Do you binge?

Once a year, the government of Canada would like you to see your family doctor for a preventative health visit. In fact, they would like it so much that they will give your family doc a bonus for filling out the "annual health check" forms.

This is good for many reasons.

1. The annual health check asks the same questions of everyone. It standardizes things so you get the same level of care, regardless of who your doctor is.
2. It creates a framework that can be compared from year to year so you can monitor chronic conditions.
3. Your family doc needs a donut fund so that every day (and not just Friday) has a desk-donut.

The drawback is this: The annual health check asks the same questions of everyone.

My 80 year old patients laugh when I ask them about their libido & recent sexual partners. (Or more disturbingly, they TELL ME DETAILS.)
My 20 year old patients look horrified as I ask them about chest pain, urinary incontinence, haemorrhoids & erectile dysfunction. (But again, there's always one...)

Honestly, the questions that bother me the most are related to drinking.

I feel totally confident saying to my 45 year old patients, "You need to have a maximum of two alcoholic drinks per day and at least one alcohol-free day per week."

But when a 29 year old says, "I don't drink regularly, often go up to a month without drinking, but then I drink 5-10 drinks in one night", I pause.

This is, clearly, unhealthy binge drinking.
This is also my exact answer.

I don't know anyone in my peer group who doesn't drink like this. The days of a drink before dinner and a nightcap before bed are gone. People in my age group (scientific polling of my friends, n= 20) have big nights, pub nights, dinner parties, etc where alcohol is consumed in mass quantities, but they don't drink between occasions.

As a result, I don't know what to say to my patients. I cop out. I read them the spiel of 1-2 max. I suggest that they alternate water with their alcoholic beverages. I vigorously counsel them against drunk driving, unprotected sex, walking alone, and risk-taking behaviours. I give them fistfuls of condoms and test them for STI's & liver damage. I try to explain why they should stop. But I can't tell them to stop without being hypocritical.

As a result, I do not go for my annual health check. Which means that somewhere in Toronto, there's a doctor without a desk-donut, all because I am a hypocrite. But everyone else is doing it...

Turn Into

I had a mother-daughter encounter last week. The 19 year old girl has been having "heart pains" for some time; they're associated with meals, especially eating fatty foods. They cause cramping pain that lasts for up to an hour, sometimes accompanied by nausea & vomiting. The pain is 10/10 when it happens, but there is no pain between attacks.

(Buzz in now if you know the answer.)

The mother was understandably concerned that her daughter was unwell. She sat in the corner of the room and shouted out answers as I asked questions.

"She works too hard! She never stops and takes rest!"
"Her diet is very poor - she never eats vegetables"
"She shouldn't be drinking, right Doctor? Alcohol is bad for young women..."

(It should be noted that these were responses to the questions "How, what, where & when")

At the end of the consultation, as I explained the likely diagnosis and arranged for some tests (Buzz in now for extra credit) the mother stood up and grabbed me.

"You have to tell her she can't drink on the birth control pill. It will kill her."

I actually laughed. I turned to the daughter and said, "If you smoke while you're on the birth control pill, there is a chance it could kill you by causing a blood clot to form and flick off into your lungs. Unfortunately (to her mother) drinking does not increase your risk."

Her mother was not impressed.

It reminded me of my parents. They used to imply that every drink I had was one step closer to my grim death vomiting in an alley somewhere. That staying up past 10pm would lead to clinical depression. That high fat foods would actually stop my heart on consumption. Parents want their kids to be safe, to slow down, to eat well and live good, clean lives.

I am up early, doing homework before heading off to Seaton House. I have eaten a balanced breakfast. I ran yesterday and I am not drinking this week. I caught myself saying to my bf, "It's not that you drink too much, it's that I worry that one day you'll die of cirrhosis of the liver or get permanent brain damage..."

I have turned into my parents. Sigh.

controversy

There was whispering at the nursing station.

"17 weeks? We can't take her!"
"But 4A says they don't know what to do..."
"But it would be cruel!"
"Medical ward might be worse. They don't know what to do with pregnant women."
"But she's 17 weeks..."

The thing is, legally, if a fetus is less than 20 weeks, it can still be terminated (the medical term for induced abortion). Thus, a woman is not pregnant until she reaches 20 weeks. A woman with a 17 week-old is not pregnant. The labour ward only accepts women who are pregnant.

This is the first problem.

The second problem is that this baby was dead.

The woman and her husband had been sent in after an ultrasound showed that their baby had no heartbeat. (And yes, since this was a wanted pregnancy, I will call it a baby). The couple had been sitting in emergency for 2 hours while the wards bickered about who had to take them.

The medical ward refused, saying they didn't know what to do with a pregnant lady.
The labour ward refused, saying the woman was not pregnant, so should be treated medically.

Luckily, the Obstetrician overheard this (we were in the tearoom).

He arranged for the woman to be put in a quiet corner of the L&D ward, away from any newborns.
He arranged for medication to induce uterine contractions so the dead tissue could be expelled.
He arranged for the couple to have a space to grieve for their lost child. When that child was pushed into my hands, he helped me to clean and wrap it, so the parents didn't have to see why their baby couldn't have lived.

I was responsible for checking on the couple overnight. I slipped into their room around 2am and found that the husband had crawled into the narrow hospital bed beside his wife. They had fallen asleep together, his arm across her chest, her arm across her belly. I let them sleep.

I fully and truly believe in a woman's right to choose and easily access termination. Birth and babies are too harrowing and permanent to experience against one's will. But the legal definitions of fetus vs baby are arbitrary. 20 vs 17 weeks vs medical vs obstetrical...

Thank goodness my preceptor stepped over all this and took care of his patient.
"Above all, Samantha, we treat the patient, not the numbers."

It was my last night of obstetrics and I am now thoroughly traumatized. Luckily, I'm back on Family Med now. I talked to a patient about his rough sex practices for 30 minutes. Back where I belong.

Listen to your body...

Alternative health practitioners sometimes use something called "sounding"***. This is where they hold things (foods, medicines, photos of serial killers) near the patient's body and see how the body reacts.

If certain muscles twitch and heart rates change, this object is deemed positive. If other muscles kick in, or you start sweating profusely or vomit, this object is deemed negative. This food/medicine/person is bad for you & you should avoid them.

In short, you are supposed to listen to your body and avoid the things that are specifically toxic to you.

I thought of this last night. At 3am I was curled in the fetal position outside a patient's room. I was using all my energy to not vomit or lose consciousness. I think that baby-catching might not be my thing.

It was a busy day. I delivered 3 babies.

#1 Was a bit of a mess; baby had the cord wrapped around it's neck 3 times, wound so tight we could barely get scissors under it. Still, once babe was resuscitated, he started breathing on his own and should be fine.

#2 I delivered alone. Baby slid smoothly into my hands, parents and I rejoiced, I delivered the placenta and my boss complemented me on my cool. Yay!

#2-b I missed. My pager didn't go off in time, so I ran into the room to hear that sheep-like cry that signals new life.

#3 - I got paged at 2:45am. I ran downstairs. She was pushing. It was her first baby. Her skin was very tight and baby was just not coming. She pushed. She pushed. She pushed. Baby's head kept pressing the skin apart, then falling back. Finally baby came. Meconium in the liquor, baby was silent, but opened his eyes right away. Lots of blood. Lots of tearing. The placenta took a while to come. My boss and I were leaning in to start repairing some of the damage when everything went hot. I realised that I was going to throw up. The nearest bowl was full of placenta. I said, "Excuse me Dr, I need to step outside" and collapsed in the hallway.

Anyhoo, I think this is a sign. Every delivery gives me flashbacks. Every delivery makes me feel unwell. I don't like the smells. I don't like the sounds. The mess. The lack of control. I also don't like waking up surrounded by smirking nurses; don't get me wrong, they looked after me well, but I have yet to convince them that I'm not pregnant. They're already booking my delivery.

So, in conclusion: baby-catching? Not for me.

On to the next block, please!

***Don't quote me on this. I learned about sounding from a high-school friend who now practices as a HORSE naturopath. She uses this technique on horses. HORSES!

How to have a baby:

2009 was the last time I tried to catch a baby. I was young and keen, with catlike speed and reflexes. I dropped her.

(Full disclosure: baby was being born onto soft mattress, fell only 3cm, was caught on first bounce, no harm no foul.)

I am supposed to be baby catching this time tomorrow night. I am older, slower and definitely more sleep-deprived. I am frantically trying to relearn the many components required for successful vaginal delivery.

The textbooks say "Only 3 things are required for successful labour: power, passage & passenger."

Power = uterine contractions. Apparently 3-5 in ten minutes is adequate, but there's no real science behind this rather blase statement.

Passage = um, the birth passage. Any obstructions, like say, YOUR SOFT TISSUE, will be rent asunder by the force of your uterus pushing an entire person through an inflexible space and...No, no, no. Calm down. Generally it works out. As long as your bones are wide enough to pass a head, you're fine. Ish.

Passenger = the important bit. The reason we're all here. There are one or two things that need to be perfect if Baby is going to be perfect:

1. Lie: longitudinal, transverse, oblique. (hint: transverse = bad)

2. Position: the way the head points - it should come halfway out at OT, then (like in the Exorcist) rotate spontaneously before shooting out at high speed in OA position.

3. Presentation: the bit that comes out first. Hope to see the back of the head. All else is doom.

4. Attitude: a real problem in kids these days. JK, attitude is the way they're flexed - if you see a chin first, that kid has BAD attitude and will need a caeser.

5. Station: how far into the pelvis we are. -1 is approaching the hole, +4 is leaving the building.

6. Size: less than 9lbs would be nice. More than 9 and we start to have tears. Rhymes with beers tears and rhymes with cares tears. So many tears. Note to self: don't date men who brag about what big babies they were.

Also, if there is more than one baby, or baby has devil-horns or a tail, this will make things interesting. If things are interesting, something's going wrong.

So there you have it. Three simple components, each with 3-5 sub-requirements, 6 caveats, 4 additional notes and a partridge in a pear tree. Having babies is hard.

Making babies? That's a whole other post.

Blip!

This post was composed last week, but I got called to a trauma before I hit send. I'm leaving for NYC to meet up with my favourite people (Banana! Dan! Sally! Randy!) and will be back in 2 weeks, ready to tell you all the gory stories of baby-catching in Scarborough!

Suddenly, it is the last week of my surgical rotation. I am hiding in the call room at 9am, wearing 3 pagers (plus my phone). This is what I have learned after a month of surgical training:

1. Always hide in the call room. If you're on the floor, nurses, case managers, dieticians & patients can see you. And then they can ask you, "Just quickly, just one thing...". This will prevent you from doing your real job.

2. Your real job is paperwork. Every single patient needs an admission note, progress notes, prescriptions, diet plans & discharge summaries. If you are not a surgical resident it will be assumed that you love paperwork. This assumption is false. But you will do it all anyways.

3. You've got to carry the trauma pager. On my first call shift, I was terrified about being first to arrive at a trauma, which would obviously result in a spectacular and immediate patient death. Now, in my last week, I am trying to carry it as much as possible. Trauma work is teamwork (yep, there are tee-shirts) and there is always someone there to stop you from killing people. Well, so far.

To quote Strictly Ballroom; "A life lived in fear is a life half-lived". And that's just not on.

4. It is possible to get sick of Tim Horton's breakfast sandwiches. I never thought it could be true, but one a day for 21 days in a row (yes, that's how much I'm working) and I have started to feel ill at the thought. I am still eating them, but now I feel a little ill as I stand in line to order the next one.

5. I am not a surgeon. I love the cutting, love the blood, love the clean & decisive management. I do not love the hours, the turnover, the death rate or the hours. I am, for better or worse, a family doc. At least until my next rotation...

Trauma Team.

On my current surgical rotation, sometimes I carry the trauma pager. That means that if a trauma arrives at the hospital, I go down to Emergency and become part of the team who deals with whatever comes through the door.

My first trauma was a young guy (15) who had fallen off the back of his friend's motorcycle. He was wearing a helmet (thank GOD!) so his major injuries were a distinct loss of skin and multiple fractures in his hands. This was a good trauma.

Yesterday we had another young patient. At 2 in the afternoon, she was crossing the street in front of her house and was hit by a car going 40kph. She was thrown through a fence and knocked unconscious at the scene. I was cutting her clothes off (to expose any hidden injuries) as they assessed her pupils; both blown. The CT scan showed a massive intra-cranial bleed. We put in a chest tube, then sent her up with the neurosurgeons to have her brain drained. I don't know for sure, but the consensus was that she would not live. This is a bad trauma.

I am loving this job; long hours melt away when you feel that you are doing valuable work. And when you are involved in these high-tension situations, every nerve comes alive and you function at a higher level than you knew possible. However.

However.

I was lying on my bed last night, reading trashy comics, when I closed my eyes. The sight of trauma 2's broken body appeared in my head. I had to call the people I love to make sure that they hadn't been hit by cars. I dreamed about the push of forcep & tube into the chest wall.

There are some drawbacks to this career path.

2 weeks till babies. Perhaps that will be less traumatic.