Guest post: Are we doing the right thing?

The opiate post segues into something I’ve been grappling with periodically - the ethics of medical intervention when the outcome for the patient might be terrible, or even futile.  Cases such as patients with massive heart attacks, who then end up with severe brain injury.  Or the trauma victim who lives, but in a vegetative state.  The one pound neonate born at the edges of viability, who survives as a severely disabled child.  I do not know the answers, and I don’t know how we make such a decision about outcome when most of these scenarios present as an emergency with no time for considered thought.  It’s troubling me more of late though.  I have a colleague who ran into an affected family member of a patient for whom she’d cared, during such an event some years earlier.  The family member recognized her, and asked if she was proud of herself for what she’d done. The patient involved was only saved through advances in modern medicine - not so long ago, such a patient would have died.  At the time, this family wanted nothing more than for their relative to survive.  Now, they carry the burden of caring for a patient with no meaningful quality of life.  Their marriage has broken down and future dreams shattered.  Although I ached for my colleague, having such anger directed at her, I could understand the place from whence it came.  The problem is, there will always be that success story, the patient brought back successfully from a devastating injury, the neonate born at 24 weeks who is now a happy, functioning, bright child.  There is no pause between the presentation and the decision to treat in which to make a choice, no crystal ball to guide us.  The principle of non-maleficence is very hard to apply in those precious moments of a resuscitation.  We have statistics, as to who might fare poorly and who might do well, but how do statistics help if you are the family member burdened with making the decision to discontinue treatment, or in the case of a very premature neonate, to never start treatment?  How do we as doctors guide them?  As we sit by the patient who looks to have a dire outcome, how do we advocate for that person and family, when we can never be sure which statistic they will be?  We can quote the statistics, but how does a parent or a relative choose to not treat, how does one choose to let another person die, when the numbers are not black and white?  What would you do if it was your family member, your neonate?  Are we doing the right thing, saving such patients, just because we can?

Jess

2 (Parody of Taylor Swift's 22)

It feels like a perfect night to dress up in mom's clothing
And spill juice on it, uh uh, uh uh.
It feels like a perfect night for breakfast at 5AM
Wake up and make me Cheerios!, uh uh, uh uh.

Yeah,
We're happy, crying, confused, and noisy at the same time
It's exhausting and magical.
Oh, yeah
Tonight's the night we clog the toilet with baby wipes
It's time

Uh oh!
I don't know about you
But I'm feeling 2
Everything will be alright
If you catch me and wipe my poo
You've barely slept all year
But I'll bet you want to
Everything will be alright
If we just keep coloring on the wall like we're
2 ooh-ooh
2 ooh-ooh

It seems like one of those nights,
I want my socks off,
Now I want them on again uh uh uh uh
(Now I want them off again)
It seems like one of those nights,
We ditch the bottle and end up screaming
Instead of sleeping.

Yeah,
We're happy, stinky, hyper, and sleepy in the best way
I'm going to rip my hair out.
Oh, yeah
Tonight's the night when we climb into your bed and kick you in the head all night
It's time

Uh oh! (hey!)
I don't know about you
But I'm feeling 2
Everything will be alright
If you find my little pink shoe
(Where is it???)
You don't know about me
But I'm the one who spilled that glue
Everything will be alright (alright)
If we just keep bouncing on the bed like we're
2 ooh-ooh (oh, oh, oh)
2 ooh-ooh

It feels like one of those nights,
We run around the house naked
It feels like one of those nights,
Then pee on the carpet
It feels like one of those nights,
You look like scissors
I gotta have you,
I gotta use you.

Ooh-ooh
Ooh-ooh, ye-e-e-e-eah, hey
I don't know about you (I don't know about you)
But I'm feeling 2
Everything will be alright
If you bring me back that toy I threw
(again)
I haven't napped all day (haven't napped all day)
But I'll bet you want me to
Everything will be alright
If we just keep watching Elmo like we're
2, ooh-ooh
2, ooh-ooh
2, ooh-ooh, yeah, yeah
2, ooh-ooh, no, no, no, NO!


(My daughter and I composed this yesterday and I had to share)

Note: Cross posted to my blog

Does it get easier?

I keep putting off taking on extra responsibilities at work, saying, "I'll do it when my life gets easier." I figure having a kid in her terrible 2's is some sort of peak of difficulty. It's got to get easier than that, right?

However, this weekend it was my grade schooler who managed to:

1) Burn her finger and injure like three other body parts

2) Wake me up WAY before I was ready on daylight savings Sunday (daylight savings is meaningless when you have little kids)

3) Not allow me to have even ten minutes to rest after a several hour excursion to the mall

Plus, whenever I make comments along the lines of that it will get easier when they're older, people are fond of telling me, "Oh no, it just gets hard in a different way."

So which is it? Does it get easier ever?

Book Review: The Devil Wears Scrubs by Freida McFadden

I love to read books written by other doctors. I think doctoring can be kind of isolating sometimes, but reading about the experiences of our colleagues can be so... validating.

This book, which was written by Mothers in Medicine blogger Fizzy McFizz under the second pen name Freida McFadden, is a humorous account of an intern's first month in an internal medicine residency. It's light, it's a quick read, and it really is funny.

The story follows newly minted Dr. Jane McGill as she tries to figure out how to survive and thrive on the floors at a county-style hospital, with little to no instruction or guidance on what, exactly, to do (sound familiar?), and all the while being picked on by a seemingly sadistic senior resident. The senior, however, has a human side as well, and a few good lessons to teach.

While this fun little book is fiction, I get the sense that it's House Of God-style fiction, meaning, alot of it is likely sort of true. I don't know this, I'm just guessing, and it made the book so much more interesting to me, as this intern's experience is largely miserable, and it reminded me of my own miserable intern experience (and I blogged about those memories in a post titled "How a fun little book dredged up buried memories of my intern year" ).

I was again reminded of this book at a recent medical conference, a Virginia Mason seminar (all about running a more humane, efficient practice) and one of the speakers was describing how setting basic work protocols and standards is so key to a positively functional work environment. She asked us how we can expect people to do tasks if they have no formal instruction in how to do them, saying: "Asking people to do things that they have not been trained to do is an exercise in frustration: theirs, and yours. Most people want to do a good job, and if you repeatedly put them in a position where they are likely to fail, they become demoralized, angry, and difficult."

I sat there thinking: Well, that's medical residency in a nutshell.

And Dr. McGill's experience in this book exemplify this: An experience so miserable, it's funny.

The book is available on Amazon.com, here is a link.

The Opiate Epidemic And Us

Our 25-year-old nephew passed away last week.  He had been fighting an addiction to prescription opiates for some time, and despite great efforts on the part of himself and his family, he died. I've written about this on my own blog.

His death has caused me to reflect on my own role in the larger problem. It has brought home an ugly issue that we all, as prescribing physicians and mothers, should reflect on.

When I first started as an attending in our small internal medicine practice, I learned to dread one aspect of the call more than any other: dealing with the requests for narcotics prescription refills.

We take a week of call at a time, and call starts Friday at 8 a.m. Friday afternoon call would roll around, and so would the requests. Not hundreds, and not always, but very commonly, one to five requests.

There was a pattern: usually someone was requesting a refill early, with a story about how the original prescription had been lost, or stolen, or  left in the glove compartment of the rental car they were driving while their car was being fixed but now the rental car was re-rented and the prescription was gone (true story). Or they had used more than was originally prescribed because they had had a particularly bad flare of back pain/ knee pain/ fibromyalgia secondary to a new injury or stressful event of some kind. Typically there would also be a mention in there of a sick child, a recent family death, a failed marriage, or a lost job. Usually the prescribing doctor or PCP was not readily available, and usually the electronic medical record showed a history of similar weekend early refill requests with notes like, "Filled amount for just a few days until PCP returns" or "Rx sent with no refills with instruction to f/u with PCP". And I usually did the same. (Except sometimes when I was really peeved).

Why didn't I (and we) generally refuse to fill these? Because you could put someone into serious withdrawal if they suddenly stopped their Oxycodone 20 mg three times a day. And if the medication was truly needed for pain, it would be cruel not to provide it, and you just never really knew.  In addition, to outright deny these requests could be construed as sort of a slap in the face of the prescribing PCP, my (senior) colleague, thereby questioning their medical judgment in writing this prescription in the first place. And, honestly, a huge time suck as well, as if I were to refuse, I would need to spend so much more time  dealing with the mess then if I just gave the patient a few, just to get through a few days until the PCP returned or the office reopened.

Luckily, soon after I was hired, more stringent prescribing standards were encouraged, and then, within the past few years and even months, actual legislation has emerged to practically help us physicians to deal with narcotics prescriptions. Pharmacies cannot accept phone orders for refills, and patients must have a signed hard copy of the narcotic prescription. Weekend phone call refills are no longer even possible. Pharmacies' databases are now linked up so that patients cannot use more than one pharmacy to fill these types of prescriptions. We have directives from our hospital to meet with all of our patients who are on any chronic narcotics, review a Pain Medication Contract, have them sign it, and then test their urine for the specific pain drug as well as for illicit substances.

Because we are in an epidemic.

All sorts of people are getting high on these prescription opiates. I see prescriptions for #90, #120, even #180 of 5 mg oxycodone. I've seen prescriptions for more. If someone or their family member is diverting even a few of those on a regular basis, it's enough to get others hooked.

Diversion is tempting. It's a good income. A Google search right now says that Oxycodone is worth about one to three dollars per milligram on the street, so that 5 mg tablet has a street value of at least five and perhaps fifteen dollars. If someone has a bottle of 180 tablets? Whoa.

Opiates are extremely physically addictive. And lives are crushed by addiction.

Physicians have a wide range of practice habits and comfort levels. Me, especially when I first started, I had zero comfort level with narcotics. Unless a patient just had major surgery or had metastatic cancer, I was NOT going to prescribe a narcotic at all, never mind chronically, long-term.

Now, honestly, I'm comfortable with these prescriptions, under certain circumstances. Surprisingly, in my own practice, most of the people I have started on narcotics (who hadn't had major surgery and didn't have metastatic cancer) are my very elderly ladies with bad arthritis who can't take anti-inflammatories (like Ibuprofen and those meds) and are maxed out on things like Tylenol, Lidoderm patches and Capsaicin cream. And so, yes, I do have a handful of patients who take Oxycodone 2.5 or 5 mg once or twice a day for breakthrough arthritis pain. Most of them walk with a cane, and I hope that their grandchildren aren't pilfering.

Then, I inherited a panel of patients on larger doses of an assortment of controlled substances, and I am currently struggling with these cases. I'm using laws and hospital guidelines as best I can to get a handle on things... it's a discomfort zone. My gut feeling is that some, probably a very small number, of these patients are sharing or even distributing these medications. But without obvious red flags or violations of the Pain Medication Contract, such as a urine screen negative for the prescribed medication and/or positive for an illicit substance, I cannot, in good conscience, refuse to prescribe.

In my own practice, I have tried to shift people towards alternative pain management, like healthy living, physical activity and physical therapy, acupuncture, yoga, massage... I really believe that a low-carbohydrate diet and regular exercise helps to reduce overall inflammation and decrease pain perception. This is not going to work for bone-on-bone arthritis, I am aware of that. But for low back pain and fibromyalgia sufferers, I give it a hard sell.

I'm curious to hear what are the thoughts and experiences of other physicians on this issue...

Hope

Residency is tough.  I read posts from those of you still in the trenches and I can remember how overwhelmed I felt.  The schedule doesn’t allow adequate time for self or family.  Halfway through my intern year, our staff psychologist did a resident assessment and I remember writing that, while I was doing alright for now, the current level of activity was unsustainable in the long term.

To make matters worse, several of our attendings would often say helpful things like, “If you think this schedule is hard, wait until you’re an attending – it’s much worse.  AND there are no duty hour restrictions!”  I know I was not the only one wondering if the rest of my life was even going to be bearable.

Well, I have good news for all of you.  I have seen the future, and it is beautiful.

The first year and a half that I was an attending, I literally felt like I was on vacation.  I didn’t have to come in until 9 a.m.!  Five p.m. often meant I was leaving the office!  What, I’m off this weekend AGAIN?!   Also, I have time to work out, time to sleep, time to work on hobbies!

It’s true there are no duty hour restrictions for attendings, and every once in a while it’s an issue.  If I do a delivery at night, I still have to go to the office all the next day.  Some days are quite long, as I do take extra time to do the odd home visit, see some nursing home patients, and call patients personally with unexpected lab results.  I take my own call during the week, and do my own deliveries unless I'm out of town. 

The first weekend of call for our practice was fairly awful – in early to evaluate a sick patient, then rounding until afternoon, followed by pages every 15 minutes that made it impossible to catch a nap.  I remember thinking, “I can’t survive three days with no sleep!”  But the thing is, it’s always very temporary.  There is always a day off in my very near future.  I know I can catch up on sleep before I really develop a deficit.

I know every field is different, and there are docs around here that work every day until 8 p.m.  However, medicine has a lot of choices and I believe that if you try (and make it a priority) you can make some family-friendly ones.

- DoctorGrace

The me-time problem, or rather the no me-time problem

Recently, I have been having a me-time problem. The problem is, I don't have any. Now, there are pressing and non-modifiable external reasons for my lack of a life, namely residency, which severely limits the total number of hours that I can devote to non-work activities. Then's there is parenthood and I know I don't have to go into detail here at MiM about the ways in which that limits me-time. Let's just say: Last weekend I turned on the shower and read a New Yorker article while sitting on the bathroom floor and telling my daughter through the door in a sing-song voice that I was almost do-one with my show-er. So my expectations in the me-time department are not lofty. I'm not talking about daily me-time and there are months when I resign myself to the fact that I might only get a few hours per month to myself. But I'm beginning to see the toll that no me-time can take when it begins to stretch from months to years. My best friend in the world has been with her "new" boyfriend for almost a year and I have never met him. One of my other dearest friends had a baby over a month ago and I have yet to talk with her in person. The list of friends and relatives whose birthday I have under-celebrated or whom I owe calls, cards, gifts, or visits is long. I have not formed very many lasting social connections with my co-residents because I never attend happy hours, dinners, or trips.

Also I am just so unbelievably tired. I am locked in an almost compulsive cycle of sleep deprivation. I race home from clinic to be with my daughter then finish notes late into the night when I should be sleeping. I get up with her at 5:30am on weekends even when my partner offers to let me sleep because I want to spend every last minute with her. I wake up only 2-3 hours post-call so I can pick her up from day care. My sleep deficit feels as insurmountable as my student loan debt, something I will be paying off until I die. Will I ever be able to go to a movie or a play without falling asleep two minutes in?

Don't get me wrong, I love spending time with E. It is my favorite thing to do without even a close second. The delight and pleasure I take in even the simplest activity with her is beyond anything I have ever experienced before. Let's load the dishwasher! I say, and her little face breaks out into a beam of excitement and suddenly arranging bowls on the rack takes on a new quality of magic a la Mary Poppins. But I do miss myself. And see above re: I am really tired. I'm beginning to feel a little wan and a little crazed and very, very grouchy in the mornings and sometimes in the evenings and sometimes in the middle of the day. I know rationally that it would be good for me, for my daughter, for my marriage, for my career, for my health -- good all around -- to take breaks and keep from getting burned out.

The problem is, I feel deeply conflicted every time I am faced with the decision of leaving my daughter for any reason other than work and especially if the only reason is my own comfort or enjoyment. When I have only four days off a month, how can I spend even part of one day away from her? When I might have only one hour with her at the end of a day, how can I decide instead to go to a bar with my co-workers? When she is cutest in the mornings and I almost never see her in the mornings, how can I roll over and let my partner toddle down the stairs with her and get all the sweet toddler action? In the abstract, I know I should do all these things at least once in a while, but when I'm in the moment a noose tightens around my heart, part guilt, part sheer hunger to be near her and hug her and listen to her talk and watch her grow up, which I increasingly find is a quantity-time and not a quality-time activity. So I end up deferring or canceling plans or bringing E along and spending the time chasing her around rather than socializing.

I have a vacation coming up in December and I'm toying with the idea of planning a one- or two-night trip by myself to visit a friend but I'm nervous that when the day comes and it's time to drive to the airport, I won't want to go. I won't be able to go. I will end up "getting sick" and canceling and wasting money I don't even have on lost tickets and hotel reservations. Or going and feeling unsettled the whole time and regretful about time lost with my daughter when I have to go back to my 80hr schedule the following week.

Fellow MiMs: How do you handle the me-time dilemma? Should I suck it up and reclaim some me-time or suck it up and realize that these years are precious and schedule a reunion with myself in a couple of years after residency and toddlerhood are over? What strategies do you have for fitting in time for yourself? In other words: help!

Guest post: Ready

In high school, I decided that I wanted to be an ob-gyn.  I felt it was my calling, and I bought books to learn as much as I could about the field.  I knew quite a bit, so much so that in medical school, I didn't have to study for my reproductive exams--I already knew everything!  (And have now forgotten it all, sadly.)  In college, I used to drive home tired from the library late at night and imagine that one day this is what it might one day be like when I would be an ob-gyn and get a call from the hospital about a laboring patient.  I loved thinking about it, imagining it, and I would never have believed anyone if they told me that it's not the specialty I would end up choosing.  But I didn't become an ob-gyn--you might ask, what happened?

Towards the end of college, long after I had already gotten into medical school, I started to get nervous about the hours that becoming a doctor, particularly an ob-gyn, would require.  When I started medical school, I regretted what I had done (going to medical school)-- I was angry that I would never be able to be a stay at home mom, which was largely because of the loans I was taking.  I complained for years about how unfair the hours that it would take to become a doctor were.  I chose psychiatry residency because it was the next subject after reproduction that interested me.  Luckily psychiatry is one of those residencies with typically less hours than most other residencies.  For almost a year, I was happy with my decision to go into psychiatry.  I felt it was a good job with good career prospects and not crazy hours.

But when I got pregnant and still had to take 24 hour calls, those feelings of bitterness re-emerged.  "What 9 month pregnant people stay up for 24 hours working??" I thought.  When I finally had my baby, I was so glad to finally get a break and finally get a chance to live that "stay at home mom" dream I'd had for years, even if it was just for 6 weeks.

About three weeks into my leave, I was done.  Done.  Done.  Done.

I hated sitting home all day and watching TV.  I hated waking up late and not having a reason to get dressed up, to put make-up on.  I hated only having my husband to talk to at night, and occasionally my mother when she came to visit.  Some days when my husband was on call, I had nobody to speak to all. day.  So is this the life I yearned for all those years?

I am now three days away from going back to work, and I'm ready.  Ready to exercise my brain.  Ready to communicate with colleagues, with patients.  Ready for it all, except for one thing:  those darn 24-hour calls!

What eats at me just a little... is that maybe I had the wrong idea of myself the last 4 years.  Maybe I've always had it in me to become an ob-gyn, and maybe I sold myself short.  Maybe I was never meant to be the mommy dearest that I thought.  If I didn't hate those 24s so much, I might even consider switching.  But I'll stick with my decision.  With my GOOD job.  And maybe in a few months, I'll be back to crying about how unfair the world of medicine is for mommies like me.

MiM Mail: How do you do it?

Hello Supermomdocs,

I stumbled across your blog when I was trying to decide if I made the wrong choice in choosing an internal medicine position over a dermatology one.  I think it's a fantastic site, by the way.

I'm Jenny, I'm a physician assistant, and currently mom to a furry 4-year-old, 70 lb. boy.  :)  At the time I chose my current internal medicine position, I was leaving a place where I was not treated very well, or respected at all.  So I went with the offer that I felt more at ease with as far as the people I'd be working with.  And so far, I must say, I love every aspect of my job except the work I didn't know I signed up for. 

My patient load here is a lot heavier than my old place, and I see more chronic illnesses than I did at the last place (I saw some follow-ups, mostly acute visits).  I find myself working late, bringing work home, and working on the weekends.  I am preparing to bring this up with my supervising doc, the owner of the practice, but I wanted some feedback from some women in the field, and I thought you all might be able to provide some insight.

The dermatologist doctor has also told me he was looking to hire a second mid-level provider come Spring.  I am tempted, for I feel that derm would not have as much "homework."  Am I wrong in thinking this?  I'd be taking a paycut and possibly vacation cut too, but at this point, I can't be leaving the office at 8 or 9 every day.  HOW DID YOU BUSY DOCTORS MAKE TIME TO MAKE BABIES?!  That is another thing on the horizon.  My husband and I would like to start a family, but we've refrained from "trying," for fear of stressing ourselves out.  So perhaps this is TMI, but we've opted to just try to increase frequency of intimacy instead of plotting calendars and such.  The problem with this-there is never any time!  I'm always working, we're always tired by the time the day is done. 

Internist(s), I feel like part of the issue with my current situation is that it's just the field of primary care.  There's always going to be a slew of labs to go through, and it's never ending.  The previous doctor I worked for never followed up on his labs for months, and then would just ambush them when he took a vacation, or was about to leave for vacation. 

I currently do not take a half day, but I'm thinking about asking for one, to work on labs (so technically I wouldn't be workingless).  I currently work over 60 hours a week. 

Any advice or input would be appreciated.  This is a struggle for me to find a balance between work and home life.  Is it something you still juggle?  Am I just complaining too much?

Thanks for hearing me out.  Again, I'm so glad to have found your site.  Great job!

Sincerely,
Jenny

BEST WEEK EVER!

I've been on vacation this past week.  Since I had nothing pre-planned I decided to make it a stay-cation.  It was much needed, as all vacations are.  This time, I didn't have my typical residency feeling of wanting to emotionally implode prior to the vacation starting.  I was just happy and ready to have some time off as I transition to another rotation.

My husband has demanded all week that I have "me time" and salon time and manicure time, etc.  But, for this vacation all I wanted to do was hang out with my precious girl.  I was literally giddy with excitement planning activities for us to do.  Now that she is almost 3, she is so curious and at a perfect age to do things.  I had prepped her for our week of "adventures" and she was just as excited as I was.  She kept telling people that she wasn't going to school because she was going to hang out with mommy.  Well, we hung out, and with one day to go I can say hands down that this has been the BEST WEEK EVER!!

We went to museums, the library (about 1 million times, its our "spot!"), different parks, we had picnics and did crafts at home - it was AWESOME!  But the even better part about our awesome week of adventures, is that, the thought of going back to work on Monday doesn't make me want to vomit.  The call night before my vacation started we had a few emergent-ish, difficult-ish cases that I felt comfortable with.  The morning after my call, one of my former med students from an earlier rotation, called me aside to help him think through a patient situation.  This call marked the end of my chiefdom at the knife and gun club hospital that we rotate through and I truly feel like I have surgically and clinically matured since I was here a year ago.  It was a great call to mark the start of my vacation.  

Today, at the science museum I ran into a former chief at our program.  He finished the year before I started but was technically in the building on my first day of intern year.  He ran into the group of new interns as he was saying his final goodbyes. He was all smiles as he left the building on his final day of a long surgical residency.  I was right at the door as he was walking out.  He gave me a hug and said "Welcome!" Then he chuckled and left.  I had never seen him again until today.  I re-introduced myself and we did some shop talk as our kids played in the aerospace exhibit.  He was still all smiles and at the end he said, "its long but its so worth it!"

So to summarize, I just had the best week ever, just being a mom.  I am really happy with my career.  And, to top it off, I've witnessed proof of the light at the end of the tunnel.

Happy Saturday!

Beauty in Crisis: the dance of the Pediatric Pharmacist

G is a beloved Pediatric Pharmacist in our hospital. She is thorough yet collegial, encyclopedic yet approachable.

Tonight during a crisis I realized yet again why she is invaluable. I am in the last weeks of my first Pediatric Intensive Care Unit (PICU) rotation. Tonight, like other nights, a very sick patient became critically ill. She needed infusions and doses of medications out of the normal ranges and she needed them fast.

I power-walked to the pharmacy to pick up some meds and I got to watch G in action. Together we researched doses and administration. And then I got to sit back and watch the master at her work. She floated. She glided. All the while silently mouthing things to herself like a dancer reviewing her choreography. She taught me her choreography, explaining why she was drawing up the medication in this way, why she was adding it to a carrier fluid in that way. The entire time I was enraptured. It made the physically and emotionally draining night more manageable and allowed me to step back and see the beauty in this crisis. I saw how the members of the team, including me, worked together to bring a patient on the brink of death back to life.

Guest post: The Leap List

A while ago, back before we decided to be honest with ourselves and cancel even our bare-minimum cable package, I saw a Honda commercial extolling the virtues of the Leap List.  The Leap List, it seems, is a sort of Bucket List of things you’ve always dreamed of doing, except the deadline isn’t death but some other major life event - namely, according to the commercial, having a baby. 

With no conscious decision to do so, my mind began spouting all of the things that have for years floated around in a nebulous wouldn’t-it-be-nice-to miscellany but had never before spooled forth as an actual set of goals with names and deadlines to anchor them into existence.  Yet suddenly here they were, insistently making themselves known.  The list went something like this: run a marathon, learn Turkish (my husband’s native language), write a book.  Go back to Paris, this time with my husband; but first, brush up on my French and put to use some of the books collected on previous visits that have for years sat untouched on my shelf.  Re-establish a yoga practice; this time make it stick.  Ride in a hot air balloon.  Travel, always more travel.

 Less than a year later, with none of these things checked off my list, my husband and I are expecting our first baby.  Fleeting thoughts of unrealized dreams floated through my head as the reality of this new development registered.  But they floated right back out as a new set of goals – a healthy pregnancy, becoming the type of parents we hope to be – set up firm residence. 

Pregnancy thus far has been nothing like I expected, nor has my own casual shrugging off of the list of things that remain undone.  Perhaps it has only served to help me highlight which things I value most and which others will not leave me feeling unfulfilled in their absence.  Or perhaps – and seasoned parents and even I myself one day may laugh at this – I will see that while there is a distinct Before and After to life surrounding the birth of a child, the pursuance of my own life goals needn’t be completely tossed aside.  Perhaps there will actually be time in between and around the diapers and the feedings and the potty-training to dedicate to undertaking the things that nurture me and feed my soul.  I hope it’s not just wishful thinking.

But the realization of one goal has already sprung from the decision to start a family.  When my husband and I decided that it was time, a voice inside me said, Well then you’d better start that blog.  It’s now or never.  I  later learned that at the time of my first post, I was already pregnant.  So maybe, just maybe, there will be a way to find room for both.  And maybe someday I will enjoy that hot air balloon ride with my child at my side.

PICU and the Biting Beast

I don’t know when it began, but somewhere in between finishing first year of residency and starting in the Pediatric Intensive Care Unit (uggghhh, acckkkk, poooo), my cute talking toddler became a biting, hitting, aggressive little beast. Sometimes he’s soo sweet and soo cute and I forget that at any moment, when we run out grapes or he can’t find his motorcycle, things could get very ugly, very fast.

When it’s ugly, he hits, he bites, he smacks. Who? Me, my husband, his favorite friends, his not-so-favorite classmates, his bath toys, his Froggy. Oh yes and when we recently tried to redirect him by holding his hand when he swats at us, he even tried a head butt. My husband and I sat stunned, where does he learn these things?

And did I mention I’m in the PICU?!? It makes everything worse. The guilt I feel about his aggressive behavior is exacerbated by my sheer emotional and physical exhaustion. I arrive home sometime during twilight outdoor playtime only to take him away from his beloved friends and the sandbox. I then clean him up and prepare him for bed while he wails and hits. Daddy pours the wine, puts his headphones on, and begins his nighttime graduate-student-writing routine. The only respite I get is story time, where Zo picks out his favorite books and says, “Sit down Mommy” and pats the couch beside him. Then I rock him to sleep as he cuddles and rubs my ears. After that I sit mindlessly perusing the internet for the countless hours while my husband repeatedly says, “Don’t you need to go to bed, don’t you have to get up at 4:30am?”

I have begun polling friends and have gotten: smack him, give him time outs, redirect him, it’s a developmental milestone, this too shall pass. Knowing that this phase is developmentally “normal” means nothing when I pick him up from daycare for the first time in weeks and his teacher says, “Sorry Miss, but Zo bit a friend, again” as she points to the cherubic chunky boy Zo has taken to like an apocalyptic zombie.

I can now proudly say that PICU is over and I learned a lot. I can also proudly say that Zo has made it 3 days in a row without biting anyone besides his toys, we celebrated at school today with dancing and he seemed very proud of himself. He starts everyday with a new family mantra “No biting people!” It’s the little-big victories; we have at least temporarily slewed the PICU and the Biting Beast.

Guest post: When doctors become patients

I recently gave birth to a beautiful baby girl.  My entire pregnancy was so incredible -- I loved every minute of it!  I never thought for one minute that my baby could have anything wrong with her.  But alas, she was born with a hand deformity that was not diagnosed in utero.  I cried non-stop for days.  My husband would come home from work and cry with me, hold me while I sobbed, "Why our baby?" While I know that this hand deformity will not stop her from becoming an amazing person, amazing daughter, I know she will struggle because of it.  I wish it was my hand, not hers that was deformed.  I wish I could take back whatever I did wrong during my pregnancy.  I wish so many things.

So it started, the doctor visits. Today was our first visit to the orthopedist.  He didn't have any good news for us.  He just said, "We'll have to try to give it function. When we walked out of his office, I was stunned.  "Why didn't he tell us more?  Why didn't he know what else to say? Why didn't he give us a clear answer about what the future holds?"  My husband pointed out that he probably did not know what the future held.  That he probably didn't know what else to say.  That only time would tell what the outcome would be.

I made an appointment with another orthopedist, in hopes of a better and clearer picture of what to anticipate. But I know that probably nobody will be able to ease my mind the way I'd like.

I know it could be worse.  There are children out there with cancer!  With immunodeficiencies. With cerebral palsy.  With all kinds of terrible things.  How lucky I should consider myself that my baby only has a hand deformity.  But I can't consider myself lucky. I just cry and cry, and ask myself, "Why my baby?"

did you take his name?

I think I had already decided to keep my name even before my boyfriend-at-the-time told me his (rather long) surname was old German for "caveman", "neanderthal" or "man who lives in a hole in the ground". I would be lying, however, if that bit of information didn't help solidify the decision.

I got married at age 25, while I was still in medical school. No one in either my personal or professional life gave me a hard time about keeping my maiden name. I thought at the time that most people would assume I had changed my name and we would, at least socially, be known as "The Caveman Family", when children eventually came around.

But that hasn't been the case. People are, for the most part, careful to acknowledge that I do not share the same last name as my husband and children. I should also note that my last name is nothing beautiful itself - my sister describes it as a grunt and has vowed that, should she ever get married, changing it would be the first order of business. Perhaps now it is clear why I never really considered hyphenation. One borderline unattractive name is not improved upon by the addition of a multi-syllabic and even less attractive name.

Wedding invitations and baby announcements are addressed to Me Grunt, Husband Caveman, and Children (1) and (2) Caveman. When told I wont be home for dinner, my daughter will reply "We'll have Caveman family night!", the obvious implication being that my last name would exclude me from "Caveman family night", which is too bad because it usually involves movies, ice cream, and late bedtime. 

I have mixed feelings about this. I guess I just care less about my name now as compared to when I was 25. I think my self-identity would just as intact if I were Dr. Grunt or Dr. Caveman. The work I did in undergrad or medical school would not be wasted if I then practiced under a different name. 

I am not sure that I would make a different decision if I were getting married now (at age 33) and I certainly don't care enough to change it at this point. I am, however, surprised by how wistful I feel when seeing my name separated out from those of my family or when my daughter talks about "Caveman family night". Honey, I might not have given you my name, but that chin dimple of yours? That's from me.