“Pumped” in JAMA

I was at our block education the other day when one of my male co residents asked me, “Did you read the JAMA reflection piece from Sept 11?” (answer to this is always no, my JAMA sits on my kitchen table where it’s main purpose in life is to be an excellent spider squisher). When I said I hadn’t, he took his issue out of his backpack and gave it to me.

If you haven’t seen it, the article is called Pumped by Dr. Charlotte Grinberg. (Article here). It is a fantastic reflection on pumping during intern year and like most reflections on pumping I identified with it so much. I almost cried when *spoiler alert* her freezer broke and she lost her stash. And cheered at the final couple of paragraphs.

I am so happy to see this in JAMA. My coresident told me - “I read it and thought of you guys”. I’d lately been fielding comments like “I wish I got a twenty minute break in my clinic schedule!” so it was great to hear something more affirming. I suppose my male coresidents are less likely to be reading blog posts on mothersinmedicine.com so I’m hopeful this will bring more discussion and more advocacy to pumping residents among the non pumpers among us.

Re: my own pumping journey - baby is 11 months and we have almost made it to a full year of exclusive breast milk due to the combination of ridiculous pumping sessions, learning to advocate for myself, a lot a lot of luck, and a pretty supportive work environment. Cant wait to celebrate his one year journey by temporarily retiring the Spectra. 

Lift Those Weights, Ladies (and Let Your Patients Know!)

Genmedmom here.

I am officially closer to 50 than 40, and it shows.

If I didn't hear it all the time from my patients, I would be complaining: "I'm exercising the same and eating the same, but I'm gaining weight... around my middle!"

Yup, it's that middle-age middle-gain. Horrified that this was happening to me, despite having lost fifty pounds after two AMA pregnancies and religiously maintaining a healthy diet and exercise routine for years, I decided to fight back.

How do Type A M.D.s fight back? The evidence, baby. I hit the books big-time. My reading and research into this area have led to a newfound passion: Lifestyle Medicine. Everything from my personal life to my primary care practice to my writing has been impacted. I've even got a book coming out in December.

Back to the battle of the bulge. I learned all about sarcopenia, a well-known physiologic phenomenon of age. We simply lose muscle mass as we get older-- and women basically hemorrhage muscle mass around menopause. As we all know, muscle burns calories just by existing. When we lose muscle, our metabolism plummets, and we gain fat. Hence, that perimenopausal pudge.

This process, left unchecked, can lead to sarcopenic obesity: high adiposity coupled with low muscle mass, which is often associated with a deceivingly normal body mass index. 

There's more to it, of course. Sarcopenia is bad for so many reasons. As one Cambridge University Press research review points out, "Sarcopenia, the age-associated loss of skeletal muscle, is a major concern in ageing populations and has been associated with metabolic impairment, cardiovascular disease risk factors, physical disability and mortality." 

I was thrilled to see this topic covered in wonderful detail by Jane Brody, writer for the New York Times, in this and this article. She provides a wonderful review of the literature and expert opinion, along with some good suggestions. As she correctly points out, "few practicing physicians alert their older patients to this condition and tell them how to slow or reverse what is otherwise an inevitable decline that can seriously impair their physical and emotional well-being and ability to carry out the tasks of daily life." It may be that few practicing physicians are fully aware of how big a deal this is. I wasn't!

A review in the Journal of Family Practice describes sarcopenia as a known major cause of debility and frailty, but highlights that it can be effectively prevented or treated with a healthy high-protein diet and resistance training. 

And it's true: when we gain muscle, our metabolism increases. The more muscle we gain, the more fat we lose (and we can even tolerate a little dietary indiscretion). There's endless benefits to toning that muscle: a stronger core prevents back pain and protects against back injuries. Increased strength prevents falls and protects from injuries if falls occur. Strength and mobility promotes the ability to manage ADLs and extends independent living. 

For all of these reasons, I've taken up a simple resistance training regimen. I have zero time to be consulting personal trainers (who here can make any appointments and keep them? Not me) so I created my own plan, including a few key pilates moves I learned over the years, and alot of basic exercises using a pair of five-pound barbells I've had since literally 2005. That's it. Sometimes I'm on a yoga mat, sometimes on my daughter's rug (it's the softest one in the house). This routine takes me all of ten minutes, but has yielded visible results in four weeks. 

On the days that I have no time, I at least drop and do ten planky-pushups, meaning I hold the plank position between pushups, and aim for ten. I sometimes do this right before bed, and typically, this move leads to a few other basic yoga stretches that really help ease me into sleep. 

When I counsel women my age, I usually advise that they seek the advice of a trainer. Some women are former athletes and know their way around the weight room, and need only be educated, and then they're off and running. For elderly folks, especially those with prior injuries or who are really very frail, I recommend the official guidance of a physical therapist, with specific goals like "increased core strengthening and balance exercises for falls prevention". 

I know there's physical therapists and physiatrists and orthopedic surgeons in this audience, and I welcome your input. What advice do you provide to patients around sarcopenia and sarcopenic obesity? What training regimen do you follow? Any tips appreciated! 



Photo by Cyril Saulnier on Unsplash

Residents Who Pump

How to succeed with pumping as a resident:

I am an intern in a busy internal medicine program. I try to pump several times a day. At first, it was very challenging for me to balance pumping and being an intern. I hope I can shed some light on how it can be done and let other moms know that that I once struggled with it too. It is part of who I am now, but it took a lot of commitment and preservence. I know not all mothers choose to pump and not all mothers can pump, and that’s great too! This is how I do it. I will first say that I have an incredibly supportive residency program. I hope that is the case for all mommas wanting to pump.

1. Make it known that you have to pump. Be upfront about it with the chief residents, senior residents and your co-interns. This way, people don’t wonder where you are. You’d be surprised how many people are supportive of your need to pump. And impressed!

2. Plan your day accordingly. I would make sure to get a session in before rounds, during lunch conference and once or twice in the pm depending on the length of the work day. It requires a lot of planning but think ahead! There have been times when rounds starts earlier than expected, but some time pumping is better than no time!

3. Have a system. Efficiency is key. A handsfree clip on bra helps! A tote bag with a cooler and ice pack helps! Find what works best for you.

4. Have a safe space. A designated pumping room with an outlet, sink, chair, table is what you need. Find a way to get the environment you need. If your facility does not have a lactation or expression room, they really should! It is required by law. Check out mamava.com if you want to help your hospital get a pumping pod.

5. Support at home. My husband helps out so much with washing my pumping bottles and preparing our baby’s bottles for daycare every night. I couldn’t do it without him.

6. Prioritize pumping. There will be times you think you’re too busy to pump. Do it anyways. Figure out a way. You’d be surprised how you can squeeze it in the workday. You’ll be so glad you did it.

7. Try your best not to skip sessions because it can mess up your supply, cause engorgement and even mastitis. This may not be true for everyone, but it was true for me. After I got mastitis from missing pumping sessions, I knew I had to be more diligent about pumping every 3-4 hours.

8. Massage/squeeze during pumping! This helps prevent clogged ducts and really increases the flow.

9. Drink lots of water and carry snacks. You have to be well hydrated and well fed for a good milk supply. Also rest is key! Good rest is hard for an intern but the more rested you are the better the milk supply!

10. Be so proud of yourself. It is a huge accomplishment to be able to pump and be an intern! Some days you’ll have a bigger supply than other days but keep going! You’re a rockstar for doing this and your healthy baby will thank you!

11. Nights can be particularly hard but doable. When I was working nights, I was so exhausted, mainly because I was unable to sleep more than a few hours during the days because I was still pumping every 3 hours. It was very hard, no other way to say it. I even got mastitis then. I was fortunately allowed 2 sick days so I could heal from my mastitis. In addition to taking antibiotics, my trusted lactation consultant advised me to just keep on pumping even if the output is low and as soon as I recover, the milk supply will pick back up. And she was right!

If you’re also a pumping resident, please comment and let me know your experience!

The myth (?) of flexibility

I had a job interview last week, in an odd surprising way, with the medical director of a local system of FQHC medical clinics in our town. It was surprising in that I was on a rotation providing medical care to homeless patients out in a park, working with one of the doctors in their practice (who, interestingly, is actually on staff as their street medicine attending, which is pretty cool!) -- and this attending came up to me, and asked if I wanted a job in their clinic system,

What did I say? "Oh, goodness, that's so kind of you. Umm."

Sometimes, I hear myself fulfilling a female stereotype and I want to punch myself in the metaphorical nuts.

Once I collect myself and act like maybe I deserve having a job, given that I'm a pretty good resident, a rising chief, and would actually be a great fit for their clinic, we make an appointment to discuss it in a meeting in his office later that week.

I agonize over what to wear. Is this a job interview? I'm also caring for homeless patients in the park that morning - it's 95F and 90% humidity. I wear a silk shirt, and by lunchtime, it's slick with sweat and stuck to my back. My curly hair is an untamed frizz ball, and I have to bike 4 miles to the clinic where his office is located. Suffice it to say, I look great.

We had a lovely conversation about what I think I could do for their practice (Adolescent methadone clinic! Expand their home visit program!), but when he asked what was important to me, all I could think about was flexibility.

Being a resident is one of the least flexible jobs I can imagine (though I've never been in the military, which is likely even more rigid). Your schedule is given out to you a year in advance, it's incredibly difficult to get out of shifts for your own illness (or your children's many illnesses), you don't get to choose your own vacations (which is hard for those of us whose partners are teachers, or with kids in school), and when you're there, you need to be 100% all of the time (which breastfeeding mom hasn't been paged for an urgent need while pumping?).

I dream sometimes about a job where I could work full time, but with flexibility - in fact, I've drawn inspiration from some of the schedules of writers on this blog, who have Tues/Thurs afternoons off (I could volunteer at preschool! I could go to the dentist!) or do fun volunteer work on Mondays all day, or get to (gasp) do some research working from home. I want to be productive, I want to be part of a million different things (I wouldn't be Med-Peds if I could make up my mind!), and I want to work full-time, but I'd like some agency over what that looks like.

To this, the medical director responded, "Well, we're open to being flexible. Lots of young mothers want to work part-time."

I'm frustrated that we live in a society where wanting to work ~50 hours/week is seen as wanting to work part time, or that not wanting to drive in during the middle of the night as an interventionalist means you aren't committed to medicine, or that if you have children you can't be a productive educator and researcher. And I'm frustrated that wanting to work part-time is a thing "young mothers" want - working part time sounds amazing, sometimes, and I have no judgment for moms that do it -- but couldn't dads be interested in that too?

I just want to not always be the first to drop my son at daycare and the last to pick him up. Is that inconsistent with being committed to working full time?

Bipolar

There is a patient that has been on my mind this year.

I was fired as her doctor.

I have had two patients fire me. The first was a sweet little old lady with mild cognitive impairment that wasn’t too cognitively impaired to realize I was moving in on her drivers license and switched to another clinic. She sent me a card though letting me know she switched clinics, wishing me the best and left me a teddy bear for my baby. The second one was much tougher. It was definitely the toughest initial OB visit I’ve ever had. I was in there over an hour. She was a mom with 9 kids at home and a partner who was controlling and emotionally abusive. She was late onset to prenatal care and came in maxing out the anxiety and depressive scales in the office. She was basically the sole caretaker of her kids, and worried constantly about things like if she passed out in the tub, who would take care of her kids? We talked a lot and luckily I had a no show following her. I thought we were developing a good rapport when she told me she had worked for 3 days straight without sleeping at a huge event downtown. On further discussion, I found she screened positive for possible bipolar disorder. I patted myself on the back for being a good primary care doc and sent her to psychiatry for further evaluation.

She missed her psychiatry appointment, but occasionally made it back to see me.

We left a lot of our appointments frustrated - most of her problems were so complex I wanted to refer her out multiple times, but she had trouble with transportation to our specialists and finding someone to watch the kids at those times, so they never happened. Every time she came into the office and we tried to fix one problem, three more would pop up. She was taking illicit prescription medications for chronic back pain and smoking marijuana, and was frustrated I wouldn’t prescribe her buprenorphine without a referral (our clinic wasn’t doing buprenorphine at the time) and I was frustrated she wouldn’t consider psychiatric medications for her fear of harming her baby, yet continued to smoke cigarettes, marijuana, and use the pain pills. She was frustrated at me because all I could offer was Tylenol and more referrals.

I bent over backwards for her. Our OB coordinator pulled strings so we could have 40 minute appointments together - which is something I have never done for any other patient. When she wouldn’t go to specialists, I would call them on the phone for recommendations. I was prepared to put her on lithium at one point with the guidance of a perinatal psychiatrist over the phone.

She fired me because she didn’t think I was doing anything for her chronic pain, and because I was always kicking her partner out of the room to ask if she was safe. She told our OB coordinator she didn’t care who delivered her baby as long as it wasn’t me. I found out later that she delivered at a different hospital system, and as far as our OB coordinator knew everything went well.

I was her doctor before I had my baby. Since then, I think of her every once in a while when I am overwhelmed by working and taking care of one little peanut with a supportive partner in the house. I think about our discussions of her working days on end without sleep - although that might go along  with a diagnosis of bipolar disorder, I also wonder if I was pathologizing her motherhood and what she had to do to support her family. I think about her inability to make appointments and her worries about what would happen to her children if she was gone. I think about what it must be like to have to choose to stay with a nasty partner who will provide at least some financial stability and a house for all your children versus turning to a system that will assuredly break your family apart in an attempt to provide safety and security.

I think of her often, and wish her the best.

Kicks

Recovery

After recovering from the the good kind of pain at the end of November last year, I developed the plain-old kind of pain that is in no way good: an intense, searing pain of a likely cervical radiculopathy that prompted me to go to the ER one fine December Saturday after leading a children's Nativity re-enactment rehearsal. My neurological symptoms were getting increasingly worse, as was the pain, despite stopping running completely for weeks, sparing my right side from any kind of lifting or serious use, taking around-the-clock high dose NSAIDs, and even wearing a lovely soft cervical collar for a week (fantastic way to garner sympathy and/or jokes from colleagues).

The ER physician assigned to me was an older man who showed absolutely zero empathy, compassion, or patience. You know when you can feel someone's impatience with your history-sharing, who just wants you to get to it? I told him I was a physician - not sure whether his bedside manner was because of that fact or in spite of it. I had plain films done showing cervical degenerative changes (I had never felt quite so old) and his plan for me was a) switch to naproxen from ibuprofen; b) reassurance that it would get better (delivered by someone without a compassionate approach, this felt tin-hollow); c) follow-up with PCP the next week. This felt like a wholly inadequate plan to me. I suggested a medrol dose pack which he agreed to.

The medrol dose pack was a temporary godsend. It worked within a day to drastically improve my pain. It was amazing! I felt almost normal again. Once the pack was done, though, the pain returned, in some ways worsened. Dealing with this pain - chronic, unclear end date - was humbling and deeply frustrating.

I have always thought of myself as a physically strong person. This has been part of my self-identity. On the playground, I used to win arm wrestling matches against boys. In high school, I was a cheerleader "base" and held girls' feet on my shoulders and bench-pressed them until my arms were extended. (If I did that now, I'm sure multiple discs would herniate simultaneously. Actually, maybe that's why my neck imaging looks the way it does.) This injury, occurring after no single traumatic moment upended that self-image. For awhile, during the worst of it, I cringed as my seven year old came in for a hug from my right side.

After a lot of physical therapy and time (probably most important), the pain lost its hard edge and now has settled to a stiffness and soreness that I don't always notice. A couple of months ago, I started running gingerly again, and a couple of weekends ago, I ran my first race in almost a year. It felt like it usually feels constitutionally-speaking: horrible during, fantastic afterwards, and I'm ready for the next one.

I'm grateful to be mostly recovered. I have new appreciation for those with chronic pain. And most importantly, I'm running again and feeling like myself.

Letting death in the room.

Taken by the author. Mukwonago, WI. Oct 2016.

One of the most heart-wrenching things I witness at work is people saying goodbye to their loved ones. Today I watched a husband say goodbye to his wife of 31 years, with their son also present at bedside, weeping as his mother died.

I stay in the room for all terminal extubations, along with the ICU nurse and the respiratory therapist. It's always an emotional thing to witness; I think we all find some kind of unspoken moral support in having each other present, besides the obvious practical needs to be there (RN to give meds, I provide orders/ explain things to the family/pronounce/ask for autopsy, RT weans ventilator and removes the endotracheal tube).

I stood in the room and watched the RN bolus morphine and midazolam...I watched the patient's respiratory rate. I watched her face for signs of struggle, her body for signs of stress. There were none, so we were ready to let her go. I gave the final "ok" to the RT to remove the woman's endotracheal tube, as I thought her respiratory rate and sedation level were adequate so that she would not struggle without the ventilator's assistance (pressure and oxygen). Her sats dropped to the 60s immediately once she was on room air, she developed circumoral cyanosis, and her heart rate was dropping. The medical staff all left the room so the family could alone be with her. She lived for about one hour after extubation, deeply sedated, and died without any struggle. I returned later to pronounce her death (1250) and obtain autopsy consent from her husband. He readily consented and said she would've been an organ donor, if her cancer hadn't prevented her from doing so. He asked "What will your team learn from doing an autopsy?" and I explained the top clinical questions that I thought could likely obtained only via autopsy.


In the moments before the medical team goes into a patient's room to do a terminal extubation, there's often a collective "let's do this" sobriety. As in "This is hard. But, we will do it, and we will do it well." And we do, our team always does. Unfortunately in an oncology/BMT ICU, we are all skilled at helping people die well. And at this point in my career, I'm skilled at that part of my job and proud of it. Not proud in a perverse way, but proud to be able to palliate symptoms of pain, anxiety, and breathlessness in one's last moments of life. Proud that I can help guide families through the emotional agony of watching their person die. Proud that the last images they see of their loved one are peaceful, quiet, calm, well-choreographed. Respectful. Clean. I am grateful that we have the ability to allow people to die without suffering, to serve our patients in this way, to calmly let death into the room after beating it back for so long with our various medications, procedures, life support. We spend hours trying to corral irrational forces (life and death) with rational means (science)--it's almost absurd at times.

But as we let the dying person leave the earth, as their suffering ends, the survivors' suffering begins. Their love wasn't free; now they grieve. All of this had me thinking this afternoon--about love. Whenever we love someone we do it knowing (somewhere in ourselves) that someday one of us will say goodbye to the other. It's an overwhelming thought to ponder for too long. You'd think this would hold us back sometimes, but no. We throw ourselves wholeheartedly into love--loving our partners, friends, children, pets...while knowing that it is all temporary and that this will hurt eventually. Talk about optimism! Humans crave love and connection, we cannot resist it (can we live without it?) even though we know that eventually it is 100% guaranteed to come crashing down around us. Every time.

5 months in - just breathe, just love!

5 months into being the mother of 2 little boys and I barely have time to breathe sometimes. I work as a Pediatrician but I had completely forgotten how very very very very very very (can I just type the word “very” for the rest of the post?!?) hard mothering a newborn is. Add to that some complications, a rambunctious, highly intelligent 6 ¾ year old, a husband 2 years into his tenure-track and 35-year-old bones and you have a recipe for fatigue that rivals the best of them.

5 months of cuddles. Of tears. Of such profound joy that it takes my breath away. For example, I remember the first time Zo told us how very much he loves his “baby bro” and how he’s his “best buddy”. Mothering for the second time has also been very humbling. When we found out that our little one was losing too much weight and could not exclusively breastfeed I felt like an utter failure. I KNOW how to breastfeed a baby after successfully doing it with our first and I thought if I powered through, me and Mau would get-it-done! But I had to come to terms with the fact that sometimes a mama’s body and a baby’s body just can’t power through, you just can’t will enough strength in his little low-birth-weight jaws to muster up enough energy to be a good breastfeeder. It took lots of letting go, lots of submitting to our reality. And y’all know I cry, a whole lot, so this made me weep and gnash my teeth like nothing else! But as I snuggle his now chubby little thighs, I remember the donor breast milk, the formula, the supplemental nursing system, the bottles, the reflux and I can smile. And it’s all okay even if it’s not what I envisioned.

So 5 months in, I know why my patients miss follow up appointments. Even with my father here with us almost full time I am inundated with Early Intervention, Cardiology, Ophthalmology, and other appointments. He’s perfectly and wonderfully made (took a while for me to be able to say this) but his little life requires a team for him to thrive. And thrive he is! We have all overcome so much and we have so much more to go. To all of the mamas out there in MiM land - wishing you and your babies so much love, health, and happiness. Even when mothering isn’t what you envisioned just remember that you and your baby were meant for each other. Learn all you can. Teach all you can. Be gentle with yourself and your baby.

5 months in. Inhale. Exhale. Smile. Inhale. Exhale. Smile. “The greatest thing you’ll ever learn is just to love and be loved in return” (Nat King Cole).

The Return Of The Resident

This isn’t the most elegant post, but I thought that I’d share some of my before and after thoughts about starting residency again after my six months at home with my little one. 

Pre-Rotation:

-I’m starting with a tough rotation. I want to get it over with, so I’m happy it’s first, but historically, it’s been my least favorite rotation of all. 

-I have a terrifying schedule, regardless of now having a baby at home to spend time with. How am I going to do this with extra sleep deprivation!?

-I think I’ll miss Baby Ticketyboo, but I feel that I’ll likely be too busy at work to dwell on it.

-Really skeptic that pumping at work will happen. But I really want it to. I put so much into making it this long breastfeeding, it would suck to have to stop now (no pun intended). Becoming attached to breastfeeding was not something I anticipated pre-baby. 

-I’m curious to see how Mr. Ticketyboo fares at home with Baby Ticketyboo (they’ll be home together for the next 6 months). 

Post-rotation:

-I’ve now been back for over a month. I finished my tough rotation, and I’m finishing up my second rotation, thankfully a bit lighter. 

-I’m so happy that the tough rotation is out of the way! Although the schedule was hectic, I had a better experience with this rotation this time, and worked with a good team. 

-The first day, I remember feeling strangely out of touch with clinical medicine. I understood all the medical lingo and my medical knowledge did come back quickly, but it all felt faraway initially. I still don’t feel 100% back in the groove and feel less confident than usual, but I’m getting back to normalcy

-Missing Baby Ticketyboo has not been too bad so far. He’s usually all smiles when I come home and not having my days dictated by baby fussiness and how well nap time goes is actually nice. We’ve not been successful in getting him to go to bed earlier than when we do (around 9 pm) and he still wakes up 1-2x overnight, so I’ve spent time with him everyday despite being back at work. I have been reticent to sleep train and move him to his own room because I’m worried about seeing him less when we do.

-I surprisingly don’t feel too tired during the day. Of course, my fatigue scale includes total exhaustion secondary to residency. For me, having a newborn was less tiring than residency. I actually came back from maternity leave with more energy than usual. I’ve so far maintained it to a certain extent. I’m still tired getting out of bed in the morning most days though. It’s discouraging to think that I’ll likely spend most of my working adult years feeling tired. 

-I haven’t been perfect about pumping, but I pump at least once per work day, ideally twice if I’m finishing around 5 pm and ideally three times if I’m finishing around 8 pm. Luckily, my supply has proven pretty robust, so we’re still EBF for now. I’d like to keep things going as long as possible. We’ll see, as I have some hectic call schedules in the upcoming months. I’m not too sold on the health benefits of EBF from 6-12 months and beyond, but I’d feel guilty stopping since it’s a source of comfort for Baby Ticketyboo, and if I stopped, my sole reason for stopping would be work. 

-Mr. Ticketyboo has been awesome at home with Baby Ticketyboo! It has been amazing to have a stay-at-home spouse while working. It meant a less stressful return to work for me, and it really helped us more equally share childcare responsibilities. Plus, there’s even more father-baby bonding now, which I feel is important for good family dynamics. 

So, overall, I’m surviving residency with a baby so far, and honestly enjoying it more with my little family to come home to. That said, I want the next few years of residency to fly by, but time with my little one to slow down. I'm so afraid of missing out on his best years.

Ode to my couch

Sometimes I think the most definitive memories I will have from this time period will come from my couch.

This is not my couch’s first life. It is secondhand from one of my aunts. We bought a house (our first house) after medical school and didn’t have a lot of time/money/interest to put toward new furniture, so we adopted this one. Her kids are now in high school and college, and give my aunt a lot of crap about selling the softest comfiest couch they’ve known for a better looking fancier one.

In our childless days, this is where my husband and I sat to play Nintendo games together with a dog in between us. We watched movies and ate Chinese food back before we had an active 9 month old who could reach  everything on the coffee table.

It is a perfect couch for post call naps with a dog at your feet. It is covered in soft fuzzy blankets thought to protect the couch from the dog but moreso add extra snuggle factor.

We brought baby home from the hospital at the first snowfall of the year. Our extended family was sick during Thanksgiving and as I was very hesitant to bring my baby near any germs under 2 months of age, so this is where our small little family sat with plates of takeout turkey and potatoes from a local cafe pretending to watch football but really all of us  intermittently napping. It is one of the favorite Thanksgivings I ever had because it was cozy and all about my own little family.

I spent the majority of my maternity leave on the couch with baby snuggles sleeping on my tummy. I either had a coffee or a book or would play my Nintendo switch over his head. The only time in my entire life I have ever completed a video game was the week I was post term pregnancy waiting for induction and they wouldn’t let me work and during my maternity leave. It is the snuggliest I have ever felt in my whole life with the snow falling outside and all the warmth inside.

Fast forwarding - baby is now 9 months old and more of a little boy than a baby each day. He is a great explorer and crawls and scoots himself around non stop. Our living room is our biggest room so it seems like all my free time is spent on this couch, watching him bang two toys together, only to find two different toys to start banging them together.

I’m post overnight call today. We have crawled and played. And Baby is napping in his crib and I am back on my couch. Time for a nap. The dog and blankets and couch are calling.

Kicks

Forty years and counting......

Random ponderings on turning forty........

• There is genuine sadness and mourning when a favorite piece of makeup is discontinued.......it has taken me years to perfect the “easy, 5-minute, naked-face” look. Now I have to start that one piece over again and it genuinely hurts me..... 
• Alternatives to having a kid: 1) purchase $12,500 worth of organic produce and just pile it up in your living room. Leave to rot. Periodically stomp through it wearing Peppa Pig rain boots and a set of PJ Masks jams. Sometimes pretend to clean it up with a set of tiny wooden cleaning tools. When it starts to smell, scream at your spouse that it is his or her fault that the mess is there. Then toss in an emphatic “you hurt me, you’re not my best friend anymore!!” when he/she denies it. 2) drive to a bank on a tiny pink tricycle with streamers, rob it using only the threat of violence with your ridiculously fast-growing finger- and toenails, then take the pile of cash you claw away from the teller and just light it on fire in the middle of your living room. Repeat monthly. At least 10,000 USD should equivocate the experience of parenting. 3) buy some clothes that you really love, but get them two sizes smaller than your fit. Then look at them hanging in your closet every day while you pull on big shapeless scrubs, or Lycra yoga pants stained with unknown substances and with a forgotten mermaid sticker on the bum. Tell yourself that someday you will wear those again, but know that you won’t. In fact, you never did. Also, download an audio file of Honey Boo Boo complaining about a lack of syrup on her hot dogs and play that on an endless loop in the background. You know, just to sharpen your mind. 
• There are many trade-offs for waiting until later in life and marriage to have a kid. For example, with the presumed extra patience afforded by years of taking so much crap from the external world comes creaky, swollen and painful joints, stretching to their limits with every game of “pretend to be a floor worm with me!” or kneeling on the bathroom floor next to the bathtub, eating invisible cake slices out of bathtub toys with all of her rubber duck friends. But, when your kid makes you some fake strawberry shortcake out of a washcloth and some Paw Patrol purple body wash and hands it to you in a plastic cup with a star-shaped hole in the bottom, you eat that shit. Heck, I’m just happy to be invited to the party. 
• Alone time is the greatest gift the universe has to bestow upon me. There is never enough of it, and it nourishes my soul for when it gets people-y out there. The kid gets the majority of my energy, followed by job and hubs, mostly in equal proportions. Regeneration time is critical, and I’m learning to not feel guilty about it. 
• The more that I age, the more that I learn to stand up for myself and what I believe in a more fierce and unapologetic way. Being told how to use my voice by any number of different people with different agendas and issues is becoming harder to stomach. I genuinely appreciate differing opinions and polite discourse (the more animated, the better!), but when people try to strong-arm their issues and life views on me with tone-policing and gaslighting, well, Iam done sitting back and taking it, especially in my own personal space. I’m too old for that noise.
• Work-life balance is impossible (at least for me). It’s never balanced. One thing is always outweighing something else. It’s more about trying to keep my head above water, occasionally being really good at one thing or another, oftentimes just getting by, and hopefully not letting anybody die on my watch. There is also reminding myself that most of the time, the job I’m doing is good enough, and I’m learning to be okay with that. Being a doctor isn’t for the weak of heart. And being a mom isn’t for the weak of head. Sometimes my heart prevails in medicine and I cry. Sometimes my head prevails in parenting and I cry. It’s all so, so hard. But also pretty badass and (mostly) rewarding. And being a wife is a delicate and ever-moving target of balancing head and heart. Sometimes this is the hardest job, loving the one you’re with and nurturing that commitment. 
•  My husband and I have had an awful lot of loss in recent years, to include both of my parents, and his mother. Raising our daughter without these loved ancestors has brought on a lot of pain in such unexpected moments. She never got to meet them, and yet we see each of them in her nearly every day. Nature is a remarkable thing, perpetuating itself in this way. I wasn’t sure that I wanted to do this whole parenting thing for a myriad of reasons, but catching glimpses of my mom and dad again every now and again in my daughter’s face or voice is about as spiritual as it gets for me. I embrace this fully. 
• I’m truly happy to see forty, and I hope to have sixty more. I do love this life, including the joy, the pain, the humor, the tears, the angst, the stress, the happiness, the closeness and the love. Each new day is not guaranteed. The first forty (wow!) have been pretty damn good. Looking forward to what comes next.......

Slime and Slides and Sutures and Fireworks

Since I'm a resident and my husband works full time, our kids are in full time camp this summer. Which has worked great. The availability of pre-care and after care in a fun environment without the bustle of the school year has allowed us to let go of our nanny for the summer and just be us. Which has been exhausting, but surprisingly really rewarding.

However, without that extra piece of our childcare puzzle, days like July 4th posed a conundrum. My husband works all holidays for the overtime pay and I had conference in the morning and a swing/evening shift. And no camp.

So, come the morning of July 4th, my Monkey (4) and Chicken (6) got to experience an EM conference. Set up with ipads, snacks, markers, crayons, peppa pig figurines, and donuts. They lasted for almost half way through, but finally got antsy that the little "bring kids to work day" experience ended 3 hours in.

As a reward for being great sports, I promised them that we could make slime when we got home. I hate slime. It's sticky and slimy and is a sensory overload of amorphous blob. But it's all the rage this summer and my daughter's "best wish," so slime experiments it was. After trecking to Target to buy all the necessary ingredients, and a cart full of not-on-the-list other Target "necessities," we made 3 kinds of slime. 2 were successful. One was so gross and mushy and was such an utter fail. Not sure how Pinterest parents do it- this was  hard and messy work!

At 5:30, my husband came home and we switched shifts. I went to work and he manned the barbeque and firework portion of the day's festivities. While I experienced the rest of the night vicariously with videos watched later, hours after they were sleeping, I smiled at the dichotomy of my life as a resident. At our lives during this residency. So thankful my I have an awesome flexible co-parent and that my kids get to learn the importance of hard work, while having all the same fun as well.

One of the unique parts of going into EM is the variety of work hours. Yes, I work a lot of nights and weekends and holidays, but I also get to be home a lot in the mornings, early weeknights, and  random Tuesday afternoons. Hopefully, I continue to enjoy it as much as I have this first year!


For reference, here were the winning slime recipes: (adapted from links from littlebinsforlittlehands.com)

Basic Slime (from
Ingredients: Elmer's Glue, saline solution (Target Brand - any saline with boric acid and Sodium Borate), water, baking soda, food coloring

Recipe:
Mix 1/2 cup glue and 1/2 cup water. Stir until well mixed
Then add food coloring and/or glitter
Stir together
Add 1/2 tsp baking soda and 3 Tablespoons saline solution. Mix REALLY FAST.
Keep mixing, then kneading, until you get the consistency you want.

Tip: hands get messy so wear gloves or be sure to wash them after to prevent staining from food coloring.

Fluffy Slime:
Ingredients: Elmer glue, shaving foam (old fashioned barber shaving foam. Gel doesn't work- we had better luck in the men shaving section), saline solution, water, (if you want)

Mix 1/2 cup glue and 1/2 - 1 cup of shaving foam (depends on how fluffy you want it- we played around so didn't measure exactly). Add color/glitter.
Then add about 5 TBS of saline solution. We added a bit of water to make it more workable, but experiment.
Mix/Stir/Knead together. This one is SUPER STICKY and very stringy and messy. So be aware.

Enjoy!

Hello from LlamaMama

Hello MIM!

LlamaMama here. I'm an MS4 going into Pediatrics, wife of my college sweetheart, and proud mama of an energetic 1-year-old (how did that happen?!?!) boy. I've been reading this blog ever since I was thinking about becoming a mother in medicine. I've always known that I wanted to work in a health-related field, but a bad case of imposter syndrome, coupled with worries about work-life-balance kept me from pursuing a medical career for far too long. There were no physicians in my family, and most of the women had given up their career ambitions to focus on their families, which made this career decision that much more intimidating. MIM was the first space where I found women honestly sharing about their joys and struggles in prioritizing their medical careers and their families. In the last few years, I've found lots of awesome women physician mentors, in addition to continuing to follow this blog. I'm so excited to join the list of regular contributors!

A little bit more about me: I grew up in a few different countries, and am now married to a wonderful man who also grew up in multiple countries, so when we do get free time, we love to travel (we've already taken the baby on two international trips and several cross-country!). I love to cook and eat delicious food, and I'm working on finding an exercise routine that I enjoy enough to do consistently. I am a social introvert, figuring out how to balance deepening relationships with my husband, son and close friends while still making time to re-charge alone. I look forward to sharing my joys and struggles with you all.  

I forgot to worry about that!

Hi! So excited to join this sisterhood. I am a pediatric hospitalist at a mid-sized children’s hospital. I am blessed with 3 amazing children and a supportive, talented husband who is thankfully not in medicine but rather works during normal human hours.

I am pregnant with my fourth child. I have had 3 normal, healthy pregnancies and delivered 3 healthy, full term babies. I was apprehensively hoping for the same this time around. No such luck; at my routine anatomy scan, I was suspected to have placenta accreta. For those of you who don’t remember from medical school, here’s a crash course. Normally the placenta adheres loosely to the uterine wall, and is able to detach easily following delivery. With placenta accreta, the placenta adheres to the uterus pathologically. It invades inward, doesn’t separate spontaneously after delivery, and can cause massive hemorrhage if manual separation is attempted. Most patients who have placenta accreta require a life-saving hysterectomy. There are 3 subtypes: in a standard accreta, the placenta simply attaches too deeply to the uterine wall; in placenta increta, it invades into the myometrium; and in placenta percreta, it invades through the myometrium and serosa, and occasionally into surrounding structures and organs (most commonly the bladder, but any organ in the vicinity is potentially at risk).

I immediately transferred care to the placenta accreta referral center in the nearest big city. Within 2 weeks I had an appointment and within 2 minutes of meeting my MFM she told me I was a “hot mess.” I have placenta percreta. Go big or go home. (I think I want to go home.)

People comment on how “well I’m taking it.” How “strong” and “resilient” I am. “You look great; you don’t even seem worried,” people tell me. I don’t seem worried? That’s cool. Because I am worried. I’m worried about a lot of things. In fact, here is a list of things I’m worried about.

• The very complicated cesarean delivery, complete with a hysterectomy. I will be on the table for about 6 hours, and there will be various surgical teams parading in and out of the OR.
• Intraoperative blood loss, with potential for massive hemorrhage. I will almost certainly require multiple blood transfusions, and if things go particularly badly “massive transfusion protocol” will be initiated, which puts me at risk for complications including fluid shifts, electrolyte derangements, DIC and ARDS, to name a few.
• Damage to surrounding structures, including but not limited to my genitourinary tract. That placenta is freaking close to my bladder, people.
• Let’s just put this out there: death. There is in fact a 7% mortality rate for cases like mine. Even in the major centers, even if the operative teams are prepared.
• Oh, and the baby. In order to reduce the risk of these complications, the baby will need to be delivered preterm. And not late-preterm. Preterm preterm. Like a preterm baby who is at risk for sepsis, IVH, chronic lung disease, NEC, and all the other preemie ailments.
• And the more minor things too. That pesky surgical incision that will extend vertically from my pubis up to my xiphoid. Recovering from this surgery, which will render me essentially nonfunctional at home. The possibility that breastfeeding may not go well, and may not be possible at all. The fear that this pregnancy may become even more complicated, and I may need to deliver even earlier than planned. The fact that I don’t have enough paid time off, and I will need to take unpaid leave for several weeks, something that I’m not sure we can handle financially. The loss of my fertility, completely and forever.

But life goes on. Thankfully the baby is fine and the pregnancy is otherwise healthy, so there’s not much to do between now and delivery. So I get dressed, get in my car, and go to work. I take care of sick patients, supervise residents, and teach medical students. And on nights in the hospital when things are slow I work on my mandatory compliance modules. Every year we are obligated to do like 40 of them. They range from mildly clinically interesting (preventing central line infections, reporting suspected child abuse) to stiffly corporate (anti-kickback statutes, reminders not to commit fraud) to downright irrelevant and time-wasting.

One night on call I had some free time so I decided to bang out a few modules. I was up to “Preventing Operating Room Fires.” Groan. This one was not only completely irrelevant (I wasn’t even allowed in the ORs! Not even to, say, do an LP on a sedated child!) but it was an 18-minute-long video. As I started watching the video, I froze. I realized that even though I wasn’t allowed in the OR as a doctor, I was about to be in one as a patient. And I slowly but suddenly wondered: WHAT IF THERE IS A FIRE IN THE OR??? THIS COULD TOTALLY HAPPEN TO ME! And it dawned on me, that with all the things I was worrying about – the massive blood transfusions, the damage to my genitourinary tract, the 7% mortality rate, the preemie baby – there could ALSO be an OR fire and I FORGOT TO WORRY ABOUT THAT! How could I forget to worry about something that had a nonzero chance of happening and could have devastating consequences? I didn’t sleep for the next 3 nights.

I remember my last night on call before delivering my youngest child. I was 38 weeks along and healthy. One of the patients I admitted was a 4-month-old infant. She had had corrective surgery to repair anorectal atresia with a rectovestibular fistula and needed to be monitored post-op. As I took the history from her parents and discovered that they did not know about this condition until after she was born, I remember having a similar realization: I had been worrying about all the usual things – prematurity, infection, birth hypoxia. But anorectal atresia with rectovestibular fistula? I had completely forgotten to worry about that!

Worry is a funny thing. Psychologists postulate that worry is beneficial insofar as it helps people do the things they need to do to keep themselves safe. Studies have shown that people who worry about skin cancer are more vigilant about applying sunscreen than those who don’t. But I already transferred to the regional center and am compliant with my prenatal care, all the things I need to do to optimize my chances for a good medical outcome. At this point most psychologists would agree that worrying won’t do me any good. It doesn’t help anything. But that doesn’t stop me.

A few friends jokingly suggested that I focus all my energy on worrying about that potential OR fire and not bother worrying about anything else. It’s not a terrible idea.

Summer reflections

Hello! My name is Michelle and I am brand new to the world of blogging (so be gentle with me). I am a Mom to two energetic boys who keep me on my toes. I also spend the rest of my time taking care of other people’s kids as a pediatrician.

Since we are now knee deep into summer (I don’t know about you but it feels like school just let out and already we are starting back to school shopping!!) I was reflecting on our busy summer days and how they are different then the laid back lazy summer days of my youth. Summers are a funny time when you are a working Mom. It starts a few weeks before school lets out when Moms start speaking of how they are looking forward to lazy days and all the fun summer projects they are going to accomplish. I often feel envious of the stay at home Mom’s summer. (And this is not meant to spark the stay at home vs working Mom debate. We are all valuable in what we do - we are all good people doing good things.) What I mean is I have a longing for lazy days with no schedule and no commitments. The ability to lounge in pajamas all day if that’s what we choose to do. I see facebook posts of cute kids with bed hair and pjs captioned ‘just woke up’ at 10 a.m. and I sigh. I hear my patients tell me that they are getting ready to go away for the summer and think ‘what is it like to take 6 weeks off’ and I sigh. I talk to other Moms and listen to them tell of putting their kids in day camps for a week to break up the boredom of their carefree summer days and I sigh. The fact is in my family our summers look a whole lot like our school year does. Summer camp is not a boredom buster for us but a requirement for our two working parent family. We still get up at the same time and leave the house at the same time to get to summer camp everyday. I still try to get them in bed at a reasonable time at night while allowing for some ‘it’s summer can we stay up late’ requests. Aside from not having homework to do and after school activities we have the same rhythm to most our days. And at times that is a great thing - because my kids do thrive on a schedule (and really so do I) But there are many moments that I long for the lazy days of my summer. When I was a kid we didn’t have summer camps and scheduled activities. We woke up whenever we wanted to and watched way too much TV and swam most of the day. We rode our bikes back and forth from my Grandma’s house where she would make us grilled cheese sandwiches and let us eat popsicles in the hot sun. I wonder sometimes if my kids are missing out on that and wonder how I can get that for them. Which is ultimately ironic because I work hard to make a better life for my children and now I contemplate a life not working to give them a more schedule free life. I know this is my own internal debate because my kids are having the time of their lives - they are doing Hogwarts camp and Lego camp and all sorts of fun things. I hear no complaints from them at all. I do worry about their need to be on the go all the time and wonder if that is a byproduct of our scheduled life. My oldest, especially, has a hard time when there is no plan for the day and has a hard time with unscheduled down time (which of course as a parent is the thing of my dreams!) So I worry - as we all do - about making the right choices knowing all along that the choices we make are often not in our control at all. But I still can daydream and live vicariously through those stay at home Moms leaving with their kids for their long lazy summers on the lake and think ‘maybe someday’.