30 Something Baby Doc

I was seeing a patient in the office yesterday for a routine annual exam. She was a very pleasant lady in her mid 30's. While I was interviewing her she said she may need narcotics to treat her persistent back pain. She felt her back pain was secondary to her "gigantic breast" as she described them. She felt she desperately needed a breast reduction. I told her I would first send her to physical therapy to determine the true nature of her back pain (usually these consults are needed before plastics will even consider a breast reduction).

I performed the pelvic exam then I told the patient I was going to perform a breast exam. She then suddenly threw off the top portion of her gown, proudly grabbed her breast and started stroking them saying " see doctor, they are soooo incredibly huge!!!!!!!" She was fondling her breast as if she were in a burlesque show. My medical assistant and I looked at each other in disbelief.


After we left the room , my medical assistant said to me, " I wonder why she wants a breast reduction? She seems pretty damn happy with those bad boys just the way they are."

It's late, i'm on call. Looking for a new blog template

I'm a big fan of Rap and Hip Hop, but I think this is carrying it a little too far.

any suggestions?

Thought it up myself:-)

2 pounnd of ground sirlion
1/4 pound of mexican beef chorizo
Dash of onion seasoning
3 tsbp of Worcestershire Sauce
Thickly slice Monteryjack Cheese
Fresh Salsa (Medium)
Hamburger buns

Combine the ground beef, chorizo, onion seasoning, Worcesterishire sauce. Create patties about 1/2 inch thick. Grill Patties (Charcoal grill) medium well to assure chorizo is fully cooked. Top burger with cheese while it is still warm and place on bun. Finally top burger with fresh Salsa.

Sit back grab a beer and enjoy.

I am referring to myself. The other day I went to the gym for my usual 5am workout. Got back to my house at about 5:40 and had to be at work covering Labor and Delivery by 7am. I pulled into my garage and realized I had mistakenly locked the door that leads from my garage to my house. I don't have a key to this door. No problem, I do have keys to my front door, so I grabbed that key ring out of my car and went to the front door. Only problem , my house keys were not on that key ring (they usually are). Damn, I'm locked out of my house. I tore my car apart looking for my house keys. I usually keep my house keys and cars keys on seperate rings. I couldn't find my house keys (they must be in the house). K has a set of keys for emergencies but it was too early and I had to be at work by 7 am. I didn't have time to wait for a locksmith.

Hey I got a bright idea, I'll kick in the door that leads from the garage to the house. It's only a single lock and the damage will likely be minimal. So I kicked in the door. 2 kicks and I was in. Along with $250 dollars worth of damage. And to add injury to insult my house key were on the same ring as my cars keys sitting in my pants pocket the entire time (I forgot I had done that).

The moral to this story......I'm a Dumb Ass





Oops

The resident tried to reposition the uterus but it wouldn't budge and the patient was continuing to bleed. We rushed the patient back to the operating room in order to stabilize her and make her comfortable while we were figuring out how to get the uterus back in place. Repositioning the uterus quickly is the goal because the longer you wait, the more likely the uterus starts to contract (clamp down) making nearly impossible to get it back in it's correct place.

When we got the patient to the OR I looked under the sheets and saw that the bed was soaked with blood. The patient had lost almost another liter of blood on the way back to the OR (Oh Shit!) Some text books recommend giving tocolytics (medications that help relax the womb) to aid in repositioning the uterus but sometime the prolonged effects of these drugs can make the blood loss worse.

The anesthesiologist sedated the patient and was preparing to give nitroglycerine to help relax the uterus. I told them I would make another attempt to reposition the uterus by hand. If that failed then we would have to surgically open the patients belly and reposition the womb by making an incision the the backside to create slack. That would mean more bleeding (what joy).

I placed my right hand in the patient's vagina and my left hand on the patients belly. I felt the firm mass in the vagina that was the womb turned inside out. I pushed against this mass as hard as I could. It was like pushing against petrified dough. The patient started screaming (obviously she needed more sedation). I started to feel the inverted uterus begin to give way and return to it's normal position. I kept pushing until my right arm was buried in the patients vagina up to my elbow. I began to feel something wet on my arm and realized that blood was soaking through my gown. After much effort the uterus was back in it's correct position. I felt the uterus start to clamp down on my arm (which is a very good thing). The bleeding abruptly stopped.

I'm not sure what made the patient happier, her womb being returned to it's correct position or the fact I had removed my entire arm from her vagina.The patient and her baby did very well.

I think I've met my quota for blood loss this year.










repositioning of the uterus

I was in the middle of a 24 hour call. The call started out on a sour note when as soon as I walked in the door my colleague left me with a cesarean section on twins to perform. I can't blame her for leaving it for me, she really got her ass kicked the night before (15 deliveries). She just wanted to get the hell out of there (I can relate). The cesarean section went fine followed by about 12 vaginal deliveries for the whole day. I came down for a vaginal delivery of a 24 year old patient. Her labor course went really well. She was completely dilated and started pushing. Suddenly the baby's heart rate began to increase to a rate of about 200 bpm (120-160 bpm is normal) Then the heart rate started to drop intermittently (decelerations) For individuals who aren't medically inclined, none of the latter is good. There was no clear explanation for the drastic changes in the baby's heart rate and my policy is " when in doubt get the baby out!" I told the resident to expedite delivery with a vaccum ( a suction device attached to the baby's head that assists in pulling the baby out). Just 2 pulls and the baby was out. The pediatricians were in the room to attend to the baby. The baby did very well after delivery but they still transfered it to the neonatal ICU for observation. I was sitting in the room writing a note in the chart while the resident was delivering the placenta. She delivered the placenta and started checking the patient for vaginal lacerations. She then had a very concerned tone in her voice and told me she thought something was wrong with the patient's womb and she was having alot of heavy vaginal bleeding. I looked at the patient and noticed she was very pale and her blood pressures were dropping. The resident said she thought the patient's uterus had inverted. This is a very nasty situation when the womb literally turns inside out (similar to turning a sock inside out). When this happen, the patient bleeds profusely then goes into shock. Unfortunately the patient was doing exactly that (to be continued).





Uterine Inversion

Taxes are done, and for the first time in 3 years I owe. (Just less than 1k) I'm single with no dependents and a physician's salary. So most of you at this point are saying "What are you complaining about asshole you should be happy that's all you owe!". I realize the latter.

I called up the financial firm that prepares my taxes to find out what transpired (aka. complain) (I was so use to a big juicy return) . I was told that I made slightly less this tax year compared to last year, so they scaled down my withholdings to match. Then I asked that probing question. Is it better to withhold more during the year and get a substantial return or is optimal to break even (or owe slightly). I personally know nothing about finances.

I was told " We would like you to have your money during the year as oppose to letting the IRS hold on to it til the end of the year (and do nothing with it) . That way you can personally invest it or pay off high interest debt. " It makes so much sense but I still miss that nice big return :-(

The other day I drove to an ATM on the westside of town to get cash for a haircut. I had just left work, so I was still wearing my scrubs. I noticed a young woman who appeared to be in her early 20's. I think I only noticed her because she was looking at me. She appeared slightly disheveled with wild frizzy hair. She appeared to be leaving the ATM and then proceeded to sit in a parked car with another female. I thought it was odd because they were both just sitting in the car (not driving away and not conversing) just staring at the ATM's.

I went to the ATM , put in my card, typed in my PIN and requested 60 bucks. As is reached to get my cash, I heard a voice behind me (directed to me) saying " Excuse me sir! Excuse me sir, could you help give me directions to the interstate ?"

I made sure I completed my transaction before I turned around to respond to her. I got my cash and patiently wait to retrieve my card. I then turned around to help her. I gave her detailed directions to the interstate, but she somehow seemed uninterested in what I was saying. She thanked me for my help and then got into the car and drove away with her friend.

As I got into my truck I realized that she was likely watching me while I typed in my PIN #. Then came up behind me abruptly and asked for directions in the middle of my transaction hoping to distract me so I would leave my card in the machine. Then she would have my card and my PIN#.

Better luck next time:-) (Mom always taught me to end one task before starting another)

Nothing frightens an Obstetrician more than a patient with post-partum hemorrhage (heavy and profuse bleeding after a delivery). Unfortunately that's what I has to contend with last week. I was called to the room of a 20 year old patient who had underwent a c-section earlier that morning. When I arrived at the room , the patient had a seizure like episode, she was pale with a low blood pressure. I examined the patient and saw she had a considerable amount of bleeding, passing large amounts of blood and clots from her vagina. I felt her uterus and noted that it was soft. She had uterine atony which is a condition after delivery when the muscles of the uterus don't contract as expected inoder to slow bleeding after the baby is delivered. I asked the nurses to give pitocin (an intravenous medication that helps the uterus to contract) to the patient. Her bleeding stopped. Her blood counts were also very low from her blood loss, so she was given a blood transfusion.

The patient and her family were very concerned because her mother had died giving birth to her brother 15 years ago and the circumstances were very similar. The patient was convinced she would die the same way as her mother.

several hours went by and the residents called to tell me the patient has started bleeding again. We performed a bedside ultrasound the show lots of material inside the uterus that could have been placenta (afterbirth) that was left behind the latter would explain her heavy bleeding.

We rushed the patient back to the OR to performed a suction & curettage (an procedure that uses a long plastic tube attached to a vacuum inorder to clean out the uterus of all contents. We performed the s & c but didn't get much placenta out , only blood and clot. The patients vaginal bleeding was steadily increasing and pooling on the floor. The anesthesiologist was giving the patient medication inorder to keep her low blood pressures from falling even more. I notice the the once dry bandages on the patients abdomen from her C-section early were now soaked with blood. The patient was going into DIC (Disseminated Intravascular Coagulation - a condition where the material in our blood that help us form clots to keep use from bleeding out cease to function properly) The patient was going to die if we couldn't get her vaginal bleeding stopped.

The Catch: Normally in this situation we would perform an emergency hysterectomy to remove the uterus and stop the bleeding once and for all. Because of the DIC, and her inability to clot her blood, a hysterectomy would kill her. We had to stop her bleeding long enough to stabilize. We tried to pack her womb with gauze to stop the bleeding, the gauze just became soaked with blood and the patient continue to bleed.

One of the nurse showed me a device that had just arrive on out labor and delivery unit. It was a long balloon on a catheter that is inserted into the womb and inflated to tamponade (stop) the bleeding. I said to myself "why not" Not to mention I was out of options I read the instructions right there in OR . We inserted the balloon and the damn thing worked. The bleeding stopped and we transferred the patient to the ICU inorder to transfuse her more blood and replace her clotting factors in order to resolve her DIC.

The next day the patient was doing well. She was awake and alert and her blood counts had improved. We removed the balloon device from her uterus after 12 hours and she had no more vaginal bleeding. We were able to discharge her from the hospital with her baby this weekend.

During the month of December I performed a hysterectomy on one of my patient's that I knew very well. She is a very sweet 35 year old woman with 3 small children. The surgery was being performed for what I thought was benign uterine fibroids. Unfortunately while performing the hysterectomy I quickly realized that she has leiomyosarcoma which is an aggressive form of uterine cancer. With the assistance of an oncology (cancer) specialist, we were able to remove a majority of the tumor. I recall how emotionless the patient seemed after the surgery when I informed her of the diagnosis. She was scheduled for radiation therapy after her surgery, but after 3 sessions she elected not to continue because of the nausea and other side effects. Within the span of one month the cancer returned. She developed a very large tumor in her pelvis and has since returned to the hospital multiple times for severe pain.

During surgery today, the residents on my team informed me that she was admitted again for pain management on the medicine service. I hadn't seen her for several months since her surgery follow-up appointment. I decided to go up to her room and say hello. When I walked into the room her eyes lit up and she told me she was very happy that I had taken the time out of my day to come visit her. I was very moved by her appreciation over something that I felt to be so simple. I sat down and we chatted with her for a few minutes. It was nice to catch up.

As a physician, at times I feel it's necessary to distance myself from patients emotinally, inorder to stay objective, but it's nice to know that a simple "hello" can be the best medicine.