Chapter 63: Pushing a Bit Too Hard

August 5, 1987, Greater Cincinnati, Ohio

"Hah!" Doctor Kelly declared triumphantly in the corridor. "Ovarian cyst!"

She pointed to the printed image which showed a fairly obvious cyst on the ovary, about five centimetres in diameter.

I chuckled, "That's good for the patient, too."

"Obviously, but that smug jerk was wrong!"

"So, no treatment, right?"

"Just monitoring. If it gets larger, then it might have to be surgically assessed. For now, I'll suggest ibuprofen for the discomfort and have her follow up with her OB. Shall we go tell her?"

"Don't you need to have Doctor Lane sign off?"

"The ER Attending will sign. This is pretty common and he can see the cyst just as you can."

We went back to Exam 2.

"We have your results, Mrs. Wilson," Doctor Kelly said. "As I suspected, you have an ovarian cyst. Mostly, they're benign, and yours isn't large enough to warrant treatment at this time. Cysts usually resolve on their own, so my recommendation is that you take Advil for the pain and follow up with your gynecologist."

"So everything is OK with my baby?"

"A cyst won't interfere with your baby's development. I'll speak with Doctor O'Rourke, and he'll get you on your way."

"Thank you, Doctor."

We left the exam room and Doctor Kelly asked the nurse about Doctor O'Rourke. He was with a patient, so a nurse went to see if he could step out. He came out three minutes later.

"Ovarian cyst," Doctor Kelly said, handing him the chart, and the printed image. "Ibuprofen, follow up with her gynecologist, and your 'gut' needs remedial education."

"He was wrong?!" The nurse, Jackie, gasped.

"We try to use science when we practice medicine in this hospital," Doctor Kelly declared. "We don't rely on gut feelings, hairs on the back of our necks, or little devils or angels sitting on our shoulders!"

"Uhm," Nurse Jackie said quietly, "this is a Catholic hospital."

"Demons are exorcised by prayer," Doctor Kelly said, "cancerous tumors are not! Anyway, I'll have Doctor Jennings sign off on the findings."

Doctor O'Rourke groaned softly, as I was sure he'd come to the same conclusion I had — Doctor Kelly was going to basically rat him out. She walked away, and I followed her to the Attending's office.

"Doctor Jennings?" she said from the door.

"Come in, Mary. What did you find?"

"Ovarian cyst, less than six centimetres, which is where we'd consider treatment. I propose recommending ibuprofen and following up with her regular gynecologist."

"Not an ectopic?" he asked.

"No. The cyst was obvious on the ultrasound while I was doing the scan. I printed images for examination and found no evidence of abnormal implantation. Granted, a transvaginal ultrasound would be definitive, but I don't think it's necessary as I did see a normally implanted fetus in her uterus, especially given we'd have to transfer her to UC for that procedure as we don't have the equipment here to perform a transvagianal ultrasound."

Doctor Jennings frowned, "Doctor O'Rourke was adamant it was ectopic."

"May I speak freely?"

"Yes."

"He claimed it was a 'gut' feeling, though I have my suspicions that it was a way to prevent a delay of a few hours before the consult. He knew an ectopic would require immediate surgical treatment, as we don't offer drug-based treatments for ectopic pregnancies."

"That argument is ongoing," Doctor Jennings said. "I'll speak with Doctor O'Rourke. May I see the chart?"

She handed him the chart, which he reviewed, including looking at the images she'd printed. He scribbled his signature on it and handed it back.

"Who's your newbie?"

"Mike Loucks, Third Year."

"Hi, Mike! Welcome! Which medical school do you attend?"

"McKinley," I replied. "I'm a visiting student here."

"Catholic?"

"Russian Orthodox."

"Same difference, at least with regard to why I suspect you're here."

"Yes," I allowed, seeing no point in debating theological differences with him.

Doctor Kelly and I left the Attending's office. She handed the chart to Doctor O'Rourke with a smug look, then we headed back up to the maternity ward.

"Doctor Kelly, Mrs. Smith just arrived," Nurse Patty said. "She reports her contractions are about eight minutes apart. Vitals are strong and normal."

"Thanks," Doctor Kelly said, then turned to me, "Shall we go see her?"

"Lead the way," I replied.

"I'm going to guess you've never done a pelvic exam for a woman in labor."

"You guess correctly, given I wasn't permitted to touch a patient before June and not too many laboring women show up in the OR!"

Doctor Kelly nodded, "Short of emergency C-sections."

"I saw one of those," I replied. "But that was during a Preceptorship, so I could only observe. I'd like you to show me how to perform a check for dilation and effacement."

"You're a pushy ... guy."

"Tell me you didn't have the same feelings when you were a Third Year and wish your Resident would give you more to do and teach you more."

"Yeah, but I kept my mouth shut."

"The Mike of two or three years ago would have agreed with that strategy."

"What happened?"

"A trio of influential doctors who believe the training system needs to be changed to give medical students more hands-on experience. Do you know how it's done in Europe?"

"No, other than it's funded by the government."

"A total of six years in school. You don't get an undergrad degree and then go for four more years. At this point, in Europe, I'd be a Resident. They begin practical training after two years, not six, the way we do."

"So why not go to Europe?"

"Because my family and friends are here and I want to serve my community. But that doesn't mean we can't learn from them."

"Do you support socialized medicine?" she asked.

"You mean like Medicare and Medicaid?" I asked with a slight smile.

"I'd say those are different, but I'm sure you have an argument prepared."

"In the end, the money comes from the same place — patients, either through direct payment, insurance premiums, or taxes. The only question is who controls how the limited resources are applied. I'm not sure insurance companies are better than government bureaucrats at that, and paying out of pocket for cancer treatment would bankrupt anyone except the Rockefeller or Ford families! And I daresay you don't want to cancel Medicare or Medicaid."

"There are charity hospitals," Doctor Kelly protested. "And this hospital takes charity cases."

"Some, yes, but in the end, even the Roman Catholic Church doesn't have the funds to cover ALL charity cases that might present themselves."

We came to the room where a nurse was helping hook up a fetal monitor to Mrs. Smith's abdomen.

"Hi, Doctor Kelly," Mrs. Smith said.

"Hi, Margaret. This is Mike, a medical school upperclassman who I'm training."

"Hi, Mike!"

"Hi, Mrs. Smith," I replied.

"How are you feeling?" Doctor Kelly asked Mrs. Smith.

"I'm ready to have this baby!" she declared, then pointed to a man I assumed was her husband, "It's HIS fault!"

"Last I checked," he grinned, "you were there at the time and didn't complain!"

"YOU don't have to go through this!" she exclaimed.

"Good thing," Nurse Abbie said. "If men had to have babies, humans would quickly go extinct!"

"We are wimps," I chuckled.

"Where'd you find him?" Mrs. Smith asked. "He seems smart!"

"Smart aleck is more like it," Doctor Kelly said with a wink. "Fetal heartbeat looks good, and so does your pulse and blood pressure. I'd like to do a physical exam to check your progress."

"OK," Mrs. Smith agreed.

"I'd like Mike to observe, and then do a repeat exam. Are you OK with that?"

"That part of my body is going to be hanging out in the breeze for everyone to see when Andrew is born, so why not?"

The nurse closed the door to the room, and Doctor Kelly assisted Mrs. Smith in putting her feet into stirrups, then moved a rolling stool into position. Once that was completed, she washed her hands, and I followed suit, and then we both put upon exam gloves. The nurse brought a tube of lubricant, which she squeezed onto Doctor Kelly's right forefinger and index finger.

"The key is to be gentle but firm," Doctor Kelly said. "First, rub lubricant on the labia, then gently insert your fingers and spread the lubricant. Once that's done, carefully advance until you feel the cervical area. Dilation is measured in centimetres, and a rough guide is your finger, being on the tall side, is about two centimetres across. Effacement is given as a percentage, and starts from two centimetres, which is considered to be not effaced, to so thin as to be barely palpable, which is one hundred percent effaced. I'll make my estimate, but not say anything, so you aren't influenced.

"Once that's done, carefully check presentation and station. Very carefully, and I do mean carefully, feel for the crown of the baby's head. It'll be obvious if it's a breech presentation because you'll feel a fleshy butt, or in rarer cases, feet. If you feel the cervical cord, that is an emergency that needs immediate attention. I don't, or we'd skip the rest of the exam. As for station, that's the relation of the baby's head to the ischial spines. Do you know what those are?"

"Yes, from anatomy," I replied.

"Station is basically the distance from the spines, from -3 to +2, with lower numbers being further inside the spines, and higher numbers being below them. The final check is of the pelvic side walls, which can be parallel, diverging, or converging, as judged by comparing the lower portion to the upper portion. Parallel or diverging are fine, converging means you want to do further exams to ensure there is no outlet obstruction. Got it?"

I nodded, "I believe I have enough information to perform the exam."

"OK," Doctor Kelly said, removing her fingers from Mrs. Smith's vagina.

"Mrs. Smith," I said. "May I perform the exam?"

"Yes," she said.

I received lubricant from the nurse, then followed Doctor Kelly's instruction, which she repeated as I performed the exam. It was strange, but not strange at the same time. I gently searched for Mrs. Smith's cervix, and my estimate was that she was about four centimetres dilated, but only about twenty percent effaced. I carefully found the baby's head, did not detect a cord, and after a bit of trial and error, found the ischial spines and determined the baby was at -1 station. Finally, I checked the slope of the pelvic side walls and found them to be diverging, which my textbooks had stated made delivery easier.

"4cm dilation, 20% effaced, -1 station," I said after removing my fingers from Mrs. Smith's vagina.

"That's very close to what I had," Doctor Kelly said. "And what it means is somewhat subjective and you can't make exact determinations of the stage of labor because it varies from woman to woman. Cassie, you can remove the fetal monitor and pulse oximeter. Margaret, you're free to get up, walk around, use the bathroom, or whatever you feel comfortable doing. It's OK to sit in the easy chair, or you can stay in bed."

I removed my gloves and discarded them, then washed my hands again.

"How long?" Mrs. Smith asked.

"You'll need to inquire of Andrew! He's in complete control of the situation."

"Great, another guy who thinks he can run my life!"

Doctor Kelly and the nurse both laughed, and Mr. Smith and I exchanged knowing looks, understanding that opening our mouths at that point would likely be fatal.

"Several hours, most likely," Doctor Kelly said. "I'll come back and check on you in a bit. Mike?"

We left the room and went a short way down the hall.

"You've really never done that before?" she asked.

"I really never did that before. I saw several done during my OB/GYN Preceptorship, but that was the first time actually performing an exam. But you gave clear instructions, and I followed them. It did take me nearly twice as long as your exam."

"Even so, you've managed to impress me. There are limits to how far we can take this, though."

"I fully understand. All I'm asking is that you teach me and don't have me just stand around and observe, which appears to be how you were treated as a Third Year."

"It was. I also didn't have any of those early observation opportunities you had. My first experience in a hospital was the first day of my internal medicine Clerkship. I was completely clueless, whereas you've observed how hospitals work for two years."

"So there might be something to my aggressive stance on training?" I asked.

"There might. That doesn't make you any less of a pain in the butt!"

"It usually takes people several days to figure that out," I chuckled.

"You're married, right?"

"That is the usual reason to wear a gold band on the left ring finger!"

"Smart aleck! Kids?"

"None yet, but one very near term. My wife is due around the 20th, though she's primigravida, so more likely around the 25th. I've arranged for time off with Doctor Cooper."

"She'll deliver in McKinley?"

"That's the plan. She's here with me this week, so if she somehow ends up in pre-term labor, you might get to deliver."

"May I make a suggestion?"

"You may."

"Turn off the 'doctor' and be the husband. She's not going to appreciate you approaching childbirth in a clinical way."

"Of that, I'm positive."

"What's your clerical rank?"

"Deacon," I replied.

"You have married priests, right?"

"Yes."

"Will you be a priest, eventually?"

"No. It's not really compatible with being a doctor, which is my primary calling. When do we check on Mrs. Smith again?"

"Usually about an hour, though the nurse will call us if contractions accelerate. At her current dilation, effacement, and station, it's probably six or seven hours, but you can never be sure."

"A gut feeling?" I asked with a grin.

"No! Basic statistics!"

"But those aren't always reliable," I said. "We did a study on divorce rates and showed they're basically BS. It's like the statistics for babies typically being born in the morning. Those childbirth studies include C-sections and induced labor, so you can guess why the statistics are BS."

"Because for real numbers, you need to exclude deliveries that occur based on hospital and physician schedules. But the timeframe I suggested is typical, even if almost no labor or delivery follows the textbook examples of a 'perfect' delivery. May I make a suggestion, having experienced your style for about four hours?"

"Sure."

"Dial back the aggression a bit. You're going to piss off Residents and it won't matter how good you are, they'll retaliate by giving you scut because they didn't get to do what you're asking to do. I'm not saying don't push, just don't push so hard. If you make an enemy, they could really screw you over. It's trivially easy for them to do so, and you'll basically have no recourse."

What she was saying was effectively true, though I wasn't sure I could back off enough to satisfy some Residents while still getting the experience I needed. It mostly wouldn't be a problem in emergency medicine or surgery, as I had two Attendings who would ensure I was given appropriate opportunities. I could, though, back off a bit, as I'd had my chance to prove myself to Doctor Kelly, and I felt that would lead to more opportunities on this rotation, so long as I didn't give her any reason not to trust me.

"Message received," I said.

"I'm going to get some coffee. Want to come along?"

"Sure."

"One downside to this hospital — they make us buy our own coffee."

"I always said the med school should stop subsidizing coffee in the cafeteria and they could reduce tuition because there was no chance medical students would quit drinking coffee!"

"No kidding. I drank gallons while I was in class and studying, and during my PGY1 year when I hardly slept."

"I've heard horror stories."

"They're likely all true."

"Have you had any deliveries go seriously wrong?"

"Two. A prolapsed cord where we couldn't save the baby and a placental abruption where we lost both the mother and the baby. Both during PGY1. We also had an ER case of a botched abortion where the mother died of sepsis, but that's not what you asked."

We got our coffee from the cafeteria and headed back up to Maternity.

"Why emergency medicine?" Doctor Kelly asked after we sat down in the small maternity lounge.

"A decision I made in fourth grade," I said, then related the story about the girl bleeding on the playground, then asked, "What about you?"

"Growing up, my best friend's mom was an OB, and I was totally in awe of her and wanted to be like her. Here I am!"

"Where does your friend's mom practice?"

"Once my friend started college, her mom moved to Hawaiߴi and started a new practice! I still want to be just like her!"

I chuckled, "I bet!"

"Ever been to Hawaiߴi?"

"No. Someday I'd like to go there, but it'll be a few years. I take it you've visited?"

"The beaches are out of this world!"

"Are you married?"

"No."

"I suspect I know the answer, but kids?"

"Who has time? And I'm sure you know the problem for female physicians."

"I do."

"What does your wife do?"

"Homemaker, plus we have a shared ministry at church."

"Scholarships?"

That was the easiest answer to give, and I had earned them. I had forgone them at my father-in-law's urging, and his logic had made sense.

"I was awarded enough to cover my tuition. For living expenses, I worked during High School and college, plus my parents contributed some, and my grandfather gave me a gift to encourage grandchildren."

Doctor Kelly laughed, "Don't give my grandparents any ideas!"

"Will you explain a typical delivery, please?"

"Sure."

She went through the process, which followed almost exactly what I'd read in my textbook the night before.

"When we go back in, you can do the exam. The basic differentiation level is six centimetres, once she progresses past that, things are moving normally. If she's not making progress after twelve hours, then we need to consider intervention. I prefer to allow things to progress naturally unless there's fetal distress."

"Which would be?" I asked.

"Recurrent late or variable decels or bradycardia, or decels lasting five minutes. Those are the most important signs. When it comes time for delivery, you'll observe and I'll explain the steps, but I can't allow a Third Year to do a delivery without approval from the Chief Attending."