Code Indigo

The season's first snow is falling. It's raw and grey outside the hospital. Inside, Ella Fitzgerald croons a languid "White Christmas" from the internet radio station. We're wrapping up at the O.R. desk after an uneventful morning case.

"Attention all personnel. Attention all personnel. Code Indigo, third floor. Code Indigo, third floor."

I look at the nurses. "Indigo? Which one's that one again?"

Every hospital has coded security alerts for unusual events - emergency room on diversion, airway crisis or cardiac arrest, infant abduction, bomb threat, unruly patient or family member, etc. I don't recall having heard a Code Indigo* recently.

"Missing patient," says one of the nurses.

"Probably just went out for a smoke," says another.

I go to do post-op rounds. The all-clear sounds overhead for the Code Indigo. But when I get to the post-partum ward, a nurse there tells me as I leaf through a patient's chart, "Don't bother. You won't find that patient."

"Breast-feeding class?"

"No. Just gone. That was the Code Indigo."

"Oh! I thought I heard an all-clear a while back."

"Yeah, because the patient's definitively gone. Baby's still here, though. Wanna see?"

She lifts a swaddled bundle of warm, sleepy perfection out of a bassinette. The baby starts drinking formula from a small bottle the nurse is holding.

I start to think of another baby, a patient I had had to discharge to a foster parent during my internship. The baby had been hospitalized with bilateral spiral femur fractures. Yet every time I approached his crib to examine him, his face would light up with a bright smile that held nothing but joy. After I turned him over to foster care, I went into the call room, called my husband, and sobbed on the phone to him, utterly disconsolate.

My mind starts churning around my current situation, trying to figure out if there's some way we could take care of this baby ourselves. But of course we're not at all prepared for a decision like that right now; all I can do is call the social worker and make sure she's on top of what needs to be done to get this child into a suitable pre-adoptive home. It seems like such a small, ineffective measure to take.

The snow has turned into something a little wetter and clumpier. It's dark by midafternoon on days like this. I've turned on a mix of Christmas music - a little Nutcracker, some Kathleen Battle, a little Boston Pops and Leroy Anderson. I go back up to the nursery to hold the baby. The nurses welcome the break.

"Here, Dr. T - have a seat right here."

The baby sleeps in my arms. His cheeks bulge out like rosy little fruits. He is totally at peace. He has no idea that either nobody loves him at all, or someone loves him so much that she felt she had to set him free. He is blissfully unaware that he is alone in the world. Abandoned.

"At least she didn't try to flush him down the toilet, like the kid we got last week."

Thank heaven for small blessings.

Advent starts today: the liturgical prelude to the Christmas season, and the new beginning of the liturgical year. There's something in the baby's given name that conjures up images of light. Light, on this grey, darkening day.

"The people who walked in darkness have seen a great light." I wish, I wish, I wish.

I start humming the baby a lullaby. My favorite song of the season, half ancient chant, half carol for a newborn.

O Come, O Come Emmanuel
and ransom captive Israel
that mourns in lonely exile here
until the Son of God appear.
Rejoice! Rejoice -
Emmanuel shall come to thee,
O Israel.

I hope this baby gets his Christmas wish, the wish all babies are born with: a wish for love, for a life that matters, and for a world of hope to be cradled in.


*(Not the actual alert used.)
Cross-posted at Notes of an Anesthesioboist.

Round 3

I am a Mom of 2 kids and now soon to be 3....yes, I know it's crazy but despite the tough balancing act, my children are the best thing that has happened to me so we have decided to add one more.

It's been very interesting sharing the news of my pregnancy with colleagues, family and friends. The response I get is different for this third pregnancy.

With my first pregnancy, people were generally very excited for me. I was embarking into the world of parenting and people congratulated the decision and celebrated the novelty with me. I got lots of advice on how to manage the pregnancy and what to savour BEFORE the kids come.

With my second pregnancy, people seemed to react as though it was the natural next step. It was more a 'matter of fact' and parents with multiple children shared parenting advice on how to cope with the extra chaos.

With the third pregnancy, I find that the reactions depend on personal situations:

Those who are not yet married, or married without children, think I'm crazy to go for a third (they just can't relate);

Those with three children of their own celebrate the news and reassure me that life will just get better;

Those with two children (young and old) all recount to me how they came to the decision NOT to have a third, as if my news has made them revisit their decision;

And those with only one child feel the need to explain why they haven't yet had a second!

Ironically, even my husband has found the same trend in responses.

Regardless, we are absolutely thrilled and praying for a healthy pregnancy and baby and eager to hear any advice on going from 2 to 3!

Happy Thanksgiving!

A Lesson for Youngest - and his mom

I'm often asked to speak at support group meetings for the various conditions I see in my practice. I try to go to as many of these as I can; it's a great way to meet with individuals on an informal basis. Many of these patients don't have much insight or knowledge about their condition (or worse, have a skewed picture of the future based on misinformation), and I hope I can change some of that in the time I spend with them. As could be expected, in my attempts to balance work and home, I occasionally run across some problems with time constraints. This happened a few months ago. I had promised a group that I would meet with them, but the week became filled with mandatory department conferences and other events which kept me away from home, so on the evening I was scheduled with the support group I was greeted with a chorus of "You're going where? Why can't you stay here for a night?" In a desperate attempt to spend some time with my boys, I asked them if they wanted to come with me. Eldest declined with a bit of a sneer, but Youngest jumped up with enthusiasm. His question, though, gave me a bit of cause for concern: "Can I bring my GameBoy?"

As we pulled into the parking lot of the church where the meeting was being held we could see a steady stream of cars pulling up to the entrance. We parked in a far corner of the parking lot and while we walked to the building we watched people in wheelchairs and using walkers approaching the doorway and struggling to get through. As we got closer, I suggested that Youngest might want to hold the door for some of the people we saw. He looked at me sideways, but then ran ahead. I could hear him talking to a couple wrestling with the door (which didn't have any modifications for people with disabilities); then with a smile, he opened the door as wide as he could so that the husband could push his wife through. After he assisted a few more individuals it was time for the meeting to start.

Before I knew it, Youngest was talking with the facilitator of the group and passing around cookies and punch to the members there. He sat quietly while I spoke to the group and answered questions without bringing out his electronic toy once. As the evening was winding down, I was approached by a woman who had been sitting quietly in the back. It was obviously difficult for her to move forward, even with the rolling walker she was using. Watching Youngest's face, it was apparent that he felt removed from this group. I could almost read his thoughts, "Poor folks; too bad they contracted this disease. Thank God it will never happen to me." The woman thanked me for the information I had provided, and the enthusiasm and encouragement she felt I had brought to the group. And then she said, "You know, I've been battling this since I was 16 years old. I never thought I'd be around this long." Youngest's mouth dropped wide open at this point - with just a few words, this woman had made him realize that none of us are immune to whatever it is that our futures hold. Before I could say anything, Youngest had moved next to the woman and said, "I'm so sorry to hear that. May I give you a hug?" While I answered questions for another person in the group, I could see Youngest speaking softly with the woman.

Afterwards, he and I helped the facilitator clean up the napkins and cups. Youngest didn't say anything while he gathered up debris and placed it in the trash can. As we began to walk through the now-quiet parking lot toward our car I said, "I'm proud of you. I think you did a very nice thing tonight."

His response was typical pre-teen. "WhatEVER, Mom. Race you to the car!"

I wasn't sure how much of that evening Youngest retained, or what an impact it had made upon him until recently. As we were talking about the upcoming Thanksgiving holiday, Youngest suddenly blurted out, "I guess we can all be thankful that we're healthy, right?"

Right, son. And I'm thankful for lessons that are learned without trying.

And to all of you - I wish you a healthy, happy Thanksgiving (and quick healing to you, Happy Mom).

A

Seriously, I wanna know...

What are your plans for Thanksgiving? Do you cook the turkey, stuffing, potatos, greenbean casserole or do you eat nontraditional fare? Have you tried a prepared dinner from a grocery store?

I could never be a pediatrician...

When I was first starting med school, I was Peds Girl. I was joined the Peds Club, I helped organize Peds Playroom in the hospital, and I loved kids. I was fiercely insistent on my future career choice.

Professor (who was also an orthopedic surgeon): "So what field do YOU want to do?"

Me: "Pediatrics."

Prof: "Christ, what a waste. You may as well become a veterinarian."

Me: "Um."

Prof: "You know you won't make any money in general peds."

Me: "I may specialize in pediatric endocrinology."

Prof: "They make even LESS."

Actually, I think if you do pediatric endocrinology, instead of getting a paycheck, they remove money from your bank account each month. So you really have to love it.

In planning my third year schedule, I took peds as my third rotation. If there's a specialty you think you really want to do, you're supposed to do it third. That way, you can decide early on if it's really for you, but it's not so early in the year that you're still a bumbling idiot.

Long story short, I'm not a pediatrician. I could say I hated the parents or that I had trouble looking in tiny ears, but really, it was that I couldn't deal with the sick kids... I mean, the REALLY sick kids. There was nothing more heartbreaking to me than an ill child. Even reading a fictional clinical vignette about a child with cancer ruined my day. It didn't matter to me that I was helping them or even saving their lives... I just couldn't bear it.

And now that I have a child, I am doubly glad that I made this decision. Every time I pass the peds floor in the hospital and hear children crying, I think of my daughter and my heart aches. Maybe I would have grown accustomed to it. I don't know. I'm grateful other doctors are able to distance themselves enough that they can do this kind of work.

Luckily, sick adults don't make me nearly as sad.

Extending the invitation

After Thanksgiving Dinner last year, my husband and I decided we would henceforth make an effort to invite people over who may not have family or friends nearby to spend the holiday with. Our house was feeling so warm and festive, dinner was so lovely, and it seemed a shame that we didn't have more people over to share it with. A new family tradition. One that I wanted my children to grow up with.

I can't believe I almost forgot about this.

So, today, I started to think of who I should ask. How does one go about inviting someone over? I didn't want to make someone feel self-conscious about it, like, Hey, since you seem like you have no friends or family...

I decided to start with a general probe. I asked a co-worker whether she had family in the area. (Yes) Great! Back to the drawing board.

Driving home, I thought of one of my residents. The more I thought of him, the more I thought he might really appreciate an invitation. I impulsively called him. "Hey, do you have plans for Thanksgiving?"

"Why do you ask?"

It turned out well. He said he really appreciated the invitation and he'd get back to me. He also asked whether this could extend to some of his colleagues. "Sure," I said. Smiling.

I hung up and felt the most amazing rush of, well, euphoria. The thought of opening our home to residents who might otherwise be alone on Thanksgiving filled me with immense joy. I'm hoping, hoping that we'll have extra guests at the table on Thursday. And even if they don't come, this feeling of just extending the invitation is pretty awesome.

Pay it Forward

There’s been some sadness at our house recently. To be perfectly honest, the holidays have been the last thing on my mind. Wallowing a little too much in self pity, has become a hobby over the last week or two…. but today was different.

I had a great day.

The morning office went surprisingly smooth. I escaped for lunch to meet my husband and son at Cracker Barrel. This is quite a treat, I rarely get a full lunch hour, rarer still to get to leave the hospital. We had a pleasant lunch. Boy Genius was thrilled to get pancakes for lunch (husband also ate “second breakfast”). As we finished eating, I noticed that a few tables over was a lady sitting alone. Shortly there after, she came over to our table and with a huge smile handed my son a crisp one dollar bill and said “Happy Thanksgiving.” She then proceeded to take a our check and say “I’m going to take care of your lunch, and Yall have a blessed day!”

I was quite flabbergasted. I tried to protest, but she gave me a motherly “don’t even think about it “look. So we simply said “ thanks” as she walked away.

Her random kindness invigorated my spirit. I’ve spent the whole rest of the afternoon thinking of ways I could pass on blessings to others.

This may seem like a cheesy e-mail spam story… but I promise it happened to me today. My sadness is still there, but the self pity is gone and replaced with the reminder that this is the season to be thankful of our blessings and look for every way we can to bless others.

Twisted for Twilight

As an avid reader, I pick and choose across the genres of fiction and nonfiction. I am an equal opportunity consumer of the printed page. When looking up my member card at Barnes and Nobles, the cashier says "Oh, I see you come here often." Basically I'm looking for a good story - the kind that is hard to put down, will make me schedule my lunch hour in a quiet location just to get through a couple of chapters. Now as I write blog posts and dabble in fiction, I find myself asking what makes a good story.

Can't tell you what made me pick up Twilight. Maybe it's the buzz about the movie that I've read on other blogs. Maybe it's that desire to have a reading feeding frenzy. Stephanie Meyer hooked me - through all four books and the trials of Bella and Edward. Couldn't put them down until I finished them all. Went back to Barnes and Nobles on a Sunday night to buy the third and fourth because I couldn't wait for USPS to bring my Amazon delivery. Emersed in this world of "vegetarian" vampires, I find myself having philosophical discussions about the books with my teen patients.

Now the movie is coming out this weekend, and I'm trying to figure out how to get my boys to go see it with me. Movies are a shared passion between my two sons and myself. Husband bows out graciously whenever we go because he says he can nap for free at home. Sometimes finding common ground between the three of us is tough. The oldest likes action, noise, and can follow the twists and turns of plots well. The younger (age seven) son still likes animated films, but doesn't do scary well. I like a clever plot with not too much violence. So I'm thinking that I can sell this movie to my kids as kind of action-adventure and still get my romantic, girly fix.

Trying to explain this preoccupation with high school vampires eludes me. Is it the classic girl meets boy story? Is it the element of danger in Bella's longing for a vampire boyfriend with pulsing teenage hormones? Is it the pace? In my second reading of the first book, I tried to look at the writing from the perspective of a writer. The words are not complicated, and the storyline is kind of predictable. Still, I'm hooked.

Voice

I used to have a lovely voice. I thought so, at least.

On Facebook, many friends I meet again from my high school and college days ask if I'm still singing.

Well, yes.

"What's gonna work? TEAMWORK!" (I loves me some Wonder Pets).

And let's not forget the Mail Song from Blue's Clues.

But here's the kicker. Son doesn't appreciate my musical stylings. He actually shushes me when I sing along. I'm crushed.

I thought myself brilliant once. But I'd take the role of mama over broadway star any day.

How to get a part-time job in medicine

I got married near the end of my last year of residency. When I started medical school, in fact when I started residency, I hadn't yet even met my husband, and I didn't have any of the 3 kids I now have. That's probably a good thing because I would surely have talked myself out of the specialty I really loved into something more "family-friendly". There's nothing wrong with family-friendly, mind you. I always read the classified ads in the New England Journal just out of curiosity, wondering whether there are more part-time jobs cropping up as women, who more often work part-time than men in general, represent a greater share of young doctors. So far, I don't think much has changed in the job advertising sphere.

When I happen to have a bad day at work, which is fortunately rare, I permit myself to back up and take a different fork in the road. In my alternate life, maybe I became a dermatologist, where "full-time" seems to be 4 days a week...but who works full-time anyway? Or infectious diseases, where every other ad seems to start "Full-time or part-time". Ah, travel clinic...seeing some healthy people and getting them ready to travel to exotic locales. Lest fear of boredom be a factor, keep in mind that the occasional traveler will come home with a fever of 40.8--is it malaria? Dengue fever? Ebola? See, that would spice things up. And clinic finishes at 3p.

But snap out of it. I became a medical oncologist, had my first baby midway through my second year of fellowship, another baby at the end of my third year, and a third baby about a year and a half into my first "real job". At some point in late second year when other fellows were beginning to do their job talks and interviews, it dawned on me that I didn't want to be away from my son and his future sibs for 60 hours a week. I didn't want to miss first steps or first words or first anythings. It didn't feel right to me that someone other than me--indeed, someone I hadn't even met yet--would be there for more of my kids' waking hours than I would, and that's exactly what working full-time meant.

I starting looking through journals, online, anywhere for part-time medical oncologist jobs. Zip. Zero. Nada. I even tried monster.com, and all I got for combining "part-time" and "oncologist" is: Busy oncologist seeks part-time front office staff. Bummer. Oh, and did I mention that I had kind of subspecialized to one particular type of cancer. And can't move out of the area because my husband is in the military, unless they tell us to move, in which case I have to pick up and leave instantly. When I told people that I wanted to work part-time, and no I didn't want to just take a hospitalist job, and no I didn't want to work in an urgent care, and no I didn't want to review charts for utilization management or do life insurance physicals for a living, and yes, I did plan to work as a doctor, and yes, I did plan to work as an oncologist, and yes, it had to be in this area, they just looked at me with some blend of pity, empathy, disbelief, disdain, and said, "Well...good luck."

Six months later, I was agonizing over my choices: one job working 3 days per week as an academic oncologist, one job in private practice oncology working 2-3 days per week, and one job in oncology public health/health policy working anywhere from 2-4 days per week. All of them were within 30 mins of my house. All of them were in the particular subspecialty of medical oncology that was my interest. None of them was advertised. None of them existed when I interviewed. So, what's the deal?

If you happen to fall in love with a specialty of medicine that doesn't bear the family-friendly label, here are your career choices at the end of your training, assuming you aren't willing to compromise on the family side:

1. Let this specialty be the one that got away and pick something that's more family-friendly.
2. Train in your specialty, but work in a more general field with your specialty as your area of expertise (e.g. take a part-time internist job with an interest in pulmonary disease--a big group private or academic practice may be glad to have one internist who likes to see all of the asthma and COPD folks, there are plenty of them, and is comfortable with critical care if patients get admitted to an ICU).
3. Move beyond the standard black or white career paths--academic or private practice--and look at jobs in the government (FDA, NIH, CDC, etc), public health, the pharmaceutical industry, hospices, and so on, many of which are more amenable to part-time employees.
4. Interview for your dream job, whether academic or private practice or whatever, and give them enough time to decide you are their dream candidate. When they start trying to recruit, play your part-time card. Most will use salary or benefits to try to sweeten the deal. What you want is flexibility or fewer hours or whatever it is that you want. Take a deep breath, picture your kids clinging to your leg as you try to leave for work in the morning, and then speak up without apology. You will surely benefit from a part-time job if that's where your heart is, but there are also benefits to the employer, and you should point them out: cost savings (part-time employees generally accomplish more on a per hour basis than full-time employees and generally cost their employers less in benefits because fewer benefits are provided), greater loyalty (from grateful doctor-moms such as yourself who are committed to making part-time work work) and therefore less employee turnover, improved staff morale, and fewer absences from work (you can schedule the kids' well-child visits and your tooth cleaning on your days off, and , if you're lucky, some of their colds and vomiting illnesses might even occur on your days off). You will likely be pleasantly surprised. I interviewed for all of the jobs I mentioned above, and they were all full-time. After I made my priorities for recruitment known, all agreed to work with me to tailor a part-time arrangement. In the end, I actually created a hybrid of 2 of the part-time jobs I had negotiated, working a total of 3 days per week, and it has been wonderful.

Bottom line: If you assume it will be impossible to find a part-time doctor job in your specialty, it will be. If you assume it will be possible, then it will be.

Not old yet

Still enjoy animal crackers, mac and cheese, grapes.
Still enjoy playing the bongos.
Still enjoy seeing Grandma.
Still enjoy painting.
Still enjoy Clifford, Berenstain Bears, Mo Willems.
Still enjoy They Might Be Giants, Dan Zanes, Laurie Berkner.
Still enjoy wearing mittens.
Still enjoy going to the zoo, zoo, zoo, how about you, you, you?

Don't like too many snaps, buttons, and zippers.
Don't like wearing shoes when riding in the car.
Don't like keeping quiet.
Don't like coats.

Can't help interrupting.
Can't help staying up late.

But the jury's still out on stinky diapers, classical music, carrots, clothes with holes, tub time, hats...

I am Old

How I know I'm getting old:

1) I remember as a kid, I used to love going down slides. LOVED it. Especially those twisty slides where you go through a long tunnel. In the last year, I've had the pleasure of going through a handful of slides with Melly on my lap, and every time when I get to the bottom, something hurts. Usually my butt. Those slides are treacherous.

2) Prior to a year or two ago, I had never experienced lower back pain. Never. When I was stooped over a patient for whatever reason, the attending would often warn me, "Be careful you don't hurt your back." I would scoff. Back pain? No, I'm way too young for that! But in the last year, I've had back pain constantly. So far, it's all just been muscle strains that got better in a couple of days, but I suspect I'm on my way to a herniated disc. I try to be careful... I tell my patients to take off their own damn socks for the EMG. I'm aware of the correct way to lift an object so as not to cause back injury, but it's hard to lift with perfect form when you're lifting a quickly moving, wriggling object, if you know what I mean.

3) I used to love roller coasters. When I attempted to ride a roller coaster a few years ago, I found that I not only did not enjoy it, but when I came home, there were actual bruises all over my poor back.

4) About a year ago, I found my first gray hair. I haven't seen any more since then, but I'm clearly still traumatized.

5) I still get the standard "gosh you look way too young to be a doctor are you sure you aren't still in grade school" response from patients, which I know most of us have experienced. The only difference is that now I'm really HAPPY when they say that to me. I don't even get fake insulted, like I used to. Then I get overzealous and injure my back while examining them.

I am impressed that people have kids after age 35. I'm not even 30 yet and as you can see, I'm already falling apart.

(Yes, I'm under 30 and complaining about feeling old... go ahead and mock me.)

You know you're a physician-mother when . . .

. . . your first inclination after diagnosing your child with fifth disease is to photograph it for your private collection of pediatric exanthems:

And your next thought is gratefulness that the diagnosis does not preclude daycare attendance. Alarming though that will be to the non-medical parents.

(For the uninitiated, I posted a summary of fifth disease here.)

Topic Day: The advice we wish we had in medical school

Welcome to our third Topic Day on Mothers in Medicine! Throughout the day today, we'll be featuring posts about the advice we wish we had in medical school. What words of wisdom do we have for entering women students? For our younger selves?

Posts will be publishing at regular intervals today so be sure to check back. Feel free to add your advice in the comments section, or if you are currently a medical student, what you think of our advice!

Scroll down to see the posts...

A straggling piece of advice

I was held up yesterday so my post is late. Straggling, as it were.

People in my medical school did not talk much about life, the universe, and everything. We were concentrating on the cerebral aspects of medicine, not necessarily the humanitarian elements, and not the life outside med school.

So if I did medical school again (and, yes, I absolutely would), I would take this advice back with me: have a human perspective on all things. During my training, we all tried so hard to be professional, but I think that, in the process, we started to ignore or even invalidate our own feelings. Our emotions and reactions may not always need to be open and visible, but it's okay to feel the burden of your patients' experience and not be closed off to it. I think too many people have the fear that allowing themselves to feel too much will cripple their medical ability. I don't think so.

In my years since medical school, I have seen many of the best and brightest doctors from various disciplines getting their hands and their hearts dirty (so to speak). They have an intimate knowledge of their patients, and I see how they are invested in their patient's care. These professionals have taken down the wall that is supposed to exist between the medical brain and the feeling person underneath. I have immense respect for them and the care that they provide. They manage to be involved, yet they don't make inappropriate recommendations or have nervous breakdowns. They just see the patients (and themselves) as the human beings that they are.

These are my role models, from my unique spot from behind the microscope. But if I were a medical student again, I think I would allow myself to feel a little more sadness, frustration, helplessness, and love.