Final thoughts from L&D nights, two weeks on

It was one of my last L&D nights, and as always, I was working with a different team at night. The beginning of the night started off slowly, and ended with a baby in the hallway, an extramural delivery in a toilet (lady didn’t know she was pregnant), two urgent sections and one stat section (lady tried to go into labor with a very unfavorable breech baby while in our triage area). Oh, what a night.

So what does “doing” L&D nights feel like? At University Medical Center, the night team has three residents and >1 attending. The R1 handles triage and assists during deliveries, the R2 sees ED consults and the R3/R4 covers most of the operative (urgent/emergent) cases as well as the labor floor. Considering the service covers up to 6 triage beds, 12 labor beds, 3 ORs (usually only 1 is running at night), and >30 ante- and post-partum beds, it’s a lot of territory. Attending coverage varies but always includes 1 staff OB with MFM (high risk OB) backup on-call. Often 1-2 community faculty are also present. We also have a very active midwife (CNM / NP) service with 1-2 appropriately trained and credentialed midwives present to deliver patients desiring their services in the supervised hospital setting.  As the medical student at UMC, you can do whatever you want, except consults. I tried to do a little bit of everything and I loved the rhythm of L&D. Triage, follow patients on the floor, scrub in on cases, lather rinse repeat. Not many fields where you are urgently assessing and operating on patients, but expecting a great outcome in >99% of cases, even at a tertiary center. It was a pleasure to have the “baseline” outcome be extremely happy and positive – which is definitely something to think about as I consider a career in Onc.

Some final thoughts to sum up my experience on L&D nights:

No one is going to tell you what to do. Conversely, you don’t need permission to do anything reasonable for a student to do. What is reasonable? Seeing triage patients on your own, scrubbing in on cases when you have previously spoken with the patient, doing a supervised, consensual cervical exam on an appropriate (intact membranes) patient, placing a foley with appropriate supervision (i.e. close supervision until you demonstrate repeated competency, then chaperoning as appropriate), doing mag checks (love those mag checks). What is unreasonable? Well, there are many other unreasonable things, but just to name a few that unfortunately do occur … Unsupervised/chaperoned exams, performing interventions without demonstrating competence, fucking up the workflow of the unit, having negative interactions with staff, examining patients without consent, and so on.

DO NOT ASK PERMISSION TO DO REASONABLE THINGS. JUST DO IT (sensitively, of course) and then report the results. Once your R1 sees that you can do work that is trustworthy, they will appreciate it. This is what working independently means, and it is a sign of an HONORS LEVEL student. Find problems and solve them. Whenever you operate independently, however, always keep your finger on your own pulse and your own comfort zone. NEVER overstep your role and if you are ever in doubt/uncertain/concerned, kick it up to your R1 or above.

Here’s how I handled one of these situations:

At the beginning of my nights, a nurse called me to bedside to check on the post-op bleeding of Mrs. J, a recent primary c-section patient, since she expressed blood during her first post-op fundal check. Okay, this is something that I had done with the R4 several times and felt comfortable, having scrubbed in on this case, and seeing post op c-sections, knowing both the actual EBL, and the expected blood loss post-operatively. As I walk to the bedside, the senior nurse asks if I could recommend ordering a sedative to stop Mrs. J’s “tremors” and if I can help reset the alarm on her monitor so that it only alarms if she gets tachy in the 140s.


At this point, I am concerned about what I might find, wondering whether I should page the senior (who is very busy) immediately. I decided that it would be unreasonable to page the senior about a patient that I had not examined unless she was clearly in extremis, and went to her bed.

Mrs. J is shivering with temp 97, tachy to the 120s with normal BP, satting 100% on RA. Okay, I’m thinking, tachy even with a normal BP is bad, and I’m worried about that, but her BP and sat are somewhat (but NOT completely) reasurring. I examine the site (clean/dry/intact), the “bleeding” (no active bleeding eliciting by fundal check, one single half-dollar sized clot expressed on the nurses check, along with ~50 cc of blood on the chucks present before the fundal check which ahd accumulated over 30 minutes), confirm that there is no further bleeding and that fundal tone is appropriate, and assess the rest of the patient.  She has cold upper extremities and is shivering, with otherwise normal cardiac, pulmonary, abdominal and extremity exams. I was considering early PE, post-operative bleeding, anaesthesia reaction amongst others in my differential. All very bad things.

At this point, I’m more confident that she isn’t bleeding externally from the incision site or vaginally, and have been able to reduce my suspicion of many of the most concerning  acute post-operative events that I was considering. However, I realize that I am nearing the limit of my knowledge and competence: this lady *is* tachy, she *does* look and feel cold in her upper extremities, and she *is* actively shivering. Potentially ominous, even with a “normal” BP. I need to find the resident, but not page him to the bedside. I found the R4 and briefly presented to her. She was unconcerned but said that she would reassess her soon. Mrs. J ended up having an uneventful postoperative course with no further tachycardia, a repeat H&H the next day was acceptable, and she was discharged with her son as scheduled.

The key point I’m trying to make is that you have limits and you gotta know them, for your patient’s sake (as well as that of your career). Had Mrs. J been uneqivocally stable (e.g. not , just cold upper extremities), then I would have been fine leaving it at that and telling the nurses to page me with any vital sign changes. But as it was, I knew that I had to respect her tachycardia and ran it up the chain of command.

It is a constant and shifting balance. As a medical student, the world most certainly does not revolve around you. No one will bring learning or patient care to you – you have to go get it. People will be abrasive (but, probably, not abusive) sometimes, dismissive often, and kind rarely. Your education is to some extent zero-sum vs. the education of residents (particularly PGY-1s). Furthermore, since the focus is patient care and not medical student teaching, often the preference is made to educate/include the residents.

You cannot take this personally. You are going to deal with a lot of nonsense as the bottom-of-the-totem pole, but the good news is that you’re at school to work and get better at your trade. Nothing else. Not to socialize or have someone personally appreciate your work (although those things are nice when they occur). Act accordingly. There’s no crying in baseball.

So overall, how’m I durrin?

I’m working hard, staying enthusiastic, enjoying almost every day, and not letting the bullshit get to me.

However, I need to do a better job at excelling (w/presentations, etc), building a better knowledge base, and getting a better understanding of what my supervisors want from me. i don’t really know how I’m doing (other than, not failing), or how I could do better, because no one really gives you feedback, and certainly not summative feedback, in real time. That’s a big fault I have with this year.


Other thoughts:

I adjusted to the night schedule very easily, which was surprising. The biggest difference was that I ate lunch at 0100 instead of 1300. I had no problem sleeping, didn’t binge eat (if anything, I didn’t eat enough), didn’t overdose on caffeine (my last night, the only caffeine I had was 2x diet sodas, and I was doing fine during my 0800 emergency section), and generally was the same person as always. The biggest difference was that nothing existed outside of work. I ran the dogs once or twice and even that was a huge effort. Girlfriend (hi!) and I barely saw each other since she was on days, and that was probably the hardest part, but it was only a week. I had no time or energy to study, aside from a few 10-question board review blocks during some downtime.

I loved the OR. I thought it was really really really nice as a student to be able to see (essentially) the same procedure and anatomy ten times in a row, albeit with different attendings. Medical student pearl: really prefer scrubbing in when the R1s are first assist, especially early. The attendings orient a lot of teaching towards the R1, while they often forget/ignore the medical students, and you can learn a lot as the R1 gets brutally pimped or makes small mistakes. I’m not sure if, procedure-wise, I would really enjoy doing the same procedure with the same approach over and over again (low-risk sections), but as someone who is still VERY new to surgery it was a much better environment than, say, GYN-oncology.

I need to learn spanish. One patient in five is primarily/exclusively a Spanish speaking, requiring translation services. A few key words have already been really useful (dolor vs. presion, ninguna vez vs. alguna vez, semana, mas, todos los dias, pecho, cabeza, corazon, radiografia/rayos X, extraer sangre, and little things like bebida/comida/lo siento, hola, como estas, bien, mal, mas o menos, regular, etc), and I’m trying to expand my vocabulary. There are a lot of silly things that I do when speaking with non-native speakers that I am trying to wean from my repertoire, like speaking more loudly, and some things that I am trying to do better, like speaking more slowly and using the simplest possible words without medical jargon or colloquialisms. Sure the translator phone is nice, but sometimes you just need a sentence or two, and you need to be sure that your patient understands, and you only have a minute …

Lastly, and most importantly, I think I learned a lot about myself during my L&D nights week. I learned that patient communication is crucial to me – I did a lot of teach-backs when the residents were busy flying around the floor and found them very personally satisfying. I realized how little I enjoy leaving a room unless I am highly confident that my patient understands the plan, my decisions, and how I made them (see above). Most doctors that I work with have not really shared that view, at least to the “extreme” that I feel. I hope that I don’t lose touch with how powerless and scary it is to be a patient.

Anyways, a super-long rambling post, as always, and not necessarily well written, but I hope it conveys a lot of my takeaways and thoughts about my OBGYN rotation. Hit the comments or message me if any questions.

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