In the dark quiet of the last day of 2016

Oh, no. Not a New Year's Resolution post. Who needs another "Live healthier, Be a better doctor, Be a better mom" post?

Well, I do.

Genmedmom here.

It's 6:30 in the morning on Saturday, December 31st, 2016, and I'm sitting typing in the quiet dark of our house. No one is stirring except for our two big spoiled cats, who relentlessly knocked things off of my nightstand until I got up.

You know how you get really busy, barely any downtime to even answer the texts from old friends, never mind call them, and all the very small spaces in your life are stuffed with overflow tasks, like making shopping lists on your phone on the train, and never going up or down your stairs without having something in your arms that needs to go up or down, like dirty laundry down and folded clean stuff up, empty tea mugs down and toilet paper rolls from the basement up, wrapped gifts down and unwrapped stuff up, so many goddamned toys and factory-new clothes and the boxes, tissue and gift bags that you can't bear to toss that will clutter your home until next year too, and even with your superior physician multitasking skills you realize you're screwing up, like forgetting to RSVP for that thing and being late paying that bill and getting lame last-minute crap for the important staff member you totally spaced out, and then even the doctor stuff starts slipping (which is always last to go, right?) like that you promised to personally get back to your longtime dear patient on a result that wasn't critical but it was important to HER and you totally intended to check that on the holiday weekend and simply send her a quick message through the online portal and you just did not do it.

Then the kids get sick, and you get sick, and any delusion of control you had goes down the toilet with the first bowl of vomit. Your Christmas agenda: poof.

Barf.

But life marches on and there's still things to do and when everyone is (mostly) better you try to keep going, get yourself and the family to rescheduled gatherings and pick up where you left off with the gifts and the cards and the outings for school vacation. Maybe you start losing track of what's really important and what's just life and lose your cool, show your frustration, yell at your kids when the situation just doesn't merit a freakout. No one is running towards a busy street or about to drink drain cleaner, they're just jumping on the couch and throwing pillows and wrestling and, well, not listening to you when you order them to get their shoes on because you're late or pick up that banana peel and take it to the trash or SETTLE DOWN already. And when they react to your red-faced temper with sass and disrespect, maybe you throw the remote control across the living room and when it lands on the hardwood with an unexpected clatter, your kids stare at you with a sad, silent combination of shock and wonder and fear that you hope you never see again.

You know you're out of balance and that this is not right and this is not you.

So in the dark quiet of a holiday weekend morning when, miraculously, there is no event planned nor pressing task nor other thing of perceived great import, you sit and breathe and resolve:

This year, I will live healthier, be a better doctor, be a better mom. I will do this by uncluttering my headspace. I will leave the little breathing spaces empty. For breathing. I will remain thoughtfully committed to my medical practice and remember the high standards I hold for myself. I will love my family, my children,  always reflecting on how blessed we are, how much we have and enjoy in this very difficult modern world. I will pray for those who are struggling and suffering, every day, I will not forget them.

Happy New Year and God Bless.

(all is not) lost

There was a heartbeat. I saw it on the ultrasound, but I knew immediately something wasn’t quite right. Was it too slow? Yes, the ultrasound tech said she noticed that too and gave me the wise, all knowing look of a Black grandma who can’t quite tell her granddaughter that something is wrong.

And then there was none at the ultrasound 2 weeks later. I asked the next ultrasound tech to angle the screen when I didn’t see movement. Saw the look on the Radiologist's face and then the Fellow. No heartbeat. The tears began to flow. My body began to shake. I held in the sob knowing if it began here with these strangers it wouldn’t end until I was safely tucked away at home.

You were there. I saw you. You were there. And now you’re not. When did you leave me? My heart breaks. I type through my tears.

I am at home. Grieving. Surrounded by loved ones.

I cry now as I type.

“Mama, are you crying? Did you have a nightmare? Are you frightened?” I stifle my tears. Say to Zo through closed door “I’m okay. Mama’s okay.” He calls out for me and O from his room after bedtime. O goes and comforts him and calls me into his room.  I gather myself, wipe my tears, blow my nose. Zo rushes into my arms “Mama, are you okay? I was having a good dream but then I woke up. Why are you crying? Everything will be okay.” As he gently rubs my face with his amazingly soft 5-year-old hands. As he pats my back. As he rubs my belly. As our family holds one another.

All is not lost in spite of this major loss. You were there. I saw you. You were with me. Now you are not there. But my husband is here. And my Zo is here. Their hearts are strong. My heart is strong.

The stories from friends poured in over the last few years. We are all in our 30s. Gut-wrenching stories of second trimester terminations due to fetal diagnoses incompatible with life. The heartbreaking call telling us of a stillborn nephew. Friends with years of infertility. A family member with seven losses. Stories of rainbow babies after loss. Countless miscarriages. Flashbacks from medical school of being present with sobbing women in the antepartum unit when their ultrasounds showed the absence of heartbeats. I didn’t understand then how the loss of something (a baby? A fetus? I didn’t know what to call it then) not yet realized could cause these women to sob uncontrollably. But I do now. From the moment I saw the positive sign I was hooked. Head over heels. Then the heartbeat. My growing belly. Zo’s “mama, is there a baby in there cuz I think there is.”

I was so excited to tell him he was going to be a big brother but I didn’t because I knew things weren’t quite right and it was all too soon, too early, too many things could go wrong - and they did. But he knew. He knew yet we feigned ignorance.Told him I would go to the doctor to find out.

All is not lost. You were there. We were together. Our family is still here and you will always be with us. We will go on. For we are not lost.

MiM Mail: Fourth year pregnancy?

Hi there!

I am currently a MS3, married to an amazing husband for the past three years, and strongly considering pathology. We would like to have a child in my fourth year. The question for us is when to start trying and hopefully have the baby, and to maximize our chances of having the child before intern year.

Our original plan was to start trying this summer, with the hopes of having a child sometime between March and May. But I'm not sure how that would work out with having a newborn as an intern. I would really like to avoid being pregnant during my intern year (or just residency in general) as well, and so I'm also worried about the short window that gives us to try for a baby.

I do not have any familial support where I live, and I'm not considering residencies that will be near family (they live in an incredibly expensive city and have very few programs around them). Our plan for childcare is my husband quitting his job and becoming a stay-at-home dad - any money he would make by keeping his job would probably not cover the cost of daycare.

At my school, we get two months off for vacation, one of which is mandated in the winter months for interviewing. I believe I can also have two more months of light rotations as well, giving me a total of 1-3 months to spend between my interview period and infant-recovery time.

So here are my current pros and cons for having a baby earlier (Fall-Winter) vs. later (Spring).

Pros for having the baby earlier:

Will have an older infant by the time intern year starts.
May be able to avoid interviewing pregnant.
More time to get pregnant.
May be able to still use my vacation months during interview season if I have my child around that time.

Cons against having the baby earlier:

May have to interview very pregnant or be at risk of giving birth.
Will probably be very pregnant during possible audition rotations.
Will probably need to have my husband quit his job (or scale down to part time) to take care of the child while I am on rotations.
Will be taking Step II pregnant.

Pros for having the baby later:

Husband can keep his job at full time for longer, maximizing our income.
Might be able to stack my rotations so that I can have 3-4 months "off" or with light rotations to be with the baby until residency.
Avoid being pregnant while taking Step II.
Will be less pregnant during interview and possible audition rotations.

Cons against having the baby later:

Will have to interview pregnant.
Stacking my light rotations and vacation at the end of the school year may make it so I have less flexibility when interviewing for residency.
May not get pregnant in the short window we have.
Would go through intern year with a <3 br="" mon="" old.="">

I would love any feedback on my tentative plans - which of these are important vs. not so important? How difficult is it having a 3 month old vs. a 9 month old baby during intern year? - and what you would recommend for my husband and I. Thank you!

Silent Day

Silence.

It’s golden right?

Silence.

I’ve craved it. Haven't we all?  As a busy doctor and mom, there’s always something in the background of daily living -- kids arguing, kids playing, kids giggling (my favorite!), the hustle and bustle of the life in the clinic, a shout of “mooooooooom” from upstairs or downstairs, the radio, the stove, the washing machine, the beeper, the pitter patter of fingers on my keyboard.  But, this minute, it’s silence. This hour, and for all the hours of today, it’s silence.

Right now, it’s feeling deep, dark, and deafening. I’m sitting on my couch in my house alone. It’s Christmas Day. I’m Jewish, so it shouldn’t feel sad or lonely. But, this is my first Christmas alone. I’m divorced now and my kids are with their dad. For the past decade, I adopted Christmas and it’s tradition of bringing families together. I cooked and baked and decorated a tree and made new traditions for my then-husband and kids. In those days, when I left work the day or two prior to Christmas, I said ‘goodbye’ to colleagues, wished them happy holidays, and looked forward to making my house warm for my loved ones and kids.  This year, I left on that last day of the work week with dread.  I savored the last few hours I had with my kids before my ex picked them up on Christmas Eve morning -- we snuggled in bed, watched tv, tickled and laughed. And then, they were gone.  And the silence set in.

That morning, I went to work as the ‘on call doctor’, seeing patients in urgent care, fielding pages from the answering service. And then about 1 o’clock, I left the office, got in my car, and wasn’t sure where to go. Others were out and about, finishing last minute shopping, or on their way to see friends and family (I presumed).  I stopped for coffee. And then I went home to The Silence.

Today, Christmas day, I slept in a little and woke to an empty house. I should be rejoicing. Free time to nap and read and sew and listen to music and clean my house is mine for the taking. Except, it just feels sad and lonely. The world is shut down today -- the stores are closed, there is no traffic on the roads, I have no where to be and I feel like an outsider again on Christmas.  My kids aren't with me on a day that is about family.

Late morning, I left the house for a bit to meet a friend and her family for lunch -- they are ‘in between’ religions, unsure how to celebrate this year after she lost both her parents in the last several months. I was glad for the company and an excuse to leave my house, and The Silence, for a little bit.  Her family welcomed me with kindness and warmth with an undertone of understanding that I am feeling like a woman without a country this year. Their hugs were warm, and lingered just a little longer than one might expect -- a subtle acknowledgement of the suffering they knew was behind my smile today.  

I have always known that the holidays are a hard time for people. Facebook feeds and tv ads are filled with the perfect storybook moments of families coming together on the holidays.  They don’t make commercials about the hearts of single parents breaking when their kids leave for the holidays.  They don’t tell you what to do all day when everyone else is home celebrating, and you are alone. No one posts a ‘’selfie” on facebook with a comment, “here I am all  by myself on Christmas. Happy Holidays everyone”. When I got a group text from a friend today, “Merry Xmas to all of you! Hope you are enjoying the day with your families!” I chuckled a little when I read it, and then felt nauseous, forcing myself to ‘stay positive’. My fairy tale family is split up and we don't fit into that cookie cutter holiday description anymore.

I don’t write this with self pity. It is more of a conscious exploration of this uncomfortable state of being. I am in a new chapter of my life. There are new realities that I need to accept about my life and my kids and my former relationship. I’m trying desperately everyday to be a mom who is present, navigating these treacherous seas for my kids and helping them get through it all, with all the usual background noise of work and schedules and a busy life.  While I should welcome today’s silence, I fight it and argue with it, and sit with it uncomfortably.  We are not friends.  

In a few short hours this day will end. We will all slowly get back to our routines. At the end of the week, I expect my house to be loud with the usual noises of kids and this heavy loneliness will abate for a time.  I’m hoping it gets easier someday.  

If you were lonely this season, I know how you feel.  No one has said that yet to me, but I'm going to say it to you. May the New Year bring warmth and light, joy and happiness. May we continue to harness our courage and strength to get through difficult times, and find ourselves better on the other side of them.  May silence someday feel golden and welcome, and envelope us with the promise of self care rather than with the dread of loneliness. I wish that for me, and I wish that for you, if you are out there and you know what I mean.

Celebrating with Gizabeth

Of course I had to attend Gizabeth's wedding party. I mean, the proposal was on this blog! Sure, I had only met her one time before in person, but through the blog and our communications, it's like we have been long friends. So, my husband and I took a quick trip to Little Rock to help her celebrate. We wouldn't know a soul besides her and her husband-to-be, and perhaps that just contributed to the adventurousness of it all. Plus, it would be just us, no kids -- bonus.

We went straight from the airport to lunch with her and her daughter. (This makes out of town guests feel very special!) She was glowing with joy; her daughter was smart and gorgeous. After lunch, we had the luxury of many hours before the big party, luxury to be work-less and child-less.  This included: a run, walking through downtown Little Rock, a pedicure (+trashy magazines +wine) and enjoying the southern sunshine.

Gizabeth and her husband were married quietly and privately at their house and then threw this massive party to celebrate at the Clinton Library.  My husband and I decided that weddings for more established adults are done right: it was so beautifully done from the white tufted banquette seating, to the flowers, to the great music.

In fact, the DJ was so good that after years of being dance-floor inhibited, I could not resist getting out there and dancing! I totally reconnected with my prior dance-loving self on that dance floor. Husband and I had a major blast. It may have helped that we didn't know anyone and thus had zero self-consciousness. (And I have a photo that is witness to this that perhaps should not be shared publicly.)

Gizabeth was stunning. And everyone was so, so happy.

For the send-off, guests were given sparklers and lined the exit. NB: Do NOT put out sparkler by stepping on it since you will burn a hole in your shoe. Note to self: buy husband new shoes.

All in all, I had such a wonderful time celebrating with a MiM sister. Congratulations, Giz! May your joy and love cup overflow.

Richard Michael Nestrud: A Retiring Pioneer

I remember my Dad telling me of those days: the ones in which no blood was screened. A NICU doctor. He said when a baby needed blood, they would just find a health care worker whose type matched up, and would get the necessary vital life source to the baby, siphoning it.

I spent my college days writing checks at gas stations. Occasionally, a worker asked if I was related to my father. I would nod in the affirmative, and they would regale me with stories of how amazing my Dad was. "He saved my baby."

He saved my baby too. My son was born six weeks early. My water broke while I was walking on the treadmill. I mistakenly thought my bladder failed me, but soon realized it was amniotic fluid. I received surfactant on bedrest in the hospital. It definitely matured his lungs. When he was born, my dad kept him from entering the NICU - arguing with his partners to keep him by my side, nursing. I took him home, and when his jaundice required a bili lamp, my dad smuggled one home to me. I remember spending nights bathed in the blue alien light, marveling at my son.

The stories told by the nurses and doctors tonight, at his retirement party, were awe-inspiring. He and his partner were inspirations to his health care workers and patients and their parents. Their methods were unconventional, but vanguard. They saved many lives, some a testament in the room.

I never thought I would see this day. The man that kept me on my toes throughout my life is closing a chapter in his. He told a story, one that I didn't know, that brought me to tears.

Before surfactant, babies were trached, and became toddlers, and spent close to 16 months in the NICU. Many were destined to spend their short lives with that community. He told of a moment when his co-workers became a team. One child spent 16 months fighting for his life. The NICU adopted him, and they all became his parents. His death was inevitable, his life inspiring. They all mourned the outcome, and in their grief they became a team. A vital community that lives on to this day.

The man that I spent my whole life in awe of, aspiring to be like, closes a chapter of his life this week. I sat at a table with his partners - ones that told me I was garnering praise from the leadership of the hospital. After ten years, I am finding time to reach out and give back. "They say you are doing wonderful things. You are just like your Dad."

 I hope to continue the legacy. And I hope my Dad continues his legacy. He's young by current standards. He does and will continue to inspire me. The apple doesn't fall far from the tree. His roots are worth nourishing. He has my love, my adoration, and my aspiration, forever and always. Love you, Dad. You have saved many lives, including my son's, and will continue to inspire me throughout my career and yours, which doesn't end with retirement. You are my favorite doctor. The one that I modeled myself after, the one I will spend the rest of my life trying to emulate.

Maybe Later We'll See

I could go on and on about the ways that becoming a mother made me a better doctor. It's much easier to build rapport with families when you can throw a genuine, understanding "yup, my kids do that, too!" into the conversation. It helps me to give much better, more realistic, advice, especially to parents of very young children. (How I wish I could apologize to every new mother whom I advised to just "sleep when the baby sleeps.") Not to mention the fact that I didn't need to study developmental milestones for my General Pediatrics boards.

But until recently, I felt hard-pressed to list any ways in which being a doctor has made me a better mother. It has made me a more tired mother, a more guilt-laden mother, a mother who excels at multi-tasking, though I'm not entirely certain that that's a good thing. Because of my specialty, my kids are growing up with an exorbitant emphasis on safety (Safe sleep habits! Rear-facing car seats past age 2! No riding down slides on grown-ups' laps!). This will likely make their lives slightly less exciting than they would be otherwise, and might even be a detriment to their social skills; at two and a half, Bean regularly points to people biking through our neighborhood and shouts, "Ridin' bike not wearin' helmet! Need get helmet!"

The other day, however, I witnessed an interaction that shook me and has already changed, in no small way, an aspect of my parenting. As a fellow in Hospice & Palliative Medicine, I frequently participate in family meetings and discussions surrounding goals of care. I'm there when people learn that their health or that of their loved one is declining, that the remaining time is likely measured in weeks to months; when they hear for the first time that their end-stage organ failure isn't simply a chronic condition but one that will drastically shorten their life. When they learn that they are no longer a candidate for cure-directed treatment. Oftentimes I am the one to deliver these emotional blows. Regardless, whenever I am involved, my job is to help patients and families understand their clinical conditions and the options that remain - the pros and cons, best- and worst-case scenarios. Their decisions and goals don't have to make sense to me or coincide with my own values and beliefs, but my job is to try to ensure that the choices they make are well-informed.

I recently met a man and his family who quickly became one of my favorites that I have worked with. The couple were in their seventies, with several grown children and young grandchildren living nearby. His diagnosis was one that most in the medical community would consider devastating, though he and his wife maintained an upbeat attitude and an intention to pursue any form of treatment offered, no matter how severe the side effects or how slim the likelihood of benefit.

The first steps in his treatment knocked him down hard. He suffered debilitating side effects. He began to recover bit by bit, but then, still miles away from his pre-treatment baseline, he landed in the hospital with another complication.

I began to explore with him and his wife the potential paths that lay ahead. There was always the possibility of declining aggressive treatment and focusing on comfort, though he insisted over and over again that he would keep fighting his disease. But after yet another complication, it became clear that he might not, in fact, even be a candidate for any further treatment.

They had many appropriate questions, and I tried for days to get the primary team to sit down with this couple and give them some answers about what might lay in the patient's future. When they finally did, the meeting began before I could arrive, and I entered the room to hear them discussing a plan to wait one more week and then meet to assess whether or not he might be able to tolerate further treatment. The patient and his wife pressed the physician further. "How likely do you think it is that he will be strong enough to get more treatment?" the wife asked.

"Well, we'll have to wait and see," replied the physician.

And there it was. The line that I had been using as of late to side-step Bean's requests, to put them off in the hopes that he would forget, to deny without officially saying no. As he rounds the bend from two and a half to three years old, he has become quite a skilled negotiator; a frequent refrain is, "Later, nappy time over, do good listening, watch Cars [his current favorite movie]?" He'll ask even if he's just seen it the day before. And because I feel bad denying his request - and also because I would prefer to avoid a meltdown - I use a variety of stock Mom-phrases that I hadn't even realized I relied on until he began repeating them back to me in response to requests of my own: "We'll see." "Maybe later." "Wait and see."

When I heard it from a fellow physician in such a loaded setting, I grew angry. Of course nothing is certain in medicine and our prediction skills are often poor. But when I looked at the patient before me, knowing his course and his current condition, I knew that I would be utterly shocked if he recovered to the point of being able to press onward with treatment. And the other physician - as he admitted later when we spoke outside of the room - knew it, too.

It made me think hard about the responses that I present to my own child. Yes, it's easier to give some hand-wavy answer in an attempt to move on, change the subject, dodge the thing staring you in the face. And yes, a toddler's request for more screen time is exponentially less serious than a family's request for a clinical prediction. But in both cases, I think that we as humans should show one another the respect that comes with an honest answer, no matter how uncertain, no matter how difficult to deliver and to hear.

So I have started explaining to Bean what we are waiting to see. "It depends on how much time we have after we shop for groceries and take baths," I'll say. Or, "Well, let's see if it's nice outside; if it's sunny, we should go to the park instead." He doesn't always love my answer, but he knows where things stand and what it is that we are waiting to see.

*Cross-posted at The Growth Curve (www.thegrowthc.com).*