Showing posts with label PracticeBalance. Show all posts
Showing posts with label PracticeBalance. Show all posts

Wednesday, November 18, 2015

Thankful For That Creepy Wiggle

Every year, there is always so much to be thankful for. As physicians, I don't think this idea is usually lost on us; we see patients suffering with difficult health challenges or even life-and-death situations on a daily basis. But what is sticking out this year as the thing I'm most grateful for?

Fetal movement. Yes, that weird sensation inside of my own body. My first child is due December 11, right between Thanksgiving and Christmas - the time that we most contemplate gratitude. This is not my first pregnancy, but I have never gotten far enough in the process to experience fetal movement before. I started feeling the movements around 20 weeks gestation, which began as little "pat pats" in my low abdomen that were easily confused with gas bubbles. They have now transformed into squirmy, distinctive wiggles several times throughout the day.

Overall, I have had a pretty easy pregnancy. My early nausea was fairly mild, I was able to continue with moderate exercise and work throughout my first and second trimester, and I have had no major complications as of yet. My tall stature has blessed me with a long torso within which baby can stretch, and I haven't been confined to maternity clothes. However, in my third trimester I have developed severe leg swelling that has significantly limited my activity (and my work, which usually involves being on my feet most of the day). It is very uncomfortable with constant itching and pain throughout my legs. To keep my mind off of it, I have been trying to focus on the good things... like the consistent blessing of fetal movement, a reminder of why I am going through all of this.

Many have described the sensation of fetal movement as "creepy", "surprising", "uncomfortable", etc. Expectant parents jokingly refer to their growing fetus as a "parasite". To me, the squirmy turns of my belly, the head-butting of my cervix and the kicking of my diaphragm are welcome reminders every day (every hour, really) of how hard I've tried to become a mother: the months of IVF cycles, shots, staying home instead of traveling, rearranging work schedules, waiting, hoping... And about how after all this time, it's finally going to happen!

Monday, October 19, 2015

Hormones and shots and procedures, oh my! What is it like to undergo IVF?

People are having children later in life, whether the reason is pursuit of career aspirations, travel, or riding the asymptotic curve to financial security. This truth is never more evident than in the field of medicine, where more and more women are taking the long road of training to become physicians. Some of us (like me) even choose this training as a second career, rendering us older from the start. You've heard saying such as "40 is the new 30", etc., but the reality is that a woman is born with all of her eggs and those eggs age with her. She may follow a perfectly healthy lifestyle and appear younger than her real age in many ways, but her eggs are as old as she is.

As eggs age, their quality declines in the form of DNA damage, which negatively effects their ability to make a healthy embryo that will grow into a healthy baby. By the age of 40, the percentage of eggs that have DNA damage incompatible with healthy embryo formation is approximately 75%! On top of this immutable fact, aging brings the possibility of medical issues that can affect fertility in both a mother and a father. The chance of a naturally-occurring pregnancy during any given monthly cycle of a 40 year old woman is approximately 5-10%, and due to the DNA damage I already mentioned, the chance of a live birth resulting from that pregnancy is even lower. It is truly a miracle in my opinion that women over 40 have spontaneously-conceived, healthy pregnancies.

Enter in vitro fertilization (IVF). IVF is a long and detailed process, requiring lots of resources, money, time, and patience. The first stage of a typical cycle involves, ironically, taking oral contraceptives to reset the hormone milieu and force all eggs into a senescent, follicular stage. The second stage involves stimulating the ovarian follicles with daily doses of a hormone cocktail. It is usually some combination of FSH, LH or an LH inhibitor depending on timing, and possibly GH. There is quite a bit of monitoring at this stage, including almost daily ultrasounds and blood draws to evaluate the growth and maturation of the eggs. The third stage is egg retrieval, in which all fluid-filled cysts within a certain size distribution are aspirated for the contained egg. The eggs are then fertilized with the intended sperm (by various methods depending on the presence or absence of male-factor infertility) and are allowed to grow for 3-5 days into multi-celled embryos. The last stage is embryo transfer, in which selected embryos are injected back into the uterus for implantation. This may occur using the aforementioned, freshly grown embryos approximately 5-6 days after the transfer, or the embryos can be frozen for testing and/or later transfer. Once an embryo transfer occurs, it's up to fate (and continued hormonal supplementation)... after the dreaded "two-week wait", it's time for a pregnancy test!

As you can imagine, the process is not for the faint of heart, nor is it for the person with no flexible time and no extra money. I had to do IVF to get pregnant, and these are my experiences.

Time: If a fresh embryo transfer is planned, all of the steps mentioned above take approximately 6-7 weeks to complete (not including the two-week wait). If the embryos are intended to be tested or frozen, the first three stages themselves take 5-6 weeks. After the egg retrieval, the ovaries must rest and the enlarged follicles must resorb over time. This is achieved by having a period and going back on oral contraceptives for at least 3 weeks. Then the uterine lining is augmented with estrogen supplementation for another 3 weeks prior to the embryo transfer. During this time, other testing may take place for the patient (such as a hysterosalpingogram, hysteroscopy, or endometrial biopsy) and/or for the embryos (such as preimplantation genetic screening for aneuploidy or diagnosis of genetic diseases).

Not only does each pregnancy attempt take a significant portion of a year (during which time a woman's eggs undergo further aging), but each cycle also requires quite a few appointments for monitoring, lab draws, procedures, etc. Although I sometimes had to apologetically make my schedule requests after my practice group's time deadline, I was lucky to have enough vacation time built into my yearly clinical commitment that I could take as much time off as I needed. Not everyone would need to take the entire day off for an hour-long morning appointment, but as an anesthesiologist I found that it was the only way to make things work. A physician who sees patients in a clinic might be able to shift her clinic hours back a bit to make morning appointments - which occur every other day and at times every day during the stimulation phase of a cycle. And at my fertility clinic, the egg retrievals were conveniently performed on the weekends.

Money: With some exceptions, IVF is commonly not covered under health insurance in the United States. That said, I found that certain ultrasounds, lab tests, and medications would occasionally be covered by my insurance based on the fact that they were recognized as appropriate interventions for my preexisting infertility diagnosis. Prices for IVF vary slightly depending on the part of the country where the fertility clinic is located, the medications prescribed, etc. A typical cycle including the stimulation period, monitoring ultrasounds, and the egg retrieval procedure runs $12,000 on average, not including medications (another $3000 - $5000). A frozen transfer at a later date is approximately $3000 - $5000. Preimplantation genetic testing of embryos adds approximately $5000 - $8000 to any particular cycle. A portion of these costs can be offset using "batching" techniques or multi-cycle discounts, tax deductions (in some cases), and an FSA; however, IVF in its many forms is undoubtedly going to present some financial stress for any patient.

"Heart": Egg retrievals are performed across the country using different modes of anesthesia. At the IVF clinic I used, it was treated as a moderate IV sedation procedure with fentanyl and midazolam; however, there are some clinics that do deeper sedation or even general anesthesia. An embryo transfer, regardless of whether it is fresh or frozen, is usually done with oral diazepam, and the patient does not need to be NPO. Prior to either of these procedures, an IVF patient can expect to have many transvaginal ultrasounds, which can be uncomfortable for some women. There are other diagnostic procedures that may figure into an infertility workup or IVF journey treatment plan as well, such as hysteroscopies, biopsies, hysterosalpingograms, etc. In addition to these procedures, the patient must receive daily injections of hormones during the follicle stimulation phase and sometimes additional daily shots after implantation. Most of these shots are subQ, but some of them are IM. I must admit that I myself am somewhat squeamish when it comes to being a patient, but I found the invasive nature of IVF to be tolerable. The mental aspect of the uncertainty, the waiting, the rescheduling of life so that appointments and cycles can be completed, etc. was much more difficult. But if you are a person who does poorly with procedures, this may be an important factor in your IVF decision path.

Speaking of decisions, IVF can take a toll on personal relationships - friendships, family bonds, and romantic relationships. This usually presents in the form of differences in opinion on direction of care, number of IVF attempts, or ethical issues with genetic testing/embryo selection/possibility of multiple gestation/etc. Going through IVF can also impact your feelings about yourself; many women complain of feeling unwomanly, and I was not immune to this myself. It is difficult to accept that you need assistance achieving something that is so basic to human life as reproduction. I dealt with this through therapy, quiet time/meditation, and journaling, but everyone differs in terms of what works for them to manage such stress. I recommend to every woman undergoing IVF that she at least attempt to get therapy for herself, if not couples therapy for her and her partner.

IVF is a physically and mentally involved endeavor. Copious time, financial allocation, and mental fortitude are required. But for many patients with complex infertility issues, it is their only path to genetic parenthood (as it was mine). I'm 32 weeks pregnant now and I am very happy with the path I took to get here. As a "success story" with a little girl on the way, it was all worth it!

Tuesday, August 25, 2015

Pregnant in the OR: Potential Hazards

Regardless of your position, occupational hazards exist when working in the operating room. Normally these things aren't given too much thought, but when my choices suddenly affected another developing life, it caused me to pause and contemplate these hazards on a deeper level. Unfortunately, studies on pregnant healthcare workers (and other occupations) are difficult to interpret due to the fact that they predominantly consist of retrospective cohort data rife with selection and recall bias or animal studies of direct exposure to substances. Nevertheless, here is a list of some things to consider when working pregnant in the operating room or hospital setting:

Anesthetic Gases. While every effort is made to avoid elective surgery during pregnancy, even pregnant women need to have general anesthesia under urgent circumstances; there is no evidence that gases administered at concentrations appropriate for general anesthesia cause fetal harm. Thus, sub-anesthetic levels that would be passively inhaled in an occupational capacity should theoretically be safe as well. That being said, it is generally recommended that pregnant women in the OR avoid inhalation of the gases when possible. We facilitate this by using ventilator circuits with scrubbing systems and taking care to turn off anesthetic gases if the circuit is open to air for a period of time (such as between mask ventilation and intubation). This is mostly routine practice regardless of pregnancy status.

Methylmethacrylate. MMA is a common ingredient in cement mixtures for joint prosthetics. When mixed, it forms a strong scent which dissipates over a number of minutes as the mixture cures. Studies, which have mainly occurred in animal models, reveal mixed results in terms of impact on fetal development. As a pregnant provider, your choices are to not work on cases using MMA, ask the scrub mixing the cement to use a vacuum device to remove the fumes, or temporarily leave the room during the mixing process. In one human study, MMA was not found above a 0.5 ppm level in breast milk of surgeons who utilized vacuum mixing devices. At our institution, the use of these devices is mixed amongst surgery personnel, but local suction can also be easily employed. If I am in a joint room and my patient is stable, I elect to step into the adjacent substerile core (which has a window to the operating room) for a few brief minutes while the mixing occurs. However, I did have a recent case where the patient was very unstable and I could not leave the room or easily turn the case over to another provider temporarily. After that experience, the scheduler changed me to a different OR.

Radiation. Discussed briefly in my previous Pregnant in the OR post, radiation is commonly used during OR procedures such as orthopedic repairs, gastrointestinal explorations, interventional pain management, interventional radiology, angiography, line placement... I could go on. For radiation, potential harmful effects are directly related to the dose of exposure. The CDC website has a table of radiation doses with corresponding maternal/fetal risks at different gestational ages. At doses higher than 50 rads, risks range from failure of implantation and miscarriage at early stages to growth retardation, mental delay, and increased risk of cancer at later stages. As with general anesthesia, pregnant women themselves must occasionally undergo irradiative procedures, but care is always taken to balance risks with benefits. In addition, protective shielding goes a long way to reduce exposure. Even in an occupational capacity we wear protective lead garments during periods of radiation. Wearing these and standing at least 6 feet away from the beam will decrease the exposure by more than 99%. However, the garments must encircle the body and not just cover the front of the body in apron form. This is especially important for anesthesiologists, who often turn their backs to the OR table to gather drugs or supplies, etc. And during my pregnancy, I have actively avoided assignments that involve continuous use of fluoroscopy (such as cath lab, GI lab, and interventional vascular or radiology).

Infection. It goes without saying that universal precautions need to be followed by everyone, but there are wider implications and possible sequelae if a pregnant woman contracts an infectious disease while working in the OR. Discussing the details of this would be beyond the scope of this article, but the gist is that potentially teratogenic effects of certain microbes and their treatments and/or long-term transmission of viral infections to the fetus such as HIV or HCV are considerations that should provide pause and vigilance when employing personal protection.

Stress. This is the most difficult "hazard" to avoid. Theoretically, emotional and physical stress can cause neuroendocrine and cardiovascular alterations that could affect fetal physiology and hence possible outcomes. Limited studies implicate longer working hours, night shift work, prolonged standing, and physical work as risk factors for preterm birth, SGA infants and miscarriage. It must also be mentioned, especially for trainees, that the financial burden of NOT working during pregnancy can cause significant stress in itself. Some women might choose to take a lighter load or less frequent call shifts during pregnancy, if possible.

I have mitigated many of these hazards during my pregnancy by notifying the schedulers early of my status, so that they could avoid giving me assignments with increased exposure as much as possible. In terms of stress, my job has no call duties, so long and tiring hours have usually not been an issue. Not everyone can be as lucky, but vigilance to self-care postcall and adequate hydration during call can help.

For readers who have been pregnant during hospital or OR duties, did you encounter any other hazards at work? What were your experiences trying to avoid them? Share your thoughts with us here!


Keen RR et al. Occupational Hazards to the Pregnant Orthopaedic Surgeon. J Bone Joint Surg Am. 2011;93:e141(1-5).
Fowler JR and L Culpepper. Working During Pregnancy. UpToDate, 2015.
Radiation and Pregnancy: A Fact Sheet for Clinicians.

Tuesday, July 28, 2015

Intern of the Year

Eight years ago this month, I entered the hospital for the first time with the label "MD". My assignment was a prestigious transitional year internship at a large private/academic hybrid hospital. Amongst my rotations would be Internal Medicine, Surgery, ICU, and some electives.

My internship year was wonderful. I relished in the new freedom of managing patients and writing orders. I thrived on the stress of the endless to-do lists; each time I checked a box on my paper, I got a sense of thrill. The learning curve was so steep, and I became addicted to finding ways to be efficient. I enjoyed my co-interns, the staff, and the attendings. At the end of the year, they voted me Intern of the Year!

Then I started my residency in anesthesiology. I had done no anesthesia rotations during my transitional year and had instead chosen to focus on getting exposure to things that I was likely to not see much in the future. The change was abrupt and was not exactly smooth. Like the swipe of an eraser on a white board, all the positivity and excitement quietly vanished. The sheer volume of material to learn was overwhelming, not to mention the technical parts of the job – placing IV’s, preparing and dosing drugs, mastering the anesthesia monitors and ventilators, patient positioning, and the delicate dance of the patient consent process that is unique to anesthesia. Every day was a great battle to keep wits and stay calm while learning the academic and procedural aspects of the specialty.

As the fall months spread into winter and the days became shorter, a gloom washed over me. Rushing to work in the dark and returning home in the dark… was this what I had signed up for? Were other residents feeling the same way? How did I compare? These questions never really get answered since we don’t work together in the same OR. Come wintertime, performance evaluations from faculty started to trickle in. Some comments were positive, but the negative ones cut deeply into my motivation and self-esteem. But I was the "Intern of the Year"; what was wrong with me?

I continued to struggle with procedures, and my In Training Examination scores were well below average. I suffered from incredible fatigue and knew deep down that something was wrong. It took many months, over half of my residency, to figure out what it was: a pituitary macroademona had taken residence in my sella and was wrapping its tentacles around my optic nerve. I was going blind and didn't even notice! Within a week after my MRI, I was on the OR table being anesthetized by one of my attendings. What followed was a long hospital stay and complications of hyponatremia requiring readmission. After a long period of healing, I returned to residency and finished my training.

A stay in a hospital ICU will change you forever. My achievement record during residency, despite having been crowned Intern of the Year, may have ended up being quite lackluster... but my experience as a patient was a priceless learning experience that I'm grateful to have had. It helps me connect with my scared and vulnerable patients every day, and it is a constant reminder of how lucky I really am. And as an attending, I now thoroughly enjoy the practice of anesthesia.

I'm shortening and simplifying a very long and detailed story, but I write this to inspire all the new interns and residents with their sights set on perfect ITE scores, accolades, votes, and awards. In the end, none of that matters. Your years of training will hold a mix of times of difficulty, times of gratitude and times of great learning. Do your best to navigate these times with balance, and make sure to take care of yourself!

Monday, June 15, 2015

Pregnant in the OR: When to Tell

I was 5 weeks pregnant and working in the spine room. Just as I finished my intubation and secured the airway, I turned to set the ventilator and administer some important medications. The surgery fellow started to position the fluoroscope near the patient's cervical spine, about a foot away from where I was working. "Please don't use the Xray right now; I need to put on a lead shield first," I said. "Yeah, ok... whatever..." he said, as he continued to fine-tune its position. Thirty seconds later he sighed, then started pushing some buttons and eyeing the screen. I looked at him sternly and said, "I'm serious. Don't do it. I'm pregnant."

After coos and congratulations from the fellow, resident, nurse, and scrub tech, I felt a bit awkward. Of course, I myself had just learned of my pregnancy; I hadn't even seen a heartbeat on ultrasound yet! This wasn't the way I expected to tell people my good news, and I really wish I hadn't been forced to do so in that situation. That being said, I really didn't want the radiation exposure at that time. I suffered a miscarriage a few weeks later and then had to engage those same people in some very awkward conversations.

The decision of when disclose a pregnancy in any situation is a highly personal one. Unfortunately, there is a lot of misguided shame surrounding miscarriage in our culture, and thus many expectant moms often wait until their first trimester has passed in order to disclose the good news. But in my line of work, there are clear benefits to telling others earlier rather than later. First, anesthesiology (like surgery and many other specialties for that matter) is a relatively physical practice. Say you're feeling faint during a procedure, battling nausea, needing frequent snacks, or have a constant urge to urinate. People are going to think you're having issues and might worry about your work performance... unless of course they know you are pregnant, in which all of these situations are commonplace and understandable.

In terms of shift scheduling, call assignments and specific work days for any given week are often determined well ahead of time. Usually, requests for days off or vacations are done so about 1-2 months in advance; however, because I work in an academic hospital, the summer poses a major scheduling challenge due to new resident orientation/training. If a baby is due in the summer, special arrangements need to be made so as to not impact the delicate balance of staffing during the transition period for brand new residents. In a private practice situation, far advanced notice might be necessary if the due date is around a major holiday. Therefore, alerting the appropriate vacation/call schedulers to a pregnancy earlier rather than later may affect your entire practice group.

In addition, pregnancy status may impact daily work assignments. At my institution, the schedulers try to avoid giving pregnant women assignments that involve consistent or high doses of radiation, such as what is encountered in the interventional radiology suite or cath lab. (I hope to address this more in a future blog post.) It's difficult to avoid assigments in orthopedic rooms since these cases are so ubiquitous, but you might want to also alert the nurse and scrub of your status so that when they mix the methacrylate joint glue, you can step out to avoid the fumes. And you definitely want your protective lead suit if a fluoroscope is in sight!

Just like disclosing a disability at work, it's a "know when to hold 'em, know when to fold 'em" situation. The right point to fold will be different for each individual. Because my first pregnancy (the one in the story above) ended in miscarriage, I was initially keeping things much quieter with my current pregnancy. However, a similar situation with the fluoroscope still happened again at 7 weeks! I got zapped twice in one day despite my veiled warnings, and after the second time I frustratingly blurted out my news to everyone in the room. Of course they paused, congratulated, and then took things much more seriously in the radiation department. It shouldn't have to be that way, but unfortunately most people are very nonchalant about radiation exposure.

Aside from that incident, I waited until about 10 weeks before I was open about my pregnancy. After I had a couple of ultrasounds under my belt and my IVF docs told me that my miscarriage chance was very low, I notified our anesthesia scheduling partners of my status. They have respectfully given me lower-exposure, lower-stress assignments (like fewer, less physical cases per day with limited fluoro, etc.) As far as other pregnancy symptoms are concerned, I have had my days of nausea and moving slowly, but it hasn't seriously affected my performance at this point.

Has anyone - trainee or practitioner - experienced issues with disclosing a pregnancy? Share your thoughts with us!

Thursday, May 14, 2015

MiM Intro: PracticeBalance

Full disclosure: I am not a mother... yet. But I will hopefully (finally) be one soon!

Like many women in the medical profession, I delayed my plans for starting a family until late in my residency training. I initially worked as a chemical engineer, and I also traveled extensively to rock climb prior to deciding on medicine. In addition to entering the medical field a bit later than average, I frankly wasn't ready to be a mom when I was a medical student. I found the amount of work ahead of me to be exciting but also overwhelming in the face of a potential pregnancy/childbirth/parenting etc.

About half-way through my anesthesiology residency (coinciding with my 35th birthday), my husband and I decided it was time to start trying. Only one thing stood in the way: I hadn't had a period in several months. I had always been irregular, but those irregular intervals had increased during internship to an eventual standstill of menstruation. After ignoring this warning sign for a while, I finally sought the help of a reproductive endocrinologist. This initiated a long journey with many blood draws, tests, and time off which finally revealed that I had a large pituitary tumor causing severe hormonal disregulation. My experiences managing both physical and psychological stresses during medical training prompted me to start my own blog,, in 2011. I continue to write regular posts there about stress management, being a patient, and self-care issues.

After my tumor removal, I have suffered from continued hormone deficiencies, which means that I need to use assisted reproductive techniques to get pregnant. I started following Mothers in Medicine a few years ago, around the same time that we actively began trying to conceive. I work three days per week as a purely clinical anesthesiologist (no research or teaching responsibilities) in a large academic hospital - what I'm hoping will be the perfect setup for balancing a career and motherhood!

So now here I am, currently expecting my first child - three years, one miscarriage, and thousands of dollars later. I hope to bring a perspective to the MiM community about what it's like to be an expectant mom (and then eventually a new mom) while working in the operating room. I could also write about what it's like to be an IVF patient (who happens to be a medical professional), if there is any interest in that. Currently I am experiencing a lot of apocalyptic worry regarding all that could go wrong in my pregnancy - feelings born out of both having had a miscarriage in the past and having work-related experience with all the "bad things" that can happen.

Please let me know what you'd like me to write about by leaving a comment below. I'm excited to be here and look forward to hearing from you!