What is an Ovarian Dermoid and Why Does It Grow Teeth!?

Photo Credit CMDRC.com

My first experience with an ovarian dermoid tumor was in medical school. I saw a picture in our text book and was immediately repulsed – how can something that creepy be a real-life finding?!

Though the tumors continue to be one of the stranger pathologies I deal with, the repulsion-factor has subsided. So, what in the heck is an ovarian dermoid and why would an ovary have teeth inside it?

What I’m calling a “dermoid” is just another name for the most common type of ovarian germ cell tumor, in textbooks it will usually be called a mature teratoma. Dermoid came about in modern medicine after the discovery that dermal elements frequently predominate the tumors.

The origination of the word teratoma is from the Greek word teras, which means monster. Since they can contain fully formed teeth, bone, hair, and other weirdness, it is not hard to figure out why this would have been the name people gave it way back before we knew about how the out-of-place tissue got there.

READ. THIS. BOOK!

If you haven’t read the book “Brain on Fire” by Susannah Cahalan you need to get your hands on it. We read it for book club in residency and all the spouses enjoyed it as well, it’s definitely not targeted at medical audiences. Dermoid tumors are occasionally (rarely) associated with an unusual condition called NMDA-Receptor Encephalitis and this is a fascinating and well-written memoir by a New York Post reporter documenting her long and life-threatening journey to this diagnosis.

Pathophysiology, Diagnosis, Treatment…

Dermoids are neoplasms which arise from primordial germ cells and there are several types of teratomas. For board exam purposes, here’s some broad, quick, key-word references:

  • Mature Teratoma = Common = Benign
         – AKA: Dermoid/Cystic Teratoma
  • Immature Teratoma = Rare = Malignant
        – AKA: Teratoblastoma or Embryonal Teratoma

Teratomas in general are defined by the fact that they arise from a single germ cell, meaning they have the capability to differentiate into any of the germ cell layers and frequently contain all three (endoderm, ectoderm, mesoderm). This is why they’re so weird – they are comprised of tissue that would not normally be found in the ovary!

There’s also a less common type of teratoma called “monodermal teratoma.” This tumor differentiates to one special tissue, most commonly thyroid tissue, which is called struma ovarii and can present as thyroid storm!

What’s the most common tissue in an ovarian teratoma?
  • Ectodermal Elements
    – Skin
    – Sebaceous & Sweat Glands
    – Hair
    – Teeth
How in the world does this happen?
  • A single cell in an oocyte gets a wild hair and goes rogue, this is the most common theory
    – So, genetically the DNA is 46, XX
    – Embryonic tissue can develop, but they do not undergo complete embryogenesis
How do they present?
Cystic Teratomas have a classic appearance on ultrasound imaging. Photo Credit to WISC Radiology
  • Ovarian Torsion
    – Patient presenting to the Emergency Dept with sudden onset abdominal pain and an adnexal mass is the most common way we find these. About 15% of Dermoid Cysts will eventually cause ovarian torsion. This happens because the fatty elements, which are low density, tend to make up a large portion of the cyst and this allows the mass to “float” in the abdominal cavity. Thus, they can easily roll/twist along the Infundibulopelvic (or Suspensory) Ligament of the ovary.
So, what if they are malignant?
  • I know, I just said they aren’t – and about 99% of the time they’re not, but they can be. If a mature cystic teratoma IS malignant, it will usually be a squamous cell carcinoma.
    Why? Refer back to the most common tissue type – skin!
  • Skin cancer in the ovary…yup.
How are they treated?
  • If symptomatic, treatment is via surgical removal with ovarian cystectomy or oophorectomy. Asymptomatic ovarian dermoids can be removed to prevent torsion or left in hopes of avoiding surgery.
What do they look like? 
Photo Credit to Queensway Gynecology
  • Here’s a great picture from Queensway Gynecology. Click on their link to see really cool videos of laparoscopic surgical removal of a dermoid cyst or click here or here or here to see some of the more interesting teras-esque internal pathology shots.

 

On Discovering It Was Twins…

As the ultrasound tech quickly scanned through I caught glimpse of two small bubbles and asked her to stop. “Is that two?” I asked, as she measured, snapped, and moved on. “The doctor will be in to talk to you in a second.”

We’d been trying for months and I could hardly grasp the two pink lines, much less the thought of this baby being babies.

… “No seriously, IS THAT TWO?”

She stopped scanning and looked at me with a ‘not-saying-yes-not-saying-no’ look and said “Everything looks fine. I’m going to get Dr. Yeomans now, just sit tight.”

I knew Dr. Yeomans, he was an incredible MFM physician who also happened to be my mentor. As a third year med student, I also knew a (tiny) bit about ultrasound. I looked at my husband – “I think there might be two. I think I saw two in there. YOU DID THIS! Did you see two? YOU PRAYED FOR THIS! Do you think it’s TWO? What if it’s three?! YOU THOUGHT TWINS WOULD BE COOL AND NOW IT’S HAPPENING – WHAT ARE WE GOING TO DO?! Oh my gosh what are we going to do? I’m going to have to drop out of medical school!”

If you’ve been following for more than half a minute you know it was, indeed, twins…and I did not, in fact, drop out of anything. I would leave that ultrasound appointment and give a collaborative presentation to 150 people for my Family Medicine rotation. Shaking, nauseated, and in a full-on cold sweat, I would get up in front of 150 people who thought I was a terrible public speaker and discuss hypertension, while silently (but not covertly) panicking about the state of affairs in my uterus.

Those two blips on the screen are now smart, sassy, beautiful 5yo girls. Someday I’ll tell them of the months it took me to go from terrified and overwhelmed to excited about the fact that there were two of them (and how I simultaneously could not imagine it any other way after that first moment). The incredible chaos they bring to our lives is exactly what we need every single day.

Finding out about their little brother was similarly shocking, but in a totally different way. Getting pregnant with the twins had been this whole ordeal involving infertility, doctors, ultrasounds, prayers, medicine, and third year rotations with ovulation prediction kits in hospital bathrooms. With Milo, however, it happened so fast that I was completely unprepared and, nearly embarrassingly, blindsided.

That positive test, however, was followed by a threatened miscarriage in the midst of a busy and mentally-challenging night float rotation. That was followed by un ultrasound with no heart beat and so little hope (from me) that he would actually stick that I just had my residency BFF scan me alone, because I so desperately did not want my husband to witness what I knew would break his heart.

As rain pattered on the clinic window, my co-resident and best friend turned the screen to me and laughed – “look, it’s fine. See right there – a little grain of rice with a heartbeat.” My tears swiftly joined the downpour outside, “I would’ve told a patient to stop stressing and wait for the second scan…I am never, ever saying that to someone again…”

In the next few days I’ll share the rest of this story and answer one of the most frequatly asked questions on MamaDoctorJoneswhat was it like having kids in medical school and residency?

Twin-Twin Transfusion Syndrome

I want to start sharing a bit more educationally-focused information here. However, in line with my long history of utilizing social media to connect with patients and understand the human side of the story, I hope to employ my non-medical, digital-friends to inspire these topics.

Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org. From the case rID: 51114
Fetal MRI of Stage III Twin-to-Twin Transfusion – Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org. Case: rID: 51114

Hannah from Daytrips & Diapers has graciously given me permission to discuss/link her in this post. She is pregnant with monochorionic – diamniotic twins and was diagnosed with twin-twin transfusion syndrome (TTTS) at 16 weeks. She recently traveled to the nearest fetal surgery center, >8 hours from her home, and underwent a procedure aimed at decreasing placental connections and improving blood flow (and hopefully, outcomes) for both babies.

She then experienced a known complication of the surgery, however at the time of my writing is still joyfully pregnant with both of her twins. Hop over to her blog or Instagram and follow her story for the human side of medicine. Read on below if you’re interested in the medical side – I’ll discuss diagnosis, pathophysiology, and treatment of TTTS below.

 

What is Twin-Twin-Transfusion Syndrome?

  • A complication isolated to monochorionic (one placenta) twin pregnancies where vascular connections on the shared placenta develop pressure/flow gradients. This allows one twin (“donor”) to become anemic and the other (“recipient”) to become plethoric and begins a cascade of physiologic changes which can become catastrophic.

How Often Does This Occur?

  • The incidence in mo/di pregnancies is about 10-15% and bout 6% in mo/mo twins develop TTTS. Dichorionic twins cannot develop twin-twin transfusion syndrome, as they have two placentas.

How Is Twin Twin Transfusion Syndrome Diagnosed?

  • The diagnosis is made clinically by ultrasound. It is classically identified by “Poly-Oli Sequence”
    • !! This will be how it’s presented on USMLE-type exams. !!
      • Refers to polyhydramnios of recipient twin and oligohydramnios of donor twin.
    • Occasionally, there will be such severe oligo in the donor twin that it develops “Stuck Twin,” which is essentially the ultrasound appearance of a donor twin being stuck to the placenta. Anatomically, this results from such severe oligohydramnios that the amniotic sac is lying directly against the fetus.

What’s The Pathophysiology?

Basic overview of donor and recipient pathophysiology in TTTS.
Basic TTTS Pathophysiology
  • DONOR: Relative Hypovolemia –> Kidney Injury –> Hypertension
  • RECIPIENT: Relative Hypervolemia –> Vasodilation/Diuresis –> Polyhydramnios –> Hypertension
  • BOTH: Hypertension –> Cardiac Dysfunction –> Hydrops Fetalis
  • Click Flow Chart to enlarge for more detail

How Bad Is It?

  • It depends on the stage.
  • Quintero Staging
    • I: Poly-Oli Sequence (Visible Donor Bladder + Normal Doppler Flow)
    • II: Poly-Oli Sequence + Collapsed Donor Bladder (Normal Doppler Flow)
    • III: Poly-Oli Sequence + Non-Visualized Bladder + Abnormal Doppler Flow
    • IV: Hydrops Fetalis in one or both twins
    • V: Fetal Death in One or Both Twins

How Is It Treated?

  • The treatment course depends on gestational age at diagnosis and severity/stage, however there are basically 3 options:
    • Expectant Management (i.e. No intervention, just watch)
    • Fetoscopic Laser Ablation
    • Amnioreduction (removing the “Poly” of the poly-oli sequence)
Fetoscopic Laser Ablation - Edited by me, click for original source from Japan Fetal Therapy Group
Fetoscopic Laser Ablation – Edited by me, click image for detail. For original source – Japan Fetal Therapy Group

What is Fetoscopic Laser Ablation?

  • This is a surgical procedure which is performed by fetal surgeons. It involved laser cauterization of superficial anastomotic placental connections through minimally invasive fetoscopes.
  • Maternal preparation includes complete ob ultrasound (including placental location, distance between umbilical cord insertions, and fetal locations/presentation/sizes) and medications (antibiotic + tocolytic +/- steroid for fetal lung maturity depending on gestational age). The procedure is enerally performed with local or regional anesthesia + sedation

Fetoscopic Laser Ablation Procedure Steps

  • Skin incision with scalpel (site determined by placental and fetal locations)
  • Entry Options
    • 18g hollow-needle introduced through maternal abdominal wall and placenta
      • J-Wire guide placed –> Needle removed –> Catheter placed over guidewire with US guidance
      • Metal trocar placed through cannula to allow for uterine entry
    • 2-3mm Fetoscope (with or without angled scope, depending on entry-technique and surgeon preference) inserted
  • Identify all fetal extremities to avoid injury
  • Identify vascular equator
    • Typically in recipient amniotic sac (parallel to “stuck twin” if present)
  • Anastomoses are mapped out and typed
    • Types include arterial-venous (AV), venous-arterial (VA), arterial-arterial (AA), and venous-venous (VV)
  • Visible connections are coagulated using laser ablation
    • Sequential selective ablation (AV –> VA –> AA –> VV) reduces intrauterine fetal death rates
  • Vascular equator re-identified and coagulated

What are the Complications and Outcome?

  • Complications of the Procedure
    • Preterm Labor
    • Preterm Delivery (Avg. gestational age is 31-33w)
    • Preterm Premature Rupture of Membranes (PPROM)
    • Intertwin Membrane Rupture
      • Essentially bringing all the risks of monoamniotic twins into play (like cord-entanglement)
    • Pseudo-Amniotic Band Syndrome
    • Fetal Demise
      • Perinatal Survival Rates: 65%
        • Still with long-term neurodevelopmental, cardiac, & renal morbidities associated with survival.
      • OVERALL AFTER LASER
        • 50% both survive
        • 33% one survivor/one fetal demise
        • 33% both with fetal demise

Wow, Those Odds Look Bad…

  • They are daunting, for sure. However, TTTS severe enough to warrant laser-intervention which is left completely un-treated will result in fetal death of one twin in nearly 100% cases and both twins in >90%. These outcomes, when appropriate candidates are selected, are far superior to no treatment.

 

That’s a brief overview of TTTS and fetoscopic laser ablation. I’ve done a few LIVE Q&As on Twins, I’ll try to round those up to get on YouTube for a more thorough discussion of the pathophysiology and also the different types of twins.

It’s so important when learning about things like this that we don’t forget there’s a human (or, in this case 3) on the other side of our text books. Hop over to the blog and/or IG linked in the intro paragraph for a view into how this looks from a patient perspective.

Why I Chose Ob/Gyn – Obstetrics Portion

Photo Cred: gnelyseo on Flickr Creative Commons
Photo Cred: gnelyseo on Flickr Creative Commons

 

Day 1 of Medical School:

I’m showered, made-up, and well-slept. As a newly wed in a new city embarking on an exciting journey, I possess a palpable eagerness akin to the first day of Kindergarten. Although I am somewhat intimidated and terrified, my mind is focused and eager to get going with this adventure to becoming a doctor.

I confidently write my specialties of choice on the welcome questionnaire.

  • Pediatrics or
  • Emergency Medicine

 

Fast Forward 4 Years to Match Day:

I’m nervous, lactating, and definitely not well-slept. As a new mom to twins in a familiar room holding an envelope encasing my future, I can’t help but feel nauseated. I open it to find relief in the contents and then see a large screen flash my “MS1 chosen specialties” alongside my ERAS picture and actual Match results revealing a totally different future than I envisioned in chapter 1.

Match Day 2013
Match Day 2013

It’s then I realize that only a very small minority of our class actually applied and matched into the specialty they came to medical school expecting to train for.

 

So, how’d I end up here?

Perhaps the most stressful decision we make as medical students is what specialty we will go into. I had distinct plans to avoid any surgical specialty, specifically including Ob/Gyn, mostly out of fear that surgical specialties were not compatible with having a family. I also had an underlying belief/worry that I did not possess the required moral fortitude or tactile skills to operate and lead in high-stress environments.

In fact, even after rotating through these specialties and realizing I enjoyed being in the OR, I still spent the next several months in a mental debate with myself creating reasons I should choose a non-surgical specialty I liked instead of this surgical one I loved. At the end of it all I simply could not justify choosing something I was less apt in and enjoyed less based purely on what turned out to be misguided fears…especially after all the time, money, and effort I had put in to simply being able to make that choice.

Ob/Gyn had several drawing factors for me, some of them I’ve written about in the past. One of those, what I call the “Happiness Factor” was particularly appealing. Despite crazier hours and more intense training than some of the “lifestyle” and “cognitive” specialities, I was happier on my Ob/Gyn rotation than any other. Additionally, I felt like the Obstetrics aspect was uniquely happy. Where else in a hospital are people EXCITED to get admitted?

That being said…

While Obstetrics actually is 90% YAY-BABY-DAY(!), one must not forget that there remains a less-discussed, ever-present 10% which is purely heart-wrenching. This field is usually good, but when it’s not good…it’s downright terrible.

  • Delivering babies you know will never cry…holding your breath for the most deafening silence you’ll ever know.
  • Cradling babies born living, but far too early for modern medicine to help.
  • Telling a mom there is no heartbeat.
  • Taking care of parents who know their baby will be born with life-threatening, limiting, or lethal anomalies.
  • Hugging grieving parents after an unexpected newborn death.

These are all things I’ve done, most of them more than once. These are tragic circumstances which come with the territory. At one point in my life I thought this was made okay by the fact that they are bookended by lots of “He’s soooo cute” squeals to a lovely soundtrack of crying newborns. I’ve come to realize, this 10% is actually a sacred part of my job. Knowing I have the opportunity to guide these families through scary, uncharted waters and give them the tools to find a glimmer of happiness in the unthinkable is what makes this worth it. These women and their families deserve attentive, compassionate, focused care on their darkest day.

Taking care of women through their pregnancy, happy or sad, is not just a job, it’s a privilege. I am welcomed into the most exciting, scary, heartbreaking, wonderful, confusing and intimate of times. The physical, emotional, and social aspects of pregnancy, labor, & delivery make the obstetric part of my job continually exciting.

Maybe the new just hasn’t worn off yet, but even after hundreds, if not thousands, of birth days it still feels like a privilege every time I set foot in a delivery room.

Imposter Syndrome

I wrote this my first year out of medical school and at the time shared it on a site I was writing for. I’m re-sharing all these years later, because it’s still very applicable (both to me and others) – particularly since many of you are at the beginning of your med school or residency journey.

Doctor Amelia
Imposter – My daughter as a lady bug, doctor, Doc McStuffins, kid.

IMPOSTER SYNDROME

Occasionally I find myself in the OR standing over a patient (on a step stool, thanks to my losing battle with a vertical challenge), scalpel in hand, with a “holy-geez-someone-call-a-doctor” feeling. It’s that surreal feeling you get as you transition into a new role, just intensified I think now that my new role involves…I don’t know…cutting people open and pulling out their babies or looking at someone’s insides with a laparoscopic camera?

Honestly, each day is a weird transition of sorts. I get up every morning and do normal things – shower, nurse a couple of babies, lock the front door with a piece of toast hanging out of my mouth and a coffee cup balancing in the crook of my arm, and I transition. The transition is usually seamless – get to the hospital, round, deliver babies, scrub for surgeries, or see patients in clinic, lather, rinse repeat. But every once in while when there’s a moment to step back and survey a situation I will suddenly notice this flood of weird feelings, like I’m a kid playing dress-up and at any minute I’ll have to come back to the real world.

It happens the first time you do a full physical in medical school, or as you sit counseling a family during a tragic diagnosis or bad outcome, maybe when you hand off a tiny, slippery, screaming human to it’s exhausted mother – this overwhelming feeling of “I should NOT be allowed to do this” delicately balanced with “how did I actually become capable of doing this?”

Everyone in medicine feels it at some point and I don’t know that it’s easily explained to those outside the medical field. The only non-medical thing I can personally relate it to is the feeling of overwhelming responsibility paired with shear terror you get as you cradle your first born (or first bornS, if you’re in the multiples club with me) in a quiet house and realize the hospital failed to send you home with a nurse or monitor or instruction manual of any sort. You know, when your brain is wavering between “I got this.” and “Nope, totally don’t got this” but hasn’t quite established where “comfortable” is just yet.  It’s this air of not belonging, almost of doing something you shouldn’t be doing, even though you’re doing exactly what you should be doing.

It’s weird. It is so weird.

I’ve heard it called Imposter Syndrome somewhere, I’m honestly not sure if that’s an actual title of something or if I pulled it out of thin air, but it seems appropriate. I assume the frequency of this feeling will continue to fade as we settle into these new roles, but I wonder if it ever completely disappears? After years of practicing medicine do you ever still get that feeling or does it become so routine that you lose sight of the uniqueness of it all? Either way, I can only assume that with a country full of interns braving their PGY-1 year that I’m not alone in the Imposter Syndrome struggle.

—————————————-

I’ve had a few distinct times I felt this – my first cadaver lab as a med student, probably my entire first year as a doctor, my first midnight and only-Ob-in-the-hospital delivery as a new attending, my first solo surgery. It’s important to note that these things never feel unsafe – it’s not so much a feeling of unqualified as it is a sense of finally realizing this dream you’ve had so long. I can only describe it as a sense that you are finally granted both permission and skill to do these amazing things.

Ob/Gyn Residency – An Update (At the End)

IMG_6626Well hey there, can’t believe anyone is still making it over this way. Residency is kind of time-consuming, who’da thunk it?

I started this post 1.5 years ago and never finished. Awesome.

Considering we’re coming up on the half-way point end of my residency experience, I figured now would be a good time for an update. Last I checked in was a year ago basically forever ago and I was learning to do LEEPs on summer sausages and perineal laceration repairs on cow tongue. Since then I’ve graduated on to being allowed to work with actual patients who are much easier to talk to and far more enjoyable to be around.

Current Going Ons

So, what am I doing these days? Well, this month I’m on Elective. As a chief electives are really awesome, because I basically get to do whatever I want. For me at this point that means I am doing book-keeping things (getting my Texas medical license, which is about 2,000 steps, updating my certifications for BLS and ACLS, etc.) and stalking all the clinic books to see more vulvar pathology and infertility things. I’m also helping out in L&D some, taking q4 traditional call (from home, because my program is awesome to the chiefs), and operating a bit with the group I’ll be joining next year.

Obstetrics

In the past 3.5 years I have delivered more babies than I can count. Some of them stand out as memorable, others fade into a pool of joyous but not unusual. I’ve delivered extraordinarily tiny babies who were very premature, very sick babies, stillborn babies, babies who died soon after delivery, babies who belong to my personal patients and friends and co-workers, babies who made their way via stat c-sections, “birthday babies” (in what other field is it AWESOME to work on your birthday?), surprise babies, twins, and everything in between. Most of the birthdays have been incredibly happy, many heart-wrenchingly sad, a handful were awkward, many were scary, some were downright strange, but most were just lovely experiences that didn’t leave long-lasting impressions due to pure volume. Despite the variety, I can confidently say every single delivery has been absolutely an honor for me. I am still truly in awe every time I attend a delivery that I get to this as my job. It’s unreal.

Gynecology

A mix of clinic patients, procedures, and surgeries – I’ve come to enjoy this sector of my field so much more than I anticipated. It turns out that surgery as a doctor is about a billion times more enjoyable than surgery as a medical student. I’ve done countless “minor procedures” like D&Cs, LEEPs, hysteroscopies, tubal ligations, and diagnostic laparoscopies. In my second year I got more experience with open and laparoscopic abdominal procedures – myomectomies, giant ovarian cystectomies, salpingectomies, ruptured ectopic pregnancies, bleeding ovarian cysts, etc. Open myomectomies are a “second year case” but still one of my favorite surgeries, I have no idea why – I just find them very fun. Third year I operated with the oncologists a lot. The past two years I’ve done more hysterectomies than I ever anticipated. I’ve gotten to do a good amount of Urogyn (pelvic organ prolapse and incontinence) surgeries. I have seen a huge range of very interesting cancer cases and I absolutely loved my Oncology rotations. I loved them so much that I very strongly considered a fellowship in Onc (which was absolutely never on my radar until last year). More on that non-decision later. Outside of Oncology I’ve operated on a handful of very sick patients, but for the most part non-oncology patients tend to be relatively young and healthy. This was actually one of the reasons I was drawn to this field in the first place.

Life

Oh, life. The twins are 4 years old now and absolutely the coolest kids I’ve ever met. We added a new addition to the family in June, he’s a cute little ball of chubbiness and is learning to crawl and pull-up now. We unexpectedly and tragically lost two of our sweet dogs earlier this year. As most of you know they were an integral part of our family dynamic and we will always have a void where they belong. I’ve accepted a job in College Station starting in August – so if you’re in need of an Ob/Gyn in the Texas A&M area, come see me! 🙂 We never planned on going back, but a great opportunity presented itself and we are absolutely ecstatic to make it back to Aggieland!

 

Residency Work Hour Restrictions

The Grass Is Always Greener?
Growing Up in the Era of Work-Hour Restrictions

Tired DoctorIn 2008, the IOM study on resident work hours came out and in the years that followed the Accreditation Council for Graduate Medical Education (ACGME) subsequently implemented a gamut of “recommendations.” As a medical student, I remember thinking it was a much needed change – why wouldn’t it be a good idea to improve patient safety and decrease resident fatigue?

Alas, as a newly minted intern growing up in the era of work-hour regulations, it’s become apparent that many of these changes may actually make life harder without achieving their main goal of improving patient care.

The 80-hour work week cap is fine; it’s been in effect on its own since 2003 and overall it seems to have made residency more humane. Most programs have found reasonable ways to limit work hours to this full-time-times-two amount, at least when hours are averaged over four-week periods.

However, the additional bullet point “recommendations” from 2010 seem to play out very differently in real life than they do on paper. Many of them seem to be arbitrary lines drawn in political sands hiding behind a facade of patient safety, but that’s another blog for another time.

So, what do the bullet point regulations look like in the hospital?

They look like: Interns can’t work 24-hour shifts. 

So, what used to be a two-and-a-half shift weekend turns into a four shift weekend. At a four intern/year program like mine, that means instead of two people splitting the weekends and having a post-call day after 24 hours on, one intern is committed to night-float six nights/week for a month while the remaining three interns take the three leftover weekend shifts. The result: Fewer hours at a time in the hospital, but more working days in a row and more days/month away from your family.

Is that worse than working a 24-hour shift? I’m not sure it is. It’s certainly not better, though, and I’ve yet to see convincing data that it’s made drastic improvements in patient care; I have seen a few mildly convincing reports that it’s potentially done the opposite. What it has definitely done is make scheduling and coverage more stressful and taxing.

I tend to agree with this recent JAMA article suggesting limiting hours without changing workload is completely counterproductive. I do, however, consider myself incredibly lucky to be a resident at a humane program that takes care of its residents.

The regulations seem to be put into place without regard to specialty or program size, which could be the fundamental flaw. What works for primarily clinical specialties like Family Practice and Pediatrics may never work for primarily surgical specialties like General Surgery or for mixed surgical specialties like Ob/Gyn and Orthopedics. In politics and in medicine, blanket regulations, while easier to create, track and implement, rarely achieve proposed goals on a global level.

I guess it won’t matter for me too long – come July 1, 2014 I move up in the ranks to “2nd year” and am suddenly capable of working a 24-hour shift…yet another arbitrary line those bullet points draw in the proverbial sand.

What do work hour restrictions look like in your hospital?

 
I originally wrote this post for my monthly column over at The American Resident Project, a collaborative blog with some of the best resident and medical student bloggers that I some how got invited to participate in. Check it out here.
 
 

Image Credit: imagerymajestic | freedigitalphotos.net

Meet Our Au Pair – Childcare in Residency, Part 1

Mary PoppinsGoing to an ultrasound, peering at the inside of your own uterus broadcast on a screen, and seeing a little embryonic heart beating is equal parts exciting and terrifying. Seeing two little embryonic hearts beating, while still exciting (especially after infertility), is mostly terrifying.

After we got used to the idea of two babies, two cribs, two carseats, two NICU bills, two co-pays, and two adorable little girls we started approaching the issue of two daycare spots.

Conclusion: Babies are friggin’ expensive. Multiples are friggin’ expensive on steroids.

  • How much would it cost to have two infants in daycare full-time?
  • How often would we be having to take off work for double-doses of the sickies?
  • How much would we have to change our preferred ways of raising our two mini-humans because of protocol or rules?

A lot. To all of the above questions and countless others, the answer is a lot.

We knew there had to be options other than daycare, so we googled and asked around and ended up researching several options, including Au Pairs.

What Is An Au Pair?

Think foreign exchange student blended with Mary Poppins and all wrapped up in a tortilla of cultural exchange topped with awesome sauce. That’s an Au Pair.

So, a few months into parenthood we embarked on our journey to find an Au Pair using the only agency that serviced our area, Au Pair Care. An Au Pair is (typically) a young woman from a country other than your own who takes care of your children and things related to them. In addition to childcare, most Au Pairs take some sort of college courses & focus on better learning the language and culture of your country.

For Twin Tuesday I thought I’d do a series on Au Pairs and answer some of the common questions I get about having an AP. But, for today I’ll introduce you to our wonderful Au Pair, Odelia.

Welcome To Texas, Odelia!

(the newest, and likely most normal, member of the Jones family circus)

Our Au Pair

Odelia is from South Africa. She’s 19 years old and meshes so well with our family if it wasn’t for her weird accent I would swear she was born into it (the fact that she can not only take our teasing and sarcasm, but send it flying back only proves this point).

She is absolutely wonderful with our babies. When we were interviewing her we told her we were looking for a big sister for our girls, not an employee, and that is exactly what we got.

She grew up outside of Johannesburg in a small town, so moving to small-town Texas wasn’t too much of a change.

Just kidding. Total culture shock. We may not live in downtown San Francisco, but can you imagine leaving your family and the place you’ve been raised to literally go across the world and live in new country with the circus that is this family? I mean really, three crazy dogs, two tiny babies, a mom who works 80 hours/week, and a dad who might as well be the paparazzi with the way he follows people around with cameras…that is insanity, y’all.

Throw in Texas football, weather, language, and Mexican food and we’re downright lucky she didn’t flee on day one.

We’ve been blessed with a new family member and loving childcare provider all in one. It will be a sad day when we all say goodbye and give her back to her “real” family. Until then, though, I’ll spend my time thanking her for her hard work and trying to convince her to guest post for me at Mind On Medicine. Don’t we think that’d be awesome?

In the next Twin Tuesday Au Pair post I’ll answer questions about having an Au Pair – so if you have any burning questions let me know!

Ob/Gyn Residency – Month 1

Danielle Jones, MDSorry I’ve been away so long! Between graduating medical school, moving across the state with 6mo old twins, traveling, welcoming our new Au Pair, Odelia, and starting residency, life has been hectic, to say the least. I can only imagine life will continue to be hectic(-er), but now that I’m back to some what of a predictable routine my goal is to blog more frequently. Not for y’all – I’m sure you didn’t miss me a bit (*tear*) – but for me, as I truly enjoy writing here and I fully intend to keep doing it.

July 1 marked the first day of residency, with a week of orientation preceding, and so far it’s been a nicely terrifying adventure. I started on Ambulatory Gynecology, so I feel like I’ve been eased into everything very slowly. My hours have been fine and I’ve been able to keep up fairly well with things, but again – I’m on basically the easiest rotation of intern year.

The biggest thing I’ve found? I have so much to learn. I often feel like a lost puppy – I do a lot of wandering around in clinic asking upper-levels where consents are kept, how to access lab values in the 25 EMR programs we use, and if we’re really sure I can give that person a refill on their Fluconazole, because holycrapmynameMDisonthatscript. I’m sure the 2nd years see me coming and battle each other for hiding spots in the equipment closet lest I ask them for 6,000th time which forms I should fill out on a pre-op hysterectomy patient. God bless their patient souls (see what I did there? heh).

Labor & Delivery call days have been fun, delivering babies and having my name go on the birth certificate is an exciting step forward from being the (extremely awesome, but typically nameless) professional placenta catcher I was in my third year of medical school. Being in charge of triaging patients has taught me a lot, but I still feel like I know close to nothing. Every upper-level and attending I’ve worked with has been extremely patient and almost all of them are eager to teach. If nothing else, after the past several weeks I am 100% convinced I chose not only the right specialty, but the perfect program for me.

Pagers still annoy me. I can’t figure out why we can write prescriptions on an iPad and it magically shows up at the pharmacy, but I still have to carry around a ridiculous piece of technology (and sometimes two or three of them) from 1970 everywhere I go. You’d think we could just get an app on our phone called “PAGER APP” and divert pages to it. I mean, really, it cannot be that hard to do. Oh well, I finally figured out how to use it and I’m slowly becoming less senile towards the little guy. At least nobody has asked me to fax anything yet.

 

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Sim labs have been great teaching tools. We’ve done some simulated complicated deliveries with Noelle (and her weird, tiny baby) which are nothing like real-life complicated deliveries, but do give you a chance to slowly and calmly think through management techniques without the nervousness. We used beef tongue for an unusually great model of perineal lacerations and hysterotomies and a couple attendings and residents worked with us learning closure techniques. We learned LEEP on some unfortunate HPV-infected summer sausages (that smelled…awesome…yah I’ll go with awesome) and the Pap Smear reps came around and gave us a nice overview of the correct technique for gathering those. All in all, I feel like these have been an awesome chance for us to practice things we are suddenly expected to know how to do.

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So, life is busy, but good. I expect in the coming months things will only continue to get crazier and busier, but the work is fun and the people are great. My co-interns are better than I could have asked for and the upper-levels and attendings here are fabulous, as expected.

Screen shot 2013-07-15 at 5.11.53 PMInterns celebrating Jenna’s birthday!

 

Patient Stories: Cancer & The Caregiver

If you’ve been around here long you know that my love of social media goes beyond tweeting pictures of the most adorable twins on the planet and talking #meded with others in the healthcare world, it extends into the world of patients and their stories. Social media is fun, it’s interesting, and it’s a good way to interact, but more importantly social media is a teacher. I’ve learned more about how to be a compassionate doctor by listening and interacting with patients who share their stories online than I ever could have learned from a textbook.

So, when Cameron contacted me and asked if he could blog about his experiences as a caregiver for his wife who has mesothelioma I was ecstatic. The chance for my readers to hear a story about how medicine doesn’t stop at the door to their clinic – invaluable.

Let me introduce you, this is Cameron, his gorgeous Mesothelioma-butt-kicking wife Heather, and their adorable daughter, Lily.

Cameron, Lily, and Heather

And here’s what he had to say about how becoming a caregiver for his wife in her fight with Mesothelioma gave him a new perspective and mission in life:

My wife, Heather, knows that I went through a great deal after she received her diagnosis of mesothelioma. Although I briefly told her about my experience, this information will show her, and anyone else currently struggling through a similar difficult situation, more about my emotions as I cared for her.

We were blessed with the birth of our daughter Lily three months before the devastating diagnosis. Instead of being able to celebrate such a joyful event, we were instead plunged into misgiving and trouble when the doctors gave their diagnosis. From that first moment, I had trouble imagining how our family would be able to get through this time.

While I mostly wanted to take time to process my emotions, the doctors required Heather and me to begin making important decisions regarding her healthcare and treatment. This was a small portion of what I could expect over the coming months, as I would continually be needed to make more choices that were demanding.

When I was able to process my emotions, I found myself full of vexation, frustration and uncertainty. I displayed these emotions outwardly in much profanity. I was only able to curb this when I remembered that my wife and daughter needed me to be their steady support. While I certainly failed at times, I always tried to be positive for my family.

Another part of the process for me was learning how to deal with such a large number of tasks. Besides work, I also had to care for my family and pets and coordinate traveling schedules. This caused me a great deal of stress in the beginning, but I soon found that tackling one important task at a time was vital. In addition, I readily accepted the help of family and friends who graciously came to our aid during this time when I do not believe that I could have made it by myself.

The hardest time was the two months when Heather and Lily were staying in South Dakota with Heather’s parents. Heather took this time to rest after her surgery and to prepare for further mesothelioma treatments. However, I was only able to see my family once during this period.

The weekend that I visited was a snowy one. In fact, I had to wait out part of the 11-hour drive in my car as I waited for the snowplows to clear the roads. Once I arrived in South Dakota, I had a little over one day with my family before I had to return to work.

I readily admit that while the decision to be apart was hard, it was completely necessary for all of us. I needed to work while Heather needed to rest. I see this, as well as all the other exacting choices that we made, without any dissatisfaction because they were vital to Heather’s health. Through all of our struggles, Heather is still here and still healthy over six years later. I hope that our story can be a source of hope and help to those currently battling cancer, as well as those battling alongside them.

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