Stop and Smell the Roses Baby

Before we had our baby 11 months ago I couldn’t really imagine how much I could love this little creature.  He is a delightful ball of light ricocheting through the house illuminating our lives.  It is a joy to watch him become a person, and each day I love him more.  But in a dual doctor household, it sometimes feels like we fit him into our lives, not the other way around.

Ever since we started our baby in daycare he’s had a routine.  He always falls asleep on the drive home, and we leave him asleep for the next hour.  And I regard this time as my own adult time.  I know I know, if I was a Good Mom I would be spending this time blending homemade organic baby food or decorating the nursery from some Pinterest inspired ideas, but evidently I’m selfish so I use this time to work out, veg out, or occasionally make dinner.  

So yesterday I finished work early, and on my long drive home I started thinking about everything I was going to get done with the extra hour of time. I was going to pick up the baby from daycare, jog on the treadmill while he slept, and then maybe veg out a bit with my laptop with the afternoon sun streaming through the windows, all before the telltale whimper from the carseat told me it was baby-time again.  It was going to be sublime.

But babies don’t really understand plans.

I picked up baby...check. He fell asleep in the car...check. He stayed asleep when we got to the house...check.  I changed into my workout clothes, and just as I picked up my running shoes I heard that little whimper coming from the car seat.  I was annoyed and disappointed.  But I also felt guilty about being disappointed.  I don’t see my baby that much during the weekdays -- just a few hours in the evening and then it’s time for bed.  I sat down on the couch with him and offered him a bottle.  He was so cranky and tired.  He didn’t want milk, he just wanted to be held.  He curled up on my chest with his chubby marshmallow cheeks pressed against my skin.  His lips opened slightly, inhaling and exhaling warm breath.  I nuzzled his silky hair and smelled his sweet baby scent.  And I thought about how there wasn’t really anything else more important than this moment.  I thought about how now that he’s almost one he doesn’t really sleep in our arms much.  How comforting it must feel for him to sleep wrapped in warm arms, listening to that familiar heart beat again.  The birds chirped outside, and dust floated through sunbeams lengthening on the floor.   The treadmill sat quietly in the corner.  The room slowly darkened.  And we sat in silence, inhaling and exhaling together, doing the only thing that mattered that evening.

Hello from Mooge

A long overdue introduction! This is a post I wrote right before starting internship, but I am just now posting. I thought about updating the content since I've been in the thick of internship for over a month now, but I decided to keep it as is to chronicle this journey.
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I’ve started drafts of this posting several times, but life keeps moving so fast that by the time I come back to finish the draft my words they seem obsolete. So instead, I’ll just introduce myself and why I’m excited to write for MiM. I’m a career-changing mother in medicine, a newly-minted M.D. balancing the excitement of finally getting to be a doctor with the nervousness of starting intern year.

With this excitement comes the realization that the last few months of weekends off and family dinners at home are about to come to an abrupt end. I’m mourning that loss of family time, and I have moments of second-guessing my chosen specialty – not because I don’t love it, but because it’s a time-demanding specialty. The children are already starting to whine about the increased time commitment since orientation started (after 3 weeks of me being home), so I can’t imagine how they will feel starting July 1st. When my oldest asks me why I didn’t choose a different job, my answer of “because I like this job and it helps people” seems unsatisfactory to both of us. I hope getting back into clinical work will help us both remember why mommy does this job, and that we as a family are a great team. I know things will get better, but the unknown of internship looms ahead and unsettles me. I look forward to just getting in it and working!

It’s been a long journey to this point, and I’ve relied many times on MiM to provide solidarity, laughter and spark contemplation. I jumped at the chance to be a contributor this year as a chance to give back to this community and chronicle a bit of the life of an (old) intern with kids! Now, here goes internship with two young children and a busy, traveling husband!

Until next time,
MOOGE

Bits n' Bobs~ Parenting 8 year olds; a fine needle aspirate.

A biopsy (FNA, not core) of  some recent parenting moments.

I have three children, ages 8, 8, and 2. My 8 year olds (girl/boy twins) are about to start 3rd grade next month which makes me feel really old--how did this happen already?! I feel like I was just waddling around HUGELY pregnant, then swaddling them, nursing them, rinsing off binkies dropped on the floor for the millionth time, changing their diapers, having delirium from the sleep deprivation, and all of that goodness and badness. And now we're talking about Big Issues In The World like homelessness, what is a mortgage, why Donald Trump is "not a nice man" (ok, so we're not subtle in our liberal tendencies. We're a West coast gay multiracial family, duh!), why it's better to compost food waste than throw it away, and on..and on. And last week my daughter saw a license plate frame that said "Army Mom" and asked me "Mom, are there any wars going on in the world right now?". What a heartbreaking and innocent question. Cue a conversation about war and conflict in the world, presented at an 8 year old level.

When did parenting suddenly get so complicated for our home? Does anyone just want to read a board book? Sing a song? Wrestle? Be totally oblivious sometimes?! And with two elementary school students, we're now entering into questions about the human body. And these questions usually come up either at dinner or at bedtime (of course).

The other night as I was putting my son to bed I reminded him that he realllllly needed a bath the next day (man, boys can be so DIRTY! Summer boy feet, oh wow); I also asked him if he was still retracting his foreskin while in the tub, to make sure he was cleaning himself properly-such a mom question. It truly astounds me that an 8yo child can get out of the bathtub after having "bathed" as dirty as when s/he went IN. He asked me "Why do I have to pull it back?" and I explained that for boys with foreskins, it's important to retract/clean because blah blah blah. He then says, incredulously "You mean SOME BOYS DON'T HAVE FORESKINS?!". Oh. I guess we never really talked about that specifically--never had a need. So there we were at 9:00 at night discussing circumcision, why we didn't circumcise him, whether most boys are circumcised (around here I think it's 50/50 for new births), penis growth (he said he thought his was "fully grown" by now....um...no, honey...it's not. So we did a bit of teaching there) and so on. It was hysterically funny, all in all.

And at the end of the conversation, my little man, being the budding biologist that he is (his obsession is mostly birds, so ornithology is actually his first love) also reminded me that foreskins are also important because they protect his penis from bad weather, bacteria, and insect bites. Oh right, but of course...

Until the next bedtime,

ZebraARNP

The things we do to succeed

I didn’t want to do it again, but here I go retaking my Pediatric Boards. I can list all of the reasons why I was unsuccessful at my first attempt: I was working too much (50-60 hours per week, getting paid to work 32), I was too stressed (issues with my former boss that I can’t discuss), I wasn’t sleeping enough, I have testing issues but my boss told me she couldn’t adjust my schedule so that I could study more. So here I am hundreds of miles away from home spending close to $2000 to take a 6-day intensive board preparation course. I am doing all that I can to succeed this time. And I refuse to allow the posttraumatic stress of retaking this test overshadow all that I am doing to succeed.

I have met so many outstanding doctors, most of them mothers, who have their own stories of failing their general boards or their specialty boards. These women are some of the best doctors I have ever met and provide exemplary care but they each failed the exam the first time. The stories read just like mine: working too much, stressed, not sleeping enough, family obligations, poor work-life balance. Some have a history of failing other board exams (USMLE or their specialty boards) but others don’t. Why does the cycle repeat? Why don’t we shake our little doctor sisters and say “wake up girl! There is no way you can balance all of this! Cut something back. Cut something out. Or else!”. “You can’t go on like this!”. “You either sacrifice now and focus primarily on passing or you’ll be forced to retake the test after failing!”. “Girl! Don’t do what I did. Let me tell you how I didn’t rock this test!!!!”. Or “Friend! Let me help you pass this test!”.

That’s how I want to recreate my narrative. I’m going to pass this test even if it’s by the skin of my teeth and then I’m going to mentor little sister docs so that they don’t make the same mistakes I did in post-residency auto-pilot mode thinking “well 60 hours is so much less than my resident’s 80 hour work week”. Let me tell you something - it’s not better after all of the years of sacrifice and don’t even pretend like you are not exhausted and burned out. And trying to work that much on top of passing this exam if you have even a hint of testing challenges is a major no-no.

So yeah, please Mothers in Medicine, send me some good vibes because I’m away from my family in this cold hotel room wrapped in blankets giving my all in order to succeed.

SIDE NOTE: In other random news, I just learned that the Peds Boards may become an open book test in 2017. Mwomp mwomp mwomp for me! If I could sit this round out, I would, but my new position depends on me passing this year. I hope the open book re-certification exam doesn’t cost more. Alright, I’m going to block all of that out and keep my nose to the grindstone.

EDIT: I removed the part about the salaries of the American Board of Peds folks because I cannot figure out how to fact-check it so it could be very untrue.

Craving

My youngest is starting kindergarten in the fall. And I kinda sorta want to have a third child.

I currently have two girls, who are absolutely wonderful. They consume a lot of my free time, I can take them to activities outside and they will behave, and I have just enough free time available for other activities that I enjoy. Everything is finally settling down a little bit, I get to sleep through the night most nights, and I'm reconnecting with my husband after some difficult times when the girls were little.

Still. I kinda sorta want to have a third child.

My brain knows that I shouldn't. I've got a laundry list of reasons why:

--my youngest daughter is incredibly attached to me and would undoubtedly be extremely jealous of any time I had to spend with a baby.

--my family has a really strong history of autistic boys. I got lucky with two normal girls, but now that I'm older, the risks are even higher of problems

--I love getting to sleep through the night.

--I have a lot of musculoskeletal issues caused by lifting my younger daughter, which would make a baby challenging

--I am finally getting back to trying to expand my career, and I don't want to give that up

--I like having free time to myself again

--my girls are still quite young, still very cute, and still need me a lot. And they absolutely do not want me to have another child.

--my husband does not like babies. He hates every aspect of caring for babies. He gets incredibly grumpy when he doesn't get enough sleep. I think our last child nearly destroyed our marriage, and now we're finally OK again. But he absolutely does not want another child under any circumstance. Convincing him to have a third child would be…probably impossible.

When I write this out, especially the last one, I wonder why I am even thinking about it. Even my husbands issues aside, the last thing I need right now is another child. The thought of caring for an infant makes me physically ill.

But I still have that pull inside me whenever I see a baby, and I feel sad that that part of my life is over forever.

The Bird Builds its Nest, or Life Lessons from a Liberal Arts Education

I worked out for thirteen minutes today. That's right, thirteen. Not because I'm on some kind of a short-duration, high-intensity workout kick. Because that was the time that I had in between finishing work and getting home at the time I had promised to relieve our nanny. And a little bit is better than nothing.

Not that long ago, I would have scoffed at the idea of such a quick workout. If I couldn't commit to at least thirty minutes, I figured, what was the point? Such a small effort would essentially be equal to nothing. But lately I've had a change of heart. I've been reflecting on the somewhat circuitous route that I've taken to get to this point in my career, and how it began with my undergraduate studies in French.

I majored in French language and literature for two reasons. One was that I loved the phonological beauty of the words and the way they string together to form a lilting song. And the other is that I knew that I would dedicate much of the remainder of my academic and working life to the sciences. I wanted the chance, at least for awhile, to explore the liberal arts and to broaden my general knowledge and appreciation of the world.

One of my professors made a point of teaching us idioms and proverbs, and one in particular has risen to the surface of my recent reflections:

Petit à petit, l'oiseau fait son nid.

Literally: Little by little, the bird makes its nest.
Essentially: Every little bit helps.
A long journey begins with a single step.
Rome wasn't built in a day.

You get the idea.

And in the past few months, as I have returned to work after Teeny's birth, started a fellowship in hospice and palliative medicine, continued to dream of developing a side career in writing, and attempted to maintain my marriage and sanity, all while hoping - though taking little action - to start whittling away at this post-baby-#2 body, I have had many what's the point and all of this is impossible moments.

But then one day, for no reason I can identify other than that I needed it, I remembered the bird making its nest. And I knew that little by little, I could make my own, in whatever aspect of my life I chose to apply that metaphor on a given day. That given the choice between a tiny bit of progress and none at all, I could, should, and now would choose the tiny bit every time.

I'm not able to spend an hour at the gym each day. But thirteen minutes is better - far, far better - than nothing. It's a step forward. It's part of a cumulative effect.

And it's just one more reason that I'm grateful for an education that extended far beyond the confines of the lab.

In praise of skin

Another work post from the burn unit, Kamuzu Central Hospital, Lilongwe, Malawi. I want to tell you about dressing change days, and interject a little ode to skin. I wrote a version of this for my private blog, but wanted to share with you all as well. As always, thanks for reading these ramblings!

Mondays, Wednesdays and Fridays bring dressing changes in the burn unit. This means that every patient—as many as 42, plus the many others who come in from home just to get their dressings changed--line up at the end of the hallway and wait their turn, while 3-4 intrepid nurses unwind and wind miles of bandages, slather ointments, and squirt morphine into their mouths. Except when there is no morphine. Then it’s diclofenac, which is, I imagine, the equivalent of getting a swig of ibuprofen right before you get scalped alive.

Walk with me. From the outside, down a dark hallway filled with people, toward the light at the back and up the stairs, three flights. The staircase is open to the outside and on each flight there's a big window with a view of the city--today it's hazy and hot, so the buildings are distant under a screen of red dirt and smog--but it's not airy or breezy. The stairs are worn from countless people walking up and down it for years, and on the second flight a woman wearing yellow wellington boots is mopping, with a broom that's seen better days and concrete-colored water. On the third floor we briefly bump along behind two policemen, big guns swinging freely, talking exuberantly and walking oh-so-slooooooowly—and finally we arrive on the third floor, and walk down the hallway to 3B, the burn unit.

Before you open the door, take a little deeper of a breath, for you're about to experience that smell. On a good day you manage to take 3 steps inside before it hits--the odor of maize meal cooked into grits-like porridge, or a paste, or a hard cake (nsima); of bodies, urine and boiled cabbage, dirty wounds, feet, doughnuts, and fear--and then you see the mother carrying her five year old daughter wrapped up like a mummy with an IV tube sticking out of her neck--and you feel ashamed for even noticing the smell.

There are six rooms, 4 beds each, lining the hallway to your right. Linking them is the open breezeway down which you’re walking, which opens onto a shared courtyard where people dry their laundry and family members cook their meals. On the other side of the rooms is another hallway, the khonde, or “outside,” which becomes another long communal room during the months when there are more patients in the unit than there are beds. During the cold season—June, July, August—the khonde is full.

Two boys, aged four and six, one with a bulky bandage around his leg and the other with a belly dressing, are playing with a glove balloon, and you toss it back and forth with them for a little while, their smiles lighting up the day.

Are you procrastinating? We have to keep walking down the hallway, to the room at the end, where all those people are queued up, since that’s where all the action takes place. Each mother dons a protective plastic gown and gloves and takes the child—the median age here is 3—on her lap. The mothers hold the children down. The first trial begins, that of forcing the morphine into the children's mouths. Most take it willingly, especially ones who have been here a while, but sometimes they purse their lips, or cry, or swat with their arms. It doesn't matter if the morphine trickles inside or outside of their mouths--there is no refill and the dressing change happens with or without it.

Next, the nurses soak the bandages in saline to help with removal. Since there are 42 patients and 3 nurses, waiting for a complete soak would take way too long. Some of the kids start screaming in the hallway; some when the mothers take them on their laps; some with the morphine; but all of them are screaming by this point. These kids are burned over 10-40% of their bodies, on average; over all possible body parts; in two main ways: they scald themselves or catch themselves on fire. It's the cold season in Malawi, no one has heat at home, and very few people have stoves; cooking happens over open fires, outdoors, and accidents happen frequently. Malawi is burnin', y'all:

 

Skin gets so much criticism. We stare at our pimples as teenagers and wish them away; at our wrinkling faces as adults, and hate their testament of the passage of time. We scrutinize moles and massage cellulite; we want elasticity and spend millions on creams and lotions that promise to keep us looking young. Even as we enjoy skin's gift of touch, in embraces, caresses, and kisses, we resent and focus on its fragility, its ability to hurt, and too often, its color. We don't appreciate scars. Skin should be blemish-less and baby-soft. Not at all like the skin I see in front of me--discolored, twisted, partially healed, in some cases with the tell-tale cheesecloth appearance of a healed skin graft. This is beautiful skin because it works in its intended way: not as pretty packaging but as a barrier to infection and pain, as the selectively permeable wrapper that allows the rest of the body’s functions to proceed uninterrupted and unthreatened, with just enough openings to allow a regulated exchange with our environment.

It's the absence of skin that exposes its absolute necessity. This six year old girl being unwrapped now has full thickness burns (what we used to call third degree) over 55% of her body: anterior and posterior thorax, both legs, both arms, a bit of face and neck, buttocks. Her big, deep brown eyes look at me with tears trickling down her cheeks as her mother’s helper raises the IV bag above her head and arranges it so the tubing is not kinked. This is a bad burn: flame generally causes deeper burns than hot water, and in this case, it looks like her clothes were on for some time, and the contact did a lot of damage. Like countless others, she was playing with her friends and tripped into a fire, where her clothes caught the flame. She cries, but not much: a bad sign. Although we teach that full thickness burns are insensate, since by definition the heat has destroyed the skin's sensory apparatus, not everything burns to the same depth, and partial thickness areas surround most full thickness burns—and those do feel pain. Her name is Chisomo, meaning Grace. She will die in 3 days.

I think about the ones we can’t save, back home, and here. I hold on to them for motivation to keep studying, keep waking up, keep leaving my family, and keep trying—and to honor their memory, although I see them usually only in a dehumanized form, although I know them usually only as bodies wrapped in dressings and not as children chasing goats, eating mangoes or diving into the lake. Knowing what makes a patient human makes me a better doctor but it also hurts more—and many times I don’t want to admit they are people because doing so makes me transiently incapable of returning to work. It’s like this in the States and it’s definitely like this here. The constant blur of activity insulates you from processing both the good and the bad, but both stay with you, and sometimes when you get a breather it all comes out, and it’s very hard to figure out what to do with all of it—so I try to just notice it and not cry, and carry on, because in the end, there are more of the ones who get to be human again than the ones who don’t, and so you keep going. As shown by the parents and patients in this burn unit, every day, with their smiles, their high fives, and their endurance, despair is a luxury. Ain’t nobody got time for that.

Three weeks in

I am three weeks into being an attending and I am writing this to all of those starting intern year (like I was when I started reading this blog), and to all of you in the middle of a long residency and questioning if you can make it through. I am writing this to put your sacrifices into perspective - all the missed recitals and mothers day lunches, the shitty clinic clothes you wear because you can't afford anything else, the many times you leave your spouse to sleep alone at night while you're on call --- I am just three weeks in, but it sure feels really worth it right now.  All I feel right now is joy (Well joy and a fair amount of fear and anxiety!! but mostly joy).  

It feels unbelievable to finally be at this point.  It has been such a long road.  I know being an attending presents lots of new challenges which I am learning about every day.  I know I may not feel so exuberant years from now.  But right now, I'm enjoying it.  I feel thankful to be in a job that I truly love, working with people I respect and feel honored to work with.  I love my patients and feel energized after clinic or a day in the OR.  I also feel very supported by the other faculty.  I feel like that bright eyed, brand new medical student 12 years ago who wanted to "help people." 

Last night, after kindergarten registration, I stared at my worn out sleeping daughter and I was proud of this model of motherhood I have provided for her.  I was proud of our new house, her new house, the house she will grow up in -  I hope one day it will be as dear to her as the house I grew up in just 10 minutes away.  My residency baby - she made me a mother in medicine.  She made me a better person, a better doctor - and every moment of this struggle feels very worth it right now. 

The special skills we have

Late last night past whatever passes for bedtime in the summer, tween daughter showed me the abrasion on her knee sustained while swimming earlier in the day.  It was the "lane rope monster" known for sheering the top layer of skin of even the best swimmer's hands, knees, etc.  She asked for me to go get her a band-aid.  Size?  Medium.  Our home is well stocked.

After checking to see that the wound was clean enough (no obvious debris), I applied the 2 inch bandage to the extensor surface of her knee, the "bendy" part.  She bent it, as if checking, testing, and then admiring my work. 

And then, with the complete absence of sarcasm (yes, even in a twelve year old) in this, the edge of the end of childhood, she asked if I went to special school to learn to apply band-aids that well.

For the degrees and formal schooling, it was 4 years college, 4 years med school, 3 years pediatric residency, plus public health and medical educator training along the way.  And most importantly, time spent as a mom.