not all of these things are big things mind you, but they sure add up over the course of a day.  So use a little common sense, people, please?  Make our days a little easier.

Physician Superstition

We docs are a superstitious bunch.  Really.  It’s absorbed with the baby food in med school.  You can never lose the paranoia.  For example:  when you are on call, NEVER say, “It’s really quiet here today.”  The call gods will hear you and will smite you with a ruptured ectopic or an abruption.  This is a fact.  I used to get so angry when my Mom would come to visit me on call and she would say brightly, “Well, it seems like a pretty good day so far!!!”  IMMEDIATELY that pager would go off and I would be pulled away from my home and my visitor for the rest of the day.  We docs much prefer a cowering look at the sky and the statement: “We’re verrrrrry busy here, Lord!”  Also, worrying is important.  When you have a patient with a strong possibility of a bad outcome, you must come up with every possible thing that might go wrong.  If you don’t think of something that could happen, THAT’S the thing that will happen.  So you have to think of them all.  Then you have to WORRY about all the possible things.  Worry constantly.  Worry while on call.  Worry when about to be on call.  Worry in the middle of the night.  And some patients, you can just TELL, have your name written on them.  I had a patient recently with multiple medical problems, with not the least of which is that she weighs over 300 pounds.  And she is not even my patient, technically.  She is my partner’s patient.  As soon as I met her, I just KNEW that her delivery day would wind up on one of my call days.  And sure enough, it did.  Just like I predicted.  There is also the rule of 3s.  All bad things happen in threes.  If you have two ruptured ectopics, a third is on the way.  You can count on it.  Two bad c-sections?  There’ll be another one soon.  This is irrefutably true.  Then there’s the full moon scenario.  We all know that the crazies come out during full moons.  Women also go into labor and come in with their water broken.  This also happens when low pressure systems come through.  The amazing thing is, we physicians believe in all of these things.  And if we are challenged, we actually become angry.  Especially if we are challenged in a way that may bring bad luck.  Amazing that such an educated group of individuals would carry those superstitions around.  Except they’re not superstitions.  They’re all true.  Of course.  We’re very busy here, Lord.

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