Considering my first 2 posts were a bit on the serious side. I just wanted to share the funny things that little C have said to me recently. Motherhood is a curveball. You never know what's coming at you but you really do live for moments like these. Recently, I've been feeling very nostalgic, reminding myself that little C is only this little for so long! Perhaps because my husband is on the east coast doing fellowship and missing out on these adorable moments! But this is a list that I've made for him that I wanted to share with my fellow mothers in medicine as well.
Little C has been saying the funniest things lately. I feel like I need to document them so I don't forget. Here's my top 10 fave from this week!
1. When P tries to lick me, she yells "No Po!! C's mama!!" (P is our toy poodle)
2. She told her teacher "mommy is a doctor!" Her teacher asked what does she do? And she said "oh she gets to drive an ambulance!"
3. When shes in trouble, she grabs her toy phone and says "mom! I'm calling grandma!" And she talks into her phone and says "grandma, I want to live with you!"
4. When someone isn't sharing with her, "Be nice!! Share with C!"
5. First thing she says when she wakes up--"Mister Sun!!!! Where are you Mister Sun!! Mom! We have to go say good morning to Mister Sun!:
6. I lost my hospital ID badge last week. (Super annoying by the way! Considering it lasted me a good 4 years and 2 months and now I'm only 10 months away from graduating residency). She noticed. "Mommy, where's your badge???? Did you get fired?"
7. When she doesn't want to go to school--she grabs her toy stethoscope and say "okay C go to hospital too. C doctor too"
8. When she doesn't want to play with P or another kid during a play date-- "Okay bye P (or insert kid's name). See you tomorrow!!" (as if that will make the dog or kid disappear...)
9. When we're going up the stairs, she doesn't want to hold my hand anymore. She goes up first and yells "Wait for C! Mommy!!!!" and when she makes it all the way to the top "Mommy's turn!"
10. And my favorite that she's been doing for the past week! Every morning she says "bye mama! I'm going to miss you!" And today she added "I love you!"
X-ray Vision
P.S. On a side note, after 7 weeks of crying and making me feel miserable at pre-school drop offs, little C has done a 180!!! She is very happy at her pre-school, made lots of friends and loves her teachers. We are slowly but surely adjusting to all the changes in our lives.
Wednesday, August 26, 2015
Tuesday, August 25, 2015
Pregnant in the OR: Potential Hazards
Regardless of your position, occupational hazards exist when working in the operating room. Normally these things aren't given too much thought, but when my choices suddenly affected another developing life, it caused me to pause and contemplate these hazards on a deeper level. Unfortunately, studies on pregnant healthcare workers (and other occupations) are difficult to interpret due to the fact that they predominantly consist of retrospective cohort data rife with selection and recall bias or animal studies of direct exposure to substances. Nevertheless, here is a list of some things to consider when working pregnant in the operating room or hospital setting:
Anesthetic Gases. While every effort is made to avoid elective surgery during pregnancy, even pregnant women need to have general anesthesia under urgent circumstances; there is no evidence that gases administered at concentrations appropriate for general anesthesia cause fetal harm. Thus, sub-anesthetic levels that would be passively inhaled in an occupational capacity should theoretically be safe as well. That being said, it is generally recommended that pregnant women in the OR avoid inhalation of the gases when possible. We facilitate this by using ventilator circuits with scrubbing systems and taking care to turn off anesthetic gases if the circuit is open to air for a period of time (such as between mask ventilation and intubation). This is mostly routine practice regardless of pregnancy status.
Methylmethacrylate. MMA is a common ingredient in cement mixtures for joint prosthetics. When mixed, it forms a strong scent which dissipates over a number of minutes as the mixture cures. Studies, which have mainly occurred in animal models, reveal mixed results in terms of impact on fetal development. As a pregnant provider, your choices are to not work on cases using MMA, ask the scrub mixing the cement to use a vacuum device to remove the fumes, or temporarily leave the room during the mixing process. In one human study, MMA was not found above a 0.5 ppm level in breast milk of surgeons who utilized vacuum mixing devices. At our institution, the use of these devices is mixed amongst surgery personnel, but local suction can also be easily employed. If I am in a joint room and my patient is stable, I elect to step into the adjacent substerile core (which has a window to the operating room) for a few brief minutes while the mixing occurs. However, I did have a recent case where the patient was very unstable and I could not leave the room or easily turn the case over to another provider temporarily. After that experience, the scheduler changed me to a different OR.
Radiation. Discussed briefly in my previous Pregnant in the OR post, radiation is commonly used during OR procedures such as orthopedic repairs, gastrointestinal explorations, interventional pain management, interventional radiology, angiography, line placement... I could go on. For radiation, potential harmful effects are directly related to the dose of exposure. The CDC website has a table of radiation doses with corresponding maternal/fetal risks at different gestational ages. At doses higher than 50 rads, risks range from failure of implantation and miscarriage at early stages to growth retardation, mental delay, and increased risk of cancer at later stages. As with general anesthesia, pregnant women themselves must occasionally undergo irradiative procedures, but care is always taken to balance risks with benefits. In addition, protective shielding goes a long way to reduce exposure. Even in an occupational capacity we wear protective lead garments during periods of radiation. Wearing these and standing at least 6 feet away from the beam will decrease the exposure by more than 99%. However, the garments must encircle the body and not just cover the front of the body in apron form. This is especially important for anesthesiologists, who often turn their backs to the OR table to gather drugs or supplies, etc. And during my pregnancy, I have actively avoided assignments that involve continuous use of fluoroscopy (such as cath lab, GI lab, and interventional vascular or radiology).
Infection. It goes without saying that universal precautions need to be followed by everyone, but there are wider implications and possible sequelae if a pregnant woman contracts an infectious disease while working in the OR. Discussing the details of this would be beyond the scope of this article, but the gist is that potentially teratogenic effects of certain microbes and their treatments and/or long-term transmission of viral infections to the fetus such as HIV or HCV are considerations that should provide pause and vigilance when employing personal protection.
Stress. This is the most difficult "hazard" to avoid. Theoretically, emotional and physical stress can cause neuroendocrine and cardiovascular alterations that could affect fetal physiology and hence possible outcomes. Limited studies implicate longer working hours, night shift work, prolonged standing, and physical work as risk factors for preterm birth, SGA infants and miscarriage. It must also be mentioned, especially for trainees, that the financial burden of NOT working during pregnancy can cause significant stress in itself. Some women might choose to take a lighter load or less frequent call shifts during pregnancy, if possible.
I have mitigated many of these hazards during my pregnancy by notifying the schedulers early of my status, so that they could avoid giving me assignments with increased exposure as much as possible. In terms of stress, my job has no call duties, so long and tiring hours have usually not been an issue. Not everyone can be as lucky, but vigilance to self-care postcall and adequate hydration during call can help.
For readers who have been pregnant during hospital or OR duties, did you encounter any other hazards at work? What were your experiences trying to avoid them? Share your thoughts with us here!
References:
Keen RR et al. Occupational Hazards to the Pregnant Orthopaedic Surgeon. J Bone Joint Surg Am. 2011;93:e141(1-5).
Fowler JR and L Culpepper. Working During Pregnancy. UpToDate, 2015.
Radiation and Pregnancy: A Fact Sheet for Clinicians. http://emergency.cdc.gov/radiation/prenatalphysician.asp
Anesthetic Gases. While every effort is made to avoid elective surgery during pregnancy, even pregnant women need to have general anesthesia under urgent circumstances; there is no evidence that gases administered at concentrations appropriate for general anesthesia cause fetal harm. Thus, sub-anesthetic levels that would be passively inhaled in an occupational capacity should theoretically be safe as well. That being said, it is generally recommended that pregnant women in the OR avoid inhalation of the gases when possible. We facilitate this by using ventilator circuits with scrubbing systems and taking care to turn off anesthetic gases if the circuit is open to air for a period of time (such as between mask ventilation and intubation). This is mostly routine practice regardless of pregnancy status.
Methylmethacrylate. MMA is a common ingredient in cement mixtures for joint prosthetics. When mixed, it forms a strong scent which dissipates over a number of minutes as the mixture cures. Studies, which have mainly occurred in animal models, reveal mixed results in terms of impact on fetal development. As a pregnant provider, your choices are to not work on cases using MMA, ask the scrub mixing the cement to use a vacuum device to remove the fumes, or temporarily leave the room during the mixing process. In one human study, MMA was not found above a 0.5 ppm level in breast milk of surgeons who utilized vacuum mixing devices. At our institution, the use of these devices is mixed amongst surgery personnel, but local suction can also be easily employed. If I am in a joint room and my patient is stable, I elect to step into the adjacent substerile core (which has a window to the operating room) for a few brief minutes while the mixing occurs. However, I did have a recent case where the patient was very unstable and I could not leave the room or easily turn the case over to another provider temporarily. After that experience, the scheduler changed me to a different OR.
Radiation. Discussed briefly in my previous Pregnant in the OR post, radiation is commonly used during OR procedures such as orthopedic repairs, gastrointestinal explorations, interventional pain management, interventional radiology, angiography, line placement... I could go on. For radiation, potential harmful effects are directly related to the dose of exposure. The CDC website has a table of radiation doses with corresponding maternal/fetal risks at different gestational ages. At doses higher than 50 rads, risks range from failure of implantation and miscarriage at early stages to growth retardation, mental delay, and increased risk of cancer at later stages. As with general anesthesia, pregnant women themselves must occasionally undergo irradiative procedures, but care is always taken to balance risks with benefits. In addition, protective shielding goes a long way to reduce exposure. Even in an occupational capacity we wear protective lead garments during periods of radiation. Wearing these and standing at least 6 feet away from the beam will decrease the exposure by more than 99%. However, the garments must encircle the body and not just cover the front of the body in apron form. This is especially important for anesthesiologists, who often turn their backs to the OR table to gather drugs or supplies, etc. And during my pregnancy, I have actively avoided assignments that involve continuous use of fluoroscopy (such as cath lab, GI lab, and interventional vascular or radiology).
Infection. It goes without saying that universal precautions need to be followed by everyone, but there are wider implications and possible sequelae if a pregnant woman contracts an infectious disease while working in the OR. Discussing the details of this would be beyond the scope of this article, but the gist is that potentially teratogenic effects of certain microbes and their treatments and/or long-term transmission of viral infections to the fetus such as HIV or HCV are considerations that should provide pause and vigilance when employing personal protection.
Stress. This is the most difficult "hazard" to avoid. Theoretically, emotional and physical stress can cause neuroendocrine and cardiovascular alterations that could affect fetal physiology and hence possible outcomes. Limited studies implicate longer working hours, night shift work, prolonged standing, and physical work as risk factors for preterm birth, SGA infants and miscarriage. It must also be mentioned, especially for trainees, that the financial burden of NOT working during pregnancy can cause significant stress in itself. Some women might choose to take a lighter load or less frequent call shifts during pregnancy, if possible.
I have mitigated many of these hazards during my pregnancy by notifying the schedulers early of my status, so that they could avoid giving me assignments with increased exposure as much as possible. In terms of stress, my job has no call duties, so long and tiring hours have usually not been an issue. Not everyone can be as lucky, but vigilance to self-care postcall and adequate hydration during call can help.
For readers who have been pregnant during hospital or OR duties, did you encounter any other hazards at work? What were your experiences trying to avoid them? Share your thoughts with us here!
References:
Keen RR et al. Occupational Hazards to the Pregnant Orthopaedic Surgeon. J Bone Joint Surg Am. 2011;93:e141(1-5).
Fowler JR and L Culpepper. Working During Pregnancy. UpToDate, 2015.
Radiation and Pregnancy: A Fact Sheet for Clinicians. http://emergency.cdc.gov/radiation/prenatalphysician.asp
Monday, August 24, 2015
MiM Mail: Paediatrics training vs. family medicine
To the mothers in medicine team!
I'm a doctor working as a second year paediatrics registrar with a new baby and was hoping you might be able to give me some advice- I have struggled with choosing a career path for the last six years since I graduated from medical school- I generally don't like very stressful jobs but on the other hand, have always really enjoyed complex, interesting patients I've seen whilst working in hospitals.
At the moment, I'm a second year paediatrics trainee (and have yet to sit the exams for the college of physicians). I have a twelve week old baby and am contemplating going back to work where I will need to do three more years of training after my exams, of largely shift work (nights, evenings, weekends). If I do the training part-time, I would need to spend six years (and thats without having more children, which my husband and I would both like).
For these reasons, I'm considering changing careers to general practice (family medicine where I will be able to finish training in 18 months (or 3 years part-time and can say goodbye to shift work forever!). I think I will miss hospital-based medicine (and just getting to see children) but I think it might be more family friendly? Any advice from people with similiar dilemmas in the past, and how they decided what was best, would be really appreciated!
MPAS
I'm a doctor working as a second year paediatrics registrar with a new baby and was hoping you might be able to give me some advice- I have struggled with choosing a career path for the last six years since I graduated from medical school- I generally don't like very stressful jobs but on the other hand, have always really enjoyed complex, interesting patients I've seen whilst working in hospitals.
At the moment, I'm a second year paediatrics trainee (and have yet to sit the exams for the college of physicians). I have a twelve week old baby and am contemplating going back to work where I will need to do three more years of training after my exams, of largely shift work (nights, evenings, weekends). If I do the training part-time, I would need to spend six years (and thats without having more children, which my husband and I would both like).
For these reasons, I'm considering changing careers to general practice (family medicine where I will be able to finish training in 18 months (or 3 years part-time and can say goodbye to shift work forever!). I think I will miss hospital-based medicine (and just getting to see children) but I think it might be more family friendly? Any advice from people with similiar dilemmas in the past, and how they decided what was best, would be really appreciated!
MPAS
Friday, August 21, 2015
Urinary incontinence
During the last couple of weeks, I’ve been on a urology elective, and I have seen soooo many patients with urinary incontinence, so I’ve been thinking about it A LOT.
I don’t know how many of you had issues with urinary incontinence during your first pregnancy - I definitely did. I tried to do pelvic floor exercises to strengthen my pelvic muscles, but almost every day in my third trimester, I managed to leak urine when laughing, sneezing, or coughing, and I frequently was running to the bathroom, hunched over, hoping that I would make it. I know some of you know what I’m talking about ;)
Now, I am pregnant again (I know, I know, I haven’t told you yet - that is for another post), and, although I am just in the early second trimester, I am already having worsening incontinence. I say, “worsening,” because I continued to have mild stress incontinence even after my first pregnancy. As someone in my mid-to-late 20s, this has been difficult to accept.
The worst part is that I feel as if there is little that I can do. Sure, I can do my Kegels every day, I have adopted a voiding schedule that is q2-3 hours (which kind of interrupts work), and I have eliminated caffeine from my diet, but I fear the future. Based on what I have seen in the urology clinic, it seems that I may be doomed to be incontinent. Any other mothers with urinary incontinence out there? How do you deal with it?
Thursday, August 20, 2015
MiM Mail: Why the disparity in advice to prospective doctors?
Dear Mothers in Medicine,
There seems to be a disparity in the advice given to prospective doctors. Sometimes the tone is tense, heavy, and almost bitter. Warning people of the commitment, the intensity, the sacrifice of medical school and residency. And other times the thread takes a completely different tone and instead offers encouragement and suggestions for making it work, and the reassurance that more and more people are finding ways to get through those grueling years with a family.
As I try to work out the cost benefit analysis for myself, I'm curious how much of these perceived sacrifices and other costs are specialty based or otherwise dependent on the choices of the student. For example, yes, the financial cost of medical school is significant, but there are scholarships, there are repayment for service programs, and there are ways to mitigate the costs. What impact does the choice of specialty have on the stressors of residency?
How often are medical students able to get a residency near their medical school so they do not have to move their family?
Currently, my kids are 1, 4, and 5. To put the next 10 years into medical school means my kids may pay a steep cost during their childhood, and I'm not sure how much benefit they will receive. From their standpoint, I'm concerned this next step for me could be particularly hurtful. But I want to focus on primary care, which I suspect could be a milder journey, and therefore ask less of my family.
My husband is 100% on board. Wholly and completely. His work allows significant flexibility but insignificant pay. So he's happy to move with me and make this work. I just need to figure out what we'll be asking of the kids before we move forward.
Any insight for me?
Thanks.
There seems to be a disparity in the advice given to prospective doctors. Sometimes the tone is tense, heavy, and almost bitter. Warning people of the commitment, the intensity, the sacrifice of medical school and residency. And other times the thread takes a completely different tone and instead offers encouragement and suggestions for making it work, and the reassurance that more and more people are finding ways to get through those grueling years with a family.
As I try to work out the cost benefit analysis for myself, I'm curious how much of these perceived sacrifices and other costs are specialty based or otherwise dependent on the choices of the student. For example, yes, the financial cost of medical school is significant, but there are scholarships, there are repayment for service programs, and there are ways to mitigate the costs. What impact does the choice of specialty have on the stressors of residency?
How often are medical students able to get a residency near their medical school so they do not have to move their family?
Currently, my kids are 1, 4, and 5. To put the next 10 years into medical school means my kids may pay a steep cost during their childhood, and I'm not sure how much benefit they will receive. From their standpoint, I'm concerned this next step for me could be particularly hurtful. But I want to focus on primary care, which I suspect could be a milder journey, and therefore ask less of my family.
My husband is 100% on board. Wholly and completely. His work allows significant flexibility but insignificant pay. So he's happy to move with me and make this work. I just need to figure out what we'll be asking of the kids before we move forward.
Any insight for me?
Thanks.
Tuesday, August 18, 2015
Guest post: How hard things can get
I am a more than full-time family doctor. I manage my own office and do extra urgent care shifts on weeknights and weekends. I have a very busy, demanding and wonderful two year old son. I am paying off my mortgage and helping my husband get started with a farming business. I am struggling to keep up all my medical skills, applying for continuing education grants and trying to stay healthy and balanced...
I thought my life was chaotic enough... then...
I find myself pregnant with my second baby. 8 months of a very difficult pregnancy follow, forcing me to eliminate night and extra shifts. I don't sleep and suffer from severe heartburn later found to be due to polyhydramnios.
My baby is born a month early and at 24 hours, I find out he has a major birth defect, undiagnosed through the pregnancy, an extra connection between his trachea and esophagus with no connection to his stomach.
I am discharged in the middle of the night, sleep deprived for 48 hours and severely anemic with my son to a children's hospital. I have to drive myself, and it is heartbreaking to leave the hospital with your flowers and gifts but not your newborn baby after giving birth.
We survive intubation, days on a ventilator, swelling, emergency surgery, jaundice, phototherapy, catheters, central lines, ng tubes, countless needles and tests to look for other problems. He still can't swallow and is aspirating. At a family meeting I learn his vocal cord was paralyzed at some point during all his testing and procedures. It should heal but over weeks or months. Otherwise he may need a gastrostomy tube for the next year.
As I drive in daily to visit him in the NICU, nearing his 1 month birthday, I cry. I blame myself even though his doctors tell me it is not known why this defect happens. I blame a sinus infection, not enough nutrition, exposure to farm pesticides I might have had on a hike...the list goes on. I can't let it go.
I sit in the NICU and hold him, wondering what the future holds. Nobody can predict how things will progress with him. All we can do is take it day by day, waiting to see if he stops aspirating and starts swallowing on his own- then his TPN and NG tube can be removed.
As I sit in the NICU, every little thing scares me- an increased heart rate, no weight gain, a rise in temperature, I usually get so worked up within an hour that I have to leave and let my husband sit with him. Normally I am calm in this environment, but that is with other babies, not my own.
And the stress of the situation is affecting everyone around me. My office staff don't know how to book my office, when day by day, I need to be in the NICU and I don't know how long it will last. One staff is billing me for hours she hasn't been at work, another is demanding a raise (could she have picked a worse time)?
My husband is snapping at me for asking questions and his parents are telling him to give up on his farming business for now to devote himself to the care of his two sons. I am the breadwinner for the family, so if we need to bring home a high-needs baby, he needs to be the one to give up work opportunities for now. I feel guilty about this too.
My intent had been to have the baby and return to work the next week, as I had done with my first. I never thought to make a plan B. So I post ads for a locum and a babysitter for my older son, but as of now, no replies to either. And my patients don't understand why the office is closed down-they just want their doctor back.
I look back to all the times I thought I had so much stress in my life, school and residency especially, and they don't compare to this.
Today the first good news in a long time came. I have won two awards for continuing medical education courses. I will also have a chance to work as a locum in a place that I have wanted to work for a long time. This hint at my past organized life as an FP is so reassuring when the rest of my life is so chaotic and the future so uncertain.
I tell myself to focus on the positive and not worry about what can't be changed. This is what I have told past patients and this is what I do. I am learning a lot just sitting with my son in the NICU. I am donating milk to other babies. I am spending more time with family. I am learning empathy and how it feels to be a patient's mom. I have some of the best night-time babysitters around- the NICU nurses. Most of all, I know that in another time or place, my son would have died from this now corrected birth defect.
If this is how hard things can get, I hope that eventually things will swing back just as far in the other direction. Once they do, I will have to write again.
I thought my life was chaotic enough... then...
I find myself pregnant with my second baby. 8 months of a very difficult pregnancy follow, forcing me to eliminate night and extra shifts. I don't sleep and suffer from severe heartburn later found to be due to polyhydramnios.
My baby is born a month early and at 24 hours, I find out he has a major birth defect, undiagnosed through the pregnancy, an extra connection between his trachea and esophagus with no connection to his stomach.
I am discharged in the middle of the night, sleep deprived for 48 hours and severely anemic with my son to a children's hospital. I have to drive myself, and it is heartbreaking to leave the hospital with your flowers and gifts but not your newborn baby after giving birth.
We survive intubation, days on a ventilator, swelling, emergency surgery, jaundice, phototherapy, catheters, central lines, ng tubes, countless needles and tests to look for other problems. He still can't swallow and is aspirating. At a family meeting I learn his vocal cord was paralyzed at some point during all his testing and procedures. It should heal but over weeks or months. Otherwise he may need a gastrostomy tube for the next year.
As I drive in daily to visit him in the NICU, nearing his 1 month birthday, I cry. I blame myself even though his doctors tell me it is not known why this defect happens. I blame a sinus infection, not enough nutrition, exposure to farm pesticides I might have had on a hike...the list goes on. I can't let it go.
I sit in the NICU and hold him, wondering what the future holds. Nobody can predict how things will progress with him. All we can do is take it day by day, waiting to see if he stops aspirating and starts swallowing on his own- then his TPN and NG tube can be removed.
As I sit in the NICU, every little thing scares me- an increased heart rate, no weight gain, a rise in temperature, I usually get so worked up within an hour that I have to leave and let my husband sit with him. Normally I am calm in this environment, but that is with other babies, not my own.
And the stress of the situation is affecting everyone around me. My office staff don't know how to book my office, when day by day, I need to be in the NICU and I don't know how long it will last. One staff is billing me for hours she hasn't been at work, another is demanding a raise (could she have picked a worse time)?
My husband is snapping at me for asking questions and his parents are telling him to give up on his farming business for now to devote himself to the care of his two sons. I am the breadwinner for the family, so if we need to bring home a high-needs baby, he needs to be the one to give up work opportunities for now. I feel guilty about this too.
My intent had been to have the baby and return to work the next week, as I had done with my first. I never thought to make a plan B. So I post ads for a locum and a babysitter for my older son, but as of now, no replies to either. And my patients don't understand why the office is closed down-they just want their doctor back.
I look back to all the times I thought I had so much stress in my life, school and residency especially, and they don't compare to this.
Today the first good news in a long time came. I have won two awards for continuing medical education courses. I will also have a chance to work as a locum in a place that I have wanted to work for a long time. This hint at my past organized life as an FP is so reassuring when the rest of my life is so chaotic and the future so uncertain.
I tell myself to focus on the positive and not worry about what can't be changed. This is what I have told past patients and this is what I do. I am learning a lot just sitting with my son in the NICU. I am donating milk to other babies. I am spending more time with family. I am learning empathy and how it feels to be a patient's mom. I have some of the best night-time babysitters around- the NICU nurses. Most of all, I know that in another time or place, my son would have died from this now corrected birth defect.
If this is how hard things can get, I hope that eventually things will swing back just as far in the other direction. Once they do, I will have to write again.
Monday, August 17, 2015
MiM Mail: PCP to PM&R?
I am an older mom to a one and only, fabulous, wonderful little boy. I had a career in human services before medical school. I completed my internal med residency. I have worked as a PCP for about a year and, frankly, it's awful! I like my patients. I chose to work in an underserved area with a lot of folks who are newcomers to the United States and I really like this part of the work. I feel like all I do is tap on the computer instead of really dealing with the human being in the room with me.
I had never heard of PM&R in med school. The more I hear about it and read about it, the more I feel like it might be a good match for someone like me. (You know, someone who likes to talk to patients, take a history, do an actual physical exam, maybe have time to do a procedure....)
Does anyone have any suggestions about residency training? It doesn't sound like the PM+R residency would be that much worse than the schedule of an attending PCP. I am able to sacrifice salary due to a very type A doctor dad in the picture. (In that way, I am very, very lucky.)
Thanks!
I had never heard of PM&R in med school. The more I hear about it and read about it, the more I feel like it might be a good match for someone like me. (You know, someone who likes to talk to patients, take a history, do an actual physical exam, maybe have time to do a procedure....)
Does anyone have any suggestions about residency training? It doesn't sound like the PM+R residency would be that much worse than the schedule of an attending PCP. I am able to sacrifice salary due to a very type A doctor dad in the picture. (In that way, I am very, very lucky.)
Thanks!
Sunday, August 16, 2015
From premed to med
So in the last two months I managed to do most of the things on my list. We moved nearly all our stuff down and unpacked while I was 37 weeks along. SK's birthday bash went smoothly. Our house is rented. Baby #2, SE arrived and is happy and healthy. We waited until she was two weeks old, packed up our remaining items in a U-haul and made the ten hour drive to our new home. (It's really only supposed to take six hours, but every 30 miles someone either needed to be fed or had to pee.) And now we are here, adjusting to life with a new family member, in a new city, with new schools and jobs. Everyone I've told about our moving experience has thought we're completely nuts, which we are, but we had a plan, stuck to it as much as we could and anything else that came up, we decided to just roll with it. In fact, these last four words have really become my motto as of late, so much so that I can basically take a picture of our crazy lives at any moment and have #justrollwithit be a fitting caption.
My first week of school was packed with such moments. No one to drop off or pick up SK from school on Monday? Just stay home with grandma and do some crafts, eat lots of treats and watch too much TV (#justrollwithit). Get to school and realize I brought my pump but forgot all my pump parts at home? Use the lactation room's backup pump and try to ignore the idea that others have used the same pump (#justrollwithit). Motion-sensor lights turn off in lactation room while pumping, leaving me fumbling around in the dark? Dance like a mad woman in the chair, still attached to my pump until the lights turn on (#justrollwithit....ok there might have been some expletives here and there).
I'm starting to realize that my med school experience is going to be a little bit different than what I had envisioned. I missed out on most of the socializing opportunities my first week because I had to run down to the first floor lactation room to pump while everyone else ate lunch. In fact, it is lunch time right now as I write this and I'm being serenaded by the gentle pff pff pff of my lovely pump. When our social calendar first came out I foolishly rsvp'd to several different events which I'm now realizing was a tad bit ambitious. I guess having a preschooler made me forget what newborn schedules are like; I forgot about the eating every 3 hours thing and the getting up multiple times at night routine. I am feeling a little bit left out, but I know the social aspect of med school will come with time, especially when the little one is a bit older. My biggest struggle right now is trying to figure out when I'm going to find time to study and I'm hoping with some trial and error I'll figure it out. Yesterday an assignment took me 5 hours...maybe 1 hour of actual work in total, 1 hour playing DJ for SK so she could perform dance routines in the living room, 30 minutes of reading Fancy Nancy books, 30 minutes of redirection, timeouts and talks, 1 hour of snuggles and cuddles, 45 minutes of breastfeeding and 15 minutes of accidental sleeping. By the time everyone else is actually in bed and I can study without distraction, I'm about to face-plant into my laptop.
I am loving what I'm learning though and I'm thankful to be in a great program. It's the logistical part that's scaring me right now. I can feel the dreaded "what have I gotten myself into" question creeping into my mind sometimes, but I'm pushing it aside for now. I'm rolling along and I'll be rolling with it for the next 4 years and probably thereafter.
My first week of school was packed with such moments. No one to drop off or pick up SK from school on Monday? Just stay home with grandma and do some crafts, eat lots of treats and watch too much TV (#justrollwithit). Get to school and realize I brought my pump but forgot all my pump parts at home? Use the lactation room's backup pump and try to ignore the idea that others have used the same pump (#justrollwithit). Motion-sensor lights turn off in lactation room while pumping, leaving me fumbling around in the dark? Dance like a mad woman in the chair, still attached to my pump until the lights turn on (#justrollwithit....ok there might have been some expletives here and there).
I'm starting to realize that my med school experience is going to be a little bit different than what I had envisioned. I missed out on most of the socializing opportunities my first week because I had to run down to the first floor lactation room to pump while everyone else ate lunch. In fact, it is lunch time right now as I write this and I'm being serenaded by the gentle pff pff pff of my lovely pump. When our social calendar first came out I foolishly rsvp'd to several different events which I'm now realizing was a tad bit ambitious. I guess having a preschooler made me forget what newborn schedules are like; I forgot about the eating every 3 hours thing and the getting up multiple times at night routine. I am feeling a little bit left out, but I know the social aspect of med school will come with time, especially when the little one is a bit older. My biggest struggle right now is trying to figure out when I'm going to find time to study and I'm hoping with some trial and error I'll figure it out. Yesterday an assignment took me 5 hours...maybe 1 hour of actual work in total, 1 hour playing DJ for SK so she could perform dance routines in the living room, 30 minutes of reading Fancy Nancy books, 30 minutes of redirection, timeouts and talks, 1 hour of snuggles and cuddles, 45 minutes of breastfeeding and 15 minutes of accidental sleeping. By the time everyone else is actually in bed and I can study without distraction, I'm about to face-plant into my laptop.
I am loving what I'm learning though and I'm thankful to be in a great program. It's the logistical part that's scaring me right now. I can feel the dreaded "what have I gotten myself into" question creeping into my mind sometimes, but I'm pushing it aside for now. I'm rolling along and I'll be rolling with it for the next 4 years and probably thereafter.
Friday, August 14, 2015
MiM intro: Hopeful MS1
Hopeful. That's the best way I describe myself going into medical school as mom of Toddler. Hopeful. As in, I hope I can handle the work. I hope I can find time for research. I hope I can keep up with Toddler. I hope Toddler can get some siblings over the next four years. I hope that I am not completely wrong about everything and foolish for even attempting the life I think I am trying to build. So I am hopeful.
Hello. Thank you MiM for existing. Reading this site has been a source of much calm during my post-bacc. I got engaged, married and had my first child while preparing for medical school. Just starting my training, I’m in my early thirties. I have yet to buy my books, and yet I enter with the weight of responsibilities and demands on my time that most of my peers won't experience until after residency. It's terrifying. It's discouraging. It's jumping head first, eyes shut, with no parachute into the complete unknown, hoping to land safely, or at the very least... Survive.
I am excited, honored and humbled to join this community. As I start medical school in just under two days (what?!), I hope (there is that word again) to share my experience as a career changer, medical trainee, aspiring researcher, and most importantly, a mama. This intro post took me a while to sit down and write, mostly because it feels like this marks the beginning. And I guess I was putting it off for just a little longer… because I was putting off admitting to myself that my world is about to turn upside down. I'm ready to jump in, and I'm glad to take MiM with me.
Thursday, August 13, 2015
MiM Mail: Not excited by the OR anymore
Hello all,
I was a huge fan of this forum as a woman in medicine, and now I am a brand new mother to a sweet 1 month old baby girl.
I have completed the 4th year of a plastic surgery residency at a competitive and busy program, and am currently taking a research year to have more time with my daughter. My husband is in medicine as well.
I am writing because when I decided to go into surgery (albeit plastics, which is a little bit less demanding), I had not even met my husband and did not think I wanted kids. Obviously my priorities have changed.
Since becoming pregnant, I have been strongly considering a change in specialties or leaving medicine altogether. My new priority is being a mom, being present, and being focused on my daughter's upbringing. Plastic surgery demands long hours to build a practice, rigorous call, and exhausting surgeries that take a lot out of me by the end of the day.
I know switching would mean lengthening my training at this point since I only have 2 clinical years (and probably fellowship) after this research year. But I can't help but think this will be so much better for us in the long run. It makes me a little sad since I have invested so much in my surgical training already, but I don't know if I would be happy continuing on this track. I am not looking for an "easy specialty" since there is no such thing, just one that better fits my priorities. Otherwise, what other options are there outside of medicine?
I liked PM&R when I was a medical student and found it uplifting since you got to see patients' long term progress. I also liked emergency medicine for the immediate feedback and fast pace (the same thing that drew me to surgery initially). I think I need to bite the bullet and find something with more of a fixed schedule that allows me to focus on my family when I am at home, rather than being a slave to my pager. I am just not excited about the operating room anymore, especially given all of my life changes. I have never loved surgery the way some of my colleagues do, and this confirms it.
Any thoughts or advice would be so helpful.
Thank you!
I was a huge fan of this forum as a woman in medicine, and now I am a brand new mother to a sweet 1 month old baby girl.
I have completed the 4th year of a plastic surgery residency at a competitive and busy program, and am currently taking a research year to have more time with my daughter. My husband is in medicine as well.
I am writing because when I decided to go into surgery (albeit plastics, which is a little bit less demanding), I had not even met my husband and did not think I wanted kids. Obviously my priorities have changed.
Since becoming pregnant, I have been strongly considering a change in specialties or leaving medicine altogether. My new priority is being a mom, being present, and being focused on my daughter's upbringing. Plastic surgery demands long hours to build a practice, rigorous call, and exhausting surgeries that take a lot out of me by the end of the day.
I know switching would mean lengthening my training at this point since I only have 2 clinical years (and probably fellowship) after this research year. But I can't help but think this will be so much better for us in the long run. It makes me a little sad since I have invested so much in my surgical training already, but I don't know if I would be happy continuing on this track. I am not looking for an "easy specialty" since there is no such thing, just one that better fits my priorities. Otherwise, what other options are there outside of medicine?
I liked PM&R when I was a medical student and found it uplifting since you got to see patients' long term progress. I also liked emergency medicine for the immediate feedback and fast pace (the same thing that drew me to surgery initially). I think I need to bite the bullet and find something with more of a fixed schedule that allows me to focus on my family when I am at home, rather than being a slave to my pager. I am just not excited about the operating room anymore, especially given all of my life changes. I have never loved surgery the way some of my colleagues do, and this confirms it.
Any thoughts or advice would be so helpful.
Thank you!
Wednesday, August 12, 2015
When the Patient Brings Presents… or Punishment
Genmedmom here.
This was an odd week. One patient brought me a beautiful bouquet of flowers as a gesture of thanks… and another totally reamed me out. Both are uncommon occurrences in my practice.
The thing is, I didn't feel like I deserved either.
I told a colleague about it, and we laughed. It's so funny, but so often the case, that we're as surprised by the patient who is grateful as we are by the patient who is angry.
Both cases ended up being professional victories for me:
Usually, when I've received gifts from patients, I have felt some pressure to treat them a bit extra-special, overly gently, with kid gloves. Oh, I won't go there this visit. But in the case of the flowers, I approached a touchy subject anyways, and we were able to address it in a positive way during the visit.
In the case of the reaming, which was really a lengthy declaration of my recent deficiencies as a provider, I was able to hear the patient out. They never raised their voice, used vulgar language, or got personal, so I was able to sit, impassive, and take it. I felt it was therapeutic for this particular patient to get it all out… I apologized for the perceived inadequacies, we reflected together, and then we were able to move on to actual medical issues. Usually, when I get criticized, I get heated up, embarrassed, emotional.
I don't know exactly why, but I was able to stay cucumber-cool. Maintain that professional distance. And, best yet, not bring it home with me.
Of course there have been other cases that have found their way into my head and into my home, intruding on the kids' bedtime routine, making their way into quiet conversation with my husband, delaying desperately-needed dreaming…
In our practice, we have a monthly Balint-style group moderated by a psychologist. We often share cases that get in our heads, and these themes have definitely been explored. Be it gifts or criticism, we have all experienced it. It's been very helpful to hear not only what other providers do in response to these challenging situations, but also to hear what they feel.
We're not made of Teflon, and the water sometimes soaks us. How do other physicians respond in these cases? and, more importantly, how does it make you feel?
I'd love to hear!
This was an odd week. One patient brought me a beautiful bouquet of flowers as a gesture of thanks… and another totally reamed me out. Both are uncommon occurrences in my practice.
The thing is, I didn't feel like I deserved either.
I told a colleague about it, and we laughed. It's so funny, but so often the case, that we're as surprised by the patient who is grateful as we are by the patient who is angry.
Both cases ended up being professional victories for me:
Usually, when I've received gifts from patients, I have felt some pressure to treat them a bit extra-special, overly gently, with kid gloves. Oh, I won't go there this visit. But in the case of the flowers, I approached a touchy subject anyways, and we were able to address it in a positive way during the visit.
In the case of the reaming, which was really a lengthy declaration of my recent deficiencies as a provider, I was able to hear the patient out. They never raised their voice, used vulgar language, or got personal, so I was able to sit, impassive, and take it. I felt it was therapeutic for this particular patient to get it all out… I apologized for the perceived inadequacies, we reflected together, and then we were able to move on to actual medical issues. Usually, when I get criticized, I get heated up, embarrassed, emotional.
I don't know exactly why, but I was able to stay cucumber-cool. Maintain that professional distance. And, best yet, not bring it home with me.
Of course there have been other cases that have found their way into my head and into my home, intruding on the kids' bedtime routine, making their way into quiet conversation with my husband, delaying desperately-needed dreaming…
In our practice, we have a monthly Balint-style group moderated by a psychologist. We often share cases that get in our heads, and these themes have definitely been explored. Be it gifts or criticism, we have all experienced it. It's been very helpful to hear not only what other providers do in response to these challenging situations, but also to hear what they feel.
We're not made of Teflon, and the water sometimes soaks us. How do other physicians respond in these cases? and, more importantly, how does it make you feel?
I'd love to hear!
Tuesday, August 11, 2015
A sucker punch
A few months ago I had brought the kids home from school (daughter, 6 and son, 3), got settled, and then they started to play in the playroom. I could see and hear they were playing in their 'hideout'--an elaborate tent with toys and places to spy on adults. As they started to play together, I went the business of getting dinner ready.
I heard my son say to my daughter, "Ok, I'm going off to work now. Love you!" They were pretending to be grown ups. Then my daughter replied, "Ok, I'm staying at home!" It was like a sucker punch to my gut. She was staying home while the 'man' was going his job outside the home.
That comment stopped me in my tracks. I have worked as a physician her whole life! Where had she gotten the idea? Most of her friends and cousins had mothers who also work. So I inquired, "[Daughter], you are staying home? What are you going to do?" Without missing a beat, she said, "Take care of the kids." I commented that she could work and take care of her kids, like many moms do.
In reflecting on the conversation, I want her to make life for herself in whatever way makes her happy--working outside the home or staying at home. Now when I ask her what she wants to be when she grows up--it's consistently "a veternarian".
Needless to say, it was a teachable moment for all of us.
I heard my son say to my daughter, "Ok, I'm going off to work now. Love you!" They were pretending to be grown ups. Then my daughter replied, "Ok, I'm staying at home!" It was like a sucker punch to my gut. She was staying home while the 'man' was going his job outside the home.
That comment stopped me in my tracks. I have worked as a physician her whole life! Where had she gotten the idea? Most of her friends and cousins had mothers who also work. So I inquired, "[Daughter], you are staying home? What are you going to do?" Without missing a beat, she said, "Take care of the kids." I commented that she could work and take care of her kids, like many moms do.
In reflecting on the conversation, I want her to make life for herself in whatever way makes her happy--working outside the home or staying at home. Now when I ask her what she wants to be when she grows up--it's consistently "a veternarian".
Needless to say, it was a teachable moment for all of us.
Monday, August 10, 2015
MiM Mail: Lost
Hi, I just started a 3 year residency program, and I'm feeling desperately close to quitting. In fact, if it weren't for the huge financial investment I've made up to this point, I almost certainly would have quit before I even got to this point.
I have a daughter who was born at the beginning of 4th year, and I think 4th year was probably the best year of my life. I loved spending time with her at home (despite being bored and lonely for parts of it). Now that she's older, she's even more wonderful and funny and fascinating, which I didn't think was possible. I dreaded the start of residency, which was, unfortunately, a black cloud over that otherwise wonderful year.
Now that it's here, I don't know whether it's worth it to continue. I don't find the work difficult or all that unenjoyable; I kind of like it and I definitely like the idea of contributing to our family financially. I feel like I could surely handle it all if I didn't have a child. I grieve every single day the lost time with her and the opportunity to watch her grow and be there for her babyhood, which is so fleeting and the part of my own life I want to experience more than anything. Add to this some chronic health problems that I am dealing with, and I feel so depressed. And of course there's no time to seek out treatment or professional help. I really have nobody to talk to about it. I feel like I'm drowning.
I have a supportive non-medical spouse who has a good job, though it would still be a blow of course to give up a future physician income. And I do have some loans, though well below the national average. So...I guess I'm looking for advice. Do I stay or do I go? Or should I approach my PD about some sort of part-time compromise (guessing that's a huge long shot). If I somehow make it though, and don't destroy all relationships in the process, my husband and daughter would probably be better off long term. If I go, I can start to recuperate some sense of sanity and mental and physical health, and I think it's better for me personally. Maybe I could convince myself it's better for my daughter since she'll be in a less stressful environment. I feel lost. -J
I have a daughter who was born at the beginning of 4th year, and I think 4th year was probably the best year of my life. I loved spending time with her at home (despite being bored and lonely for parts of it). Now that she's older, she's even more wonderful and funny and fascinating, which I didn't think was possible. I dreaded the start of residency, which was, unfortunately, a black cloud over that otherwise wonderful year.
Now that it's here, I don't know whether it's worth it to continue. I don't find the work difficult or all that unenjoyable; I kind of like it and I definitely like the idea of contributing to our family financially. I feel like I could surely handle it all if I didn't have a child. I grieve every single day the lost time with her and the opportunity to watch her grow and be there for her babyhood, which is so fleeting and the part of my own life I want to experience more than anything. Add to this some chronic health problems that I am dealing with, and I feel so depressed. And of course there's no time to seek out treatment or professional help. I really have nobody to talk to about it. I feel like I'm drowning.
I have a supportive non-medical spouse who has a good job, though it would still be a blow of course to give up a future physician income. And I do have some loans, though well below the national average. So...I guess I'm looking for advice. Do I stay or do I go? Or should I approach my PD about some sort of part-time compromise (guessing that's a huge long shot). If I somehow make it though, and don't destroy all relationships in the process, my husband and daughter would probably be better off long term. If I go, I can start to recuperate some sense of sanity and mental and physical health, and I think it's better for me personally. Maybe I could convince myself it's better for my daughter since she'll be in a less stressful environment. I feel lost. -J
Friday, August 7, 2015
Routines
I love routines. I am the kind of person who is perfectly happy to eat the same thing for breakfast and lunch every day, while cycling through a handful of choices for dinner. I like knowing what I am going to do, and when, and with whom, and for how long (and then what I am doing afterwards). Not surprisingly, I have found the lack of routine to be one of the most challenging aspects of the clinical years of medical school. As one of my classmates said: "Going through your MS3 year is like having a new job every four weeks". With each new rotation comes a new schedule, new preceptor, and new set of expectations.
One of the perks of the research year sandwiched between my MS3 and MS4 years has been the freedom to set my own schedule - which has meant the freedom to develop a routine for my family. These summer months have been particularly wonderful. I am loving the daily habits my 18-month old daughter and I have developed. In the mornings before daycare drop-off, we go for a walk around the neighborhood. She starts by insisting that she wants to walk, trotting beside me and excitedly pointing to various objects with an exclamation of "diiss?!?" (this), then nodding in agreement ("yah") when I identify them by name. After a few blocks, she puts up her arms for me to carry her - which thankfully doesn't last long (the one-armed toddler carry while pushing the stroller is something of a feat these days). Finally she consents to sit in her stroller, sipping on some milk while we walk to the nearby market or just around the block.
The content of my day may vary (lately including thesis edits, manuscript preparations, half-day clinics, and residency applications), but I know that in the afternoon I'll pick up my daughter from daycare and we'll spend a few hours at the playground or splash zone while we wait for my husband to finish work. In the evenings after dinner, I give her a bath and brush her teeth before settling in for some board books (Corderoy is the current favorite, followed by Chicka Chicka Boom Boom, Goodnight Moon, and Machines at Work). Then we turn off the lights, put on some jazz, and snuggle for a few minutes before she falls asleep.
My research year is coming to an end, however, and soon we'll be back to living life four weeks at a time. I'm excited for the rotations I have scheduled for my final year of medical school, but I'm also sad to leave behind the daily rhythm we've developed. With only a few more days of our summer routine left, I'm soaking up as many walks and baths and trips to the park as I can.
Any tips from other MiM's on how to maintain some semblance of a family routine while on busy services or when working long or unpredictable hours?
One of the perks of the research year sandwiched between my MS3 and MS4 years has been the freedom to set my own schedule - which has meant the freedom to develop a routine for my family. These summer months have been particularly wonderful. I am loving the daily habits my 18-month old daughter and I have developed. In the mornings before daycare drop-off, we go for a walk around the neighborhood. She starts by insisting that she wants to walk, trotting beside me and excitedly pointing to various objects with an exclamation of "diiss?!?" (this), then nodding in agreement ("yah") when I identify them by name. After a few blocks, she puts up her arms for me to carry her - which thankfully doesn't last long (the one-armed toddler carry while pushing the stroller is something of a feat these days). Finally she consents to sit in her stroller, sipping on some milk while we walk to the nearby market or just around the block.
The content of my day may vary (lately including thesis edits, manuscript preparations, half-day clinics, and residency applications), but I know that in the afternoon I'll pick up my daughter from daycare and we'll spend a few hours at the playground or splash zone while we wait for my husband to finish work. In the evenings after dinner, I give her a bath and brush her teeth before settling in for some board books (Corderoy is the current favorite, followed by Chicka Chicka Boom Boom, Goodnight Moon, and Machines at Work). Then we turn off the lights, put on some jazz, and snuggle for a few minutes before she falls asleep.
My research year is coming to an end, however, and soon we'll be back to living life four weeks at a time. I'm excited for the rotations I have scheduled for my final year of medical school, but I'm also sad to leave behind the daily rhythm we've developed. With only a few more days of our summer routine left, I'm soaking up as many walks and baths and trips to the park as I can.
Any tips from other MiM's on how to maintain some semblance of a family routine while on busy services or when working long or unpredictable hours?
Thursday, August 6, 2015
Going to the Doctor
Recently, I took Blur2 to the doctor. He’d been having a diaper rash for weeks. Initially, it started out like any other rash and my usual treatment (40% zinc oxide) worked. But weeks later, it was worsening and my treatment wasn’t working like it should if it was a typical diaper rash. So we went to our doctor.
I love my/our doctor (and the whole office) but I hate going for these minor ailments. As an ED doc, I knew what the next step was likely an antifungal cream; as a Mom, I didn’t want to be treating my own kid. Some of my colleagues and doctor friends would have just called in their own prescription. I feel dumb sitting there, telling the story, just really wanting reassurance. I do have a small supply of medications and laceration repair supplies at home for minor things; we don’t go for every URI/fever/etc but when things aren’t going how I expect, we go to the doctor. When Blur2 went through ear infection after ear infection, I kept hauling him into the doctor, to get them all documented because I was afraid he was going to need tubes - he ultimately did.
We have a separate Pediatric Emergency Department that is staffed by Peds EM and plain EM doctors. I do about 20% of my shifts there and most of them on the overnight shifts. I remind myself of my feelings that I have sitting in my own pediatrician’s office and teach my residents that the parents are often just looking for reassurance - that this fever is a virus, that this GI bug will pass, that this rash is not a serious rash, that the simple closed head injury does not need a CT scan - and guidance as to what to look out for next that would mean something serious.
I got my reassurance and prescription for an antifungal cream. And I feel better and so does Blur2.
When do you take your kid to the doctor? What’s your threshold? What do you take from your personal healthcare experience and add to your practice?
I love my/our doctor (and the whole office) but I hate going for these minor ailments. As an ED doc, I knew what the next step was likely an antifungal cream; as a Mom, I didn’t want to be treating my own kid. Some of my colleagues and doctor friends would have just called in their own prescription. I feel dumb sitting there, telling the story, just really wanting reassurance. I do have a small supply of medications and laceration repair supplies at home for minor things; we don’t go for every URI/fever/etc but when things aren’t going how I expect, we go to the doctor. When Blur2 went through ear infection after ear infection, I kept hauling him into the doctor, to get them all documented because I was afraid he was going to need tubes - he ultimately did.
We have a separate Pediatric Emergency Department that is staffed by Peds EM and plain EM doctors. I do about 20% of my shifts there and most of them on the overnight shifts. I remind myself of my feelings that I have sitting in my own pediatrician’s office and teach my residents that the parents are often just looking for reassurance - that this fever is a virus, that this GI bug will pass, that this rash is not a serious rash, that the simple closed head injury does not need a CT scan - and guidance as to what to look out for next that would mean something serious.
I got my reassurance and prescription for an antifungal cream. And I feel better and so does Blur2.
When do you take your kid to the doctor? What’s your threshold? What do you take from your personal healthcare experience and add to your practice?
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