A Day In The Life Of.....

8.30 am: "Crap, I'm late again!", I heard myself say as I hurriedly kicked my car door and ran towards the elevators. As I entered the elevator I made a mental note, of not stopping at Starbucks in the morning before coming to the clinic. Invariably the person before me in the line is always not sure of what he/she wants and will spend a good 5 mins staring at the menu and changing their mind at least thrice (ok not always but you get the point na). Anyways I rush in to the clinic and enter my room. Dim lights are switched on in my cave (that's what ppl in the clinic call my room since it's always so dark in here), I log on my computer and look at the patient schedule. "Only five patients this morning, great", I say. After that regular checking of email happens, I make a round of the entire clinic to see who is there, some early morning chatting happens with a couple of people, you know the general hi, how are you, how was your day yesterday etc etc...

9.00am: "I have a patient ready for you Rupin", I hear my sonographer say (for confidentiality reasons except mine no one else's name will be disclosed here). Quickly I look at all the images, " CRL is within the range, NT looks good, nasal bone is seen, heart rate is good, i see the placenta, the ovaries, cervix and the BPD", I say to myself. I glance through the screening questionnaire and the patient has checked 'no' everywhere. Allright this is gonna be a easy one, 10-15 mins and I will have given good news to my patient, she will be happy, I will be happy and everyone can then live happily every after (this is the consequence of watching too many hindi movies...why do they always have to have a happy ending???). I enter the room, introductions are made, we start off with small talk, the usual howz your day been coming along so far, and the likes.... We talk about the ultrasound findings which are all very good, patient is very happy, I am very happy, she doesn't have any questions (now I am not happy, I always like patients to ask me questions...more about this later), so I take her to the blood draw room, blood is drawn patient is ready to go.

One down four more to go. I sit in my room looking at the images for the next patient on my computer screen. Ok everything looks good here again. So coming back to my point of me liking patients asking questions. Maybe for purely selfish reasons, I love patients asking questions. To me it's a sign that they are definitely paying attention to what we are discussing, it's usually an indication that they are understanding what I am saying and more importantly it's a feedback mechanism for me. It helps me get better at my craft when patients ask me questions. So like I mentioned earlier, if not for anything else then for purely selfish reasons I encourage questions always. As I gulp down the last sip of my coffee, there's again a knock on my door and my second patient is ready. I've already looked at the images and everything here looks good. Now I skim through the questionnaire and oh nice the patient has marked 'yes' on a few items here. So there is a family history of hemophilia here, interesting. It's a maternal first cousin, so mentally I am already doing risk calculations now to see what is the chance my patients pregnancy could be an increased risk. This is the only place where me and math get along! Thank God I like probability, otherwise me and the field I am in would have had some serious issues. I finish doing my risk calculations, look up testing options, look at what insurance plan the patient has, briefly go through what I will say to the patient to myself and think about the last time I had a patient who had a family history of hemophilia and what we had discussed. I always do that! As I enter the room, I see the sonographer take the next patient in the ultrasound room. She looks very happy, her husband/partner is with her and I hear them say, " This is our first pregnancy are we are so excited about this."

Again the same routine, go in and introduce yourself, small talk happens, you tell the patient about the ultrasound, then you discuss the family history. Ask the patient if she is interested in proceeding with prenatal testing. "No, I don't want to do that." 'That's fine, it's definitely your choice," I hear myself say. Then we talk about hemophilia, what it is, symptoms, inheritance patterns, I start with my favourite drawings of X-linked inheritance, we talk about genes and chromosomes and all those good things. Then I ask her what her understanding of hemophilia is and what her experience is of being around a person with hemophilia. Basically I am trying to see here if she knows what a typical life is for someone with hemophilia. Considering there is a chance that she may have a child with it, it is my responsibility to make sure that she knows what it is like to raise a child with one (I am not saying it is tough or easy here no judgments at all, I am giving her a balanced view). Sounds like she has a good idea of it, her cousin is the same age as she is and they were raised in the same sort of environment and are really close so growing up she had a good idea of what it is. I make sure that I document everything that was said, especially the fact that patient declined prenatal testing. In a country where ppl are very "lawyer happy", I want to make sure I save my ass! All right all done here.

10.30 am: I just about manage to enter my room and as I enter the room I see a note on my door from the sonographer,"Please look at the images immediately and call up the OB's office". This is definitely something serious, I say to myself. I look at the images.... CRL is less that what we would expect at this point, I see a couple of other images and then I see the reason for the note.... no heart rate. It's a fetal demise. "Crap, crap crap, not today". I can see myself going in the room, this time I can't have a smile on my face when I enter, I can't say congratulations to the couple for the pregnancy, I can't say so far on the ultrasound things look good...instead I have to be the bearer of bad news....and as I walk down the corridor to enter the counseling room, I pass the ultrasound room where I heard the couple laughing half a hour ago, " This is our first pregnancy and we are so excited about it", is what I remember them saying. And now I have to go there and tell them , " I am so sorry, but there is no heart rate for the baby" (well i don't use those very words but essentially that is what I have to convey). I stop outside the room, I don't want to knock and enter the room and go inside. I don't want to be the bearer of bad news. I take a deep breath and say to myself, " You've done this before, you can do it now". How will they react? Will they be angry and shout, will they not believe me and insist on having another ultrasound, will they just sit there and take what I say with a stoic, blank face (I hope not), will they cry (pls pls do cry). I knock on the door and I enter the room. I introduce myself and I sit down. This time there is no small talk, how can I ask them about the weather two minutes before telling them their baby is no more? I directly get to the point. We talk about the ultrasound and then slowly my voice starts getting softer and cracking as I break the news to them. My patient looks at me and I can see tears rolling down her cheek, I can see her husband hold her hand, he's trying to be strong but can't hold back his tears. They try controlling their tears..."It's okay to cry", I hear myself say as I pass tissues to them. "Why did this happen to us" Maybe it's something I did", my patient says. I hear her out and gently say,"This was not your fault. Unfortunately we don't know why this happened, what I do know is that this did not happen because of anything you did" (okay important to note she is a non smoker and a teetotaller). They want pictures of the baby, so I give them some pictures. Lots of psychosocial counseling happens and in the end the couple leaves. I make sure that they are checked out from the back door so that no one else knows what happened.

11.30am: I am ready to just crash on my chair and sit quietly for some time. This is always difficult to do, and so it should be. I've done this before, but it's always just as tough to tell someone that they have lost their baby (and so it should be). I want to just sit and do nothing for some time, but my sonographer has two patients ready to be counseled and so I must go on.....

Fast forward to 5.00pm: I've just finished writing all the letters for all the patients I've seen and finally I have "Rupin time". My friends are well aware of this concept. Rupin time essentially is that time where I don't like being disturbed. I want to be by myself and will not entertain anyone at this moment and today I need Rupin time bigtime! I reflect upon my day and think about the hemophilia patient first. I remember how she was not interested in prenatal testing and I think about how my previous patient with a family history of hemophilia was so paranoid about it and wanted testing at any cost. I think about how different patients make different decisions and I can hear Tressa (my supervisor in grad school) say, "Rupin if all our patients made the same decisions, we would not be doing our job properly". I think about the patient with the fetal death and think about how I could have counseled that patient better, make a few notes about it, so that the next time I have to deal with it, I can use some other techniques...yes next time, coz I know there will definitely be a next time. It's not a question of if, rather it's a question of when...