Holiday Cheer

"For unto us a child is born, unto us a son is given: and the government shall be upon his shoulder: and his name shall be called Wonderful, Counsellor, The mighty God, The everlasting Father, The Prince of Peace." - Isaiah 9:6

Merry Christmas!

This December season has been filled with much holiday joy; here is a quick post on Christmas Day to recap the month's events.

Although I admit I have not been a great picture-taker, I have a few highlights:

Family Medicine Holiday Party,
with "babies galore"
(Susanna/Gemma, Betza/Rafa, and Sarah/Eleanor... missing are Noelle/Kacey and Anika/Madeline)



Merry Christmas, Kunkels! (Betza, Rafael, and Tom)



Wine-tasting around Livermore, where the Satows graciously hosted us pre- and post-tasting :)

Kelvin and me



We had an eggnog (mmm) and tree-decorating party at Char's but, alas, I took no pictures.

We had a Family Medicine Resident holiday party/applicant dinner at Rocky's mansion, which was awesome. We did a gift exchange of nice-ish gifts, but white-elephant (a.k.a steal-) style, which was absolutely hilarious. Who knew that Trivial Pursuit and a leopard-print Snuggie (in California!) would be such hot commodities?!

Kim, Char, me, and Jessica, staying warm by the fireplace (one of four in that house!)


Last weekend, we had a delicious dinner at Kyla's, which included her baked mac and cheese, some tomato soup I attempted from scratch, Joe's famous artichoke dip, salads, and delicious desserts including baklava and chocolate cookies w/ peppermint icing (the rumballs were just okay).
Then, we headed to Davis to watch Handel's Messiah which, as always, was enchanting.

Char, Kyla, and me at the Mondavi Center


And.... perhaps one of the best gifts of the season has been .... being home in Virginia.
I was lucky last year to have the Christmas holiday off, and was able to be home with my parents and doggies; we celebrated in McLean while my sister (living in Europe at the time) was gallavanting across the Ukraine. This year, all four of us were able to be in the same place! Although VA feels less and less like "home" the longer I'm away, it is always great to see family and old friends. I hadn't seen my parents since last year, and hadn't seen my sister in over a year and a half, I think, so it's been a phenomenal blessing to have had the 4 day weekend to travel here and hang out with all of them!

I had no travel delays (nor luggage delays... hooray!) flying Wednesday evening from Sacramento (through LA) to DC and luckily missed the delays that came with last week's blizzard which dumped something like 2 feet on the Washington area (Vanessa said she shoveled snow for 7 hrs!). I'm so glad to have skipped the midwest layover on my cross-country journey, and (as expected) slept the whole way here; I am convinced that the red-eye is the best way to get east from the west coast, which can often suck up a whole day of travel time.

Since being home, I have:
- slept a lot (my dad asked me yesterday, "Why are you so sleepy? You just slept the whole plane ride here!" to which I replied, "I haven't slept in 2.5 years!")
- ventured out on the icy roads to pick up my dad from the car repair place due to the Ford's car battery (or alternator) dying (I felt like I was back in MN!)
- read a lot (currently reading Cutting for Stone by Abraham Verghese, which is fantastic)
- gone to the Christmas eve service at Redeemer Lutheran, which brought back many memories from high school. I knew virtually no one there, but did run into Dylan, a guy I graduated with (my 10 year high school reunion was last month and, although I couldn't attend, it would have been fun to see everyone. How old I feel!)
- slept some more
- opened Christmas presents with the family which included some awesome and practical gifts including a water filter and travel adaptor, which I very much needed!
- talked, via Skype (awesome, by the way!) to Marco, Vanessa's Italian boyfriend, who is in Torino right now
- played with the doggies
- drunk lots of tea and eaten mom's rumballs, which are far superior to mine

Vanessa and me with the doggies (me with Duncan; she with Freya) and tree



I think a viewing of It's a Wonderful Life, which may be one of my favorite movies of all time, is in store this afternoon.

We have some more meal plans with friends (the Heimers, my sister's godparents/family) and John/Inara (my godparents) later in the weekend, but today, it will just be us.

It has been a glorious break so far, and is passing all too quickly.

Merry Christmas, again! (and, per Tiny Tim, "God bless us, Every One!")

Clouds

" If all of life were sunshine

our face would long to gain

and feel once more upon it

The cooling splash of rain"

- H. J. van Dyke

Most of us residents are familiar with the "cloud" phenomenon; that is, at one time or another, you get a reputation of either being a "black cloud" or a "white cloud," depending on what "goes down" during your shifts.

A "black cloud" is someone on whose watch disaster strikes. This applies to all call, but particularly seems to be the case with respect to OB patients. Rocky had about 4 code c-sections called on FP patients in labor (including one preterm labor/breech in the vaginal vault) while she was on night float as a 2nd year. I remember hearing about a call in which Jeremy had, amongst ER admissions which he always has, a 26 week pregnant FP patient come in with PPROM (preterm premature rupture of membranes) and another woman who basically coded on him post-delivery. Call is seemingly always like that for him which makes most of us very reluctant to switch for days when he was supposed to be on :). I did my last week of nights as an intern on OB with him, and I remember it was disastrous!!


Mehrdad, one of the FP residents that graduated last year, was also very very "black." On FP calls, he'd have like 7 ER admissions, 4 patients in labor, central lines to place, and at the end of the night he'd say things like, "That was such a great night! I learned so much!" VA calls were the same way-- I don't know how many codes he had to run there while on night float. But he had such a wonderful attitude.

Hao, one of the OB chief residents last year, was perhaps the blackest cloud I have met. She had a horrible vaginal breech head entrapment which everyone still talks about today. I prolapsed my first (and only) umbilical cord on AROMing someone on a shift with her, and have never worked so hard on ER consults or labor management as when I we were on nights together (I remember saying one time to her, "Hao, I have never had a night as bad as that one" and thinking to myself that that it was unsafe for patient care. You know she was a black cloud when she replied lightly, "You think that was a bad night?!".


However, lately, I wonder whether being a black cloud (in terms of work) is really a bad thing, or whether it just makes you better trained, as "what doesn't kill you makes you stronger," right?


I tend to have a white cloud. On FP night float, I found it amazing that I was able to sleep most nights due to the ER being quiet. I had no one code on me while on VA night float. There have been some 24 hour OB calls (including Thanksgiving, as well as last Saturday and this past Friday night) when, despite having the ticking OBGYN ER consult time-bomb pager, I have not had to go down there once. I felt so bad because last Friday night before I came on for my Saturday call , Sarah had, amidst a fairly busy night on the L and D floor, in a 12 hour period, seven ER consults, including delivering a placenta down there, and a couple of D and Cs! I think her former white cloud label (along with that of Jen, the chief she was on with), got revoked after that night.


Granted, I do a lot of pre-call praying that I won't get overwhelmed. I pray that the ER residents will just use their brains and figure out how to manage a miscarriage or vaginal bleeder rather than reflexively calling the obgyn resident every time (do they call cardiology every time someone comes in in afib? I think not. We joke that they consult us every time someone with a uterus rolls in to be seen!). I prayed my way every day to the VA in Rancho Cordova, and had not one veteran code on me. I'm not sure I can always attribute my luck entirely to prayer, but I'm wondering: why am I a white cloud, and is it really good for me?


I feel that, in some ways, being "lucky" may not be optimal for residency training and actually may, really, be very unlucky in the grand scheme of things. I have had pretty good OB training, including decent c-section numbers and antepartum management; however, I am limited in my experience particularly in operative deliveries (vacuum, forceps) , higher-degree repairs, and in dealing with shoulder dystocias. I have not been involved in any c-hysts (cesarean-hysterectomies, usually done emergently to control excessive bleeding).


It is pretty standard that we FP/OB residents don't get quite the volume of the categorical OB residents in most everything, particularly because they rotate at Kaiser, but I have basically had no training in the above. Maybe no one on my calls have needed operative deliveries because I am more patient with pushing, fetal monitoring strips, or am strong at getting people push harder or more effectively. I have not had any bad shoulder dystocias. I have not had a patient have a deep 3rd or 4th degree tear (maybe I protect the perineum well?). In c-sections, I have not yet lanced the uterine arteries or had a cystotomy (bladder puncture). Although it certainly wouldn't be good for the patient, I have joked that, one of these days, I am going to poke a hole in the bladder just so I can learn to repair it.


And while I got to do some cool things last week (such as a c-section for triplets I'd been following for the better part of the month!), I also felt very unlucky. I had never delivered twins vaginally before and it is pretty rare that mom a) goes to term, b) has the twins in a position to permit vaginal delivery and c) wants to try a vaginal delivery over just scheduling a c-section. However, last week we had two twin inductions, one last Saturday while I was on and another later in the week. The first mom (a multip) got to complete dilation with her twin A and then decided that she couldn't push any more than about 1.5h and requested a c-section. I almost said to her (but was definitely thinking), "you have got to be kidding me!" The second mom being induced ended up not having a stable presentation with twin A moving from vertex to oblique/other and, while I also got to do her c-section, I was very disappointed at not being part of a twin vaginal delivery, as I have had a grand total of zero.

This past week (my only week of the block that I was not antepartum resident) was my last full week on UCD Labor and Delivery until the end of the year when I may have to be "acting chief" (I do have some OB calls here at there this next month). There were four assisted vaginal deliveries this week during the hours I was on. I was present at each of them. I got to do zero of them. Maybe it's because I am not assertive enough. Maybe it's just not meant to be. However, as far as building my skills goes and in missed opportunities, this was the the "blackest" week I have had, which punctuated a pretty unsatisfying month in general filled with lots of call, early mornings, rounding, note-writing, and painful clinics.

While it is great for patients for me to generally be such a white cloud and it really isn't fair of me to wish an obstetrical emergency on anyone, I am nervous (esp knowing I will be chief next year) because I haven't seen/managed those complications so that, when they do happen, I'm not sure I will be prepared. Someday, and rather soon, I will be out in the real world without the kind of backup we have here and the best time to learn such skills is now, in residency, when we have a lot of help and supervision. I am pretty sure those people who are the "blackest clouds" are going to be the best trained physicians, and I do envy them in many ways.


So, from now on, I am going to stop wishing I am such a white cloud. Despite loving the sun, I'm going to try to embrace the rain. I'm going to tell myself that stress and a little disaster is probably good for me. Even if it means I have to go to the ER! :)