Chapter 61: Obstetrics and Gynecology

July 31, 1987, McKinley, Ohio

On Friday after lunch, before Grand Rounds, I met with Doctor Roth to hear my evaluation. I had given him my procedure book and my surgery notebook before our round of golf the previous afternoon, and he returned those first.

"If you don't object, I'd like to photocopy some pages from each notebook and use them as examples for the future."

"I don't mind," I replied. "The lab reports that Fran Fredericks and I collaborated on at Taft were handed out as examples."

Doctor Roth nodded, "I'm not surprised. Your freehand drawing is excellent. I didn't realize you illustrated your procedure book."

"Not for every procedure, but for important ones."

"Has your wife seen the Foley diagram?"

"No!" I chuckled. "She might be more than a bit put off by that. But it's easier for me to remember if I visualize the procedure."

"The EKG lead diagram could go straight into a textbook. Did you put sample EKG strips in your cardiology notebook?"

"Yes. Doctor Strong provided them. He taught me to read them, and I annotated them. My entire study group used them to learn to interpret them."

"Clarissa Saunders is second in the class to you. What about the rest?"

"Fran Fredericks, Maryam Khouri, and Peter Baldwin are all in the top 10. Nadine Cross, who joined our group after Sandy Pierce died, is ranked 22nd."

"I know we're supposed to be doing your evaluation, but I doubt we'll need to discuss the results. Do you mind me asking what specialties the others are intending? Well, besides Ms. Saunders, who I know is internal medicine."

"Fran wants OB/GYN; Peter and Nadine both want surgery; Maryam wants cardiology. Just for completeness, Sandy, who was ranked tenth when she died, wanted pediatrics."

"Do you know their MCAT scores?"

"Yes. Fran, 96th percentile; Maryam, 96th percentile; Nadine, 92nd percentile; Peter, 93rd percentile. I assume you know mine and Clarissa's."

"Yes. 99th and 98th respectively. You, Fran, and Clarissa were in a study group at Taft, right?"

"Yes, along with Sandy. Maryam asked to join our group because she's Orthodox and saw me in my cassock. Peter and I met at the Freshman banquet and hit it off."

"Mind if I ask your study methods?"

"Basically, six days a week, plus we all had decks of flashcards we reviewed whenever we had free time, or were standing in line or waiting on something. In effect, we were studying for the MLE from the first day of medical school."

"And it shows. So, what do we do wrong?"

"See, if you asked my wife what I do wrong, she'd give you chapter and verse!"

"You are not alone in that," Doctor Roth chuckled. "And my kids would be worse! So?"

"I'm not sure you can do much about this, but at times, you and Doctor Lindsay are working so fast and are so focused that you aren't explaining the procedures to Doctor Taylor. And before you ask, he and I have not spoken about that. It's just something I observed."

"That's one of the problems in medical education for which there isn't a good solution. The surgical Attendings have discussed budgeting for a videotape system which would let us record the surgeries from an overhead camera. Then, later on, we could go back and narrate what we're doing and medical students and Residents could watch those tapes after the fact."

"That's a great idea! What's stopping it?"

"Guess."

"Money."

"That's the main one. We'd have to outfit all four ORs with a system that could be kept properly sterile, have someone to maintain the system, and some kind of editing equipment to add the audio descriptions after the fact. There's also some concern about patient privacy, but we think we can mitigate that with consent forms. The other thing we need is a large surgical theatre, so that when we do rare procedures, any interested doctors, nurses, or students could watch. Unfortunately, that would require a complete remodeling, and that's not likely to happen. There is a plan for a new surgical wing which would have upgraded operating rooms and a proper surgical theatre, but that's not expected to be completed until 2000."

"That plan includes a new ER wing as well, if I remember correctly."

"Yes. Basically, the only way we can expand without closing down is by building two new wings. The other option would be a completely new building, but that's not in the cards. The old surgical floor and the old ER will be remodeled and we'll shift services around to keep things running while the entire building is remodeled. The fundraising is going well, and if everything goes according to plan, they'll break ground on the new surgical wing in late 1997."

"I also heard from my mom that Rutherford is expanding their ER into a regional trauma center, with a completion date of 1995."

"That's sorely needed. There isn't one between here and Cincinnati. Anything else we do wrong or where we could improve?"

"Not from my perspective. You kept your word to me, and Doctor Taylor has been great."

"You won't be surprised that you received perfect scores and that you'll be at the top of our interview list in eighteen months."

"Thanks. My evaluation of my rotation was equally positive," I said. "I'm really looking forward to the second rotation. Doctor Mertens suggested skipping three electives and volunteering for six months with Doctors Without Borders, but I can't imagine being away from my wife and new daughter for six months!"

"That's a noble cause, and for some med students I'd support it, but given the plans we're working on for you, it wouldn't be wise. I do want to say once more, and then I'll drop it, that you shouldn't use up an elective on a second psych rotation."

"On that, I have to keep my own counsel."

"Understood. As for the proposal, I plan to take it to Doctor Cutter on Monday. Do you have a number where I can get in touch with you?"

"I'll be at Good Samaritan, near Norwood, on the OB service. That's probably the best way to reach me next week. After that, call my house and Elizaveta will get the message to me, because I'll speak to her every day."

"Then I'll see you when you get back."

We stood, shook hands, and I left his office and returned to the lounge. About ten minutes later, Clarissa came in and we headed to the auditorium for Grand Rounds. There wasn't anything out of the ordinary, and other than updating one set of notes, I didn't write anything down, as I was leaving the surgical service and would no longer be responsible for the patients. When Grand Rounds ended, we were free to go.

"Perfect evaluation, I take it?" Clarissa asked as we walked out.

"Yes. You?"

"Yes. I heard Hope having a very public argument with Doctor Lindsay when I went for my evaluation meeting."

"I'm sure she received a sub-par evaluation and that could kill any chance of her Matching for surgery. I'm sure that her dad, grandfather, and uncle will just pull the necessary strings to fix it."

"That's wrong on SO many levels."

"I agree. I know a Resident whose father and mother are both top surgeons who went to a different medical school and who specifically avoided Matching at their hospital. The Resident doesn't even want it known, because they want no favors."

"Not even giving away the gender!" Clarissa laughed. "You were asked for complete confidence?"

"Yes."

"And if you won't tell me, you won't even tell your priest!"

I chuckled, "There are, indeed, things you know that Father Nicholas does not!"

"Are you and your pussy cat joining the gang for dinner before you head to Cincinnati?"

"You do seem obsessed with that part of her anatomy!"

"I am a lesbian, Petrovich! But it's nothing compared to YOUR obsession!"

"True! We'll have to pass on the movie, but given Elizaveta had to get up halfway through Roxanne, that's probably for the best. I have office hours with Doctor Cooper at 9:00am tomorrow morning, assuming a baby doesn't muddle the plans."

"What's your plan for coming home?"

"In general? I'll try for Sundays and Mondays, but being on call makes it difficult. Doctor Cooper will be flexible, but there's a limit. If she has nobody near their due date, then I can probably swing it. One option Elizaveta and I discussed is meeting at my grandparents' house, but that takes her 45 minutes from home, which is further than Doctor Forsberg would like. So, I think, in the end, it depends on Doctor Cooper's patient load and her willingness to be flexible."

"Did you consider Elizaveta delivering at Good Samaritan?" Clarissa asked.

"Yes, but all her friends are here, and the hospital already agreed to give me five days, which is basically the max. Of course, Sunday and Monday don't count, so it would be a week, basically. Depending on how Elizaveta feels, she may come to stay with me after that week if Doctor Cooper is amenable. If not, Angie's mom would certainly allow Elizaveta to stay there."

"Did you consider that when you were thinking you might not be able to stay at Doctor Cooper's?"

"No. I have no idea how Angie would react to me being in the same house with her. The last thing I want to do is anything that might make things worse for her."

"That makes sense," Clarissa agreed. "See you in a few hours?"

"See you!"

July 31, 1987, Indian Hill, Ohio

"Welcome!" Doctor Cooper said when we walked into the house.

Neil had come out to the car to carry our bags and took them to our room.

"Thank you for your hospitality," Elizaveta said.

"You're probably going to want to get right to bed, I'm sure. We usually have breakfast around 7:30am on Saturdays and I leave for the office at 8:40am. It's about ten minutes to my office and about fifteen to the hospital. We can ride together tomorrow, if you want. I don't have anyone near term so barring an emergency, we'll be home for lunch at 1:00pm."

"That sounds like a good plan," I replied. "And yes, we would like to get to bed."

"Then we'll say 'good night'," she said.

Elizaveta and I walked down the short hallway to the first-floor guest room where we were staying and shut the door behind us.

"I want to unpack before we go to bed," she said.

"Why don't you sit and let me do that," I suggested.

"I'd argue, but I really am tired."

"Then get ready for bed while I unpack so you can get right to sleep."

"OK," she said, going into the bathroom.

I quickly unpacked our bags. Elizaveta had brought only a week's worth of clothing, while I'd brought the majority of my limited wardrobe. One thing I hadn't discussed with Doctor Cooper was the dress code she expected me to follow, but I had the necessary shirts and ties, as well as my cassocks, so I could ask in the morning. I had just finished hanging everything in the closet when Elizaveta came out of the bathroom in just her panties.

"Sexy!" I declared.

"I look like an elephant, and I waddle like a penguin!" Elizaveta groused. "That is NOT sexy!"

"And yet, I find you incredibly sexy!" I countered.

"You are weird!"

"Thank you!" I chuckled. "Everything is unpacked and in the wardrobe or closet."

"Thanks, Mike."

"Get in bed and I'll join you as soon as I brush my teeth and stuff."

"OK," she agreed.

I took care of my evening routine, and joined my wife in bed after dousing the overhead light, leaving only the dim glow of a nightlight near the door.

"Are we going to Vespers tomorrow evening?" Elizaveta asked.

"I'd like to, if you're up for it. Saint George is about fifteen minutes from here, so it's not too long in the car."

"What about next week Sunday?"

"I'd say we leave directly after liturgy at Saint George. We'll have dinner with my grandparents, then drive back to McKinley. I'll stay the night with you, then drive back to Indian Hill early on Monday morning."

"Assuming no babies interfere!"

"Ours or someone else's!"

"We're still a few weeks away, even though it's obvious Rachel has dropped, given I'm waddling and feel like I have to pee every five minutes!"

"But no excess pressure on your pelvis, right?"

"No. In fact, I feel a bit better with a bit less heartburn because she's pushing even MORE on my bladder, but less on my stomach."

"That's pretty much the normal 'lightening' as it's referred to and occurs anywhere from two to four weeks before term in primigravida women. For second, or later, babies, it might not happen until right before labor. That depends on how your muscles stretch from Rachel. You do not want to know what comes next!"

"What?"

"Often abdominal cramps and diarrhea. The hormones that cause labor often cause that as well. Then comes the loss of the mucous plug called the 'bloody show', which usually happens about seventy-two hours before labor begins, but it could be less."

"Nobody mentioned that last one. Anna talked to me about all the bathroom problems! How do I know about the other thing? You know I've been having slight discharges, which Doctor Forsberg said is normal."

"It can be thick and gooey, but it can also just be stringy. You'll know because it'll be tinged red or pink, not like your period, but more than what you're seeing now."

"I think I should read your medical book on pregnancy!"

"And scare yourself into labor? Unfortunately, the book spends WAY more time on what can go wrong than on typical labor and delivery. But most women don't have complications and most babies are perfectly healthy. Given you've passed your tests with flying colors and Rachel is developing normally, I wouldn't worry about it.

"And honestly, even trouble such as Sasha had is really minor, in the scheme of things. Sure, she had to have a C-section, but those are routine, and generally have great outcomes for mother and baby, which is exactly what happened with Sasha. I have to read all those nightmare scenarios to be ready for that one time it happens, and even then, I'm not likely to see anything other than the most minor complications in the two months I'm on my OB rotation.

"It's basically the opposite of the ER. There, you have to expect the unexpected, and it often happens. An OB mostly deals with low-risk pregnancies and has plenty of warning when there are likely complications. That's a very different mindset from an ambulance showing up with a guy with his leg more than half amputated from a traffic accident."

"I still don't understand how you don't seem affected by stuff like that! Or people dying in front of you."

"Everyone says you're either cut out for it or you aren't. I appear to be. Honestly, that poor girl who was diagnosed with leukemia affected me more than the woman who wasn't wearing her seat belt and was ejected from the car. I can objectively say that woman caused her own death by riding in a car without a seat belt. Her husband survived because he was trapped and not ejected. The backseat passenger was treated and released because they were wearing a seat belt. That nineteen-year-old girl got up one morning feeling poorly and went to bed that night with a likely death sentence, and she didn't do anything wrong."

"Cancer is very scary."

"It is. As Doctor Gibbs said, if you tell someone their heart is failing, the first thing they'll do is ask you for a new one, you know, a transplant. You tell them they have cancer and the first thing they think is that they're going to die quickly. That's not necessarily true, but cancer scares people more than just about anything you can think of. It's one thing to smoke and develop lung cancer; it's a whole different thing for your body to turn on you when you're nineteen and otherwise healthy."

"So what can they do for her?"

"It all depends on the type of leukemia, and I don't have any training at all in oncology except for the modules we did in the medical school, which were just overviews. I'm not doing an oncology rotation because that really doesn't help for my chosen specialty. And, as I've mentioned before in other cases, I'll probably never know what happens to that young woman. That's one of the downsides of working in emergency medicine; I mostly will never find out what happens to patients once they leave the ER. That was very strange at first, but now, more than two years in, I understand why it has to be that way."

"It's so strange because I always thought doctors were doctors, and just chose what to do, like being a GP or OB or whatever. I didn't realize how limited your training would be in that regard."

"It starts out very broadly, but once you begin your third year, it narrows further and further, especially in your fourth year when you take your electives. Then, you begin Residency and it narrows further. And during Residency, there are choices which can narrow it even more. That's why we call consults in the ER, because we're specialists in emergency medicine, not cardiology or oncology. And pediatrics is a world unto itself. In large hospitals, there are pediatric emergency medicine specialists. And not having that specialist training is why your GP will refer you to other doctors for treatment."

"I'm just amazed at how much I've learned simply by helping you study and listening to you talk to other doctors."

"And I've appreciated your help and your tolerance for the 'shop talk'."

"I promised to do everything necessary to help you be a great doctor, Mike, and I meant it."

"I love you very much!"

"And I love you, too!"

"Shall we get some sleep?"

"Yes," she replied, after yawning. "Once I recover, YOU are going to need a week's vacation to recover!"

"I'm very much looking forward to that!"

August 1, 1987, Greater Cincinnati, Ohio

"One thing I failed to ask," I said to Doctor Cooper, "is about your preference for how I dress."

"You mean wearing your cassock versus shirt and tie?"

"Yes."

"Well, for deliveries, we all wear scrubs, obviously. For rounds and exams, it's professional attire. At the hospital, there are some nuns who wear the traditional habit, though most of them wear skirts and blouses with a cross around their necks. Obviously, the priests wear their usual black clothes with a white collar, and there are a few brothers who wear a cassock, so you won't be out of place, though the wedding ring might throw a few people for a loop!"

"Greek and Antiochian priests dress like Roman Catholic priests and get very strange looks from people when they're out with their wives and children!"

"I bet!" Neil interjected. "Do all of your clergy wear cassocks?"

"It's up to each bishop," I replied. "Some OCA bishops allow Western clergy dress — the black shirt and white collar, but most have rules similar to our diocese — cassock in public. I also wear a ryassa, which is the cloak-like garment I was wearing over my cassock when we arrived last night."

"What do you wear for Mass?" Doctor Cooper asked.

"We celebrate the Divine Liturgy, not Mass," I replied. "I wear what you would call a 'dalmatic' and a stole, though it's worn draped over one shoulder and wrapped around the chest and lower back."

"And your priests?" she asked.

"A much more complicated set than the simplified vestments your priests wear — alb, chasuble, and stole. It generally consists of an equivalent of the alb, the phelon — which is similar to the chasuble — a stole, a belt, and a triangular piece of cloth which hangs over one hip, which is metaphorically a sword, but was traditionally a kneeling pad.

"Outside of services, our priests wear cassocks similar to mine, but add a pectoral cross. The bishops wear a cassock as well, though it's flowing, not form-fitting, and they have a cross and an engolpion, which is a medallion with an icon of Mary. They also wear a miter, though it's soft cloth, not like the Roman miters. During the service, they wear a different style miter which is like a crown.

"And speaking of services, my usual practice is to attend Vespers on Wednesday and Saturday, and then Matins and the Divine Liturgy on Sunday. My bishop instructed me to worship and serve, if possible, at Saint George in Loveland. They do things a bit differently from how they're done at my home church, and celebrate what's called the 'All-night Vigil', which is a combined Vespers and Matins, and that begins at 6:30pm on Wednesdays and 6:00pm on Saturdays. The Divine Liturgy begins at 10:00am on Sundays."