Baby names

Warning! Your name or the name of someone you love may be disparaged in this post. Read at your own risk.

It boiled down to two possible names for my daughter: Claudia or Ariana.

Pete wasn't keen on Claudia. "Would you name your son Claude?" he asked.

"No!"

"Then why would you name your daughter Claudia?" he asked practically.

Because I love the name. It's beautiful, it's solid, it's got years behind it, it's not overused. And yet, something didn't quite sit right about it. Finally, when I looked up the meaning, it all came crashing together: Claudia means lame. Of course - from the Latin claudus, from the same root as claudication. I was mortified that this hadn't been immediately obvious to me.

As a physician I'm more finely attuned to the medical implications of names than most, and I don't expect others to associate Claudia with vascular disease. But the name had been spoiled for me. Ariana it was.

Having narrowly averted my own baby naming fiasco, I am sympathetic to parents who inadvertently grant their newborns medically inadvisable baby names. By which I mean, I may inwardly gasp but I keep my mouth shut.

I met a little girl recently named Nevis. Maybe to her parents the name conjures up the beauty of a Caribbean island, but to me, well, she was a living, breathing mole.

Then I came across a variant spelling of Kyle, a name which until then I had considered benign. Chyle is a milky fluid consisting of lymph and emulsified fats, formed in the small intestine during digestion - not a preschooler.

Tanner reminds me of the stages of puberty, Addison warrants an endocrine referral, Lance is asking to be incised and drained, and Brady needs an ECG. 

I can medically bastardize most names, but that doesn't mean the general public can. So I don't recommend that parents fret over the medical implications of their name choice. Unless they're planning for a medical career for their child.

Because Melena isn't going to get past round one of the medical school selections process.

How I met your nanny

Most working moms stress about what they're going to do with their babies when they first go back to work after maternity leave. I was no exception. I had just made this beautiful, perfect baby and now I was horrified at the idea that I was going to leave her for even one second. But of course, I couldn't quit and let all those 30 hour calls be for nothing.

Initially, we were thinking about day care. A well established day care seemed somehow less frightening than letting a stranger into our house. However, most day cares in our very expensive area had a two year waiting list.... so basically, you had to get on the waiting list before you even were pregnant. And the prices were scary. The alternative was a "family home", where a registered person took a handful of babies in their home. They tended to charge less, have more openings, and fewer children.

I brought Melly to visit a family home in our area. I liked it immediately. It was very small: only two women and six children. But I still can picture the image of my helpless little 2 month old girl screaming on the floor of that day care. She was so young and I wanted her to have more individual attention. I couldn't leave her here. Not yet.

So I decided not to cheap out and I hired an agency to find us a nanny. I figured this way we'd get the absolute best quality nannies. The agency would check out the nannies, verify their credentials, and find us the nanny of our dreams. In exchange, we'd pay them $250 plus 10% of the nanny's salary for the first year.... pricey but worth it to get our "dream nanny". One agency guaranteed to find me someone in the four weeks before I went to work, so I hired them on the spot.

If it didn't compromise my identity, I would expose this horrible agency and how they turned out to be a lying bunch of scumbags. It took them over a week to send us one single candidate and she was the opposite of what we told them we wanted... for starters, she wasn't even able to work the hours we needed. I later heard an awful story about this particular agency: they instructed a nanny candidate to accept a job that she didn't want, then told her to cancel at the last minute (leaving the mother stranded), in order not to lose the client. We also read some news stories about nanny agencies who didn't check out their candidates as closely as they promised, such as one that sent over a nanny who was wanted for MURDER in another country. Scary. We lost our $250 deposit on this agency but at least we didn't end up hiring The Babysitter Bandit.

Meanwhile, my maternity leave was dwindling down and I was getting desperate...

With precious little time left, desperate times called for desperate measures: I advertised on Craig's list. I know you probably think Craig's list is just a way for murderous med students to meet their victims, but as it turns out, you can also get a nanny on Craig's list.

Several potential nannies didn't show up to their interviews and one even showed up on the wrong day (not a good sign). One was an older, very experienced and no-nonsense Mary Poppins type that my husband immediately liked, but I was wary, mostly because she wore too much perfume. Then I met Gloria. She showed up on time (score!) and the second I laid eyes on her, I immediately knew she was our new nanny. I just had a FEELING about her--this was the woman I had been picturing when I first started the nanny search. She seemed so loving, asked to hold Melly, and wasn't demanding like the more experienced nanny.

Unfortunately, my husband was stuck on Mary Poppins, so I had to convince him to give Gloria a chance. She also didn't have any actual nanny experience, but hey, the woman had three kids. We did a background check and called her (non-nanny) references, then did a practice day with her, in which she totally won us both over.

Two years later, I think Gloria was the best thing that ever happened to us. She was an amazing nanny, who took care of Melly like she was her own. I never had to worry about my daughter's safety when I was at work. One of the reasons we have been reluctant to move was that we didn't want to lose Gloria!

In the last year, we have mostly transitioned Melly to that family home we rejected when she was two months old. She's older now and we want her to have more social interaction with her "baby fwends" as she calls them. But I will always be grateful to Gloria for helping to raise Melly during that precious first year.

And that, kids, is the story of how I met your nanny.

(P.S. Happy mothers day!)

MiM celebrates one year: Anesthesioboist

The end of this month marks Mothers in Medicine's one year anniversary. In honor of this great occasion, I asked our writers to share their favorite post (of their own) from the last year. Throughout the month, I'll be highlighting their picks.

Anesthesioboist joined Mothers in Medicine last fall. Since then, we've been graced with her phenomenal writing - a true aesthetic purist (hope I'm not putting too much pressure on her with that).

She writes:

I think my two favorites would have to be "Code Indigo" and "Mom's Apple Pie."

T., thank you for making us routinely swoon from the beauty of your words and insight.

Mother's Day

My oldest gifted me my mother's day gift a couple of days early. You can have one, too: http://news.cnnbcvideo.com/index2.html?p=jbj. We have a running joke about Mother of the Year awards and my credentials (or lack thereof) at my house. This was a perfect present from my IT-savvy son. At the beginning of the school year, each child in his middle school took possesion of a Macbook for the year. Technology in the hands of my children is an amazing thing....the websites, the comfort level of navigating the WWW, the animation and movies Will has made this year blow my mind.

Happy Mother's Day to all!

MWAS

The intersection of science and motherhood

Upon learning that we were approaching our first anniversary at Mothers in Medicine, I sat down to reflect upon what I have learned. I am, relatively speaking, a newbie to blogging and to this site in particular. I think I have only posted 7 or 8 things. Most of the other bloggers have a lot more to show for themselves, and Fizzy blows me out of the water. Anyway, what I discovered is that the parallels between motherhood and doctoring are many. It has been fun to notice them, share them, and ruminate on them. But what about the parallels between motherhood and science? Are there any? To quote a one-time VP candidate, YOU BETCHA. Here are just a few of my favorites.

The following scientific definitions come with a nod to Wikipedia.

Heisenberg uncertainty principle, as originally proposed:
"In quantum physics, the Heisenberg uncertainty principle states that certain pairs of physical properties, like position and momentum, cannot both be known to arbitrary precision. That is, the more precisely one property is known, the less precisely the other can be known. This is not a statement about the limitations of a researcher's ability to measure particular quantities of a system, but rather about the nature of the system itself."

Heisenberg uncertainty principle, with children:
In parenting, the Heisenberg uncertainty principles states that pairs of siblings, like "Munch" and "Iggy", cannot both be known to arbitary precision. That is, if I can actually see my 3 year old daughter and reassure myself that she is not coloring on (as in directly on) our kitchen table, I cannot also be simultaneously upstairs to observe my 5 year old son using my two mostly full leftover tubes of Lansinoh to glue ALL of his Lincoln Logs to his closet door (true story). This is not a statement about my limitations as a mother, but rather about the nature of parenting itself. Well, that's reassuring. I love physics.

The Law of Conservation of Energy, as originally proposed:
"The law of conservation of energy states that the total amount of energy in an isolated system remains constant. A consequence of this law is that energy cannot be created or destroyed.
Another consequence of this law is that perpetual motion machines can only work perpetually if they deliver no energy to their surroundings. If such machines produce more energy than is put into them, they must lose mass and thus eventually disappear over perpetual time, and are therefore impossible."

The Law of Conservation of Energy, with children:
With children, the law of conservation of energy states that the total amount of energy in an isolated system, such as when we do not have grandparents visiting for a long weekend, remains constant. A consequence of this law is that my husband allowing me to sleep in on Saturday morning leaves him doubly trashed and incapable of functioning for the remainder of the day, even though I am peppy and grateful and ready to have a big family day. Another consequence of this law is that perpetual motion machines (aka mothers) can only work perpetually if they deliver no energy to their surroundings, which means that I basically have to quit going to work, going to the gym, going anywhere at all actually, in order to keep my head above water with these kids. Apparently, they haven't gotten to this part in preschool science yet. If mothers produce more energy than is put into them, they will cease to exist. Take heed, children and husbands...and note that Mothers' Day is just around the corner, and they don't call it the "Rejuvenating Spa Day" for nothing. It could save a life.

Second Law of Thermodynamics, as originally proposed:
"The second law of thermodynamics states that the total entropy of any system cannot decrease except insofar as it flows outward across the boundary of the system. By implication, the entropy of the whole universe, assumed to be an isolated system, cannot decrease. In fact the entropy of the universe is always increasing. We know this because we can identify processes that produce entropy from scratch, and the second law tells us that these increases cannot be undone elsewhere."

Second Law of Thermodynamics, with children:
With children, the second law of thermodynamics states that the extreme disorder and chaos of your minivan (substitute favorite location: kids' bedroom, playroom, etc) cannot decrease except insofar as you have a successful yard sale, consignment store transaction, or Salvation Army pickup. Note that if you move the clutter from the playroom to the attic or unfinished room in your basement, the entropy of your system remains constant. By implication, the clutter associated with childrearing in the whole universe cannot decrease and indeed is always increasing. We know this because we can identify processes that produce entropy from scratch (baby showers with swings, jumperoos, infant carseats and bases, activity gyms, pack n plays, and diaper pails before you even have anyone to use them). And the second law tells us that once you have this stuff, you will end up holding on to it for an inordinate number of years even once you are absolutely, positively, (almost) definitely done having kids. And when you do get rid of it once and for all--usually because your childless younger sibling, to whom you have ranted that you are "so done" having kids after a particularly frustrating day, tells you she is pregnant and wants your stuff--the empty space vacated in your home and cars will be promptly filled with Matchbox cars, Polly pockets limbs, Legos, and jigsaw puzzle pieces.

And finally, I was a literature major in college, so I am not aware of the corresponding law in physics for this one, but I know it must be there somewhere (science majors, speak up): Children expand to occupy the number of adults present. This refers to the phenomenon that I am currently living as a temporarily single parent while my husband is deployed for 5 months. It takes me half the day to get a shower on the weekend when I am here alone with them. When the grandparents or aunts and uncles come to visit, it takes all of us half the day to get a shower. Even if there are 4 adults present, everyone is occupied. Someone is changing a diaper. Someone is helping to build a pizza shooting robot out of Legos. Someone is cleaning up the food thrown all over the kitchen floor by the 16 month old during lunch. Someone is attempting to catch the muddy child and wrestle her into the tub before she leaps onto the yellow sofa. If this has never been reported as a phenomenon before and you take a notion to scoop me by submitting it to Popular Science, please consider naming it Tempeh's Law.

So, just in case you have decided against becoming a radiation oncologist and now wonder why physics was required for med school, it was because those med school admission committees knew it was only a matter of time before you would want to pass on your genes. And when you did, with Physics 101 under your belt, you'd be ready. Or at least you couldn't say you hadn't been warned...I mean, consented.

MiM celebrates one year: MWAS

The end of this month marks Mothers in Medicine's one year anniversary. In honor of this great occasion, I asked our writers to share their favorite post (of their own) from the last year. Throughout the month, I'll be highlighting their picks.

MWAS has been writing here from the beginning, sharing her stories of being a pediatrician in a private practice and being a mother of two tween boys. She writes:

When I went back and scanned my posts - the standouts were different than I expected - my writing has definitely changed over the year - which I love. I have a hard time just picking one favorite - Favorite things, 5 ways I know I'm not my mother at Christmas, & Bees and Birds are my selections.

MWAS also created the signature Seriously, I wanna know... posts where she throws out a pressing question on her mind to all of our readers. The one on keeping last name/changing name/hyphenating and the one on fiction recommendations got almost 30 comments each.

Thank you, MWAS, for a wonderful year, and hopefully, more to come.

Membership

When I arrived at my office this morning, I had a walk-in patient waiting for me. In the winter months, it’s not unusual for a parent to try to “jump the line” and want to be seen first thing, and I try my best to accommodate parent and patient. I had promised to do a medicine re-check for my nurse’s child after I made morning hospital rounds today so that we could get her child to school, and my nurse back to work. My partner saw the walk-in who had stalked Lori, my scheduler, at the back door forty-five minutes prior to my arrival, while I saw my scheduled re-check.

Sometimes parents believe that medicine is a club – one that you can join if you have the right political affiliations or money or a very important job. Membership in this club gets them exclusive bonuses –kind of like frequent flyer miles or box tops – bonuses that include a physician’s home phone number or pager and the right to call them any time of day or night. Occasionally a parent will ask for my direct number- sometimes with a smile or a giggle as they promise not to call me at 2 AM for a diaper rash or spit-up. Acceptance into this club also allows members to talk about their child’s sex education in Starbucks, or ask for antibiotics (just in case) whenever they are leaving the country for Turks and Caicos for the next two weeks.

Being truthful with myself, I accept that I am part of a club of sorts. When my triage service calls about a family friend who bit his tongue and needed advice about whether to go to the ER or not, I call the family because they‘re friends, and they would show the same concern for my children. I’ve also referred my brother-in-law with appendicitis to Dr. Ileum because he’s a friend and I know he’ll take good care of my relative. I’ve also met a fellow partner and her child in the middle of the night when she suspected her daughter had new onset Type 1 diabetes. (She was right!) My family and close friends (I can count the number of families on one hand) are default members, and they know there are rules about membership.

The notion of an exclusive membership or concierge medicine doesn’t sit well with me. As humanly possible, I try to treat my patients as well and equally as I would treat my own family or friends regardless of socioeconomic status. There are boundaries, though, and limit pushers that make me put my foot down. I won’t write prescriptions on the fly for administrator or staff’s children anymore when I’m trying to make hospital rounds. It’s not fair to my patients to get distracted like that. I cannot prevent a patient with lice showing up on Sunday morning on my front porch, but I won’t let them expose my kids. My phone has caller ID, and we screen the calls heavily, so when I’m not on call, I’m focused on my family, and my personal time. It’s all part of a balancing act that I’ve had to learn bit by bit.

Ship 'em off!

When I made a post last week about fellowship, I was surprised by one commenter who suggested the idea of living apart for a year while I did a fellowship. Either my daughter could come out with me and I could manage as a single parent (eep!) or she could stay with my husband and I could just visit on odd holidays.

Now I've lived apart from my husband for periods of time and it was not fun, but it was doable. But living apart from my child is a totally different ballgame.

I know the commenter meant no offense in this statement, and the truth is, women do this. I know of a few female residents who have sent their babies to live in their home country with the grandparents while they furthered their careers. I don't judge these women but it's not something I would ever remotely consider.

In my daughter's entire life, I have only been away from her for one single night. (Not easy to manage as a resident!) My husband has only been away from her for a handful of nights. For either of us, it is painful to even contemplate a year spent apart. I can do a fellowship in ten years from now if I want, but AGE TWO is only going to happen once. I'd never forgive myself if I missed out on it.... or if I put my husband in a position where he was forced to either give up his job or miss out on it.

For me, feminism does not necessarily equate with always getting my way in terms of career.

Mother of the patient, part II

Since our last visit to the ER less than a month ago, we have been to the doctor's for my son several times. First it was the acute visit follow-up, then his routine well-child visit along with associated vaccines, and then this week, another acute visit for allergies.

I had been noticing him rubbing his eyes a lot, often with the appearance of allergic shiners, rubbing his nose, and the occasional rapid-fire sneeze sequence. My poor boy, one day, was itching his eye so much that it became swollen and red and I feared he would gouge out a layer of his cornea with his thumb. He couldn't sleep due to the itching, crying while standing at the crib rail, itching his eye. Even after I came in and rocked him to sleep, holding him, he continued to rub his eyes in between soft snores.

Of course it was the weekend. Everything only happens during the weekend.

So early this week, I took him in for a visit at the Pediatric Clinic.

We saw a resident. This time, I did not say anything about being a physician, but it must have been in the chart because he knew. I got the sense that he did not have much experience with toddlers with allergies. I sat patiently while he read Up to Date and consulted his Harriet Lane. He presented the options of just treating symptomatically with Zyrtec, skin testing via an Allergy consult, and performing a RAST screen on a blood sample. I was leaning towards some kind of testing; it seemed more logical to me to identify potential triggers and to try to eliminate them as much as possible rather than blindly treating with medications indefinitely.

But, I also wanted to know what his attending's experience was with this and trusted his/her guidance on this. Plus, I wasn't too familiar with the different sensitivities, specificities of the various tests. He went to go discuss our case.

I have to say I was a bit disappointed that the attending never came in to introduce herself or talk to us. Instead the resident just came back and said she thought we should just treat with zyrtec and that skin testing, in the absence of planned immunotherapy, was pointless. She thought allergy testing was way too aggressive, at least that's what I heard second-hand.

I left feeling kind of dissatisfied with the whole experience. With not seeing an actual attending. With a management course I wasn't 100% on board with.

But, after talking it over with my husband and doctor friends, I decided to push for the allergy testing, at least the RAST as a primary screen. I didn't want to commit my son to medication long-term without knowing the causes.

I called and left a message for the resident who did not call me back until I left a second message. (Was I just a pain in the butt physician parent that had to be avoided?) I think I nicely stated my concerns about not knowing my son's triggers and he ordered the RAST right then.

Today, I took my son to get his blood drawn. So, he's never had blood drawn outside of routine newborn tests and it's been a long while since my peds rotation...I failed to remember how traumatic getting blood from a 15 month old can be.

There were 2 adults holding him down while another poked him with a butterfly needle in his right antecubital. Oh, how he cried and struggled and looked at me as if I betrayed him. I kept kissing his forehead and wiping the beads of sweat on the bridge of his nose and his face. They could only get a few cc's from the right and had to switch to the left. At one point, I was ready to call the whole thing off. No more. But I also didn't want to have to do this again.

I suddenly appreciated how this might be the aggressive approach.

Just a few hours later, I was holding him while at the store. He kept raising his shirt and itching. Detergent? I set him down and lifted up his shirt. Red patches, scattered, maybe where he was itching. Yes, definitely a rash. I showed my husband. It was looking more urticarial by the second, yes, definitely the beginning of hives. He looked otherwise well. No trouble breathing. Not feeling ill but itching.

My heart started to race. I had benadryl in the diaper bag, just in case (ever since Tempeh's post actually). Our plans for the afternoon took an immediate detour back home, keeping a close eye on him during the 15 minute car ride for any clinical changes.

Husband: He's itching his leg.

Me: His right leg?

Husband: Yes.

Me: He always itches his right leg. That's where his worst eczema patch is.

At home, I stripped him down to his diaper. I gasped.

Huge urticarial welts covered his back. HUGE. Just the sight of them on his soft baby skin made me cringe. What did he eat? We grabbed packages to read the ingredients. Got on the internet and did rapid searching. I thought back to earlier this week when our nanny gave him some green beans in a peanut sauce that made me hyperventilate when I discovered it, despite our instructions not to give him nuts or shellfish.

The hives melted away within 15 minutes of taking the benadryl. I, however, am on perma-edge. I still don't know what he ate that did it - nothing new. Cheese and Ritz crackers right before.

Suddenly, I'm glad we got the blood test. Maybe it was the right decision after all.

To Get to the Other Side

There are times in life when everything seems to fall right in to place, and then, there are times like now. I can see the shimmering oasis of a new life, just on the horizon. A better call schedule, closer to family and friends, a chance to work in a collegial (not competitive) environment, more time with my precious kids and husband, and a chance to grow as a physician. Between the oasis and where I stand, however, is a treacherous, rock-filled, rapid river, swirling and threatening my ability to ever reach the opposite shore.

Obstacle #1 - Our house is on the market, and we have shown it at least a dozen times. Yet, despite positive overall feedback, not a single offer. I don't mean to boast, but our house is a beautiful house. I love it. I was ready to buy it the second I walked through the front door, and I can't believe that everyone else that sees it doesn't feel the same way. We never thought we would have to sell this house. Maybe we should have thought about selling it before we bought it. If we don't sell before we move, we'll have a hefty house payment, along with any rent payment we need to pay in Newville. This alone will be a financial strain.

Obstacle #2 - Mr. Whoo has yet to find a job, nor procure an interview in Newville. Granted, he has only starting looking in earnest recently. However, he is looking for work in the finance world, which isn't the best place to be seeking employment given the current state of our economy. We have been fortunate that he was able to quit his job last fall when our family really needed it, but now we worry that the employment gap may cause an impetus with new employers. Plus, without an additional income after the move, there will be more financial strain on our family. (See Obstacle #1)

Obstacle #3 - My current place of employment is not letting me go without a fight. There have been veiled and outright threats of lawsuits and damages and liabilities for me leaving earlier than my contract had mandated. There is also the matter of giving back a portion of student loans paid by the hospital. The fact that we would have to pay back was not unexpected, however, the amount that we calculated is about half of what the hospital estimates. We are procuring the services of a contract negotiator and a lawyer, who seem to believe we have a case for inducement, but I'm having angina just thinking of it. Not to mention the fact that, if the hospital's calculations are correct, they want us to pay up in less than 2 months. Add more financial liability to the swirly, cold, and fast water.

Obstacle #4 - Emotionally, I am wrung out. I am completely exhausted, and barely hanging on by my fingernails to make it to the date I indicated I was leaving. Being on call, continuously, with only 4 days off per month (plus vacation time), has left me completely burnt out. I find it hard to drag myself to work and muster compassion for my patients. They deserve better than the doctor I am right now. My health, mental and physical, is suffering. The remainder of my contract is a mere six months, and by finishing it out, I can alleviate much of the financial burden of the above obstacles...for the price of my very sanity. I want to cry just thinking of it.

So, I sit here on the bank, pining for the oasis, and unsure how to navigate the obstacles that lie before me. Oddly, I am reminded of the "old school" computer game, "The Oregon Trail." When faced with a river, you can try to ford the river, float the river, or hire someone else to help you across. Right now, I am pining desperately for someone to throw me a life line, or at the very least, a strategy for surviving these treacherous waters. The best advice I can relate to our readers is to know what you are getting in to before you sign a contract. There is no such thing as a perfect job, and if it seems too good to be true, it, in all likelihood, *is* too good to be true. Caveat emptor...and pass the caulk.

*cross posted at Ob/Gyn Kenobi

There's a reason they call them "fellows"....

This is going to be a bit of a rant, so apologies in advance...

I've made no secret of the fact that I'm not terribly enamored with the field of medicine or being a doctor, but I've managed to actually find a specialty that I love. And within that specialty, there's a subspecialty that I'm very interested in. I've been nerdishly dreaming about a one-year fellowship for a while now, but it's beginning to look like that dream isn't going to be able to come true for me.

I'm not going to get into the details of my own situation, because "it's complicated" (like my younger brother's Facebook relationship status). But I am going to make a really broad generalization and say that it's really rough for a woman with a child to do a fellowship. Granted, some women do it. I know because I see female fellows with pictures of babies on the back of their IDs so I'm guessing they're mothers (unless the photo came with the ID badge). But it's rough.

Here's why:

Fellowships tend to be competitive. So unless you're doing a fellowship nobody wants, like, in rectal exams, you have to be geographically flexible. (There's no such fellowship, by the way. Didn't mean to get anyone's hopes up.)

Being geographically flexible means possibly uprooting yourself to do the fellowship. It's not quite as big a deal to camp out in Whereverland for a year if you're a single person, but it feels a lot more selfish to force your spouse and child to move with you. To give up your home, your daycare/nanny, your spouse's job, etc.

For a man with a family, it can be just as hard, but I'm going to go out on a sexist limb and say that it's harder for a woman for a couple of reasons:

1) There are a lot of men who are totally cool with being stay at home dads and I salute them. But most men aren't. In this economy, it's not easy to find a job and there's a chance your spouse could be unemployed indefinitely if he gives up his job. For a lot of men, this would be a huge blow for their self esteem, possibly one that's unacceptable and would result in marital discord. For women, less so, in general.*

2) I think a lot of women tend to feel that their career takes a back seat to their husband's career and their family's needs. For me, the thought of uprooting my family for my own selfish career aspirations just feels really wrong. I can't do it.

So that's that. My nerdy dream, up in flames. Sigh.


*I am making a bunch of broad generalizations. Please don't throw something at me if you are an exception.

Medical training and marriage

At the park today, I was talking to another parent I know who is not in the medical profession (for the sake of ease, let's call him Fred). Since Fred knows I'm a doctor, he mentioned he had been watching a TV show on NOVA that followed 7 Harvard-educated doctors over 21 years.

Fred told me that he was amazed by both the hard work that these people put into their careers but also by the way their relationships were ripped apart by their professions. He said all but one of the doctors ended up divorced.

I always felt that med school brought my boyfriend (now husband) and I closer. He was actually a much better boyfriend when I was stressed out and upset--he was incredible at calming me down. If I hadn't been dating him during my surgery and ICU rotations, I might never have discovered what a perfect match he was for me. And he learned that I was willing to put my relationship before my career.

For this reason, I tell med students who are concerned about relationships that med school is actually a great test. After all, with all the stress of my 3rd year clerkships and internship, the hardest year in our marriage was probably the first year after our daughter was born. I've heard that's common. Wouldn't you rather know your relationship stands up to stress BEFORE you have a child?

Yes, a lot of long term relationships fall apart during medical training. But 50% of marriages in the general population fail anyway, so clearly a lot of people are getting married who aren't right for each other. Perhaps medical training just hastens the inevitable.

ASS-U-ME

So you probably all know the old saying about what happens when you assume, but just in case anyone is coming late to the game, I'll remind you: when you assume, you make an ass out of u and me. Nowhere is this truer than in medicine.

My 5 year-old son has a life-threatening allergy to eggs and peanuts. His allergist told us ominously a few years ago, "Kids with known peanut allergies have a life-threatening event every 4 years on average." Ever since then, we have been holding our breath, thinking that we are past due. We have been extraordinarily cautious since learning about his food allergies when he was only 4 months old. We have no peanut-containing products in our house ever, period, and have eggs at home, but keep them far from my son and cook with them only under very controlled situations (since his egg allergy is less severe). He attends a "peanut-free preschool." We have Benadryl and Epipens in every bag and car and never leave home without them, even to go for a walk down the street. We have stopped flying airlines that serve peanuts. Everyone in his life, from family members to friends to our nanny to his preschool teachers, knows that we have to read the labels on every food every time. Most of them are far more conscientious about this issue than I would likely ever have been before it touched my own life, and many have gone to great lengths to learn where to buy or how to prepare foods for him safely.

My son's preschool teacher is one of the most endearingly over-cautious individuals of the bunch. She will often dash outside on mornings when I am dropping him off to make sure that the candy they will be using for the buttons on a snowman is safe for him, even though the ingredients are literally "sugar and Blue #4". Our nanny is also meticulous about keeping him safe, having chased after me more than once when I left his Epipen behind as I headed out to the car with him, and having noticed that the same cookies we have been buying every week for 2 years, which have always been safe, now say "May contain peanuts". I really don't worry about his safety when he is in their care, and they are pretty much the only two adults I ever leave him alone with for any length of time as a result.

Yesterday was the 4th birthday of one of my son's preschool classmates, Anna. Unbeknownst to me, Anna's mother had asked their teacher weeks ago if she could bring cupcakes. The teacher told her no, not unless they were made without eggs. Apparently she also inquired about bringing in a variety pack of mini candy bars, which his teacher also rejected not only because of his allergy, but the fact that the preschool is officially peanut-free and many of those would surely contain peanuts. Anna's mother, determined not to give up, went to Costco and bought a big container of gourmet jellybeans, which she divided into little snack sacks for each of the kids and sent to preschool in Anna's backpack. Their teacher helped Anna to pass them out to each of the children, including my son, at the end of class.

I am in clinic on Wednesdays, so our nanny picks up my son. When she got there, he had his head down on the table and said he didn't feel well. She noticed that his bag of jellybeans was mostly full, unusual for my son who is a sweet fanatic. He had eaten only a couple of them, he told her, since he felt kind of sick to his stomach. But then he asked to be able to stay and play with his friends in the adjacent play area, so she forgot about it. After playing for awhile, he came back to his goodie bag and ate a few more jellybeans. Within 5 minutes, he was complaining of nausea and saying he needed to put his head down. Noting that his "nausea" coincidentally occurred as they were being asked to clean up, she didn't make much of it. By the time they got back to our house, less than 2 miles away, he was coughing and wheezing, complaining that his throat was tight, and dry-heaving. She promptly gave him Benadryl and called my cell phone, Epipen in hand. By the time I answered 3 rings later, his face was noticeably swollen. She knew he was having an allergic reaction, but to what, she said, she had no idea. He hadn't eaten anything that should have peanuts or eggs.

When I talked to my son about what had happened later that day and asked him what he thought had made him sick, he said without so much as a pause: "those speckled jellybeans I ate at Anna's party". When I asked him how he knew, he said, "the package didn't have any words on it, which means there could always be peanuts," a rule I have repeated over and over to him for the last 5 years of his life. At least he has been listening.

Ultimately with treatment, my son was fine, but how on earth did this happen? My son is extraordinarily aware of the seriousness of his allergies and routinely surprises me with his own cautiousness about foods that didn't come from our home. He was in the care of multiple people who know him, love him, and are frankly paranoid of messing this up. I called his preschool teacher later that day, quite distraught, to tell her what had happened and to let her know that he was fine, in case she had already heard through the grapevine. She had and had immediately called Anna's mother, who checked the label of the jellybean container and confirmed what I already knew: peanuts, plainly listed among the ingredients. In fact, one of the gourmet jellybean flavors was PB&J.

It turns out that Anna's mother JUST ASSUMED that jellybeans would be safe, so she never actually thought to read the label or bring the original container to preschool. Understandable. Who would suspect jellybeans might have peanuts in them? I wouldn't. His preschool teacher JUST ASSUMED that Anna's mother must have checked the label since she had asked so many questions about which foods were safe to bring to school for Anna's birthday, so she never actually asked her whether the jellybeans were definitely peanut- and egg-free. Understandable. Anna has been in preschool with my son for months, and his allergies were widely known in the class. My son JUST ASSUMED the jellybeans were safe since Anna had brought them, and his teacher had handed them to him, so he never actually asked. Understandable since he is just beginning to read and has learned he must rely on a few trusted adults, one of whom is his teacher, to tell him if a food is safe for him to eat. Our nanny JUST ASSUMED that the jellybeans must be okay for him since a friend's parent had brought them and his teacher had let him start eating them, so she never actually asked to see a list of ingredients. And our nanny JUST ASSUMED that, because he had already eaten some and was apparently okay that, when he began demonstrating the earliest signs and symptoms of anaphylaxis, which she knows very well, it could not have been the jellybeans.

This could all have been prevented had anyone NOT JUST ASSUMED. This is why two OR nurses count sponges at the end of a case, to make sure none get left inside a patient. This is why two oncology nurses independently verify the chemotherapy dose the medical oncologist has written before giving it. This is why the blood bank requires that the nurse check the hospital bracelet of the patient she has been caring for all week and match it to the name on the bag of red cells before starting the infusion. These policies realize explicitly that when you assume, it is only a matter of time before you make an ass out of u and me. And if you're a health care worker, you might kill someone in the process, too.

As I tried to think of medical examples for this post, I was struck by one thing. All of the ones that quickly came to mind involved nurses. The reality is that, on this issue, they are light years ahead of doctors, who may have historically been too proud to acknowledge their potential for error...and who in many cases remain so. The attention recently given to the alarming prevalence of medical errors has led to some positive changes in physician behavior, such as surgeons initialing the correct side of surgery while a patient is still awake before a planned amputation or joint replacement, for example. But we still have a long, long way to go before these double-checks are built into every important medical decision. And finally, let us remember that all of these practices arose from the terrible tragedies of patients, most victims of health care workers JUST ASSUMING.

If you are a medical student or a nurse or a physician in training, there is a lot of unspoken pressure to just assume that someone "superior" knows what he or she is doing and not to question that person. If you are that someone "superior," there can be a lot of unspoken pressure to appear to know what you are doing and not stop to question yourself. Please, for everyone's sake, don't assume anything. Stop to question. I can promise you that it is only a matter of time before your questioning will save someone's life.

Love and Wonder in a Carcass

I got out of work unexpectedly early yesterday and went for a walk with my husband around our peaceful neighborhood.  The weather was sunny and cool - glorious, really.  It's about time we started seeing days like this in New England.

Just as we were coming back around the block toward our house, my husband spotted something on a neighbor's lawn.  It was a tiny skull of some sort attached to a vertebral column with some ribs still connected to it.  The remains of a small animal picked clean of all its flesh, its dry bones curled almost into a fetal position.

I immediately went to get my camera and find my son, who was watching some of the neighborhood boys shoot hoops in a nearby driveway.

"Where are we going, Mommy?"

"I want to show you something.  It's a mystery.  The skull and spinal column of a small animal.  I'd like your opinion on what it might be."

At this, my son acquired more of a spring in his step as he followed me to the grassy area where I had first seen the bones.

"Cool."

He put his baseball cards in his pocket and knelt on the sidewalk to look at the specimen.  "It could be a chipmunk," he suggested.

"That's not a bad idea," I said.  "It's certainly about the right size.  Shape of the head seems right too."

"Or maybe a bird?"

"Possible.  I don't know enough about the skeletal anatomy of birds versus mammals to be sure, come to think of it, though I'm thinkin' mammal."

We looked at the skull from different angles, and I noticed in the concave hollow of the base of the skull a very similar architecture to what I remembered about the base of the human skull. There was even a recognizable foramen magnum leading like a secret portal to the vertebral column.  

"Hey, look at that," I whispered to myself.

"What?"  my son asked.

"Our skulls are not that different on the inside from this little animal's.  They're engineered so similarly.  Amazing."

I said I would go back to our house to find my anatomy book.  As I got to the door I heard one of the neighborhood boys ask my son why his mom had brought him down the road, then heard my son explain about the "cool" animal bones and invite them all to look. I had a brief mental picture of a group of neighborhood boys gazing intently at the little skeleton on the grass, and I smiled at the possibility.

"Honey, have you seen my Netter?" I called as I entered the house.

"I think it's at the bottom of a whole pile of your medical books upstairs."

I rummaged through various piles of books and finally found it - an old friend from medical school, still with me after all these years.  I went back outside to where the boys were shooting hoops and called my son over.  I turned to the page showing the inside of the base of the skull.

"See?  Remember how the animal's skull had these depressions in the bone, just like this, like someone scooped out part of the inside of a bowl?  Our skulls are the same."  By this time three or four other boys had gathered around to look.  I was delighted with their curiosity.

I was pleased to hear, too, that they had been debating the identity of the animal.  A boy my son's age had suggested a mouse.  "There are some mice on B Street, so maybe there are some over there too."  I agreed it was a reasonable suggestion.  Another, older boy proudly put forward his hypothesis:  "It's probably a baby squirrel eaten by a crow.  They fall out of the trees a lot."  This sounded eminently plausible to me as well.

I closed the book and started for home again.  "I'll see you there for dinner," I said to my son.

My time with him had cast a glow inside me.  It was as if the afternoon sunlight had managed to get through even there, to places unseen, and turn what was dark into gold.  The little hollow of a dead creature's bone held our closeness like a cup.  A tiny chalice pouring out wonder.  A passage through death and mystery to blessed life.

[Cross-posted at Notes of an Anesthesioboist.]

Mothering

Relationships with our mothers can be complicated, and mine is no exception. Our past 12 months have been challenging owing to illnesses, schedules and the 600 mile distance between our homes. Through the help of a wonderful therapist, I understand the dynamic between myself and my mother – intellectually – but the emotional part still struggles to keep up. The funny thing about therapy is that it helps me understand the past but not how to navigate aspects of the future.

For example, my father recently left me a message on Facebook (of all places!) that my mother was going to have a bone marrow biopsy for a chronically low platelet count. Based on fuzzy memories of my heme-onc rotations, bone marrow biopsy = cancer until proven otherwise. I google chronic thrombocytopenia looking for answers and a differential. That’s the default setting on my brain – back to logic & science & evidence. I also pick up the phone.

“Hi, Mom. How are you?”

“I’m fine. I’m supposed to have this test tomorrow in the hematologist’s office.”

From the tone of her voice, I can tell she’s on the verge of being unhinged by the test – not the potential diagnosis – although to her credit she’s been through early breast cancer (DCIS) & a course of radiation.

“Dr. Bone Marrow is very reassuring that the test is not a big deal.”

“Mom, you need to ask for Versed & lots of it.”

Flashback to standing at the bedside in the wards of the Navy Hospital. My face is hot as the blood is rushing to my toes in sympathy for the 6’5” man who is howling as the team of physicians are drilling into his pelvic bone. Flash back number two is in the OR with our heme-onc attending as they are putting his 8 year old patient with ALL to sleep. He readies the biopsy tray with classical music tinkling in the back ground.

“You don’t need to be pain.” (Thus my reason for being in therapy in the first place: the complicated dance of daughter nurturing mother. Once again the choreography takes off before I’ve even got my shoes on. )

“How do you spell that drug?” She asks.

“V-E-R-S-E-D.”

“OK, I’ll ask.”

She leaves me a message the next day thanking me. She and her doctor have decided to schedule the procedure in the interventional radiology suite with conscious sedation. She’s still somewhat unhinged by this. She wants to know more about conscious sedation. This time our exchange is mid-day by e-mail.

MWAS@gmail: It will be like your colonoscopy. Probably some Versed and monitoring.

MOM@gmail: OK. They have me scheduled for Friday with the radiologist.

MWAS@gmail: Talk to you later. Love you, Mom.

Post procedure was anti-climactic. She did well, and had glowing things to say for the radiologist and his nurse. With my father on the phone, some more piece of her puzzle slide into place. Mom’s been losing weight unintentionally for several months. She also has a low white cell count. She feels fine, otherwise. We all dance around the big C - and it leaves me wondering if that’s mom and dad’s doing or the doctors until they have a diagnosis. Intellectual mind whirrs through the differential: leukemia – maybe a chronic form like CML, viral infection (that’s the pediatrician in me), or some type of autoimmune problem like rheumatoid arthritis which runs in our family. There could be other reasons, but my adult medicine is rusty and inexperienced.

Emotional mind is reeling. Oh Crap! (and several other expletives) As much as I want just intellectual mind to deal with this, the therapy that’s trying hard to integrate the two aspects intervenes. I feel lost – not sure who is supposed to show up – the intellectual nurturer or the emotional daughter in need of her own nurturing but afraid to ask. To be continued….