long hiatus

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

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

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???

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

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

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

Albert Einstein

snow, glorious snow!

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

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

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...

"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

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...

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

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

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

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

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

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

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

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

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.