night float

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

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...

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

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

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

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

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

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

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

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

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

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

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

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

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

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...

...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

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

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

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