A Beloved Mentor Falls

I walk by the closed double doors and frosty windows of the ICU. You’re lying in there, intubated. It feels weird to go to work now. I can’t see you or talk to you, don’t know the drips, don’t know the plan... and it’s killing me. I, along with many others, desperately want to express my love. So many feelings are swirling inside:

Guilt... For having a chill workday that day, leaving early to sneak in a pedicure before the evening’s family duties. All the while, you collapsed in the OR. Our colleagues rushed to your side. Emergent intubation. Hours in surgery... A trivial moment for me that was horror for you. It hurts my head and heart to contemplate that this is the case for any two people on Earth at any given moment.

Bitterness... For the memories that have surfaced of my own health crisis. My own rush to the OR and surgery and stay in the ICU. The immediate change to everything in my life, the upset of all routines. The label of a disability, the worries about the future. A dark time that I try to forget but never can. For having the knowledge that you will experience this same bitterness later on... if you’re “lucky.”

Gratitude... For my health now. For the part you played in it. You were the one I went to when I knew something was wrong with me all those years ago. My tears didn’t phase you for a second, and you helped arrange my much-needed absence from training. Others thought I was just performing poorly; they judged and moved on, but you knew what mattered. When I was finally diagnosed, you facilitated my prompt surgery with our most skilled surgeon. The same one who is now taking care of you.

Admiration... For your completely nonjudgmental approach to everything and everyone. I have experienced it myself but never realized it was your M.O. with all people. We all exchange stories quietly in the lounge, then fall silent with sadness and worry. For your goofy sense of humor. For our days in the OR and call nights together during my training; you were the one I felt most comfortable failing or struggling in front of; only now do I realize why.

Anger... For why this had to happen. What higher being would take down such a beloved leader, such a good doctor? At you for not knowing something was wrong inside sooner, so as to maybe prevent this catastrophe. At your family for keeping us from seeing you now. They don’t understand how much we love you, how much doctors bond together in a practice, working in parallel to preserve life and limb. Damn you for not sitting up in your bed right now, pulling that tube out and cracking a joke with a mischievous smile.

I have to write all this here to get it out of my head. Work is not the same without you there. I miss you.

Witness the Sickness

I am so sick. Like miserable, no energy, hacking cough, congestion, achy muscles type of sick. Who knows what it is, but does it really matter? At work the other day I desperately had one of the X-ray techs do an AP on me. No pneumonia. That would have been too easy. How did I get this? From my 14 month old daycare attending daughter. Only she's moved on and is back to her normal, playful self.

The same thing happened around Christmas, but my husband was the innocent victim. She brought something home that knocked him down with a viral malaise that turned into a raging sinus infection. The babe got better in a few days; he lingered on with "man cold" for a couple weeks. We all know how painful that is for everyone!

I hear that what my household is experiencing is a thing. People tell me, "I've never been as sick as I was my first winter with a child in daycare." I hear, "Every time they change classrooms you'll get deathly ill." I have also heard, "It gets better once they turn two." Please God, let this be the case.

So Mothers in Medicine, my question is, what are your strategies for dealing with this? Is there any preventative magic I should be invoking? Because I don't know that I can go through something like this (two plus weeks of feeling like utter crap) again. We all know how hard it is to take care of our patients (and our children) when we are the sick ones, and we as a profession are the absolute worst at staying home and nursing ourselves back to health! What do you all do?

G2 P1011: life after loss and D&C

This post may be a trigger for those who have had an abortion, miscarriage, or fetal loss. I wanted to share my experiences because in the weeks following our fetal demise, I read several blogs by mothers but couldn’t find a single post written by a physician mother. This post is also part of my healing process. In it, I will share some of my challenges and also will explain my D&C*. I have found over the past months that many of my friends and colleagues have experienced pregnancy loss. Almost every single friend I shared it with have experienced their own loss. We are not alone. I hope that this post helps someone in need.

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It’s been 2 weeks since my D&C, over a month since we learned that our little kidney bean sized fetus-baby had died, and 3 months after finding out we were pregnant with our second child.

Thankfully, the nausea has resolved, the fatigue has ended, and the waves of grief are less intense and less severe. But sometimes the grief washes over me and I can’t breathe. And I fall into my husband’s arms or I call him or my mother or my best friend A and I weep. And then I wipe my face and I go on.

Zo asked enough questions for us to know that we needed to tell him something. So, I recalled my time during residency with the Palliative Care Team and did my best at providing a 5-year-old appropriate explanation of miscarriage. “Mama, there is no baby anymore.” “No, there was a baby growing but it stopped growing and then it died and the doctors helped my belly feel better and now I’m feeling a lot better.” He pauses, looks around. Says “okay” with a smile and a hug and then “I’m going to go find my Wolverine so we can play.” And then we move on. Now that my belly has started to rapidly deflate, I’m not exhausted or nauseous anymore, his questions have become less frequent. He is satisfied with our answers.

One of the hardest parts of this process has been all of the changes my body underwent that feel downright wasted. Big old breasts that won’t nourish a baby and that sadly have deflated just like my belly. A big old belly that poked out immediately and still makes some strangers pause. I pray incessantly that no well meaning elder asks “are you pregnant?” because I have stopped telling friends about our miscarriage (I am allowing the message to be passed by osmosis because at this point, I’m tired of retelling it and everyone who needed to know now knows) and I’m not sure I won’t either curse them out or start crying. New stretch marks that show my body underwent a change and unlike my breasts and belly, they are permanent. They will always be with me.

The hardest places to go for me have been the gym and the Ob-Gyn office. The gym because all of the mirrors show me exactly what I look like. I tend to sit in the car for 30 minutes before going in. I usually have my worst cries there building up the courage to go inside to work out. Losing weight after having Zo was so easy. He nursed like a champ and I weighed less than my pre-pregnancy weight within 4 weeks. This time. No such luck. At the gym there is no cute baby to tell other people about. I see the eyes on my belly (folks probably thinking “this pregnant lady knows she needs to be at home). I see the bulge in my shirt. The popped out belly button. The widened hips. I know I have to work extra hard to fight the flub without the help from breastfeeding. It hurts. All of this good chunk and no cute baby to show for it.

The Ob-Gyn office because there are cute waddling pregnant women. After finding about about the demise, I transferred my care from a midwife community practice to an Ob-Gyn practice recommended by one of my friends. I literally could not go back to the old practice; when the office called to follow up, I quickly thanked them and hustled them off of the phone. I had to let them go, they are the practice where I was hoping for a happy, uncomplicated pregnancy. I just can’t go back there.

And now with the new Ob, I don’t want to go for my follow up visit (but I do, on time!) because I know I’ll have to tell the Tech who gets my vitals that we had a miscarriage. And then the sad response, the averted eyes. I want to yell “I’m not a leper” but all I say with a smile to make her feel better is “we are okay! I’m feeling much better and the procedure went great!”. And I don’t want to hear the Ob tell me “you can start trying again next month.” And when I say “we are taking a break, this was a lot to handle” he says “yeah, yeah, yeah, you’ll be back soon pregnant with the next one. You two are healthy, you can have 3 or 5 more kids if you’d like” I have such complex emotions that I can’t mount a response. I just sit and nod. I literally am too scared right now to think about getting pregnant again. So I read books and I read blogs and I talk to friends who have lost babies and they tell me I am feeling exactly how I should feel right now. Confused. Scared. Hopeful. Encouraged. Sensitive. Fearful. Apprehensive. Angry. Loved.

It is 1pm and I have been putting off going to the gym since 9am. It’s time to get up and go. Hopefully writing this post means that I won’t spend any time sitting in the parking lot. Time to work on this belly bump.

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G2 P1011. Gravid 2 (meaning I have been pregnant twice), Parity: 1 term infant delivered, 0 preterm infants delivered, 1 abortion/miscarriage, 1 living child.

*D&C - dilation and curettage. This is a procedure where the cervix is dilated and a curette, almost like a spoon or a scraper, is used to remove contents from the uterus.

My D&C:

• In my D&C a small vacuum was also used.

• I received conscious sedation during my procedure, meaning I did not require respiratory support. I was in the pre-operative area for several hours until a c-section was completed and then I was taken to the Operating Room and it was over within 15 minutes. The Anesthesiologist provided midazolam and propofol and I was awake within minutes after with no cramping. I was very hungry and ate lots of yummy snacks and a big lunch and then came home and was promptly sent to bed by my family.
• The Obstetrician performed an ultrasound before to confirm the demise and an ultrasound after to show that the products of conception had been removed. I asked for them and have them in my files.  
• I had light spotting for 3 days after. Then only spotting with exertion (embarrassing but this means after pooping) for 2 weeks, then it stopped.
• I have had intermittent cramping and just like my Ob promised, I dind’t need any medication stronger than ibuprofen 600mg as needed.
• I had a follow up appointment 10 days later and was cleared for all activities.

(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.

When The Doctor Is Sick, Again

Genmedmom here. Coughing, coughing, coughing. This is the third respiratory thing to catch me in as many months. Damn germs, can't get away from them.


I'm apologizing to everyone: my husband, for waking him up all night with my uncontrollable hacking; my kids, for my medicated and exhausted attentions (or lack thereof); my patients, for spewing my droplets about the tiny exam room; my fellow commuters, for daring to get on the train sick.


I'm following all my own advice. I know I've got cough-variant asthma and I'm on top of the Albuterol. I'm taking Dayquil and Nyquil, and snarfing tea with honey and endless Ricola.


But still coughing, coughing, coughing. No fever, non-toxic, I'm eating and drinking and walking and talking and parenting and working and COUGHING.


Not sick enough to call out; miserable enough to want to.


Docs, what do you do?


Never mind, I know the answer. Suck on my inhaler, take Dayquil and Nyquil, snarf tea with honey and endless Ricola, and suck it up.

Vomit, Poop, Snow, and Chlorine: A Week In Review*

Genmedmom here, venting.

It's just been one of those weeks. There was no one particular event. We're fine, we're (mostly) healthy, we're happy.

But, it was just one of those weeks.

I was on call for our practice last weekend. Now, our weekend calls are not that bad. We do not round on inpatients at our hospital anymore; the hospitalists care for our patients. There were not that many pages.

But, the pages came at odd hours, and in bunches. Sleep was totally disrupted. There were stressful moments. Then, we have a brand-new, very complex electronic medical record to content with. I struggled with ordering prescriptions and documenting… Again, nothing big, just, annoying.

Then, Sunday afternoon, Hubby started having nausea, and chills, and muscle aches. Ruh-roh!

Yup, we were in for it. One by one, we were felled by the GI bug. Hubby had a mild version Sunday. Minimal active GI symptoms, but, down for the count. Overnight Sunday, Babyboy started spewing. I was on bucket duty. God love him, he never missed the bucket.

Monday, Tuesday, Wednesday, all clear. Long days at work: twelve-plus hour days, mostly immersed in this new computer system. But, no one was sick at home. We all breathed a sigh of relief.

Then. Thursday evening, I started feeling a little queasy. I vasovagaled in the kitchen, caught myself. I went to bed early, wracked with nausea, chills, body aches. I considered calling in sick for Friday. But, I wasn't actively spewing, I just felt like crap.

I debated: There was going to be a snow storm. Going to work in a snowstorm is bad enough, but feeling ill, would be even worse. On the other hand, calling in sick meant I would have to contact the few early morning patients myself, to cancel. But, these patients may be canceling anyways, given the snowstorm... I just couldn't decide, couldn't even deal. It was easier to just suck it up.

Friday morning, 5:30 a.m. I shivered into the shower, bundled up in wool, and headed down. I brewed the coffee, but I couldn't stomach it.

It was just starting to snow. The driving wasn't bad. I drive to the train, and take the train into the city. For the first time since pregnancy, I had to sit down on the train.

Now, I hate when healthy, able-bodied, lazy-ass people take up seats that others may legitimately need. I felt ashamed for sitting, but at the same time, I didn't think anyone would want me passing out onto them, either.

At work, I had plain Earl Grey tea to ward off a caffeine- withdrawal headache. The snow came down. Most patients cancelled. My stomach actually settled. I felt better as the day wore on.

Friday night at home: After I picked up the kids from Nana's house, where they had spent their snow day largely outside, they helped me help shovel out our neighbor. It was after dark, and cold, but they couldn't get enough snow. I was just relieved to be off-call and feeling normal. Whew! I'll get some better sleep tonight, for sure! I thought.

Then Babygirl vomited on the couch.

Babygirl vomited multiple times. Despite strategically placed buckets and towels, we had to change her bed out entirely, twice. She stopped vomiting abruptly at about 11 p.m. and declared that she'd like a glass of water, please. She downed it, and another, and was fine the rest of the night.

Saturday morning, this morning, we were supposed to have a behavior therapy group session with a new family. Babyboy is mildly autistic, and needs help interpreting and managing a lot of social situations. We were supposed to bring Babygirl, too.

We debated. She'd been spewing the night before, but had awoken bright and cheerful. She had wanted warm milk. She drank it, and it stayed down. She was playing, she was smiling.

We decided to take her.

Bad call.

Ten minutes into the session (at another family's house, people we had never met before) she vomited. She managed to warn us, and we managed to get her to their bathroom, but it all ended up on the floor. I cleaned it all up, on my hands and knees, apologizing right and left.

Then, right afterwards, Babyboy had a poop accident. He's five and a half years old. We've been working on toilet training for over two years now. We'd just had a week and a half without a poop accident, our longest stretch ever. We thought maybe, just maybe, he's toilet trained!

Nope. Hubby took care of this mess, in the same bathroom. The family was so kind and understanding, but still. We were so embarrassed. You could smell it for the rest of the session: rancid milk vomitus, foul stool reek.

The kids were supposed to have their first swimming lesson today, as well. It was out of the question for Babygirl. I envisioned her vomiting in the YMCA pool… Good God. No way. Hubby took her home to watch endless Peep and the Big Wide World, all wrapped up in her pink blankie on the couch.

I took Babyboy to the Y. It was his first swimming lesson ever. I was nervous. He was nervous.

It didn't start off well. We walked into the locker room labeled "Family Locker Room". It was packed and bustling with half-dressed men and kids of all ages and moms with babies and SO MUCH NOISE in such a small space… There were changing booths with curtains on them, but I could not remotely imagine getting myself undressed and into my bathing suit, separated from the men and young boys by a flimsy curtain.

But Babyboy made the decision first: "Mommy it's too noisy in here, please let's GO…" He had his hands over his ears like they hurt, overstimulated to a painful degree.

So I took him into the women's locker room with me. We had already changed into our bathing suits when the YMCA police (or whoever she was) came in and informed me that children under eighteen years of age aren't allowed into the women's locker room. At all. Ever. And we had to leave. Now.

The lady was very stern, and Babyboy started to cry. He thought he was being scolded.

"Listen", I pleaded. "I just don't feel comfortable in that Family locker room with all those men and boys around, you know?"

The lady relented. "Well, you can use the Girl's locker room, if you like. Technically, it is for girls, but, he's pretty little…."

And so we did. Apparently, there were no girls of an age that would use the Girl's locker room around, because it was completely empty. We relocated, stuffed our winter gear into a too-small locker and entered the pool area.

Whoa! The pool was super-steamy and the chlorine odor was almost overpowering. I wasn't sure if Babyboy would be able to stand it, but he did. Other than the fact that he slipped and fell on the tiles, requiring a helpful lifeguard to get him an ice pack for his head, Babyboy enjoyed his first swim lesson, such as it was. He wouldn't get in the water without me (I had anticipated this) and there were several other special-needs kids, plus, it's the Y, so of course it was a little scattered and chaotic. But, it was fun, and he was more comfortable in the water at the end then he had been at the beginning.

Back at home, we all laid low the rest of the day. We drew, we read, we watched Peep.

Now, we sleep. I hope…

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*This post was written Saturday evening. Sunday morning, our longtime pet cat passed away unexpectedly. The kids were brokenhearted. We were brokenhearted. Obviously, that event overshadowed all of the crap I've complained about here. I decided to let this post stand, however, because it's how I felt at the time. I wrote about our kitty on my own blog: The Biggest Pain In The Ass Cat You Ever Could Love: We'll Miss You, Raffy

This child and his sensitive skin

It all started out as a little papule on his left buttocks. In the middle of a busy week of relatives visiting and make-up clinic days, what started out as a small papule morphed into something worse. Zo has had exceedingly sensitive skin since he was 1 years old. Hyperkeratotic plaques behind his knees that sprout up in the span of 2 days if he isn’t slathered in a thick mixture of shea butter and petroleum jelly twice a day. Diffusely itchy maculopapular rashes if we miss his nightly dose of cetirizine. That type of sensitive skin.

I thought I had things under control. But I didn’t.

Monday - I see a little papule on his left buttocks. I put on a thin layer of triamcinolone 0.025% on it. Later that night, I see a few more papules. I put him in the bathtub and then put on more triamcinolone and begin our twice a day ritual for exacerbations.

Tuesday - I see more papules. He is itchy. Is that a ring? Nahhh, I’ll just step up the emollients.

Wednesday - I return home and notice him scratching. How was swimming? His response, “it was fun” as he continues to scratch. Bathtime. Is that a 2 centimeter scaling ring-lesion?!? Oh goodness! He’s got tinea!!! I don’t have time to get clotrimazole and I forget to text my hubby what medicine to get from the pharmacy.

Thursday - satellite lesions. After clinic I run to the local CVS and wait in line for 15 minutes to purchase clotrimazole and by the time I arrive home he's asleep. That peaceful sleep where you know not to interrupt them or all hell will break loose so I let him sleep as I fret about his tinea outbreak.

Friday morning - we begin twice a day clotrimazole use.

Weekend - more lesions. Lower back, posterior and anterior thigh. Areas I won't mention for fear of him one day reading this. But seriously who knew tinea could spread so quickly and that toddlers can get jock itch! Major fail!!! Quick consult to my doctor friends with pictures of all of the lesions minus his groin. Definitely tinea. Definitely spreading; it’s all of the summer camp fun and splash park play dates. Primary care friend KJ says just go ahead and suck it up and put him on griseofulvin too, it’s already too out of hand and you'll stop it before it spreads to his scalp.

And just like that, I have written my first prescription for my son. Too ashamed and time-pressed to bring him in to my new clinic for tinea corporis. I knew the liquid wouldn’t go well as he is now 16 kilograms and our last go round with amoxicillin ended in us making daily smoothies. Based on my calculations, he could do one-half of a 500mg tablet daily - and after all of the pill swallowing for kids I observed due to an awesome program one of my co-residents did, I knew what to do.

Tuesday - I took him to the pharmacy to get him excited about his new medicine to help with his itchy parts. He shook the bottle to a nice beat and did a happy dance. We got home and I cut the pill. Hubby says “shouldn’t you crush this, it’s huge.” I say “nawww, we’ve got this.” Equipped with 1 tablespoon of honey and half of the pill, I say, “okay, you’ve got to swallow this without crunching it up.” Zo smiles, says okay and then hubby offers him some extra water and then VOILA!!! My almost four-year-old swallowed his first pill!!! Proud doctor-mommy moment in the midst of a crazy week.

Mothers

This blog is about mothers in medicine, but most centrally it is about mothers.  I considered many times over the past few weeks telling KC that I was going to resign from writing.  But, I would stop myself because I so love this community of women.  I felt I didn't have much to give.  I'm drowning a bit right now.  To catch you up, I've started a new, amazing, super supportive fellowship.  I feel like I have my life back after 7 years of residency servitude.  I've passed the first part of my boards.  I have some exciting job prospects that may be materializing soon.  My daughter is in a wonderful school and thriving, and my husband just landed his dream job.  I get to hang out with my siblings on a regular basis.  I'm writing grants with my baby sis (so amazing).  But most importantly, and most poignantly, my mom has treatment resistant aggressive metastatic breast cancer.  On the bright side I get to see her nearly everyday, her doctors are my colleagues and we have far from exhausted every option.  But on the other side - I feel like I am drowning.

My mind is constantly thinking about my mom.  I constantly fight to push some medical knowledge out of my head while using other parts of my medical knowledge to help.  I feel quite ineffective at this.  I strive to bring her grandbaby to her side every day because my baby girl is a beacon of joy in the midst of this.  To busy myself I cook and clean and organize - thankful for my siblings and my dad as we all share these tasks together.  I yearn to just lay in bed and talk to my mom for hours, but I am so unstill.

At work I try to bury my constant thoughts so that I can excel, so that they see me as an asset.  Most days it seems to work okay, other days - like the day we realized it had spread to the liver on therapy - its hard for me to stand.

There is a centrality of mothers in a childs life.  This is the beauty of this blog and certain groups on facebook.  We realize that we have two awesomely important jobs.  Well now my mind is on the one who was so central in my life and how I can't envision a life without her.

So, I don't have lots of MiM specific insight or questions.  Just that this blog is about mothers.  So, I thought I'd talk about mine.

My mom quit her Economics PhD program when I was a baby.  My dad had to travel for work, so she chose her family.  She was a stay at home mom until I was about 12.  Then she started doing economics work for the state and selling real-estate.  It wasn't until I had my own child that I realize that she must never have slept or ate when we were little!  3 active kids in a million activities and she essentially worked two jobs.  Despite that she seemed just as present then as when she stayed at home.  She has always found a way to always make us feel that she is right there.  I never really had teenage angst with my mom.  She has always been my best friend and my cheerleader.  She never made me feel like I was anything short of the best and she is crazy proud of any and everything we do.  She told so many of her physicians that I was a surgeon that I'm pretty sure they flagged her chart.  She rescued me from my post partum depression.  She is the one who made it okay for me to get help.  She taught me that I could do anything, that I could be fierce and accomplished and made me feel like I deserve it.

So now, I can't bear the thought that my sweet baby girl (who wants to do everything with grandma) might forget her.  If I'm ever blessed to have another child I can't bear the thought of that child never meeting her.  My siblings are younger, they have weddings and pregnancies in future that she will likely never see.  I always thought that choosing oncology as a career was my calling, because with cancer people have time to prepare, unlike the immediate finality of trauma for example.  But, now that we're in the middle of this "time to prepare," I can tell you it sucks.  It is hard to make the most of it/treasure every minute/make happy laughing videos and everything you see on Hallmark movies.  My mom is tired and worn down from chemo right now.  She needs rest and pain medication - not a montage.  What we really want is the time before this all started.

Thats all for now.  Make life count.

Guest post: Trust me, I am a mother

I never went into medicine to become a better mother. I never became a mother to become a better doctor. But, the two journeys merged in 2013 when I knew something was seriously wrong with my almost six year-old son. My son is like any other boy his age, other than occasional mild irritability that is slightly over the average and incredible creativity. He usually springs out of bed ready to tackle the day, excited about all the projects he is going to do. For about ten days, I noticed that not only was he not interested in any activities, but he was incredibly irritable at even the most minor setbacks. He has always had a high pain threshold, yet we started noticing an increase in his frequency of "got hurt" episodes. There were no focal deficits on physical exam. I sent an email to his teacher asking if she noticed any limitations at school. She said no. I didn't know if I should go to a pediatrician or a psychologist. Then, he developed a minor unprovoked pain in the shin. I jumped on it as now I had a reason to take him to the pediatrician. I reasoned with the pediatrician that given the irritability and mild low grade temps at night time for two days, his shin pain may have been an indicator of something systemic. After an exam, she ordered some blood work and X-rays which came back normal, other than a slightly elevated WBC and platelet count. She told me to trend the fevers and to come back if there was no improvement.

The same night, I noticed a slight temperature and called the on-call doctor. I explained that I was concerned about the low grade temperatures without an obvious source, and that the shin pain might point to a musculoskeletal or neurological issue. She also told us to "trend" the fevers and call her back in the morning. Completed unreassured, we took him to the emergency room. A full day waiting in the emergency room led us again to blood tests that were mildly abnormal but not convincing for any diagnosis. An MRI of the leg was done which was read as normal. I pulled the pediatric ER physician aside and told her my concerns: was there something systemic? As an adult critical care physician, I was not the kind of parent to seek attention unless I was truly concerned. I alerted her that I was concerned regarding the elevated white count and thrombocytosis without an obvious source and even more concerned that the MRI was normal. We were told to "trend" the fever, and if it became more than 101.5, to seek attention. We were also to give scheduled ibuprofen to suppress any synovial inflammation that may be happening in the hip from a viral infection two weeks before. After a dose of ibuprofen, they tested his walking, and said that it was noticeably better, so it must be Transient Synovitis, a diagnosis of exclusion. One caveat to this "give the drug, and see if this gets better, if then, it must be this" argument is that it is absolutely flawed. If the participant knows that "he or she is supposed to get better" then the free will overcomes any pain and of course, he is going to walk better. It may or may not have anything to do with the drug. We walked out of the Emergency Room still concerned.

I continued to give him ibuprofen over the next day. He continued to limp. The ibuprofen suppressed the fever, so now we had an afebrile child who couldn't walk. After no significant improvement, we took him back to the pediatrician office the next day and asked for a neurological exam and, bingo, over the course of a few hours my child developed cerebellar ataxia, clonus, and inability to stand. All of this happened within the time we saw the pediatrician, got him back to the emergency room, and a MRI was scheduled. That night as I sat at the edge of the MRI machine holding his leg, I had never been more frustrated with the fragility of the human body. I loathed hospitals. I never wanted to step foot in the hospital again. The doctor inside of me put the differential diagnosis of "epidural abscess, brain tumor, meningitis, encephalitis" on the list, while the mother inside of me put "something really bad" at the top. While the initial scout films started coming up, my husband, who is a body radiologist subspecialized in MRI, stood by the MRI technician with a solemn look in his eyes  -- one that I had never seen before. As he drew his finger in a vertical line across the computer monitor, the heart of the mother inside of me sank, while the doctor inside of me said, "Wait, that could mean it is not a focal tumor or an epidural abscess, but could it be a diffuse tumor? Maybe, it is meningitis."  With one hand on my child's leg amid the deafening noise from the machine, I kept waving to my husband to see if he could tell me something. He asked me to come outside and knowing my child was already asleep in the machine, I stepped out and could immediately notice the flair abnormality that swept across the spinal cord. As the axial cuts were pouring in, we could see the flair signal lit up like two snake eyes pointing to the diagnosis of Transverse Myelitis, which we knew only held very good prognosis one third of the time. There was no Brain MRI ordered as the ER staff wanted to "focus on one thing at a time," and it  seemed that the spine was the problem. Thankfully, the neuroradiologist who was examining the scout images, and who was about to leave in thirty minutes for the night, noticed the transverse myelitis throughout the spinal cord and asked the technician to add a brain MRI. Within minutes we found her and discussed with her and confirmed the diagnosis of Acute Disseminated Myeloencephalitis with Transverse Myelitis, a disease that occurs in my child's age group, typically after a viral infection or a vaccine.

During the hours in the emergency room, my son went from being able to walk with a limp to being unable to move both legs and becoming tachypneic. Prior to returning to the emergency room from the MRI, I told my husband that knowing the diagnosis, they will for sure want to do a lumbar puncture to rule out active bacterial/viral meningitis and this will of course delay steroid treatment if the lumbar puncture was not done in an expedited manner. We were already in the emergency room for twelve hours by the end of the MRI and given the progressive course of his symptoms, further delay could have caused him to progress into a coma and the risk of hemorrhagic encephalitis existed. Upon return, we asked the team to be present at his bedside, and we made our concerns open to them. The on-call ER physicians were skillful and quickly performed the lumbar puncture. We soon knew that there were no alterations in protein/glucose/gram stain and that we had the right diagnosis. The ER team hung the bag of 600mg of IV solumedrol before we were transferred up to the ICU and every successive day resulted in more return of neurological function. Within five days, we were at home recuperating after this nightmare of an illness. The neurologists repeatedly told us that they have never seen a child with such degree of MRI severity not have the physical signs to reflect the changes; it is likely because we sought attention right in time. The mother inside of me was strong during the five days, and the doctor inside of me was quick to decline any unnecessary blood draws and made sure that he got out that hospital as quickly as possible. For if anyone knows how deadly hospitals can be, it was the doctor inside of me. We were welcomed at home by a supportive community and his return to school and activities was a breeze because of the love and support from family and friends. When I bought my son a couple of youth basketballs to help his recuperation phase, he jumped out of the sofa, ran to me, gave me a big hug and said, "Mommy, how do you know me so well?"

I said, "Trust me, I am a mother."

How's your summer?

Since you asked...  If it weren’t for her dose of chemotherapy q 3 weeks and some iatrogenic wbc-boosting induced bone pain, it’d be fine.  And yet, my mother and I are still having a reasonably good summer.  Slowing it down a bit and being together.  Even if the togetherness is while we have a picnic in the chemotherapy suite, or while we walk to the local pharmacy to pick up a medication refill. 

Because nothing says bonding with your mom like shaving her head.  She reminds me that early on I’d wanted a career as a hairdresser.  Alas, now there is no hair. But to my pleasant surprise she is the same strong, smart woman with or without her hair. 

Hats abound.  Tennis caps, floppy sun hats, indoors or outdoors.  They suit my athletic mother --who scheduled her first chemo treatment around her tennis game-- better than a wig.

So how’s your summer?

Taking it one day at a time.   Fortunately or unfortunately, I can conjure up that old car commercial ("this is not your father’s Oldsmobile") and say this is not my father’s chemotherapy.  That was another summer 20 years ago, a different regimen, and for an incurable disease.  This time around it’s like cancer 2.0 with a better chemo concoction and a much better prognosis.

And how do you like this summer heat?

I’m trying not to sweat the small stuff, but sometimes I have trouble figuring out which is the small stuff.  Even now, when I should have perspective on what matters most in life.  Sometimes when I’m stressed about the big stuff, the small stuff makes me sweat too.  I’m working on it.  And overall, it’s been a good effort in rebalancing.   It’s mid-summer and there are lots of balancing acts, being here in the middle.  As I am a doctor but not her doctor.  As I care for mom and am a mom.  As my mother cares for her mother and for her daughters and for her grandchildren.  Chemo more than halfway done and yet other treatments still ahead.  So we try not to sweat the small stuff.  Unless it’s while on a jog or on the tennis court.

When Does The Doctor Get To Call Out Sick?

We've seen posts on this before... But I struggle every time I'm ill. This week, it's not so much my own illness that's been the major problem. It's the kids'. Because they can't sleep. And if they can't sleep, we can't sleep.

It started last week with this upper respiratory bug that's going around. Cold viruses mutate just enough over time that every few years, I get hit hard. I call it the "Three Year Cold". This one was really bad as it hit me on top of my undertreated seasonal allergies and having a 9 month old who doesn't sleep through the night. (I'm just not getting to the Neti pot.)

So no surprise that after a week of this virus, I started to get an earache. Within an hour the earache went from kind of annoying to consistently throbbing. I had a colleague look at my ear to confirm that there was a dull, red, bulging TM there. By the time I got to the pharmacy to pick up my antibiotics, it was screaming, pulsing, popping. I kept putting my hand to the canal expecting to feel pus and blood.

This is on top of a toddler and a 9-month old with copious nasal discharge and coughing. The baby HATES having her nose aspirated, but is used to sucking her binky as she falls asleep. With all the green mucous, she can't suck the binky and breathe at the same time. Thus, misery, for her and us. It's been over a week with this struggle to clear her little nasal passages so she can soothe to sleep...

Our toddler is a bit better off, but still cranky, clingy, picking at meals, whining... And waking up during the night coughing. A cup of juice and some quiet rocking lulls him back to dreams, but meantime, either me or hubby is up, again.

Night before last, it was midnight, and neither child had been able to fall asleep yet for more than a few minutes. Stuffy snotty noses, coughing, diarrhea poopies, fevers, et cetera et cetera, and we had spent hours trying all the tricks... Steamy shower, nasal aspirator, saline wipes, Tylenol, juice, singing, reading, cuddline, cartoons... And I had to be up at 5:15 a.m. for a 7:40 am start time in clinic.

I admit that I kind of lost it. I was personally miserable with my own symptoms, exahusted from several nights in a row of this sort of shenanigans, and I knew I would have only a few hours' poor sleep before I had to truck it to the city and take care of people.

"You have to call in sick," insisted my husband.

"I CAN'T," insisted me.

And I didn't. The kids eventually drifted into snoring/coughing but sustained slumber. My alarm went off at dawn. I hauled my sorry drugged-up ass into the shower, and made it to work alive. I popped Phenylephrine, chugged Dextromethorphan, snorted Afrin, gulped a whole lot of coffee, and tucked a full bag of Ricola into my white coat pocket. I saw my full panel of patients. I got some looks from people, colleagues and patients alike, for my red, swollen, flaky nose, and this wet cough. I kept assuring people, "I'm at the tail end of a cold, I doubt I'm contagious. It's my own misery."

I've commiserated with colleagues. Everyone's been through this before. But we all agree. You SHOULD call in sick for this stuff.... But we all feel like we CAN'T call in sick for this stuff.

So when can the doctor call in sick?

I remember as an intern on a busy overnight call, one of the senior residents started the evening with GI bug symptoms. It was severe, coming out both ends. By 1 a.m., he was laid out in the call room, and the nurses hooked him up to IVs. Still, we interns were coming to him for all the usual overnight precepting: running admits by him, reviewing labs, discussing cases. There was no question of, could he go home sick. We knew that he was febrile and dehydrated and not thinking straight, but it was like, there was no choice. And in the morning, the attendings heralded him as a hero for sucking it up and holding down the fort, despite having active nausea/ vomiting and diarrhea... that was contagious. That left a strong impression on me. Today, I think that was INSANE.

More recently, I had to fight with a patient of mine who also happened to be a surgeon. She had developed flu symptoms and wanted Tamiflu, but didn't want me to test and confirm Flu, so she wouldn't have to call out sick, as is mandated by Occ health. "I'm on the schedule, I have to operate," she explained.
Those are extremes. More common, I think, is our family's situation. We're all miserable, but can't justify calling out.

What would you do?

Sick mama

I'm sick. Again.

Ever since we started Melly in day care six months ago, I've been sick more than I ever have before in my life. People are beginning to think there's something seriously wrong with my immune system and the jokes about sequestering myself in a germ-proof bubble really aren't funny anymore.

"You're sick again?"

"Yeah."

"Again??"

"Yes!"

"But you were just sick like two weeks ago."

"Yes, I know."

"Boy, you get sick a lot."

"Thanks for noticing."

Aside from some more minor viruses, I've completely lost my voice on two occasions and had two pretty bad stomach viruses. I haven't had a stomach virus since I was four. And now I've got a runny nose and cough in the summer, which hasn't happened to me since I was twelve.

I understand that babies get sick a lot because their little immune systems are still developing, but why do I (presumably with a mature immune system) have to catch every single one of her colds? And how come my husband NEVER catches ANY of her colds? (As if we really need to ask why the resident who barely sleeps is more likely to get sick. Hint: it's not because I'm drinking cups of baby saliva.)

I could deal with being sick, except for how it affects my work. I always try to at least show up, no matter how awful I'm feeling, but I can't dictate or interview patients if my voice is gone. And patients don't want me to touch them, even with gloves on, if my nose is running. I try to hide it the best I can, but every now and then I can't take it anymore and actually do the unthinkable and blow my nose in front of the patient. I got thrown out of the room for that little stunt.

Too bad I don't work in a field where it's possible to call in sick. (As if it's possible for a mom to EVER have a real sick day.)