girl MD

let's talk nuclear

2008-10-04T12:59:00.004-04:00

Hey folks. I know this might seem harsh and nit-picky, but it's not a nuc-u-lus...it's a nucleus. It's not nuc-u-lar, it's nuclear. Governor Palin (and W.) clearly did not pay attention in high school biology class.

I might go a little batty if I have to listen to four more years of someone repeatedly using this botched pronunciation.

long hiatus

2008-09-06T17:45:00.002-04:00

blogging requires motivation to write. i have been lacking this in this strange transition that i've been going through. i've uprooted my life from the quiet and solitude of new england and moved into the maelstrom of new york city. i now live in manhattan. i'm letting this sink in and settle.

for those who are still checking this website and wondering where the heck i've gone, thanks for sticking around.

a question to ponder in light of sarah palin's emergence into the spotlight...
is the term "conservative feminism" an oxymoron?

PB&N

2008-04-23T09:44:00.006-04:00

GirlTuesday may eat Oreo's for breakfast, but I prefer peanut butter and nutella sandwichs first thing in the am.

Truth be told, I usually have coffee for breakfast, but when post-call, I need more sustenance. Luckily, our resident call room is stocked with huge tubs of peanut butter and, occasionally, a small jar of nutella.

(For the uninitiated, nutella is chocolate hazelnut butter and the reason why so many girls from the U.S. gain 20 pounds when studying abroad in France.)

finding your limit

2008-03-06T20:54:00.006-05:00

indoctrinating oneself into the culture of medicine is literally and figuratively like jumping through a series of hoops, each hoop slightly higher and more challenging than the first. just when you jump through one, the next hoop comes into focus. supposedly, there's a carrot dangling magically at the end. or so i've been told. i've never actually seen it, but everyone says it's there.

the next logical questions would be: what is the carrot? why do you want it? why do you keep jumping through these hoops in order to get it? how many damn hoops are there?

i, like many in my profession, am a bit of a perfectionist. it was recently pointed out to me how crazy this is. one of our noon conferences was on medical malpractice. the speaker, an engaging lawyer whose father was a surgeon, gave the following example to highlight the stark difference between lawyers and doctors:

(at a deposition)

mr. lawyer: mr. doctor, would you say that it is likely that the crash caused this man's injuries?

mr. doctor: well, i don't know if i could say that...

(mr. doctor's lawyer whispered to mr. doctor, "he means 'greater than 50%', not 'greater than 95%' ")

mr. doctor: ... oh, yeah, i could say that!

voltaire said, "le mieux est l'ennemi du bien." roughly translated, "the best is the enemy of the good." are we forever doomed to seek the best and never find it? can we ever really reach the best? or is it like an asymptote, forever approaching but never actually intersecting? if we can't ever reach it, could we be content with just good?

does P really = MD?

over the next two days, P (for me) = passing step 3 = medical license = fellowship. i'm hoping that it's not a mathematical impossibility.

is it likely that i will pass? well, i don't know if i could say that. if i were a lawyer, i might be able to. but for now, i'm just a doctor.

how do you spell that???

2008-02-16T11:17:00.003-05:00

as a pediatrician, i'm always amazed at some of the names i encounter. there are some that are associated with a particularly poor prognosis. they should tell parents that when they are filling out the forms for the birth certificate. before you name your child nevaeh, for instance, you should really make sure you have good health insurance.

seriously. do not name your child nevaeh. heaven spelled backwards? it's just begging for trouble.

some others that future-parents should be warned about, variations in spelling not withstanding:

charity

savannah

cayden

serenity

trinity

destiny

tristan

brady

brittany

faith

corbin

jasmine

kaelyn

jazlyn

peyton

summer

cadence

the more creative the spelling, it would seem, the poorer the prognosis. also, combining these names seems to increase the odds exponentially that something horrible will befall these children.

to any readers who carry these names or have already named their children these names, you, and they, are likely exceptions that prove the rule. so please do not take offense. some of them are actually really cool names.

juggling

2008-01-04T20:58:00.000-05:00

lately, i have felt like i've been juggling about 5 different things and that if i looked away for even for a second, everything would crash, unceremoniously, to the floor.

this illusion of self-importance was the thing that came crashing, mercifully, to the floor. i left for 6 whole days. i went to a land without internet (and, therefore, without email), without reliable cell coverage, without reliable electricity for that matter. i played in the snow. i went for long walks with my dog. i baked cookies. i tried out the ice cream maker that my brother got for me for christmas. i spent 5 blissful days with my family, whom i haven't seen since july.

i came back to the hospital yesterday and found everything just as i had left it.

i guess i can look away after all.

this is an object lesson in humility that i think all residents must learn. i'm just glad i learned it while i still have 174 days left to enjoy it.

random thought for the new year

2008-01-03T10:34:00.000-05:00

"I have no special talents. I am only passionately curious."

Albert Einstein

snow, glorious snow!

2007-12-20T23:18:00.000-05:00

it's been a delightful few weeks, full of snow, snow and more snow. the forecast for today was, you guessed it, more snow. 3-5 inches. just to prove that this winter will be nothing like last winter, we got 9 inches today.

the only not-so-great thing about so much glorious snow is shoveling it. our house, while lovely in most aspects (high ceilings, lots of sunlight, energy efficiency), the roof is constructed in such a sloping fashion as to dump all the snow in front of the garage doors. my poor obliques!

on a side note, i went to an applicant dinner tonight and found my jaw on the floor when no one in the room knew who gloria steinem was. Ms. Gloria Steinem! i think i may have finally figured out what is wrong with this world. the young ones have forgotten gloria. or maybe never learned about her at all. but they benefit from her courageous spirit every day.

An open letter to Ron Paul

2007-12-16T11:50:00.000-05:00

Dear Dr. Paul,
As a lifelong Democrat, I was unexpectedly moved by your message. Small government, taking responsibility for ourselves, the fundamental right to privacy...these are incredibly powerful ideas that resonate with many people. However, I find that I cannot support your candidacy due to your unenlightened views on abortion. Moreover, I find your views on this issue to be incongruous with the rest of your platform.

I am a pediatrician. I see the effects of unwanted pregnancies in stark, unfiltered detail everyday. Abuse, neglect, emotional scars that never heal, generations living in poverty. Personal responsibility encompasses many things and includes making responsible family planning choices. Whatever her decision, it is a woman's fundamental right to choose whether or not to have a child.

Our society is unenlightened on this issue. Abortion has existed, hidden in the background, throughout history. As long as women have been able to bear children, women have chosen to prevent or abort a pregnancy. Due to Roe vs. Wade, women in this country can now obtain safe, legal abortions that do not kill them or result in subsequent infertility. Due to organizations like Planned Parenthood, women can obtain reproductive and family planning services regardless of their ability to pay.

I respectfully disagree with your views on this issue and wanted to let you know that I will not be voting for you.

Sincerely,
girl MD

199

2007-12-10T18:22:00.000-05:00

there have been several milestones in the last few days that i thought i'd share, if there are any readers left with such a long hiatus. sorry. but read on and you'll see why i've been absent.

1) i am done with the nicu. i just finished my last call of my last month in the nicu. this is a huge relief. i made it through 4 months of this crazy unit without having any babies die on my watch. some, if the universe was truly merciful, should have, but none did. to be sure, there will be consults when i am a fellow, but it just won't be the same.

2) for the first time in my life, i have pneumonia.good old community acquired pneumonia. of course, my community is a hospital and my crackles were focused in one lobe of my lungs, so i'm getting two weeks of moxi, but it could be worse. i figure better to have it now than when i'm a pulmonary fellow. better now, so i can have more empathy for my patients. of course, i haven't missed a day of work. people cringe when i cough, but i wear a mask. the mask i wear is a badge of honor. or so they tell me.

3) to explain the title, today i have broken the 200 day threshold. 199 more days of residency. but who's counting?

please feel free to share your milestones...i'm quite sure they are more impressive than mine.

i've got nothing...

2007-09-16T21:06:00.000-04:00

"I mean, people have access to health care in America. After all, you
just go to an emergency room." -- George W. Bush, July 10, 2007

when i read this quote (which was yesterday because he happened to say this when i was in the midst of my picu nightfloat month and was flirting intimately with the boundaries of human exhaustion) i was completely dumbfounded. i mean, seriously? where do you even start with such an ignorant statement?

and where is the outrage that he could say, let alone think, something so ridiculous? i googled the quote to see where all the buzz was...nowhere. there were a few articles and blog posts about it, but really not much.

all i can say is that hillary can only do better, because there's nowhere to go but up from there. to her great credit, at least she understands the magnitude of the health care problem in this country and has understood it for years. don't we deserve a president who can grasp the rudimentary issues, if not the subtlety, of a problem this important?

there was an article in the ny times today about the release of hillary's new and improved health care plan tomorrow.

i await with bated breath.

lazy holidays

2007-09-03T12:47:00.000-04:00

i'm spending the labor day holiday NOT laboring. it's blissful. it's a wonderful, sunny, breezy fall day. i slept in. now i am sitting on my porch, watching the river flow by, drinking iced coffee and re-reading pride & prejudice. this is heaven. at least, to me. and that's all that really matters today.

honestly...

2007-09-01T23:37:00.000-04:00

we admitted a little girl tonight. she's a 6yo who clearly loves everything and everyone, even when she's sick and even when it's nearly midnight and way past her bedtime. she was telling the nurse and me about the very itchy bug bite on the back of her leg. after she showed it to us, she pointed to the red spot on the nurse's chin and said innocently, "look, you have a bug bite, too!" she seemed genuinely ecstatic to have something in common with her. the nurse, who, thankfully, is as kind-hearted and good-humored as they come, said with a laugh, "no, honey, that's a zit!"
the little girl actually reminds me very much of myself when i was her age. i was sitting on my uncle's lap at christmas and, very sweetly my aunt assures me, told him that i thought he must be the hairiest man i'd ever met. i have no recollection of this conversation, but my aunt swears it's true.
you just have to love kids. when else in your life do you just call it like you see it without fear of retribution?

a running query

2007-08-23T20:21:00.000-04:00

i was running last weekend and was flagged down by a couple in a car with out of state plates who clearly looked lost. i took out my iPod headphones and inquired if they needed directions. they did. i directed them back to the interstate.
as i was about to put my headphones back in my ears and continue on the last leg of my 9 mile run, the passenger asked me if i knew where there was a mcdonalds.
i told them that i actually did NOT know where the nearest mcd's was, as i did not really eat fast food. they were both perplexed by this and continued to probe if i knew where ANY fast food establishments were located.
"well, did we get off at the right exit for food? it said there would be food at this exit but we didn't see any. do you know if there's at least a KFC?"
"well, there's a dunkin' donuts just before you get on the on-ramp." i said shrugging.
that counts as fast food, right?

a sorry lot, indeed

2007-07-30T11:37:00.000-04:00

consider the following:

If people are good only because they fear punishment, and hope for reward, then we are a sorry lot indeed.

what motivates people to be good? is it fear? or is it truly a sense of what is right or wrong? and who decides what is right or wrong? is it a static decision or is it a subjective phenomenon? sorry to be so philosophical, but there you go.

health care blogger code of ethics

2007-07-24T20:04:00.000-04:00

sorry for the prolonged absence. it was not intentional. i was away on vacation in the land of no internet (or, at least, no internet available to me, the person who did not bring her laptop even though there was free wi-fi everywhere, although it was pronounced "wiffy" by several amusing tourists). while driving from denali to anchorage, i stumbled across this cartoon in the anchorage newspaper (artist Mike Lane). i laughed so hard i almost cried.

i am now back at work, but it's amazing how things pile up while you are away. so, i'm digging my way up from the depths, all the while trying to prepare a one hour case presentation for tomorrow. ugh.

"once more into the breech, dear friends, once more"...i promise i will surface again soon. before i go, i promised rob that i would update my blog with the code (see right). thanks rob.

summer safety tip #1

2007-06-26T13:19:00.000-04:00

it's sweltering today.

i mean, hot and humid. the reason i can never live in the south.

i tried to run early this morning to avoid the humidity, but it was already almost unbearable. the only place with a breeze was by the river. seems like people might be tempted to go swimming today. in fact, i'm sure that a lot of folks will. i only hope they adhere to this very important summer safety tip:

DON'T SWIM IN FECULENT POOLS!

i am on PICU night float this month. already, we have had two cases of hemolytic uremic syndrome, or HUS, one of which was likely caused by a child swimming in a water source contaminated by Escherichia coli 0157:H7.
HUS is a syndrome that is typically characterized by a prodrome of diarrhea (90%) or an upper respiratory tract infection (the other 10%). the classic triad of HUS is hemolytic anemia, thrombocytopenia and acute renal failure. it usually occurs in kids <4 style="font-style: italic;">Yersinia, Salmonella, and Campylobacter species, Streptococcus pneumoniae and Clostridium difficile. 70% of HUS cases in children result from E. coli 0157:H7 or Shigella dysenteriae, both of which produce a toxin (shiga- or vero-toxin) that damages the lining of the blood vessels, or endothelium, throughout the body.

the effect of this toxin-mediated damage is profound. fibrin and platelets adhere to the damage on the vessel walls, resulting in low platelets (thrombocytopenia) and tiny little clots called microthrombi. red blood cells are either damaged by the toxin or chewed up as they try to flow past these thrombi (a process called microangiopathic hemolytic anemia).

(normal red blood cells above, damaged red cells below, called schistocytes.)

in HUS, these microthrombi occur primarily in the kidney, resulting in kidney failure. but, really, any organ can be involved. the picture below is of a portion of a kidney called the glomerulus, which is really just a tuft of small blood vessels. the light pink smudgy stuff at the end of the arrow is a microthrombus.

in a similar disease process seen more commonly in adults, thrombocytopenic thrombotic purpura (TTP), microthrombi occur in the brain, spleen, liver, pancreas, heart and kidney. TTP has a much poorer prognosis.

both kids in question had had several days of bloody diarrhea. we're not talking a few streaks here and there that you could explain with a fissure or hemorrhoid. we're talking lots of blood. both were dehydrated, anemic and thrombocytopenic. both had stool cultures that were positive for E. coli 0157:H7. both were in renal failure and are now at TBFCHITW (that's for you, flea, if you are reading this) on dialysis.

one of the most important questions from a public health standpoint is how did they get it? E. coli live among us. most are not harmful and are considered normal flora in our intestines. you might hear them referred to as coliform bacteria. we actually need these commensal organisms to digest our food. They actually make vitamin B12, amongst others, that we need to live. the 0157:H7 serotype is not so friendly or helpful.

0157:H7 is in contaminated meat, such as hamburger. if this doesn't make you want to be a vegetarian, nothing will. you are actually more likely to get 0157:H7 from hamburger than from a steak, as the bacteria are on the surface of the steak (and, hence, are killed in the cooking process) but get mixed up when the beef is ground up to make hamburger. raw or undercooked hamburger is often the culprit with outbreaks of 0157:H7.

another potential source is inadequately washed or unwashed produce. remember the spinach that was the source of the outbreak last fall? it's called fecal-oral contamination. enough said.

0157:H7 also lives in and on cows and other farm animals. some outbreaks have been tied to petting zoos.

contaminated water supplies are another concern, particularly in rural areas where there are a lot of cattle. pay attention to the coliform counts! this tells you how much poop has been in the water. the fish and wildlife service checks water supplies for coliform counts regularly and will close a pond or lake if the level is high enough.

the moral of this cautionary tale is to:
1) avoid contaminated water supplies (aka, the feculent pool)
2) take your child to the doctor when they have bloody diarrhea (please do this if nothing else!)
3) avoid raw/undercooked beef, unwashed vegetables/fruits, and unpasteurized milk or fruit juices

when it comes to E. coli 0157:H7, an ounce of prevention is worth everything.

ondine's curse

2007-06-23T13:56:00.000-04:00

he lay quietly, the rhythmic breaths from the vent lulling him deeper into sleep. his mother, weary from lack of sleep, sat in a chair at the bedside, unwilling to leave him. if he woke, he would want her.
before this night, i did not know the extent of their journey together, this young boy and his mother. as it became clear that he would sleep soundly, the tension drained from her face. i asked her how it all began. as she eagerly began to recount their story, i was struck by how young she looked, after having been through so much.
there were multiple, frustrating trips to emergency rooms, doctors who told her that there was nothing wrong. once it became clear to all who knew him that there was, indeed, something wrong, an excruciatingly long stay in the PICU. yet, still, no diagnosis.
finally, after much searching and many tests, the diagnosis was clear. ondine's curse. congenital central hypoventilation sydrome (CCHS), a rare disorder that causes sleep apnea and usually requires tracheostomy and life-long mechanical ventilation, but only at night.

the name of the disorder, ondine's curse, comes from the myth of ondine. in the current rendition of the story, ondine was a water nymph, stunningly beautiful, who fell in love with a human. when she married him and bore his child, she lost her immortality. as she aged, her husband lost interest in her and was unfaithful to her. she discovered him in the arms of another woman and cursed him, telling him that as long as he remained awake, he would live, but as soon as he slept, his breath would desert him.

in the original tale, "Undine" by Friedrich de la Motte, undine's father, a prince of the mediterranean sea, wishes for her to possess a soul, as undines' do not have souls. (undines are spirits of the elements, earth, water, wind, fire.) he sends her to live with a fisherman and his wife who have lost their own daughter, bertalda, after she wandered away (lured by undine's uncle, kuhleborn).

when undine is 18, a knight, huldbrand von ringstetten, comes to the fisherman's cottage and falls in love with her. only once they are married does she tell him of her heritage. she tells him that if he is to reject her, to do it then and she will return to the crystal palaces of her father, "a soul-endowed woman". huldbrand does not reject her, but vows his never-ending love for her and takes her to live with him in his castle near the danube.

bertalda, who finally discovers her true identity, lives with undine and huldbrand. undine's water-spirit uncle, kuhleborn, will not let them live in peace. he haunts them by emerging from the fountain of the castle and taking human form. to prevent him from doing so, undine places an enchanted stone over the fountain to keep kuhleborn away. they live peacefully for a time.

however, when the three of them attempt to travel to vienna, bertalda drops her necklace, given to her by huldbrand, into the water. undine summons a beautiful red coral necklace out of the watery depths. huldbrand is enraged by this, realizing that his beloved wife is still connected to her water-spirit family. despite undine's warning that should he ever be angry with her that her family will recall her to her watery home, huldbrand expresses his anger and undine is taken back beneath the water where she lives in sorrow. as long as huldbrand is faithful to her, he can continue to draw breath. if he is not, he will die.

at first, huldbrand is grief-stricken and weeps and weeps for his beautiful undine. however, his grief for his wife fades and he eventually plans to wed bertalda, even though his love for undine remains true. bertalda agrees to marry him even though she knows he is still in love with undine. the night before their wedding, bertalda foolishly removes the stone from the fountain, allowing undine to rise from the water to fulfill her curse:

There was a gentle tap at his door. Undine used to tap thus when she wanted playfully to tease him "It is all fancy," said he to himself; "I must seek my
nuptial bed."

"So you must, but it must be a cold one!" he heard a tearful voice say from without, and then he saw in the mirror his door opening slowly--slowly--and the white figure entered, carefully closing it behind her. "They have opened the spring," said she softly, "and now I am here, and you must die."

He felt in his paralyzed heart that it could not be otherwise, but covering his eyes with his hands he said: "Do not make me mad with terror in my hour of death. If you wear a hideous face behind that veil, do not raise it, but take my life, and let me see you not."

"Alas!" replied the figure, "will you then not look upon me once more? I am as fair as when you wooed me on the promontory."

"Oh, if it were so!" sighed Huldbrand, "and if I might die in your fond embrace!"

"Most gladly, my loved one," said she; and throwing her veil back, her lovely face smiled forth divinely beautiful. Trembling with love and with the approach of death, she kissed him with a holy kiss; but not relaxing her hold she pressed him fervently to her, and as if she would weep away her soul. Tears rushed into the knight's eyes, and seemed to surge through his heaving breast, till at length his breathing ceased, and he fell softly back from the beautiful arms of Undine, upon the pillows of his couch--a corpse.

the story has been immortalized in many different forms, ballet, theater, animation (disney's "the little mermaid" is a veiled re-telling of the myth), painting and sculpture (the above painting, "Ondine", is by Paul Gaughin). time has changed the essence of the story, which, it turns out, is quite beautiful and tragic.

the boy slept soundly all night. after telling me their story, his mother slept soundly, as well. the reason they are in the PICU? he had phrenic nerve pacemakers placed. once they are turned on next month, controlled by a remote control box, the pacemakers will stimulate his phrenic nerves, which stimulate his diaphragm to move and, thus, to breathe. eventually, we will be able to remove his trach and he will be able to talk and laugh and breathe, even as he sleeps. amazing.

terrapin station

2007-06-17T22:32:00.000-04:00

i was driving home tonight after a surprise farewell dinner party organized by a 5yo CF patient for her beloved pulmonologist (and my incredibly wonderful mentor). it was a fun evening, full of stories, laughter, and the entertaining antics of the 5yo and her little brother, almost 2yo.
as i walked to my car, feeling a little bittersweet, i looked up and saw a thin sliver of a crescent moon and venus, nestled in the moon's curve. it reminded me of an old, favorite grateful dead song.

"Counting stars by candlelight, all are dim but one is bright;
The spiral light of Venus, rising first and shining best,
All along the northwest corner, of a brand new crescent moon,
While crickets and cicadas sing, a rare and different tune,
Terrapin station."

i can't quite explain why, but it was one of those moments when you just have to pause and wonder at the beauty of everything.

a rhetorical question

2007-06-16T20:23:00.000-04:00

why is it that men are never more interested than when a woman seems disinterested or, at the most, ambivalent?
i got called down the the ED last night for some emergent ear pain at 3:30am. turned out to be a ruptured ear drum, quite painful but also not quite an emergency. while i was down seeing this child, i ran into another resident with whom i used to hang out. we may have had a few dates last fall. he seemed interested at first, but then not so much, so we just drifted. i hadn't seen him in quite some time until last night. suffice to say, he seemed interested again. what is it about guys? why can't they make up their minds?

a running interlude

2007-06-10T16:12:00.000-04:00

i went for my long run today. yup. i'm training again for the half-marathon in august to raise money for our hospital.
i went on a new route today, courtesy of one of the picu nurses who lives in my neighborhood and runs it all the time. it's was great. it takes you out on back roads in vermont that ever so gently roll. there are a few hard hills, but they fortuitously hit just as the nirvana section of my running mix kicked in. plus, the view at the top is stunning. there's not too much traffic, only when it loops back around to cross over the bridge into new hampshire. but that section is pretty short and there's a sidewalk.
i was post-post-call today, which is actually the worst day in terms of fatigue after being up all night. but i pushed through the haze and protest from my quads and persevered.
this year, my goal is to raise more money ($1006 last year) and finish faster. last year was all about proving to myself that i could actually do it. this year is about doing it with style and much, much more grace. given that i actually have time to train, it just might happen.

cross-cover

2007-06-09T22:06:00.000-04:00

so i've got a lot of cross-cover in the picu this month.

cross-cover is when you are on-call at night for a service that you are not rotating on that month. in the picu, this can be a bit dicey, as the kids can be quite sick (obviously) and you don't really know them. we have a 10-bed picu. compared to some hospitals, that's pretty small. so, you think, how bad could it really be, right? well, it can be bad. especially as our attendings are not in-house and you are basically on your own. Thank god for picu nurses.

i blogged about my first cross-cover this month in a recent post.

last night wasn't as bad, but it still freaked me out and i didn't leave the unit.

i managed 9 kids, 4 of whom are on vents, 1 of whom was the first kid i'd ever managed with DKA, or diabetic ketoacidosis.

DKA is how many children present when they are first diagnosed with type I diabetes, which is the type associated with autoimmune destruction of the pancreas and, thus, endogenous insulin production.
Normally, when you eat food, your body breaks it down into smaller parts, including glucose from carbohydrates. When glucose levels in your blood rise, this triggers your pancreatic cells (see diagram below) that make insulin (the islets of Langerhans) to secrete insulin. your liver, fat and muscle cells need insulin in order to use glucose for energy.

In type I diabetes, the islets of Langerhans have been destroyed by autoantibodies. So you can't release insulin in response to elevated blood glucose levels.
when glucose builds up in your bloodstream, that's bad. in order to keep your brain going, your body starts to use fat to make energy, resulting in the formation of ketone bodies (the keto- in ketoacidosis). these use up your buffers, resulting in acidosis. the elevated blood glucose results in an osmotic diuresis. a typical patient with DKA is about 7-10% dehydrated as a result. dehydrated and essentially starving. this kid had lost 15lbs in 3 weeks.

in a purely abstract way, it's sort of fun to manage these patients. i'm an orderly person. i like things that are predictable, things that make sense. when you are reversing the acidosis of a kid with DKA, it's orderly, predictable. the glucose falls, the pH corrects, the sodium rises, the potassium falls. usually the phosphate falls, too. you can anticipate all these things, plan for them. hourly labs. data sheets to track your progress.

in a not so abstract way, it's not so fun to manage these kids. they're scared. sometimes they are super sick. they are getting poked hourly for blood. their life is changing and they feel completely out of control. from a doctor's perspective, you are scared to death that they will get one of the dreaded complications of DKA, cerebral edema, so you're constantly checking their mental status to make sure they are not deteriorating. i kept asking this kid's nurse to wake her up and see if she had to pee. she didn't. and i think i just ended up annoying my nurse. good thing he likes me and just thinks i'm funny when i get all paranoid.

this kid did really well. no cerebral edema. by 4am, her glucose was normal again, her serum ketones were almost cleared. she didn't have horrible sodium or potassium derangements. her acidosis had corrected.

all was well in terms of her physiologic state.

she has a long road ahead of her, but she strikes me as one of those mature-for-her-age kids who will do just fine.

knocked up

2007-06-06T21:13:00.000-04:00

for those who need a good laugh, go see the new jeff apatow movie, knocked up. it's fairly clear that the script was written by a man, but it's worth seeing anyway. i laughed. and i desperately needed a good laugh.

the myth of sisyphus

2007-06-05T15:36:00.001-04:00

post call today after a long, sleepless night in the PICU. i have this vague recollection of leaving the bedside at one point to brush my teeth, but otherwise, not at all.

i am left with a sense of defeat, as if i have been foolishly trying to hold water in a sieve. no matter how much water i put in, it all just flows out again, mocking my efforts and highlighting my naive, all-too-tentative confidence that i know what i am doing.

as the sun began to appear on the horizon, the nurses and i took a moment to breathe and enjoy the beauty. she was momentarily improving, but my intuition was that this, too, would pass.

these are the patients that leave you wondering why it is that we do what we do, when it just seems futile? as if god, if you believe in such an entity, just has a different plan? you struggle to eek out some small iota of change. but in the end, the DIC, ARDS, and sepsis win, just as sisyphus' rock inevitably rolls back down the hill. yet, he rolls it back up again.

i have blogged in the past about other chronically ill children who have passed away, some with more peaceful deaths than others. as a general rule, i support a family's desire to do everything possible. so what do you do in cases where respecting the family's wishes feels unethical? when it feels like every intervention is painful and only serves to prolong the patient's suffering?

when i came home this morning, the sun was shining. spring is in full force here and it is breathtaking. i fell asleep and did not dream. i awoke this afternoon to lightning, thunder and the sound of sheets of rain falling on my metal roof. as i sit here typing, the rain has passed, the storm clouds are receding to the east, the sun is peeking through the clouds again over the greens. mother nature as metaphor.

what are the chances?

2007-06-03T13:19:00.000-04:00

i drove home from smallish state to even smaller state last night through the most amazing lightning storm. it got me thinking. what is it about a car that makes it a safe place to be? what are the chances that you'll get struck by lightning? are you more likely to get struck by lightning or to get swept away by an avalanche? well, i suppose the latter would depend on whether you lived in a place where avalanches occur.
at any rate, i googled lightning strikes this morning and found all the answers to my questions and then some.
-you have a 1:5000 chance of getting struck by lightning during your lifetime
-9 out of 10 people survive a lightning strike
-a lightning bolt strikes the earth a hundred times a second, heating the air around it 5 times hotter than the surface of the sun
-lightning strikes kill more people each year than tornadoes or hurricanes (about 2000 people worldwide each year versus 150 people killed by avalanches each year)
-cars are safe not because they aren't struck but because the tires conduct the charge to the ground
-lightning bolts start as negatively charged particles that extend towards the earth and are met by positively charged particles called streamers extending up from the earth; when the two oppositely charged particles meet, an electric current is formed that makes the flash (for a really neat demo, check out this national geographic interactive site (yes, i am aware that i am a geek).

some safety tips from national geographic (what can i say, i'm a pediatrician ;):

If outside, seek refuge in a car or grounded building when lightning or thunder begins.
If inside, avoid taking baths, or showers, and washing dishes. Also avoid using landline phones, televisions, and other appliances that conduct electricity.
Stay inside for 30 minutes after you last see lightning or hear thunder. People have been struck by lightning from storms centered as far as 10 miles (16 kilometers) away.
If caught outside away from a building or car, stay clear of water bodies and tall objects like trees. Find a low spot or depression and crouch down as low as possible—but don’t lie down on the ground. Lightning can move in and along the ground surface, and many victims are struck not by bolts but by this current.

google is a miracle (edited post reflecting flea debacle)

2007-06-03T09:27:00.000-04:00

seriously.
how did we manage before google existed? how did we ever find images to put in our power point presentations? how much more tedious was it to find scientific articles when we had only pub med? how else do you find out if the guy you met in that random NYC bar who said he was an "architect" is, in fact, an architect and not an ax murderer?
i challenge any and all readers to honestly say that google has not changed their lives in some meaningful way. how you define meaningful is, of course, up to you.

addendum:
i published this post this morning, before i realized the maelstrom of scandal going around the blogosphere regarding my friend flea. (hey, i've been on vacation in a place with no internet. yes, places like that do still exist. you just have to drive really far to get there.)

if you have no idea what i'm talking about, check out this post by Adventures of an Awesome (Sometimes) Mother. it has links to both the globe article and the blogosphere response, from both the medical and legal side.

i'm also intrigued by kevin MD's post on your google reputation.

there are many opinions floating around out there about what happened. i'll refrain from giving mine, as i'm not sure more needs to be said. all i will say is that medical blogs are forever changed, for better or worse. flea has left his indelible mark, as he always did and hopefully will do again.

I may have had my head under a vent for the last month but c'mon...

2007-05-09T16:23:00.000-04:00

In news that can only go under the category of why do we care , I give you this link from the BBC. No wonder we are so despised around the world.

In other news for those with more on their minds than the fate of over-privileged heiresses who are going to jail for crimes they obviously committed, here is a story worth reading. Contrary to all the anticipatory guidance that pediatricians have been giving parents for years about juice, the abstract, which analyzed data from the NHANES study, basically says that 100% fruit juice won't make kids obese. This is only an abstract, the article points out, and needs to be further scrutinized in a peer-reviewed journal. However, the message is truly revolutionary.

Think I'll go have an Odwalla Superfood to celebrate the occasion.

MIA

2007-05-09T13:07:00.000-04:00

So things got a little busy, as evidenced by my lack of posts. April was consumed in a whirlwind of micro-preemies on oscillating ventilators, many sleepless nights filled with record-breaking numbers of blood gases and an overall feeling of exhaustion. I started the month with 3 really sick babies, two of whom were on an oscillator and had profound nosocomial sepsis. By the end of the month, all 3 are off the vent and have "graduated" to the less-acute side of the nursery where they enjoy kangaroo care, isolettes instead of open-bed warmers and are working on their feeds. Now that is what I call a satisfying month.
After a week on community practice, the exhaustion is fading, although I am now plagued with a viral illness that decided now was the opportune time to strike. I guess I have to agree with the timing, as it really wasn't an option to get sick in the NICU.
It's spring here, finally. Trees are blooming. Daffodils are coming up. I no longer cough when I run outside. Life is good, or at least better.

you know you work too much when...

2007-05-09T10:44:00.000-04:00

...you and 2 other peds residents can think of nothing more scintillating on a Friday night than wandering through the aisles of CVS comparing ingredients in children's cold and flu remedies.

long lost friend

2007-03-29T09:27:00.000-04:00

I found an old friend today. We went to med school together. He graduated a year ahead of me and went into the Marines. We sort of lost touch for a while. Last week, I sent an email into the void, just to see how things were. His reply came this morning to my inbox, "unclassified" status. Turns out, he just left for Iraq. Before he left, though, he started a blog, Another Doc in the Sandbox. Check it out and wish him safe journeys.

U2

2007-03-26T12:53:00.000-04:00

On the way to work this morning, I heard three songs on the radio. I tend to flip stations frequently, so they were all on different stations. But all three songs were by U2. What are the odds?

don't get sick in july

2007-03-25T11:24:00.000-04:00

There's a piece in the NY Times Week In Review that details the worst days to do certain things. To sum up:

Don't have a heart attack on a weekend, as you are more likely to die from lack of aggressive treatment.
Don't go to the theater on a Saturday night, as you are likely to be surrounded by snoring, drunken couples who wanted to have a night away from the kids.
Don't go to a nice restaurant on Monday, as you are likely to be served left-over fish by second-string staff.
Don't have a baby on a weekend unless you can help it, as the hospital is more likely to be under-staffed and your baby is more likely to die (the author's contention, not one that I agree with).
Don't send email on Sundays or late at night; apparently spam goes out between 2-5 am and your email will be mixed in with offers for cheap Viagra or notices that somehow they lost your personal identifying information on that order you never placed (under the rock they think you were born under) and would you please re-send your SSN and bank routing number?
Don't buy a car on a weekend day in the fall (try weekday in July or August).
Don't fly in the late afternoon (or anytime in December if you can help it). Duh.
Don't get arrested on a weekend, as you will likely find yourself in a holding cell until the judge gets back from his golf game or hunting trip.

I would add the following:

Don't get really sick in July unless you want an intern taking care of you who has no idea what they are doing.
Don't make appointments in clinic for late in the afternoon (early morning or first appointment after lunch are better bets for not having to wait).
Don't go to the emergency room for anything that isn't an actual emergency (bleeding, broken, not conscious, can't breathe...well, you get the point).

Any other tips from readers out there?

if you want to end the war and stuff, you gotta sing loud!

2007-03-21T20:08:00.000-04:00

My housemate decided to play Alice's Restaurant tonight. I haven't listened to it in ages but all the words came flooding back, filling me with nostalgia for that summer afternoon when I first heard it.

I was 12 and my life was never quite the same afterwards.

My brother was outside, washing his VW GTI. He was 17, my idol. I wanted to be just like him when I grew up. He had his JVC boombox outside with him. Playing at the loudest possible volume was Alice's Restaurant.

I had never heard of such a song, a song that was essentially a story. It was a completely revolutionary concept to me. I wandered outside to ask him who this was, this avant garde story teller.

He rewound the tape and started it over again. "Arlo Guthrie," was all he said. We both sat on the concrete of the driveway for twenty minutes while the song played, laughing at the funny parts.

"Yes, sir, Officer Obie. I cannot tell a lie. I put that envelope under that garbage."

"Obie, I don't think I can pick up the garbage with these handcuffs on."

"Kid, we don't want any hangings." And I said, "Obie, did you think I was gonna hang myself for littering?"

And the meanest, ugliest, nastiest one, the meanest father-raper of 'em all, was coming over to me and he was mean n' ugly n' nasty n' horrible and all kinds a things and he sat down next to me and said, "Kid, whaddya get?" And I said, "I didn't get nothin'. I had to pay fifty dollars and pick up the garbage." He said, "What was you arrested for, kid?" And I said, "Littering."

"I mean, I mean, I mean, I'm sittin' here on the bench, I'm sittin' here on the group W bench 'cause you wanna know if I'm moral enough to join the army, burn women/kids/houses n' villages after bein' a litterbug." He looked at me and said, "Kid, we don't like your kind."

The intangible thing about this song, the genius of this song, is the subtle, radical nature of the story. It's a simple enough story about a guy who was, fortuitously as it turns out, arrested for littering. That turns out to be the reason he was rejected from the draft. The messages are clearly relevant to the 60's anti-war movement, but if you listen carefully, they are still applicable today.

"If you wanna end the war and stuff, you gotta sing loud."

I think the seeds of my liberal activism were already planted, maybe they had always been there, but they certainly blossomed a little that afternoon in the driveway.

I didn't grow up to be exactly like my brother, but we are very close. He's been pretty sad lately, which makes me sad for him. We were IMing tonight and I randomly typed some of the above lyrics. He immediately got the reference. It made him smile.

cura te ipsum or primum non nocere?

2007-03-20T10:16:00.000-04:00

I didn't enter the medical profession to make money. I entered medicine, pediatrics specifically, because I had that semi-altruistic desire to help people. I say semi-altruistic because some would argue that true altruism does not exist, that there is always something in it for you, even if it's just feeling good about helping someone.

But that's a philosophical debate for another day.

I read an article this morning in the NY Times that troubled me on many levels. Doctors in Shymkent, Kazakhstan being sued for giving unnecessary blood transfusions because they profited from it. They claim that their salaries are so low that it forces them to make money where they can, $10 per transfusion as it turns out.

Ok. While the ethical quandaries abound, some might argue that if they're not hurting anyone, then what's the problem, right?

Wrong.

Some of the children who received these unnecessary blood transfusions now have HIV.

Primum non nocere, in this case, trumps cura te ipsum. $10? Seriously?

updates

2007-03-17T11:17:00.000-04:00

It's been an interesting week in health care. Just a few highlights, in no particular order, in case you were paying more attention to the Alberto Gonzales shenanigans.

Low-acid coffee, like low-acid OJ, is now being marketed for people who have bad reflux. Not that there's really any evidence to support this. An excerpt from the NY Times article by Andrew Martin :
A recent study by Stanford University researchers found that there was little scientific evidence to support the idea that eliminating coffee — and several other foods and drinks — helps cure persistent heartburn.
“It’s as much mythology as anything,” said Dr. Joel E. Richter, chief of medicine at Temple University’s School of Medicine in Philadelphia and past president of the American College of Gastroenterology. “The evidence that coffee is injurious to the stomach isn’t there.”
The Stanford study, that appeared in May in The Archives of Internal Medicine, evaluated published medical reports from 1975 to 2004 on heartburn.
The study found that there was no evidence that giving up tobacco, alcohol, coffee, spicy foods, citrus or chocolate helped decrease heartburn, known to professionals as gastroesophageal reflux disease, or GERD.
Research on coffee’s impact on the digestive system was contradictory, the Stanford study found. “Given the conflicting reported data, the relationship between caffeine and coffee and GERD remains unclear,” the study concluded. “There is insufficient evidence to support the routine recommendation that patients with GERD avoid such behavior.”
Dr. Lauren B. Gerson, one of the study’s authors and the director of the Esophageal and Small Bowel Disorder Center at Stanford University, acknowledges that when patients complain that coffee irritates their stomachs, she tells them to stay away from it.
But she questions the wisdom of routinely telling patients with acid reflux to stop eating certain foods, even though such advice is still offered by the National Institutes of Health and the American Gastroenterological Association.
All I know is that when I eat garlic or tomato, I regret it. Luckily, coffee is not an issue for me. I don't know what I would do if it was. Isn't it funny how anecdote trumps evidence in an individual, if not a population?

Antidepressants don't help kleptomaniacs. Well, if you read the lay media coverage, that's the impression they give. However, if you read the fine print, the study published in the Journal of Clinical Psychiatry was a very small trial of Lexapro (escitalopram) vs placebo in 15 people diagnosed with kleptomania. No significant difference was found between the drug and placebo. Interestingly, this study was funded by the manufacturer of Lexapro. In case you wonder why any of this matters, there are an estimated 1.2 million kleptomaniacs in the U.S. alone.

The FDA is putting new warnings on sleeping pills (Ambien, Lunesta), confirming what many people chalked up to urban myth. From the NY Times article by Stephanie Saul:
The review was prompted, in part, by queries to the agency from The New York Times last year, after some users of the most widely prescribed drug, Ambien, started complaining online and to their doctors about unusual reactions ranging from fairly benign sleepwalking episodes to hallucinations, violent outbursts, nocturnal binge eating and — most troubling of all — driving while asleep.

Night eaters said they woke up to find Tostitos and Snickers wrappers in their beds, missing food, kitchen counters overflowing with flour from baking sprees, and even lighted stoves.

Sleep-drivers reported frightening episodes in which they recalled going to bed, but woke up to find they had been arrested roadside in their underwear or nightclothes. The agency said that it was not aware of any deaths caused by sleep-driving.

The reports gained credence from scientific studies. A forensic toxicologist in Wisconsin, Laura J. Liddicoat, gave a presentation at a national meeting on six instances of Ambien-impaired driving.

And Dr. Carlos H. Schenck and Dr. Mark W. Mahowald of the University of Minnesota said that they had been studying cases of nearly 30 Ambien users who developed unusual nighttime eating disorders.

Last May in Washington, Rep. Patrick Kennedy, Democrat of Rhode Island, blamed Ambien when he crashed his car near the Capitol building.

The agency also received reports of people making phone calls, purchasing items over the Internet, or having sex under the influence of sleep medication.

In each case the consumers had no recollection of the events, which they said had occurred after they took their pills and headed for bed.
Hillary Clinton and John Dingell (Dem, Michigan) introduced a bill that would expand CHIP (Children's Health Insurance Program). No matter what you think of Hillary, expanding health insurance coverage for kids is a fantastic idea.
Under the bill, virtually all uninsured children would have access to coverage of some type, with or without federal subsidies. Mr. Dingell and Mrs. Clinton would give states financial incentives to cover children with family incomes up to four times the poverty level. A family of three is considered poor if its annual income is less than $17,170. Thus, the bill would allow the federal government to pay subsidies for coverage of children in a three-person family with annual income up to $68,680.
That is higher than the limit in any state. In January, 24 states had limits at 200 percent of the poverty level, 10 had lower limits and 16 had higher ceilings. New Jersey covered children up to 350 percent of the poverty level. Gov. Eliot Spitzer of New York has proposed increasing the limit to 400 percent, from 250 percent.
The latest budget request from President Bush would move in the opposite direction. He proposed reducing federal payments for children with family incomes above 200 percent of the poverty level, saying that would return the program to its “original objective.”
Under the Dingell-Clinton bill, states could allow employers and parents to buy coverage through the Children’s Health Insurance Program. States could subsidize the premiums, and the federal government would help pay the cost in states that expanded their programs to cover children with family incomes up to four times the poverty level.

Not a complete round-up but at least food for thought. I didn't even mention the birth control pill ruling, as that will be a separate post when I am less irate.

more caffeine with that donut?

2007-03-12T19:21:00.000-04:00

Caffeinated Donut Invented

Molecular biologist Robert Bohannon has created pastries with the caffeine equivalent of two cups of coffee. What do you think?

Since this is from the Onion, one immediately scoffs and says, it can't be true. However, why not? They put caffeine in so many other things, why not donuts? It would just defeat the purpose of drinking coffee with your donut. But who does that anyway?

night float

2007-03-09T12:04:00.000-05:00

I don't think I've ever been so exhausted.

I am a person who craves sunlight.

Not only are the days shorter but I've been working nights for the last month. Sort of.

Our program, in it's infinite wisdom, designed our night float system to flirt with the boundaries of sanity and safety.

It all starts on Sunday, when you work a 24h shift through Monday morning at 7am. On Monday afternoon, you come back by 5pm and work overnight until 9am on Tuesday. Tuesday night you have off. Wednesday from noon to 5pm is continuity clinic, because God knows the earth would stop spinning if I missed a clinic. Another overnight shift from 5pm on Wednesday through Thursday morning at 7am. Back for another overnight from 5pm until 9am on Friday. Blessedly, Saturday you have free. To sleep. Then it starts all over again on Sunday.

To add to the torture, you have to do rounds with the attending on Tuesday and Friday mornings after you sign out the ward. This consists of going over patients you saw in the ED, parent calls that you had and any management decisions on the inpatient ward. The reason for this charade of a session is quite simple...it's required by the RRC (Residency Review Committee) in order to justify a night float rotation and somehow make it seem like there's actual learning taking place. Who's kidding who? You can barely think by the end of a shift, let alone rehash what happened overnight.

My circadian rhythms are severely out of whack. I have been the most cranky I've ever been. The guy I had been dating decided that now was the time to call it quits. Like I have the energy to care.

Here's to adolescent medicine. Bring on the healthy college students who want to get out of class or exams or practice because they have the sniffles. I'll take that any month over night float.

Here's to Daylight Savings, which starts Sunday. More sunlight is good.

How many of me

2007-02-23T20:39:00.000-05:00

This was sorta fun. Thanks to Megan for the inspiration. Turns out I am the only one of me in the U.S. I could have told you that. It's nice to know that my parents chose a unique combination of not-so-random letters to describe me. Try it for yourself.

HowManyOfMe.com

There is:
1
person with my name
in the U.S.A.

How many have your name?

traveling...

2007-01-27T12:16:00.000-05:00

We have social anxiety disorder, premenstrual dysphoric disorder (PMDD) and any number of odd disorders in the DSM IV, none of which I have. How about PBTDD, or pre-Boston-travel dysphoric disorder?
When I have to travel in Boston, I get the worst anxiety. Driving only. If I can take the T, it's no problem. But driving the streets of Boston or any of the surrounding towns just fills me with dread. Give me Manhattan any day of the week. At least it's a grid.

Boston is anything but a grid. I think the roads were originally meandering cow paths.

I am going to Boston today to see some friends. Then flying to an interview for fellowship in Ohio, which means Logan. Ugh. I was pleased to find out that it's a little easier to get to the airport via the T (Red Line to South Station to get the Silver Line to Logan). The last time I lived there, that did not exist. You had to take some concoction of the Red to the Green to the Blue and then get a shuttle. Much less confusing now.
So, off I go through the snow. At least it's a Saturday, so you crazy Massachussetts drivers won't be driving in the breakdown lane. Seriously. Who thought that would be a good idea?

infinite wisdom

2007-01-26T19:17:00.000-05:00

Children are precious. My housemate from medical school has a 7 month old baby girl with chubby, dimpled cheeks. Her parents sent a picture of her with her faithful, omnipresent dog, Bosco, as their holiday card, which now adorns my fridge. Every morning, I look at her smile and and am thankful that there are loving parents in this world and children who receive their undying devotion.

I mention this as a study in contrast to some truly horrifying cases that I have seen in the last few weeks. The details of said cases I just don't have the heart to write about tonight, as they fill me with such anger and venom for the human being who could inflict such suffering upon an innocent child. If I could write about it, there would be words that sound clinical and detached, yet wield such power for those of use versed in the jargon...

posterior rib fractures

metapyseal fractures

retinal hemorrhages

subdural hematomas

These words describe for medical providers the nightmare that some children endure.

I am left wondering why. I am left wondering if any explanation could ever suffice.

to tap...or not to tap...that is the question

2007-01-21T15:25:00.000-05:00

Pleural effusions are collections of fluid in the pleural space (the space in between the lung and the chest wall). In the lateral decubitus film shown here, Arrow A shows the fluid layering out. Directly above the fluid is the right lung, somewhat squashed and displaced by the fluid. You can imagine that that would make it harder to breathe. Arrow B shows the normal width of the right hemithorax.

There has long been a debate between general pediatricians, pediatric surgeons and pediatric pulmonologists (as well as infectious disease specialists) as to how best to manage these cases. Option A is conservative management with IV/PO antibiotics. This is really only an option for kids who do not develop respiratory distress. Option B is diagnostic and therapeutic thoracentesis. Option C is a chest tube, which is really just an extension of Option B. Finally, Option D is surgical intervention with VATD, or video-assisted thoracoscopic decortication.

If you read the surgical literature, early VATD shortens hospital stay and duration of chest tubes. The rest of the literature is less conclusive. The management, as a result, depends on who you ask for a consult first, a surgeon or a pulmonologist. My bias might be obvious to some.

Over the last 3 weeks, we've had a 2yo, a 5yo and a 7mo with complicated pneumonias with effusions. Taken together, they illustrate the debate as it stands today (and as it has stood for as long as I can reckon):

*3yo admitted to the PICU: intubated electively for VATD (video-assisted thoracoscopic decortication), chest tube, IV antibiotics, extubated on day 6, transfered to the ward on day 8, home with 2wk course of PO antibiotics
*4yo admitted to the ward: IV antibiotics only x 5d with stable clinical course (no significant worsening of respiratory status and some improvement as illustrated by increased energy and less tachypnea), home with 2wk course of PO antibiotics
*9mo admitted to the ward: IV antibiotics x 3d with no improvement in clinical status, diagnostic thoracentesis showed exudative effusion, surgery consult, VATD, chest tube

The last child is still admitted. The chest tube is still in, post-op day 2 today. Apparently the pleural space was a bit of a mess of pus. I did the thoracentesis, my first. It's not a technically difficult procedure, but it was still pretty cool. For those not familiar with the term, the procedure consists of sticking a needle in between the ribs and drawing off fluid from the pleural space. The tricky parts are sticking a needle into an awake, crying baby and not aspirating the lung by sticking the needle in too far. If you are doing a therapeutic tap (i.e. drawing off as much fluid as you can get out), you can cause air to enter the space and create a pneuomothorax (literally air in the chest). If you draw off too much fluid, you can also cause hypotension. Not a good thing. I am happy to report that neither of those complications occured.

nativity scenes

2007-01-08T20:39:00.000-05:00

the nativity scene is still up in the entrance of the hospital where i toil.

one could question the propriety of putting up a nativity scene in a hospital that serves diverse cultures and religious faiths.

one could argue that if you display a nativity scene at all that you should also put up displays important to other religious faiths and cultures during this time of winter celebration. Bloomingdale's actually had some fantastic window displays this year doing just that. Each window depicted traditions from around the world, including Ireland, the Netherlands, and Kwanzaa.

one might draw the conclusion that keeping the nativity scene up in january is simply in poor taste. or perhaps it is just lazines in taking it down.

here's to a more tolerant, peaceful 2007, no matter where you are from, no matter what you believe.

chuck close

2007-01-08T20:33:00.000-05:00

i saw the niftiest book when i was perusing Lee's Art shop...
it was a flip book of chuck close's self portrait. if you happen to find it on some store counter somewhere, take a flip.

making the switch

2006-12-03T13:36:00.000-05:00

really not so painful.
i switched today to blogger beta. a few little things changed, perhaps for the better. love the new label feature. not that this matters all that much, as i haven't been blogging much lately. but there you have it anyway.

i'm having a fairly lazy sunday. writing holiday cards. catching up on blogs that i've been too busy to read for the last few weeks. there are some really great blogs out there. why anybody reads this one, i can't imagine.

i've pulled out last year's MS Holiday Cookies magazine (they didn't publish one this year that i can find) and have been in a baking frenzy. the new favorite recipe is snickerdoodles. for those who care, if you add a teaspoon of cinnamon, 1/2 teaspoon nutmeg and 1/2 teaspoon allspice to the batter (in addition to rolling the dough in cinnamon sugar before baking), they are extra good. today we will be trying a new recipe for molasses ginger cookies.

i just love this time of year. makes me want to drink hot chocolate with extra marshmallows.

brain fog

2006-11-11T19:37:00.000-05:00

i was in LLBean this afternoon and the salesperson asked me for my zip code.

i could see the numbers in my head, only they were really fuzzy.

finally, i retrieved the numbers from the haze by stating the town, then the state, then the zip code.

it's amazing what tricks a tired brain will play.

but i have to say, it was an incredible night. i love picu call. i intubated an 8yo kid with pneumonia who was breathing 70 times a minute, started a central line, and then proceeded to play with a dopamine drip all night long.

was that me?

the RRC and work hours revisited

2006-11-01T14:21:00.000-05:00

in a series of interesting and somewhat humorous comments on my last post, an anonymous reader brought up the topic of work hours and the RRC:

"You signed up for this no? Good thing you have the RRC to wipe your nose (and your butt). God forbid you might actually stay up all night. Jeez you are going for a post-call hike. You really think that's what happened before the RRC held your hand? No you were a DOCTOR and worked post call. Tell me, what do you think is going to happen when you get to the REAL WORLD, you are on call all night and then spend the whole next day working? The RRC won't be holding your hand then. ... The present work hour rules have turned the present crop of residents into wussies. I know this from experience. Medicine is not shift work. You don't walk away from the patient when the bell rings. You don't know what I am talking about. In 1 and 3/4 yrs you will...."

for those of you who don't know, RRC stands for the Residency Review Committee. it is the part of the ACGME (American Council of Graduate Medical Education) that oversees residency programs. every few years, all accredited residency programs have a site review to make sure that they are up to standards.

recently, the ACGME instituted restrictions that limit residents to working 80 hours per week, averaged over 4 weeks, no more than 30 hours in a row, no less than 10 hours between shifts and at least 4 days off in a month. these rules echo the Bell Commission reforms that have been in place in New York since the late 1980's after a patient died (Bertrand Bell's daughter, Katie) due to resident fatigue.

anonymous' opinion, it would seem, is that the work hour restrictions have made an entire generation of doctors into "wussies". i'm curious what opinions people have about this, both medical and non-medical readers. does it positively or negatively affect patient care in your experience? if you are a resident currently, is your program in compliance? what are non-US training programs doing to address the issue?

songs to play at my funeral

2006-10-07T11:06:00.000-04:00

blogMD started quite a morbid meme. list 5 songs that you would want played at your funeral. here's his list:

"Now, I will admit to both having thought of what song I would want played at my funeral and I’ve also discussed it with my wife. I told her that I wanted a traditional Jewish funeral … with bagpipes. And Guinness. All that being said, I’ve not yet composed a top five list of songs to play. And so, without further ado, I present to you the Top 5 Songs I Want Played (Over My Dead Body):
“When the Levee Breaks” by Led Zeppelin: Because “Stairway to Heaven” is so obvious.
“Dies irae” from Mozart’s Requiem: This piece speaks for itself. I’ve loved it for years.
“A Love Supreme” by John Coltrane: I consider this to be one of the greatest pieces of music ever composed. Coltrane’s “humble offering to God” in the “Acknowledgement” converted this tired agnostic.
“Steppin’ Out” by Joe Jackson: A fitting way to say adeiu.
“Non, je ne regrette rien” by Edith Piaf: No regrets. None."

this was actually quite a fun distraction, not that i like to imagine my own demise. here's my contribution, which is, oddly, not that melancholy:
1. "shine on you crazy diamond, parts 1 & 2" by pink floyd. according to wikipedia, the album, wish you were here, was written as a tribute to syd barrett who i can only assume was the crazy diamond.
2. "serenade" by emiliano torrini. it's hauntingly beautiful.
3. "sweet thing" by van morrison. "we shall walk and talk in gardens all misty wet with rain. and i will never grow so old again."
4. "wond'ring aloud" by jethro tull. one of my all-time favorite songs. "we are our own saviours. ... it's only the giving that makes you what you are."
5. cello suite #1 in G by yo yo ma. i just love it and it's beautiful and peaceful.

as for who to tag...the usual suspects. you can blame sam for this one. :)
sister smile
fat doctor
workinprogress
megan
juniper

the music meme

2006-09-19T22:50:00.000-04:00

so flea tagged me with the 7 songs meme.
"Seven songs you are into right now. No matter what the genre, whether they have words or even if they’re not any good, but they must be songs you’re really enjoying now".
thanks flea.
really. thanks.
seriously.

iTunes doesn't lie.

to figure out my top 7 songs, i looked in iTunes and found the most frequently played tracks.

it was a little scary.

here's how it broke down.

#1: what i know only as "track 09" by built to spill. it's a great song. it's on my running mix, which is probably why it is the most often played track. yeah. i run a lot.

#2: graduation day, chris isaak. i just love it. what more can i say. his voice embodies McDreamy.

#3: in the waiting line, zero 7. from the garden state soundtrack. the whole soundtrack is fantastic. zach braff's new movie just came out, the last kiss, with a similarly splendid soundtrack.

#4: mushaboom, feist. makes me smile.

#5: i want you, bob dylan. the man is pure genious.

#6: nothing brings me down, emiliana torrini. she has an amazing voice. actuallly, the whole album, fisherman's woman, is amazing.

#7: better together, jack johnson. from the curious george soundtrack. if you're curious why i listen to this, check out some of my previous posts from august.

and coming in a close #8 was a tie between camping next to water (badly drawn boy) and crazy in love (beyonce featuring Jay Z) ... what can i say ... i have eclectic taste in music.

now 7 tags. well, i'm not sure i can tag 7 who have yet to be tagged, but i might come close.

sister smile
fat doctor
blogMD
vitaminKmd
workinprogress
juniper
sid schwab

that was 7, right?

fellowships

2006-09-19T22:23:00.000-04:00

so. one of the perks of being in a small residency program is mentors.

i have a great one.

he just came to our fair institution three years ago from a much bigger place. he's the only pulmonologist here. and he has taken me under his wing, so to speak.

i am the guinea pig in a new pilot program that we're trying here. for my continuity clinic, i alternate every other week in his pulm clinic, managing my own panel of patients. CF, asthma, i even have a kid with primary ciliary dyskinesia. pretty cool stuff.

in compliance with the RRC guidelines, i even have my very own set of goals and objectives.

i know, i know...just what you've always wanted!

i still have my panel of gen peds patients whom i love working with, but i really love my pulm clinic. and i'm not a clinic person.

he also set me up with a research project, working with one of the microbiologists here. it's really neat and i now have access to the cf database. i can query searches to my hearts content. i know, i'm a total dork. i can't help it. can any of us? seriously?

during my intern year, ever since he found out i wanted to do pulm, he has talked about setting up a pulm fellowship here, in conjunction with another small, academic children's hospital up the highway a bit, which also happens to be where i went to med school. i always nodded and said, yeah, sure, that would be great. but i never really took him seriously.

until this week.

he basically told me that i should look at other programs because the timing might not work out, but that he was trying to get things started and what did i think?

we're pretty academic here, so research wouldn't be a problem. and certainly there is no lack of patient volume given that there would just be my lone self.

but i guess that's my question. there would just be me.

would i be missing out on having other fellows at the same stage of training? is there some benefit to being in a big institution with lots of fellows in other disciplines?

i'm still finishing my cv and figuring out where to send it. i'll send it to all the programs in big cities. but eventually, this is a place i wouldn't mind working. so the idea of finishing my training here is quite tempting. but also a little daunting.

musings on a sunday

2006-09-10T20:57:00.000-04:00

i have a relatively new housemate, since August, really. he's quite nice, quiet, respectful. it's been sort of fun to live with someone after having been on my own for awhile.
well, he went to his brother's wedding this weekend, leaving me with the apartment all to myself, which was sort of nice. i spent the weekend catching up on things that had been piling up during my picu month...bills, laundry, journals, etc.
there was an article in the most recent Pediatrics (Pediatrics 2006;118(3):888-895) about screening for cystic fibrosis with the newborn screen (NBS). they looked at a cohort of children in northwestern Italy diagnosed by NBS between 1997 and 2004, looking to see if there was a difference between the NBS children and the historical controls in the time to infection with Pseudomonas aeruginosa, a bacteria that is associated with a decline in pulmonary function and an increase in morbidity and mortality.
interestingly, they found a shorter mean time to P. aeruginosa infection in the children diagnosed by NBS (183 days for NBS children vs 448 days for historical controls), suggesting that newborns are more readily infected with nosocomial bacteria than older children diagnosed at a later point based on clinical symptoms. this would sort of fit with our understanding of the newborn's evolving immune system.
what this study brings up is that the NBS is not an entirely benign intervention. one could assume that earlier diagnosis and access to treatments and resources would be a positive thing for kids with CF. theoretically, it is. however, we as practitioners need to be vigilant about infection control, with the recognition that our adherence to CF precautions is profoundly important in protecting these vulnerable infants. in our clinic, we see a mixed population of pulmonary pathology, including asthma, CF, PCD, complicated pneumonias, etc. we try to segregate the CF patients to the CF clinic days, but this is not always possible. in addition, the allergy/immunology clinic is run out of the same clinic hallway, increasing the chance for more nosocomial infections. makes me want to carry around lots of alcohol swabs.
coincidentally (or perhaps not), the next article (Pediatrics 2006;118(3):896-905) in the journal was about the cost-effectiveness of various methods of CF NBS in the netherlands, where they use several different methods to confirm the diagnosis. cost-effectiveness studies sort of creep me out a bit. i guess that's the clinician in me. how can you boil a child down to "life years gained" and "willingness to pay values per life year gained"? and whose willingness to pay are we talking about?
another topic this article addressed was parents who chose to terminate the pregnancy if they knew the fetus was affected. in the abstract, i can understand this. however, having met so many kids with CF who lead lives full of happiness and normal kid experiences, albeit punctuated by more frequent visits to their doctor, i struggle with this on a personal level. it is akin to the debate regarding terminations for trisomy 21 fetuses in a way.
i don't pretend to have any answers. just food for thought.

little miss sunshine

2006-09-09T22:19:00.000-04:00

if anyone is in need of a good laugh, i recommend little miss sunshine . it's dark in parts, but i like that sort of thing. my friend who always falls asleep in movies, no matter how interesting they are, didn't fall asleep in this one because she kept laughing. you'll find yourself thinking, 'how can i be laughing at this?' but you'll laugh nonetheless.
isn't laughter the best medicine?

recovery

2006-08-27T21:28:00.000-04:00

so i did it.
i ran in a charity half-marathon for the hospital yesterday afternoon. outrun the sun, if you will, which i did.
my goal was to finish without walking (except at water stations, three of which i slowed down for).
13.1 miles. 9:30 min miles (i know...not impressive for you marathoners, but consider for a first-time half-marathoner who trained whilst doing her picu rotation)
$1,006.
the pain i feel now is worth it. it was all for the kids.

i was severely impressed with c.j.. he's a medicine resident whom i was chatting with before the race. he had not trained specifically for this race. he decided to run on wednesday, with the race being saturday. he non-chalantly told me that he used to run track and cross-country in college and that he would have been a professional runner were he not 6'8". maybe if he were 6'2", he said. or 6'5" at the most. i nodded my head, thinking that the last year as an intern, if not the grueling 4 years of med school, would have gotten him slightly out of shape. nope. he placed in the top 20 overall, 3rd in his age group. why does being 6'8" disqualify you from being a professional runner?

today is about recovery. i slept in. brunch at lou's with my brother, who drove up with sister-in-law to cheer me on.

i did do one productive thing...my laundry, which in my new abode means going to the laudromat.

note to self: never do laundry on a rainy sunday afternoon.

you know you work too much when...

2006-08-17T22:29:00.000-04:00

...the most amusing event this evening was when the a-la-mode scoop of ice cream slid off your friend's molten chocolate cake and she said,

"i SCFE'd my cake!"

and the table full of peds residents burst out laughing.

it probably would have been funnier if it were actually an ice cream cone.

transformation

2006-08-16T19:56:00.000-04:00

there have been a lot of changes in my life of late, many of which have not made it into this blog. some have been good changes. some have been more challenging. most, actually, have been more challenging. i'm still struggling to find the good in those changes.

suffice to say, i've been wearing a little thin.

picu has been a whirlwind of sadness and stress. we've had several kids die over the last few weeks, including a little boy i've known almost my entire residency and his entire life and a little girl with a brain tumor whom everyone adored.

in an attempt to de-compress after a stressful night on call and the events of the early afternoon (see previous post), i went for a run. i told my roommate, who was making pizza for dinner, that i probably wouldn't be more than 30 minutes and that was being optimistic.

i was gone for an hour.

the first mile was a little painful. but then the runner's high kicked in and it was like i could suddenly fly.

have you ever felt like you were filled with strength that was not wholly your own? that's how i felt today. it was incredible and i felt, for the first time in a long while, that things are going to be good again. different, but good.

so now i'm sitting at my new kitchen table, eating really good pizza and listening to yo yo ma's cello suites, watching the sun set over the hills across the river, feeling peaceful. it's a nice feeling.

broken heart

2006-08-16T14:05:00.000-04:00

i've lost a friend today.

to those who knew him, he was and always will be the bravest, strongest, most courageous of souls.

for those who will never get the chance to meet him, my heart breaks for you that you will never know this boy.

this boy has the most amazing smile. every time i walked into his room he would hear my voice and his whole face would light up. i could have been having the worst, most stressful day and one trip to his room and seeing his sweet little face would erase all the irksome things in this world.

this boy has the most infectious laugh. it was so wonderful to watch him grow up. when i first met him, he was not one for talking. but over the course of my time with him, he learned to coo. the coo eventually became a babble. the babble turned into a laugh. sometimes, i'd be standing outside the room of one of his neighbors and hear a cheerful squeal. i'd poke my head in his doorway and see him in his crib, grabbing his favorite green hippo and laughing to himself.

this boy had good taste in music. early on in his life, someone gave him the soundtrack to curious george. if ever he was fussy or agitated or not feeling well, all you'd have to do is press play on his cd player and listen to the first song, upside down, and he would calm down.
"And as my mind begins to spread it’s wings
There’s no stopping curiosity
I want to turn the whole thing upside down
I’ll find the things they say just can’t be found
I’ll share this love I find with everyone
We’ll sing and dance to mother nature’s songs"
i kept telling him that the lyrics were right, that nothing could stop curiosity. that he could change the world with his two pudgy hands.

one afternoon this spring, he was out of sorts. no one could settle him. it was a slow afternoon, so i took him in his room, sat by the window in the rocking chair and held him, rocking him until he fell asleep. he slept for two hours in my arms, rocking back and forth. every once and a while, he would let out one of those quivering breaths and then settle somehow deeper in my arms, his pudgy little hand resting over my heart. it was the most peaceful i've ever seen him. i'll always remember him that way, snuggled in the crook of my arm, watching his eyes flutter beneath the sleepy lids, dreaming some wonderful dream where he could do anything...even pee his name in the snow.

this boy came into my life for a reason. his life has been too short, but it has been full of every happiness we could give him. of that, i think we should be proud. i will always count myself lucky for knowing him. i will always wish i had more time with him. but i also am thankful that he will not suffer any more, that he won't have to endure any more hardship or pain. he has suffered enough. if there is a heaven, he is there, watching over us as we watched over him.

"...and flights of angels sing thee to thy rest."

books and such

2006-08-06T22:59:00.000-04:00

for all those who think i'm mysterious ...
not so.
really.
an open book, i tell you.

the book that changed my life: to kill a mockingbird
hands down, the most amazing book. i read it when i was little and it's always stayed with me. atticus always reminded me of my dad.

a book i've read more than once: wasted
don't ask why. it's just one of those kinds of books.

a book i'd want with me on a desert island: a book about how to survive on a desert island...if such a book exists...if anyone has ever survived a desert island.

a book that made me laugh: thank you for smoking
i read it years ago when it first was published. turns out christopher buckley summers in the town where my parents live and came to give a reading just after i had finished it.

a book that made me cry: lots of books make me cry. several more notable ones are:
the kite runner
no matter how loud i shout
Baby ER
cry the beloved country
savage inequalities

a book i wish had been written: central lines for dummies

a book i wish had never been written: my organic chemistry textbook ...gawd that was painful...but it made a good doorstop once i passed the class.

a book i am currently reading: at the top of the pile currently is the history of love

a book that i am meaning to read: appetite for life, a biography of Julia Child.

five bloggers i'd like to tag:
sister smile
fat doctor
blogMD
vitaminKmd
workinprogress

the magical fluid bolus

2006-07-30T22:02:00.000-04:00

a little girl came in to the ED today with a fever to 39.5. i had spoken with her mother several hours earlier about the fever, as well as some bug bites that looked infected and asked them to come in to make sure the bites weren't cellulitic. at that point, her mom told me over the phone that she wasn't too worried, because she was still playing.

by the time she got to the ED, she was no longer playing.

she was, in fact, lethargic.

the dreaded L word that parents throw around willy-nilly without proper respect for the weight it carries. it does not mean they're sitting on the couch all day playing video games or just wanting to watch movies. it means that they are sleepy and very difficult to wake up.

this girl slept through my exam, including the belly exam. even still, this mom did not describe her daughter as lethargic, but, rather, as "a little more sleepy than usual".

1 IV, 300cc of NS, 240mg of tylenol...and presto!

all better.

up, talking, smiling, asking for apple juice and stickers that were pink.

i gave her all the pink stickers we had, including the one of the bear with a pink bow and the caption, "i'm all better!"

non sequitor(s)

2006-07-28T21:44:00.000-04:00

went running today. on a windy, hilly dirt road, i could have sworn i saw a mushroom as big as a basketball. turned out to be a rock. some runner's high.

i have a new housemate who is about to start med school after his first career in computers. he's a total wiz and is, as we speak, figuring out how to transfer all my music on my ipod (that came from a computer that no longer exists) to my current computer. brand new music library for me. well, not brand new. it's all my music. but it's now manipulatable on my iTunes.

my new favorite show on t.v. when i can't seem to wind down from a night in the ED is "Throwdown with Bobby Flay", in which the Iron Chef travels hither and yon to challenge ordinary, everyday people to a cooking challenge. Last night was a Texas Chili cookoff. hey, new yorkers can cook chili, too.

work beckons in the morning. at the moment, i am feeling masochistic enough to get up even earlier and run before clinic. i think i really am nuts.

bad day

2006-07-27T00:43:00.000-04:00

ugh.

(post edited)

on a brighter note, i did my long run yesterday and feel fairly good today. minimal diaphragmatic irritation. hills that used to kill me are now an afterthought. could it be that i am actually getting in shape???

when you are sicker than your patients...

2006-07-22T23:21:00.000-04:00

so it's never a good omen for your day when you feel worse than most of your patients. there's a lovely gastroenteritis going around and, lucky me, i seem to have caught it. not surprising, considering how many times my face has been sneezed and coughed in over the last few weeks.

here's a tip that i learned the hard way. wear a mask when swabbing people's throats. that way, when they gag and cough, you are somewhat protected.

saw some neat stuff today, though, despite feeling wretched.

a resident came in with a dislocated shoulder from a slip-n-slide incident (presumably involving a lot of alcohol). pretty much behaved like an ass, which is sort of what he's known for. a little boy with a septic joint from a laceration that was sewn up a few days ago. a young baseball player with a nasal fracture from trying to catch pop-up flys with his non-dominant hand who had clear rhinorrhea ever since the injury...didn't turn out to be csf rhinorrhea, but it was good to go through the differential. lots of non-specific viral stuff but overall really pleasant families, which always makes things easier.

plus, i was working with one of my favorite ed docs who totally gets my sense of humor. we have a good time. he wouldn't give me an iv, though, for my own rehydration, but that's ok. i guess i didn't really have mental status changes...yet. i've been working on the ORT. alternating gatorade with emergen-C. if i wake up tomorrow obtunded, you'll know why.

based on the number of parents that i convinced over the phone to wait until clinic tomorrow to be seen instead of coming to the ed tonight, tomorrow is a busy day. off to sleep i go...

a running question

2006-07-22T00:48:00.000-04:00

a question for fellow blog-reading runners out there.

i've been training for a half-marathon of late. it's a fund-raising event for the hospital where i work. it's going well, now that the blister is healed. but every day when i start out, i have left shoulder pain, no matter how much stretching i do. after about a mile or so, it stops. why is that?

on a somewhat related note, i was just down in new york visiting family and went running in central park, one of my favorite things to do. i started out near columbus circle and ran up around the reservoir. it was a weekend morning, so the park was full of other runners and bikers and families and couples. it was quite distracting, and still somehow motivating, to have other runners around. not that i was competing with any of them, but it helped a bit with pacing, particularly since it was 11am and 95 degrees out.

there was a musician playing on the grass near tavern on the green, a crowd of people sitting and listening raptly. lots of people having picnics on the great lawn with their coffee and bagels. i absolutely love the peace and quiet of living in a small place, but it was nice to be immersed in the city again, even just for a few days.

blisters and such

2006-07-10T12:58:00.000-04:00

i've not been able to run this week due to a nasty blister on my left heel.
it's finally healed.
well, sort of.
enough to try running again today on my day off from the ED.
life on the ED rotation is sort of interesting. it's a little lonely, as i work when most of my other friends are sleeping. but it's also pretty neat. i get to see people who are really freaked out, whether for valid reasons or their own imagination, and help them in a very real way. whether it's getting a kid with an asthma exacerbation a neb and a wopping dose or steroids or sewing up a laceration on a little boy's knee. i always tell them how brave they are, even if they weren't really, because that's as much of a band-aid as anything else i can offer.
the families whom i've met so far in my short 2 weeks on this rotation have run the gamut from those reeking of cigarette smoke and neglected dental hygiene to the most well-educated with glowingly polished veneers. i have to say that i learn something from each and every encounter.
even if it's just that i should really floss more.
here's to healed blisters (and other body parts) and to a glorious, sunny day off.

quiet afternoon

2006-07-07T22:34:00.000-04:00

i spent the afternoon sitting on a bench at the edge of the town green reading my latest favorite book, The History of Love. it was an interesting exercise in people-watching, too.
there was the group of girls who all looked the same, as if they had consulted one another before getting dressed that morning. the little boy in his motorized wheelchair who was racing in circles around his nanny and her friends with their young charges, all the while a huge grin on his face. the family waiting for their dinner reservation at the fancy restaurant across the street, all dressed up in suits and high heels. they seemed like such a content family. the youngest amongst them was a 9yo girl who reminded me an awful lot of myself at that age. she was just dancing around on the grass, blissfully un-self-conscious, doing cartwheels and congratulating herself when she did a particular move well. she caught me looking at her at some point and we forged an immediate bond, as if she sensed that we were dopplegangers. when they all went across the street for dinner, she looked over her shoulder at me and waved good-bye. i smiled and waved back. i wish her well, oh so well, in this crazy world.

independence day

2006-07-04T23:27:00.000-04:00

today was one of those amazing days that i want to preserve forever. if only you could put those days in little snow globes so that you could pick them up, look at them and remember why it was that the day meant so much to you at the time.
my sister and i hiked mt. moosilauke with my chief resident and his girlfriend, who also happens to be an old med school friend. from the ravine lodge, we hiked up the gorge brook trail to the summit. it's a steep hike up but so incredibly beautiful. there's something so amazing about how the vegetation changes from tall, dense pines and birches to the wind-stunted dwarfs at tree line. it was not the best day for views, but that didn't seem to matter, as there was a mystical, blue-purple haze that gave everything a somewhat ethereal hue.
we sat on the rocks at the summit and ate nutella and pretzels. there's nothing quite like chocolate at the top of a mountain. french fries might be better, but i've never been able to find them in such a place.
we hiked down the carriage road (beware the poison ivy!) to snapper, re-entering the dense, lush forest. so many wildflowers blooming, growing in the crevices of the rocks that lined the trail. i wish i remembered more botanical names from my undergrad ecology labs, but they have been replaced with the names of muscles and nerves and bones. for some reason, bird calls have stuck in my memory, though. white throated sparrows were in abundance, singing heartily as we entered their territory. i've always loved their call, so plaintive and almost melancholy.
at the convergence of snapper and gorge brook, there's the class of '97 swimming hole. the water as deliciously cold and made my tired feet feel so much better. i splashed the water over my face and head, feeling the freezing rivulets drip down my neck. nothing quite like it in all the world. it was almost torture to put my shoes back on for the walk up the hill to the parking area.
the last time i was at moosilauke was late fall. the lodge was deserted and it had already started snowing. yesterday, however, the lodge was full of summer staff and visitors, the sweet smell of cornbread lingering in the air. there was a man with dreadlocks playing guitar, trying to learn a song before tonight's 4th of July celebration perhaps.
we filled up our now empty water bottles and headed back, stopping at fat bob's for ice cream. to give you a sense of why it's called fat bob's, a baby size is 1 scoop, kid size 2 scoops, small 3 scoops, medium 4 scoops and large 5 scoops. no wonder americans are overweight. i got a twist with rainbow sprinkles. a little girl in line behind us said excitedly to her mother, "she got rainbow sprinkles!" i remember being that excited for rainbow sprinkles once upon a time.
after a late afternoon nap, my sister and i went to watch the fireworks. it was really quite impressive. greens and golds, red, white and blue, pinks and purples all showering over the river, the boom echoing loudly off the hillsides. during the finale, the song "born in the USA" was blasting over the loudspeaker. my sister and i both looked at each other and wondered why they chose that song, as the lyrics are not the most glowing portrait of life in this country. but i guess as long as the chorus is catchy, what does it matter?
all told, it was a cleansing, restorative and grounding day...reminding me of my own, innate independence and strength and also of my inextricable link to the earth and the people in my life whom i love dearly. i think i'll have to make this a new july 4th tradition.

morning edition

2006-06-30T14:19:00.000-04:00

one of the good things about being on my ED month is that i get to listen to the entirety of morning edition, as opposed to the 10 minute snippet i usually get on my drive into the hospital. so today, there was a really neat piece on jerry falwell. i was not aware of this, but apparently, everyone sends him Tinky-Winkys and the guy who ghost-wrote his autobiography has come out of the closet and sits front and center in his church every sunday. talk about poetic justice. i highly recommend a listen.

last day as an intern

2006-06-25T18:08:00.000-04:00

so, it's almost done. everyone has been congratulating me today for getting through this year. like it's some great accomplishment, like i did something more worthwhile than running around like a chicken with my head cut off.
truthfully, i'll be glad when tomorrow morning comes and i can sign out the ward to the new crop of interns, all bright-eyed and trepidatious (if that's even a word). but i have no real sense of accomplishment about it. i've just been barely keeping my head above water. if that's an accomplishment or giant feat of strength, well, then i guess congratulations are in order.
frankly, i'm just exhausted and numb. everyone says second year is better. is it better or are you just used to feeling this way?
i am the runner up for the black cloud award (an award given to that lucky resident who has the worst call nights). my chief said i would have won it outright, except the girl who won it was graduating and i had 2 more years to achieve that particular honor. my goal for my pl-2 year is to win the white cloud award. my fortune is bound to change. here's to quiet nights (knock on wood)...

i'm an aunty!

2006-06-23T12:55:00.000-04:00

well, sort of.
my housemate for most of med school recently had her baby.
she's absolutely beautiful. really, objectively beautiful. her head wasn't even very squashed, which is impressive.
i'm an honorary aunt, which translates into buying her lots of really cute baby clothes and toys.
aren't kids amazing?

what do you do when you don't know what to say?

2006-06-19T22:20:00.000-04:00

i went to visit a boy today. i've taken care of him a lot on the inpatient floor. i wrote the discharge summary when he was going home after his 207 day hospital stay for his bone marrow transplant, complicated by everything you could possibly imagine. he's in our picu right now, on an oscillator, edematous, in multi-system organ failure. he has graft vs host disease from his bone marrow transplant. he's dying. i had no idea what to say.
i stood awkwardly in the doorway for a second, my eyes meeting his mother's. there was still so much hope in her eyes, as well as defiance. it was almost as if she were silently daring me to say something sympathetic, as if that would be confirmation that her son was dying.
so i said nothing.
i walked past him, barely glancing at him but seeing immediately that look...if you've ever seen a dying child, you will know what i mean.
i sat down on the chair by the window next to his mother.
"how are you?" i asked.
she smiled. apparently, i had passed the test.
"i'm doing ok," she said with a shrug. "he looks better than yesterday."

national headache awareness week

2006-06-05T16:56:00.000-04:00

it's day 2 of national headache awareness week. does this mean that i'm going to have this headache that started yesterday all week?

things that irk me...

2006-06-04T13:18:00.000-04:00

...that are, in the long run, not important, but irritating nonetheless.
a friend of mine was supposed to call me before she left her house (as she is without a cell phone) to give me directions to a picnic that we're going to today.
she didn't call.
luckily, she was picking another friend up on the way, so i called him and got directions after all.
when asked, she said she just forgot. she was sorry. that's just how she is. maybe she'll get better about calling people.
i guess it irritated me because if the roles had been reversed, i would have called her. i'm sorry. that's just how i am. maybe i'll learn to be more forgetful.

rainy saturday idealism

2006-06-03T14:06:00.000-04:00

So I awoke this morning to the sound of the work truck backing up the driveway. They're here to put in the new kitchen counters. They were supposed to come yesterday, along with the plumbers, so I could have a functional kitchen. The plumbers showed up yesterday afternoon as planned, but the installers did not. So here they are now.
It's gray and raining here today and fairly dreary. So I guess it's a good day to have workmen tromping in and out of the house, drilling and filling the air with the smell of silicone. Mmm, silicone.

I spent the morning sitting on the couch trying to develop a new curriculum for professional development, something that has been fairly ignored in our program to date. But now we have an RRC site visit coming up and our new program director is suddenly very interested in what research and advocacy projects the residents are involved in. Not very many, that much is clear. How many residents attend national professional society meetings? Hardly any. How many residents have an updated CV? Probably only the ones graduating who nad to finish them for their job applications.
So the idea we came up with is to have a certain number of PEDs, or personalized education days, to devote to professional development. The pun wasn't my idea. But it's a good idea. Maybe it will inspire people to try again to make a difference on a larger scale, something that seemed to be more expected when we were med students.
I think we've lost something in medicine of late. A sense of professional responsibility. Collectively, we've lost our way and have gotten bogged down in the quagmire. A respected surgeon from my med school once said, “There are three professions in this world: law, clergy and medicine.” The implication of his words is that being a doctor or a lawyer or a religious leader entails more than going to work everyday and going through the daily grind. There is a professional duty and responsibility that pervades every aspect of life.
In this era of the 80-hour rules, rising health care costs, and cynicism about the practice of medicine in general, there is the temptation to do only what is necessary to get through the day. The practice of medicine is becoming ever more specialized and compartmentalized. The 80-hour work rules that were intended to protect us from grueling hours and fatigue have only served to give us a sense that what we do is shift work; our hours are up and we punch out, not literally but emotionally. There is an emphasis on more efficient delivery of care and RVU-generation that attendings have likened to working in a factory: 15 minutes in one room, then on to the next and the next and the next. There is an emerging sense that we, as physicians-in-training and future leaders of our profession, cannot make a difference. This in contrast to the dewy-eyed new medical student who fought to get into medical school so they could make a difference in the world and help people. There has never been a greater need to promote professional development and responsibility in our learners, to re-instill in them that sense of passion and motivation to do good works.
I'm not sure that this new curriculum will change anything, but maybe it will give someone an opportunity to try. An idealistic attending that I respect enormously for his passion and dedication to some of the most desperate children in this world once said to me, "We've got to save the world." At first, I thought this was a silly thing to say. But then I realized that he was right.
Who else will if we don't?
Here's a rainy day toast to passionate idealism...

parent phone calls: episode II

2006-05-27T05:05:00.000-04:00

04:44 5/27
mommy: yeah, i'm calling about my son. he's 8 months old. he's had this cold for a long time.
girlMD: how long is a long time?
mommy: a couple weeks. he got some medicine for an ear infection last week, but i know his ear is still bothering him 'cause he's still digging at them. and now he's got this cough.
girlMD: can you describe the cough at all?
mommy: well, it's dry but tight.
girlMD: any fevers?
mommy: no, not really.
girlMD: do you feel like he's having trouble breathing?
mommy: no. right now he's pretty calm.
girlMD: alright. he's not flaring his nostrils or retracting or breathing fast?
mommy: no. he's drinking his bottle.
(awkward pause as girlMD tries to figure out how to politely say, why the heck are you calling me at 5 in the morning if your kid is fine and has been sick for several weeks?)
mommy: well, i guess i'm just worried that you might think he needs to be seen now, instead of waiting until the clinic opens.
girlMD: well, if you don't think he's having trouble breathing, then i think it's ok to wait. our phones open at 8am and our appointments start at 9am. do you feel comfortable waiting until then?
mommy: yeah, i think so. we'll get some rest and call in the morning. thanks a lot.
girlMD: oh, you're welcome.

lost art forms

2006-05-24T01:53:00.000-04:00

the laying on of hands is truly a lost art form. tonight, i was asked by one of the floor nurses to come evaluate a baby who was quite agitated and setting off her alarms. this baby has quite a complex past medical history and has plenty of scary reasons why she could be setting off alarms. so, with respectful trepidation, i walked in to her room (after washing my hands, of course...hey, we've got a pertussis outbreak here).
she was lying in the crib, exposed, mottled, crying. her sat was 78, she was breathing 60-70 times per minute. i listened to her chest, a cacophony of sound that is a testament to her cardiothoracic surgeon in Boston. no crackles, though. no heart failure. no pneumonia to explain why she is needing more oxygen. she's still crying. i look around for her mother, who is usually, tirelessly, present. however, she is not. she is hopefully home getting some much-needed rest.
i decide to stand-in, imperfect as i may be.
i rub her back, make soothing sounds. shhh. you're ok. shhh. i covered her cold little feet with a blanket.
i look at the monitors, still blinking red alarms, but numbers that are moving in the right direction. respiratory rate down, oxygen saturation up. crying stops. she sleeps again.
the laying on of hands. it may just be coincidence, but i'm going to delude myself and believe that it worked.

parent phone calls: episode I

2006-05-24T00:04:00.000-04:00

"Hi. I'm calling about my son. He's been crying for over 2 hours and I can't get him to stop."
(I listen intently to the background, waiting for the wailing she described.)
"Uh, what's he doing right now?"
"Sleeping."
This was at 1am.

coffee break

2006-05-23T14:27:00.000-04:00

i think coffee breaks are essential to sanity. we run ourselves ragged virtually every day. sometimes, we just need to stop, put our feet up and have a hot cup of coffee.
to what do i owe this luxury? well, both my attendings started their afternoon evals before i got back from noon conference.
i've already had one cup this morning, but there's no such thing as too much coffee.

nostalgia

2006-05-19T18:38:00.000-04:00

i was browsing the itunes music store this evening and stumbled on their U2 collection. i was somehow magically transported back to summers with my best friend, sunbathing on her lawn and listening to war or october. this was before joshua tree, although we loved that, too, in it's time.
in our girlhood fantasies, anne was going to marry the edge and i was going to marry bono. no offense to larry mullen or adam clayton.
of course, we also pretended we were the go-go's, but that's a story for a different day.

conduct unbecoming

2006-05-18T19:26:00.000-04:00

i met a disturbing child today.
6 years old, emotionally detached, without empathy. hurts animals, punches and kicks his brothers. yet, seeing him in the office today, you'd never guess that he could be so disturbed. he was pleasant, smiling, behaved himself tolerably well. but there was also a coldness to the quality of his interactions, even with his dad and stepmother.
i asked his father if he ever cried, like when he fell down and scraped his knee or something. "no, never." his father replied.
this is a child with conduct disorder. at the age of 6, this is indicative of something terrible happening to him at a very young age.
the goal of treatment for this child is to keep him out of jail. that is what would be success for him. if he learns to empathize with other people, that would be a bonus.
i left work today with this heaviness in my heart. what happened to this boy to make him so insecure in his world?

Discovering widgets

2006-05-17T14:54:00.000-04:00

I love my Mac Powerbook. It's cute, portable, and has all these useful widgets.

(Haven't you ever wondered what a widget was?)

I've just been browsing through all the new widgets (there are a ton) and found a blogger widget. All I have to do is type (as I am doing right now) in this little dialog box, hit publish post, and voila! Post accomplished. No opening Safari and typing in the blogger address, logging in or any of that nuisance.

Let's give her a whirl, shall we?

free to be

2006-05-17T04:39:00.000-04:00

One of my favorite records has been re-released this week. Free to be you and me. One of the best children's albums of all time. Think my favorite was Atalanta, the story about the girl who won the race. Somehow, that one always stuck with me. That or the one about the girl who was eaten by tigers because, the lesson implies, she wouldn't share her mango. I know, it's hard to share mangos.
I highly recommend this album...I guess now it's a CD...for anyone with kids.
Think I'll get a copy for the ward. Seems like there are more than a few kids who might benefit from some timeless life lessons about freedom of choice, gender equality and talking about their emotions.

compassion

2006-05-16T07:31:00.000-04:00

Three of the lacrosse players have been indicted in the Duke assault case. They claim that, while they may have been taunting her and generally disrespecting her due to her race and gender, they did not sexually assault her. The spokesperson for Duke University urged people not to jump to any conclusions, to exercise compassion and reserve judgement, as an indictment does not a conviction make.

My question is, who was he urging to exercise compassion and for whom?

I can only hope he was referring to the three lacrosse players and their families, who are heaping insult upon injury as they scramble to clear their names whilst casting not-so-subtle aspersions on the character of this woman. let's all have some compassion for her.

"i didn't know they had hospice for kids"

2006-04-08T10:52:00.000-04:00

Yes, hospice exists for kids.

The grandmother of one of my patients said that to me last week.

In the last week, I have learned the ins and outs of this all-important transitions. Two of my patients on the ward went home yesterday. By ambulance. One with a chest tube that persisted in pouring out fluid speckled with malignant lymphoma, the other with a body that was devastated at birth, yet still managed to allow one of the most beautiful spirits to inhabit the earth for a short time.

It's a sad time, but also a celebratory time. I didn't fully understand that until this week. This is the critical time for these families, now that they've made this most difficult decision, to celebrate the life of their child, their love for each other. Once that focus shifts, it's as if all the love just pours out.

Some families never get there. Perhaps there is something yet inside them that cannot let go. One of the families was in a most bizarre quagmire of arranging home hospice and comfort care, including the pre-hospital DNR/DNI order, but are still hoping that the alternative medicine treatments will save her. Her mother said to me as they were leaving yesterday that she hoped to bring her back in in a few months, a completely healthy girl. I smiled on the outside and murmured, "I hope so, too." On the inside, what I am hoping for is that they find the strength to let her go before it's too late for them to say goodbye, before it's too late to help her prepare for her death. She's 12. She's scared. She needs them now more than ever to guide her. I hope with all my heart that they can let her go so that her last days might be peaceful.

They are both wonderful children whose lives are far too short. But we love and care for them while they are here. That's the best we can offer, right?

a question of experience

2006-03-25T14:03:00.000-05:00

Let me just say that this post is in no way intended to offend any of the radiologists out there who may stumble upon this blog.

Ok.

So the kid we saw in clinic last night came back this morning. He felt much better. He was playing. He was drinking. My attending decided to get a chest x-ray. The wet read on the x-ray by the radiology resident was that there was no consolidation, no pneumonia.

He still had crackles in his right lung fields, mostly over the middle lobe.

My attending and I scratched our heads for a moment, then looked at the x-ray ourselves. The right heart border on the AP projection was fuzzy, a classic sign of a right middle lobe pneumonia. The lateral projection had a clear consolidation in, you guessed it, the right middle lobe.

We prescribed another 6 days of antibiotics and sent them home.

The moral of this story is to trust your physical exam, as well as your own read on an x-ray. You are your patient's best advocate.

a teaching point

2006-03-24T21:32:00.000-05:00

A 3 year-old came in to clinic today, referred from a family practice clinic in the area, because he was dehydrated from a presumed gastroenteritis. Here in our tranquil, sleepy town, we see kids who would normally have to go to the emergency room up in our outpatient clinic as long as things aren't too too bad. This little guy needed IV fluids, but maybe not more than that, so was triaged up to clinic.

We gave him 2, 200 cc boluses of normal saline and started maintenance fluids while we monitored his progress in clinic all evening. Even after the 2 boluses, he still looked pretty punky, not fussing too much when I would come in periodically to examine him. After he'd gotten the full 400 cc, I listened to his lungs. Lo and behold, he had crackles! He had been so dry that we hadn't heard his pneumonia. One shot of intramuscular ceftriaxone coming right up. Thirty minutes later, he looked a little better and was asking to go home, which we took to be a step in the right direction. He fussed and fought with our nurse as she tried to take the tape off his arm. Another sign that he was feeling a little better. He wanted chocolate milk, too. I mean, who wouldn't after the day he's had?

So, the moral of this story is that sometimes severe dehydration can mask a bad lung infection. The physical exam is a nebulous target that you'll miss completely if you don't pay attention. If we hadn't heard those crackles, we would have just sent him home and called it a gastroenteritis.

He'll be seen in clinic again tomorrow morning. There's no rest for the weary. Somehow, I don't mind, though, because we caught this one and know how to fix him. Even after a long day of not-so-clear-cut-cases, that feels pretty good.

the simplicity on the far side of complexity

2006-03-22T10:28:00.000-05:00

Our grand rounds speaker this morning was Edward O'Neil, MD, one of those inspiring people who have transformed their lives in an effort to make the world a better place. His talk painted a bleak picture of the world in which we live. Poverty, war, disease, despair, apathy. Yet, as bleak as it was, it was also hopeful. There are no simple solutions, no matter what your perspective. But one person can make a difference.

I ask you...if Bono can convince Jesse Helms that withholding funding for AIDS relief in Africa is wrong using scripture, anything can happen.

I plan on reading O'Neil's two books, about to be published next month, Awakening Hippocrates and A Practical Guide to Global Health Service.

I also encourage anyone interested in global health issues to read Mountains Beyond Mountains by Tracy Kidder about Paul Farmer. Another truly inspiring individual who has changed the course of global public health.

follow-up

2006-03-19T14:28:00.000-05:00

There has been one silver lining to this ambulatory month...the ability to schedule patients for follow-up. Usually, in our weekly continuity clinic, we hope to see our own patients for well-child care or some neat, easy-to-address-in-30min problem, like ADD or thumb-sucking. Most of the time, we end up seeing some other resident's patient and then never see that family again. This month, however, since I am here every day, all day and some nights as well, I have been able to do the quick follow-ups for sore throats, ear infections, etc. I've even been able to manage a kid with recurrent nephritis secondary to Henoch Schonlein purpura.

What the heck is that, you ask?

The short answer is that it's a systemic small vessel vasculitis, or inflammation of the small blood vessels in your body, from your skin to your intestines. No one's really sure what causes it, but it may be triggered by infections such as strep, chicken pox, or hepatitis. It usually gives you a characteristic rash on the legs/feet, as well as joint pain, abdominal pain, and blood in the urine. The blood in the urine is caused by small vessel inflammation in the kidneys, or nephritis.
Usually, it goes away in 4-6 weeks, but can recur. That's what happened with this kiddo. She had it in September, including the nephritis. Six months later, she had similar abdominal pain that prompted a trip to the ED, where they dipped her urine and found a lot of protein and a lot of blood. Recurrent HSP nephritis.

I've been able to see her twice weekly for the last 3 weeks. Once, I was unable to see her and she ended up seeing my senior resident. She thought he looked like Mr. Tumnus from The Lion, the Witch and the Wardrobe.

To his credit, his ears aren't that big, but the hair is quite similar. That, and I'm pretty sure he's not a faun. We now call her Lucy, which amuses her to no end.

That's the best part of medicine, getting to know these great kids and their families.
Next month, I go back to the inpatient floor, which has its own rewards, as well as frustrations.

bff

2006-03-06T11:40:00.000-05:00

I returned home the other day after a particularly long day of complicated SDAs to find a belated birthday card from my best friend. Enclosed was a picture of us at her wedding, standing arm in arm as we did when we were kids.

Ever since, I have been pondering best friends and what that means. I have found that people use that term too carelessly, too superficially. A best friend is not a fair-weather friend. A best friend is not someone on your holiday card list that you think of once a year. A best friend is someone who has weathered many trials and tribulations with you. She shares your panic when you hear on the news that an escaped convict was last sighted in your hometown and races over to your parent-less house with a butcher knife...just in case. She fights with you about silly things, but is always there when you need her to ask a boy if he'll "go" with you, because she is much braver than you. She inspires you to try new things, constantly marveling at your achievements, no matter how small, and rarely acknowledging her pivotal role in who you have become.

I wonder if it is possible to form such close relationships as an adult. Or is it relegated to childhood, when you are learning as much about yourself as each other?

note to self

2006-03-03T11:42:00.000-05:00

Note to self...never go to the market when you are ravenously hungry. No good can come of that. I now have Jalapeno Cheese Puffs, so Turboglacier better get here soon.

SDAs

2006-03-01T18:13:00.000-05:00

Same day appointments...yup...that was my day. Here are the highlights:

1. Bronchiolitis in a 5 month old...the minute I walked in the room and heard his cough, I knew it was bronchiolitis, likely RSV. 'Tis the season!

2. Dog bite in a 2yo...they're getting rid of the dog!

3. Recurrent Henoch-Schonlein purpura with possible renal involvement...this was a tough one...spent most of the afternoon tracking down her old records, talking to her PCP and interpretting her lab results from our visit this morning...thank god for no-shows, otherwise I wouldn't be going home any time soon.

4. Diarrhea

5. Diarrhea

6. Diarrhea

7. More diarrhea

8. Vomiting

'Tis the season! Watch out for that rotavirus...

widen your circle of compassion

2006-02-28T17:58:00.000-05:00

I had a very disturbing interaction with a subspecialist yesterday. It was my last morning on the ward for the month and I had just signed out all my patients to the new team. I get a page from this specialist about a consult I had ordered the day before. I called him back and the exchange went something like this (identifying details changed to spare the innocent):

"So, what can we help you with?"

"Well, he is an 18yo with end-stage lung disease and we were wondering if he had cor pulmonale."

"Well, how would that change his management if he were?"

"We might encourage him to wear oxygen more frequently if we knew that he was in failure."

"Does he wear oxygen now?"

"Well, yes, but not all the time. Only when he feels short of breath."

"It's a little late for compliance, isn't it?"

[an awkward pause, as I'm not sure how to respond. Finally, I say:]

"Well, we'd like you to see him and possibly get an ECHO."

"I'm just not sure what that would accomplish. Essentially, he's dying and you don't have a cure for him!"

As I reflect on this conversation, I am struck over and over by this man's callousness. In our particular institution, you have to get a cardiology consult to get an ECHO. That's not true in other institutions. Due to that peculiarity, they've developed a sense of superiority that enables them to question without impunity other specialists. Basically, a power trip.

This is a patient who IS dying. We don't have a cure for him, but that doesn't mean that we don't owe it to him to make him as comfortable as possible during the time he has left. We need to find out if he is in heart failure due to his lung disease. We need to revise our management based on that knowledge. This boy has had a hard life, beyond what most people can or should fathom. He deserves to have an easy death, to slip quietly away in his sleep without pain or worry.

We owe him our compassion.

We owe him our diligence and perseverence in finding treatments to help him.

We owe him a god damn ECHO.

In the end, I told the consultant with the sensitivity of a doorknob that my attending would love to have this conversation with him.

I am reminded of a quote from Albert Einstein..."widen your circle of compassion."

finally...

2006-02-26T16:47:00.000-05:00

A short preamble...

During my 8 months as an intern, there have not been an overwhelming opportunity to do procedures. My first month in the ICN, I had 3 opportunities to intubate one of the little wee ones. My record was 1 for 3. Not the best. Also not all that confidence-inspiring, considering that next year, as a 2nd year resident, I will be on call without the back-up that I've had this year. During my second month in the ICN, I had NO opportunity to intubate. None. Zero. So, needless to say, I was a bit apprehensive about my looming role as a 2nd year.

I was happily minding my own business this afternoon over on the ward when the nepnatal nurse practitioner calls over and asks if I want to intubate one of the babies in, say, 20 minutes? Sure, why not. I'm 1 for 3. I'll either be 1 for 4 or 2 for 4 after it's all said and done, right?

Several, deep, calming breaths. I can do this.

I am now 2 for 4.

It went fairly quickly, although I think I initially intubated his right mainstem in my zealousness to get the tube in the right hole. Just pulled it back a smidge and, voila! Equal breath sounds on both sides. If only they were all that easy...

off-service notes

2006-01-27T13:59:00.000-05:00

Tradition has it that your last day on service, you write a comprehensive note with a summary of the hospital course to date. So last night, while I wasn't busy with a misbehaving 28weeker who was on maximal pressors and inotropes, I sat dutifully in front of the computer and wrote detailed descriptions of what has happened during the last month.

Of course, the intern who is taking over my list on Monday likely won't even read these notes. Plus, everything will change over the weekend.

The weekend...my golden weekend...the first since the holidays. It stretches out blissfully in front of me. 2 whole days of sleeping in, seeing friends, skiing (only if there's been enough snow), and staying up past 10pm (something I try not to do when I have to get up at 5am).

Definitely no misbehaving 28wkrs. they're not allowed to be out past 10pm.

on the bright side

2006-01-25T18:37:00.000-05:00

I recently heard that Jason Lee is taking a break from filming his t.v. series, My Name is Earl, because he has "adult chickenpox". It's a good excuse for missing work. I'm wondering whether he has shingles or primary varicella, but that's really not the point of this post.
The point of this post is that I, too, have a good reason for not blogging over the last week or so. I mean, besides the obvious/lame "I've been really busy with work" sort of thing. I have been busy, but the real reason is that I've been struggling with how to set the tone for this blog. We've had a very sad week here in the ICN. I could have posted about the death of this beautiful baby boy who struggled for months after having a very severe meconium ileus (and cystic fibrosis) and how sad AND relieved it makes me that he's not suffering anymore. I wasn't sure, though, that this was the best forum for processing all of that grief.
I see a lot of horrible things in my line of work. What I try to take from it, though, is that, given how miserable things can turn out, isn't it a wonderful occurence when it all works out? As a for instance, we got a transport from a small, community hospital of a 26 week baby. His mom had had an abruption after a fairly uneventful early pregnancy. The initial story was that he was very depressed at birth and was being transferred to our hospital essentially to die. When he got here, however, he looked a million times better than we thought he would. He's now several weeks old and doing wonderfully. Not out of the woods by any means, but doing so very well for a baby of that extreme prematurity. His parents are the sweetest people in the world and have nothing but faith in their "fiesty" little boy. For them, the cup is always going to be half-full. I'd love to always have that optimism.

things that go pop in the night

2006-01-15T00:40:00.000-05:00

there's a beautiful baby here in our nursery who almost died a few nights ago. she developed one of the worst complications you can get in this age group...necrotizing enterocolitis, aka NEC. our resident was called at 3am by the nursing staff, reporting that she had some blood in her stool. in his sleepy wisdom, he decided that he needed to get up and examine her, instead of just attributing her symptoms to something common, like a fissure (which, incidentally, she did have). her belly was very firm and she looked extrememly uncomfortable, so he ordered the first of many films that showed one of the worst cases of NEC that we've ever seen. her whole bowel, from duodenum to sigmoid, was filled with pneumatosis intestinalis (air in the bowel wall). i think if the resident had not examined her and gotten that film, she would have perforated her bowel, the consequences of which are dreadful.
well, she did not perf. 4 days later, she looks like a peach. i sit up tonight waiting for a belly film on another baby with NEC. it's written for 2am, but i wait without bitterness, the lessons from this other baby fresh in my mind. we are human...we have to take the lessons whenever and wherever they come along. these babies are so fragile and depend upon us entirely. that kind of responsibility is hard to sleep through.

fyi

2006-01-14T13:42:00.000-05:00

just an fyi...for the few who have seen this blog over the past week or so, you might notice that the name has changed. used to be "girl friday", which i thought was a very cute title for a blog.

funny thing...if you google "girl friday" you don't just get links to the very cute cary grant movie. you also get lots of x-rated sites. so i decided that i'd prefer not to attract that kind of reader. just g-rated...well, maybe pg-13 and an occasional R for language. but definitely not x.

saturday call

2006-01-14T13:21:00.000-05:00

ok. so saturday call sounds like complete drudgery. you come in on the weekend, have a skeleton crew of staff and have the same number of patients with the same amount of work.

i'm of two minds about saturday call. on the one hand, it means you get no sleep-in day for the whole week. however, it's the only time you really have a straight, 24-hour shift. so, being the polly-anna that i am determined to be this month, i am looking on the bright side. i get to go home tomorrow morning at 8AM.
my plan is to sleep all day, then, as is our weekly social activity, watch desperate housewives and grey's anatomy with 2 other peds interns. it's silly, we know. we just sit there and are constantly amazed at the improbably turn of events that occur in fictional seattle. but, hey, you can't go wrong with patrick dempsey.

back to the grind...still have several notes to write and feeding advances to start, not to mention all the phototherapy! seems like every baby has hyperbilirubinemia.

the grant

2006-01-13T19:37:00.000-05:00

every year on martin luther king weekend for the past decade, my boyfriend and a bunch of his friends take this trip up to
the grant, officially known as the 2nd college grant. what happened to the first one, you ask? well...follow the link for the history. it's basically acres upon acres of land up in northeastern new hampshire with some old, rustic cabins. in the winter, it's freezing cold and the only heat source are the woodstoves, the culprits in many a cabin burning to the ground. they all go up there and x-country ski or snowshoe. i went last year, as "the new girlfriend". it was actually kind of fun, albeit cold. but i got to use my new snowshoes, which was awesome. we had zip-together sleeping bags, too.
so i'm on call this weekend (saturday call...ugh) and cannot go this year. of course, this year, for the first time in the grant history, it's supposed to rain. wooops. i think the plan at this point is to get really sloshed on mudslides (made with kahlua, snow and Silk soy milk) and "snowgharitas" (sorry, don't know the ingredients for that one, but assume tequila). i've never been a big drinker, but the mudslides are pretty tasty.

makes me wanna holler

2006-01-12T18:58:00.000-05:00

so, today i had to do one of the hardest things there is to do when you are a pediatrician. call dcf. i'm on this crazy rotation in the ICN and i get a call from my continuity clinic secretary. she says there's a department of health worker on the line about a patient of mine whom she had seen in her WIC office. turns out (details spared to spare the innocent), this baby was well below the 3rd percentile for weight (formally called "failure to thrive"). this is a family that i desperately wanted to succeed. an older child had been removed from the home for a similar problem, but this time, the parents professed a great desire to be better parents. at their last visit with me, i was optimistic that they would succeed. however, you can't argue with the numbers, especially numbers like these.

so i did what i am mandated to do...i picked up the phone and called my local department of children and families and made a report. what they do with the information is up to them, but based on the family history, my money is on removal and foster care. hopefully before there's too much developmental delay from malnutrition.

it just breaks my heart to see these kids and families in such turmoil. really, if you think about it, they're set up to fail. they have no positive role-modeling. if you grow up in a family where it's normal to have babies at 15 or do the bare minimum to get through high school or huff until your brain is numb...how are you supposed to want anything different for yourself or your child? i remember this kid i had as a student once (in my former life, i wanted to be a teacher)...his dad had taught him how to huff and he did it every morning before school. it also happened that he had a visual impairment that prevented him from focusing on one point (so doing math problems, he would mix numbers up from different problems), but he'd been told his whole life that he was stupid. no one figured out that he had a learning disability until he was 16 and already addicted to toxic chemicals.

what's up with that???

it all just makes me want to scream at the tragedy of it all. it's such a waste.

bow ties

2006-01-05T18:37:00.000-05:00

i've been leaving the hospital late a lot, usually around 7 or 8pm. my record thus far this year came in november during the middle of a very busy in-patient month when i stayed, working solidly, until 10:30pm. 15 and a half hours. truth be told, i really love what i do and usually don't mind the late hours, particularly since my boyfriend lives 2 hours away. sometimes, though, i stay late for the free hi-speed internet access. i only have dial-up at home, which is really just not worth the money.

well, for the last few weeks, i keep seeing the same man every night as i walk through the empty hallways...this grey-haired, wizened attending, of what specialty i'm not sure, who is always dressed impeccably, right down to his polished shoes, tweed jacket and bow tie.

this is the detail that first caught my eye.

the bow tie.

no one wears bowties anymore, right, except your grandfather who smells faintly of pipe tobacco? wrong. there appears to be a resurgence in the popularity of the bow tie...i've seen some young(er) men wearing them lately,too. like today, for example, my attending in the ICN was wearing a bow tie...dark navy blue with hunter green frogs and little black flies. very cool, if you ask me. it's also quite practical if you think about it. they don't hang down into your tomato soup and they can't be used to hang anyone so people in psychiatric facilities could wear them without fearing for their lives or the lives of others.

they're also pretty cute and somewhat stylish...even J crew is selling them this year. i asked my boyfriend if he liked them. he indicated that he did, but that he did not own any. nor does he know how to tie them. this is the problem, as i see it: what happens when there's no one left who knows how to tie a bow tie? this would be tragic. so, you see, we must encourage this bow-tie-wearing resurgence.

i'm going to learn how to tie them, just in case.

word of the day

2006-01-04T20:01:00.000-05:00

here's the word of the day...

anachronism (uh-NAK-ruh-niz-uhm) noun
1. The error of placing a person, object, custom, or event in the wrong historical period.
2. A person, thing, or practice that does not belong in a time period.
[From French anachronisme, from Latin anachronismus, from Greek anakhronismos, from ana-, (backwards) + khronos (time).]

sometimes i feel like an anachronism. sometimes i don't.

today was a good day

2006-01-04T18:21:00.000-05:00

today was a good day, although my version of a good day might be different from ice cube's.
my goal for the day was to not cry. not once. i just signed out my list of patients to the night team and, lo and behold, not a tear.
for those of you who know me, you know that i'm not an easy cry-er. i just happen to be on a particularly difficult month in the intensive care nursery (ICN, NICU, what-have-you). i just had a wonderful holiday break with my family, whom i have not seen since september, and my boyfriend. then this.
it's been something i've been dreading ever since starting in the ICN in july, my first month of internship. now, july would have been a difficult month, no matter what i was doing, just by virtue of the fact that being a new intern is incredibly overwhelming...as much as you wanted your signature to count, all of a sudden it does and you really wish there was someone still looking over your shoulder checking those drug doses...but starting in the ICN was beyond overwhelming.
it's not that i don't like the babies. i love the babies. they are actually really amazing. the medicine is challenging, which i love. it's really only when you do it every day that you truly understand how to interpret a blood gas or manage someone on a ventilator.
it's just the toxic work environment that drives me to the brink of madness.
why is it that when you get a bunch of women together, there's just no end to the drama and passive-aggressive behavior???
well, i'm back for a second month. my goal is humble, modest even. just don't cry. whatever you do, don't let them see you cry.
of course, on tuesday, i snuck into the staff bathroom and lost it.
but not today. today was a good day.