A Loss Rich With Things Gained

Some things are only noticed in their absence. The hum of a fan when you are falling asleep. The tension in your shoulders after a deep massage. The leaves on the trees after they have all fallen to the ground.

I did not notice the anger and tension I carried with me everytime I walked into a particular room in the NICU. The infant in the bed in the far left corner, through no fault of her own, inspired in me a jaw-tightening, face-flushing frustration of a strength I am ashamed to admit. And I only realize that strength now that she is dead.

She was delivered at 24 weeks gestation and had the usual early lung disease and inflammation with which the extremely premature infant struggles. Her parents wanted us to 'do everything' and we abided by their wishes. We did everything medically at our disposal and pulled out all the stops until we were sure she was going to survive. There is a difference among living, existing, and surviving. Surviving is a physician's goal for their patient, especially if their patient is at the beginning of their life. Living is what a parent wants for their child; to hear them laugh, to see them smile, to watch them observe and learn from the world. My friend in the far left corner was doing neither. For 8 long months, she struggled to pull air into her lungs that were for all intents and purposes, the consistency of leather. During this time, a tracheostomy was placed so that the breathing tube would not wear through the roof of her mouth and she would be able to suck on a pacifier when she was upset. She never sat up. She never cooed and babbled. She never rolled over. Her lungs were so badly damaged that everytime she got agitated she would become hypoxic and her heart rate would drop dangerously. Because of this, we gave her ever increasing doses of sedation and pain medicine. Towards the end, we could barely let her wake up at all for fear of losing grip on her tenuous oxygen saturations. She was merely existing. And yet we kept going.

After watching a baby struggle so hard to live, it hurt me to watch her struggle so hard to die. I realize now that my anger came from walking into that room and feeling like I was playing on the wrong side of the field, fighting for a cause in which I didn't believe. I don't make the big decisions here. I'm not sure that I could. I make critical acute care decisions so these infants will survive until morning. I looked at her night after night and silently told her that I was sorry, so sorry for doing this to her.

A week ago I walked into that room and reflexively glanced at the far left corner. She was gone. I felt the weight lift from my shoulders and the breath that I had been holding let go. There was a lightness in the room that hadn't been there before. What was left behind, for me, was that her struggle was not in vain. She won after all. I choose to believe that she is at peace. Finally.

A "Novel" Landscape

Is anyone else sick of hearing about the flu? I mean, i'm safely sequestered from the masses up here in the NICU, which typically shows no bias for any season, and I can't tell you how many times I have been asked about the novel H1N1 flu. I walked into work the other day and the charge nurse practically tripped over her own feet trying to aim a loaded needle at my deltoid with one hand and waving a consent form in the other. To be completed simultaneously no doubt. I felt like I needed to hold up my armored shield. Renaissance-style.

The visitation policy here has become severely restricted since the epidemic hit (just in October here in the suburbs of Chicago). Only the parents of the infants here can visit....no siblings, no grandparents, no aunts and uncles. Regardless of whether they have been ill or had contact with anyone with flu-like symptoms. For some, this sounds like no big deal. Common sense even. But, for the woman I spoke to earlier this evening, whose 30 week twins are threatening to arrive any moment now, it was a crushing blow that her mother, who traveled all the way from Israel to be here for the preterm birth, cannot see these babies in person for the foreseeable future.

Are we overreacting? Are we responding to mass hysteria surrounding the H1N1 flu? Is the pandemic really severe enough to warrant fast-tracking a vaccine through limited testing to be produced in limited supply? Will the worst of the wave be over before those 'priority groups' even have access to the vaccine? Yes, I get my flu shot every year like a good health care worker. My response to those who say "I've never gotten the flu so I don't get a flu shot" is this...Do you not wear a seat belt just because you've never been in an accident? And yes, I did get my H1N1 flu shot this year as well (the nurses were coming at me with needles like darts at a dart board!). I am not a conscientious objector. But I do wonder...

Going Back to Cali. Cali. Cali.

I just returned from a fabulous trip to Washington DC where I had the pleasure of attending the AAP National Conference and Exhibition. The fact that I was able to hang out with my closest friend from residency and see some colleagues I had lost touch with made it even better. The conference is an enormous conglomeration of pediatricians combining learning, networking, reconnecting, and socializing (with the aid of a drink or two) and it all runs like clockwork. At least it appears that way to my untrained eye! There is a welcome reception on the first night and I can only compare it to a wedding reception complete with a band, buffet, open bar and embarrassing numbers of uncoordinated doctors dancing. The next day is kicked off with talks beginning at 7am. No, I didn't go to any of those. There is a limit to my passion for learning... The next night the conference attendees were able to take over the Smithsonian American History museum and left to wander for 3 hours. An amazing opportunity to see the museum without hordes of tourists. So fun! And do you want to know my favorite part? Julia Child's kitchen. Oh I drooled over her pots and pans and the counter space! Holy heck! The Young Physician's reception the following night was another opportunity for free food and drinks and connecting with residency classmates from around the country. All in all a great time for everyone...except maybe the circumcision protesters hanging around outside for 4 days. They looked a little lonely. And cold.

Can I let you in on a little secret? I'm charged with planning the Young Physician Section programming for next year's conference. The topic is advocacy and so far i'm really pleased with our potential speakers. This is timely in the wake of health care reform and the legislative battles being waged. Don't you wish you knew more about how to get your voice heard? Or how to get the people around you excited enough to want their voice heard? It's hot. It's fresh. It's delivered right to your door and all you have to do is meet me in San Francisco next October. And don't forget to wear flowers in your hair. Or something to that effect.

Guilt is a 4 Letter Word

The strangest thing happened to me this week. I woke up one morning and literally could not move my neck to the right side without a searing pain shooting up into the back of my head. Sort of like someone surprising you by yanking on your hair as hard as they can. Or greeting you by whacking the back of your head with a baseball bat. Yep, some morning. Of course I cursed myself and my pillow for lack of a better etiology of said immobility and proceeded to take ibuprofen and get on with my day. I taught my PBL class as usual and the plan was to meet my husband for lunch and then head home to rest (and take more ibuprofen) before heading into work for the night. I got through class alright but while eating lunch discovered I could not lift my fork to my mouth without a spasm of pain. In fact, I couldn't use my right arm much at all without being reduced to a cringing mass of tears and yelping. I judiciously checked my self for nuchal rigidity and fevers. Nope, no meningitis or novel H1N1. Just a good old fashioned...neck pain? My dear husband put pathetic me into a cab for the ride home, sparing me the embarrassment of wailing on the bus. Once I got home I had a dilemma. If I couldn't use my right arm and neck pain was getting worse (I was just waiting for the fever, rash, and photophobia so that I could run across the street to the ER and cause a public health panic), could I really perform procedures and resuscitations and stay up all night while giving my job the focus it requires? Well, no. But does that mean I should stay home? I literally sat at my kitchen table (with a heat pack around my neck) for 30 minutes pondering this reality. I came to the conclusion that I couldn't do it. At that point I couldn't even undress myself. And I was scared. What the heck was going on?! So I called my boss and told him I couldn't work my shift that night and explained why. He completely understood and told me to let them know how I was feeling the next day. And do you know what I felt when I got off the phone? In equal amounts to the physical pain I was feeling (plenty, I'm no baby) I felt...guilt. Guilt because I was a physician who couldn't repair myself well enough to fulfill my obligations. Guilt because my boss was so generous even though he would have to scramble and find someone to cover for me in the next 3 hours. Guilt because that meant someone would have to spend the night unexpectedly in the hospital after a full day of work. Guilt because that someone would likely have to apologize to their families for not being able to come home because "someone called in sick". And it didn't end there. Back at work last night, everyone was gracious enough to ask how I was feeling and tell me that if I needed more time (I didn't) they would have covered more of my shifts. The attending who covered for me that night has a 3 month old breastfeeding baby at home AND was up all night performing an exchange tranfusion on an infant. Oy! If my thighs were as well toned as my guilt muscle I would be strutting on the beach til December.

I started to think about this. Why on earth did I feel so guilty about something over which I had little to no control?! I know plenty of people who will call in sick when they have the sniffles or a headache or just need to take a 'mental health day'. Some of you may identify with the feeling that as a physician, we are supposed to perform our duties unless we are patients in the hospital ourselves. Physicians who come to work come hell or high water are revered as being 'committed doctors'. I know a critical care attending who spent so much time in the hospital his wife would have to beg him to come home to spend time with the family. He was exalted as a model to which we should strive. But really? Does that make one a better physician? The novel H1N1 protocol for healthcare workers at our hospital states that anyone with a fever and influenza-like symptoms must stay home for 7 days from the last day of fever. Anyone. The nurses take this very seriously. The doctors? I bet you dollars to doughnuts they are laughing and wondering how they can evade the infection control officers. Unfortunately, I'm afraid in this culture taking an unscheduled week off work is tantamount to handing in your 'good doctor badge' and who really wants to deal with the guilt when there is work to be done?

Need A Netflix Fix?

Whoa! So sorry it's been this long since I last blogged. My excuse is that I was out of town (hiking in Boulder, CO! Awesome!) and then came home with a brewing cold (damn those dirty airports!) and then, well...I had writer's block. I tried and tried to think of something thought-provoking, timely, pertinent, or witty and came up empty again and again. As I was complaining about my scarcity of creative juices to my husband, he flippantly said "Why don't you write about your favorite movie?". And I thought, perfect. The movie I have in mind is both pertinent and thought-provoking and somewhat timely as it came out in 2008. This film is a take your breath away, punch in the gut, nauseating emotional roller coaster and I highly recommend it. I dragged my husband to see it on an icy weeknight last spring and I still don't think he's completely forgiven me.

The film is a documentary called Dear Zachary: A Letter to a Son About His Father. The brief premise (no spoilers here) is that the filmmaker's best friend, a Family Practice resident in Pennsylvania, is brutally murdered by his ex-girlfriend. This ex-girlfriend reveals after the murder that she is pregnant with his child, Zachary. The filmmaker knows that Zachary will never know his father so he sets out to make a documentary about his life by interviewing everyone who ever knew him. Meanwhile the murder investigation is still going on...If you can resist, don't read anything else about the movie before you see it. It is most powerful if you go in not knowing what to expect. You might sob uncontrollably. But it is so worth it.

Old Habits Die Hard

Have I mentioned yet that I love Fall? I love the weather, the leaves, the back-to-school sales, the food. Not to mention that my 1st wedding anniversary is coming up this fall. One thing I haven't gotten used to since making my move from Arizona to Illinois is the change in my outdoor activities. See, in Arizona people take the summers off from outdoor sports due in part to the very real risk of death from heat exhaustion. Third degree burns from a seat belt is not an unheard of occurrence. You've heard that people in AZ can bake cookies on the hood of their car in summer right? Anyway, I would cut back on my running and resign myself to exercising in the gym. My friend Barry always laughed at me when I heralded the "start of the running season" come mid-September. Right about now in fact, when it is cool enough to run outdoors at 6am and not die. I practically bounded down our running path because I missed it so much over the summer.

The opposite phenomenon occurs here in Chicago. People come out in the summer in droves. Most major races are in the fall assuming a summer well spent outdoors training. See, I just can't get my head around that. I do my best running Oct-April. Old habits die hard. So what did I do this summer during my running hiatus? Bikram yoga. If you are unfamiliar with this particular form of torture, errr, exercise, let me enlighten you (so to speak). Picture a large room heated to 105 degrees and 40% humidity, lots of scantily clad people dripping sweat while folding their bodies into vertebrae-curling, tendon stretching, muscle-quivering positions and holding them. For an hour and a half. Hmmm, well I do enjoy a challenge. My goal was to do this class everyday for a month. That lasted about 2 weeks. What they don't tell you is that along with the enlightenment, serenity and peace you feel comes a boatload of laundry. A towel to lay on your mat, a towel to wipe your face, a towel to dry off after class (because the other ones are soaked), a change of clothes (because who wants to ride the bus soaking wet? I don't and neither does the person sitting next to me), then another change of clothes because the clothes you rode home in have become soaked because you can't stop SWEATING. See what I mean? I actually liked Bikram yoga and plan on trying it again someday when I don't have to ride the bus home (I have my limits). But what I really got out of taking that class, what I earned was a new appreciation for running. I missed it so much, just like the old days back in Arizona. Now when I head out to the park for a run in the chill evening air I feel that old giddiness. Welcome to the start of my running season. Bring it on.

Remember When?

There are moments in which I am reminded of the passage of time, and the increasing speed with which this occurs as I get older. Remember when the world seemed pretty much the same to you when you were age 10 as when you were 9? And then when you were 12? Sure your body and your friends may have been different, but the world was essentially the same. The same actors were hot. The same bands were cool. The same man was President. This summer, I realized the world was essentially different. This began with the death of Michael Jackson. So much of my childhood involved idolizing him. My younger brother used to 'dance' like Michael for the rest of my family in our living room and he always thought we were laughing because he was so good at dancing. But reality was he was just so damn funny trying to be MJ. Patrick Swayze died today. One summer, my sister and I made it a point to watch Dirty Dancing everyday. I'm not sure why, it was just something we had to do. Chevy Chase is playing a part in a new TV show premiering this Fall. Again, the Vacation and Fletch movies have singlehandedly allowed my brother and sister and I to have conversations composed entirely of movie quotes. Now Chevy looks like a puffy, squinty-eyed, snow-haired version of himself. Barely. But in a good way.

When those figures who defined your youth are gone, is your youth gone too? And if it is, did you send it off with fantastic fanfare? Or did you let it trickle away like the bathwater through a hair clogged drain? Call a friend or a brother or a sister. Play the 'remember when' game. If for nothing else than to celebrate that while the world is changing, the best things remain the same.