Note to Self

Dear Future Self,

A year ago, you were sitting at a computer wondering where 2009 went and what 2010 would bring. You were worrying yourself sick about making perfect and absolutely correct decisions. You were changing your mind on a daily basis. And you were driving your poor husband crazy. You're lucky he stuck around! Don't you feel silly now Future Self? Looking back on all that worry...it didn't change a thing did it?

You found a job you really love. And guess what? You're good at it too. When it came down to it, the job found you. All the agonizing about where to live and whether to move closer to family or be in a city you love came down to following your heart. So simple.

Those goals you had for yourself? You know the ones...finish a triathlon, practice speaking spanish, conquer your fear of making bread from scratch, learn how to knit. Well, you reached them all. Not so bad for a year! So stop being so hard on yourself and just appreciate the little victories because they add up to something pretty special.

Future Self, you may not believe me but there will come a time when life is crazy and you and your husband can't hear each other over the noise of screaming kids and you are feeling burned out by the practice of medicine and you no longer have the time to bake bread from scratch. And you will long for these days.

So, a bit of advice from 2009 me to 2010 you. Learn from this year. This wonderful amazing year. It has gone by so fast. Let go of the angst and enjoy the ride. The memories you've created will get you through those crazy years ahead. Promise.

Love,
Present Self

And To All A Good Bite

I've admitted before that I have this fetish...I love to read recipes. I love to cook too, but not as much as I like to read about cooking. I love imagining spring-green blanched vegetables, a creamy roux, a rich gratin, and a perfectly golden seared scallop. In a cookbook, every recipe comes out perfectly. Every tablescape is delightfully understated yet classic. Everybody cooks seasonally and organically and uses the term 'farm-to-table' as if we were raised with fatty ducks waddling around our backyards waiting for the chance to become a smooth foie gras. Life is orderly and measured and you know that if you put in A and B you get C in the end.

Recently, waiting in the airport for my plane to take me to my next job interview, I settled in and pulled out my New Yorker magazine. Reading The New Yorker is a special indulgence I allow myself when I fly. I always buy one at the airport magazine stand and allow myself a few hours of reaping the reward of other's intelligence. Anyway, I read a passage that stuck with me and i'll share it with you.

When you start to cook, as when you begin to live, you think that the point is to improve the technique until you end up with something perfect, and that the reason you haven't been able to break the cycle of desire and disillusion is that you haven't yet mastered the rules. Then you grow up, and you learn that that's the game.

I'll be honest, when I read this passage I can't explain to you exactly what it means, but I love to take it apart and examine it. And it kept coming back to me as I struggled once again with trying to portray my 'perfect' self and find the 'perfect' job. What exactly is the right formula? What combination of factors will make a job that will be 'perfect' for me and I for it? Where is that ideal city where both my husband and I will find fulfilling careers and ample social opportunities while nurturing our spirit of adventure? Or am I missing the point entirely?

Soul Food

Ok, i'll be straight with you. I've been circumventing a truth because I don't know how to explain said truth without sounding like a caricature of myself. But, i'm getting a head start on my New Year's Resolutions (how's that for overachieving?) and i've decided to come clean. Here goes...I came to Chicago to do a fellowship in pediatric infectious diseases. I knew after the 2nd month that it was not the right thing for me. Whether "it" meant the field or the people or the hospital or the program, I don't know, but I suspect "it" encompassed all of them. Do you know how long it took me to call it quits? Two years. Two long years. I spent 22 months after realizing that I was nowhere near where I wanted to be, trying to prove that everyone else was right and I was wrong. It's been a year and a half since I turned in my badge and pager and I've explained my reason for leaving countless times. Every job interview, every new resident I work with, friends, family, they all want to know the road I traveled to get where I am now. My answer is as familiar to me as my bathrobe and no less honest than the vegetables I buy at the farmer's market. But here's another truth. It has taken all of that year and a half for me to make peace with my road. I am a perfectionist and a pleaser and a planner and nowhere on my list of life goals is quitting a fellowship. I don't recommend it.

So what does this have to do with New Year's Resolutions? Well i'm working on something. And that something is authenticity. Authenticity is defined as not false or copied, genuine, real. Isn't that a lovely concept? Paying attention to how something or someone makes you feel, and then honoring that by allowing it/them into your life (or not) is a way to live authentically. I am evaluating my relationships, the foods I eat and the habits I hold onto and holding them up to the standard of whether or not they truly satisfy my soul. In fellowship, it took 2 years for my head to realize what took my heart 2 months. I read somewhere that time is not given, it is taken. I don't have anymore time to give. My hope is that if I take time to do this, really do this, come New Year's I will be well on my way to being a happier more peaceful me.

Holler for a Dollar

Did I tell you i'm looking for a new job? No? Well, I am. Don't worry, it's all on the up and up. My current employer knows already. Let's just say that when your heart tells you enough is enough, time to move on, you better listen. Good advice for jobs and relationships. Not to mention for chocolate glazed doughnuts from Dinkel's Bakery in Chicago. But I digress.

I'm sure everyone remembers the pain of their last job interview. Maybe it was for your first job, or your first 'real' job, or fellowship or residency. Either way you cut it...painful. Walking around in your interview suit and heels with a confident smile pasted across your face all the while thinking...when is it appropriate to ask to go to the bathroom to check my hair, teeth, and awkward stiff collar? Not to mention the feeling of being sick of yourself. Yes, i've plunged myself into this world again. All in the hopes that I will find a job that satisfies me intellectually and emotionally and sates my need for personal challenge. In a warmer climate.

Here's how I would like a job interview to go:
Them: We've already looked at your CV and cover letter and loved it. Now we just need to know who you really are and what makes you tick.

Me: Oh ok. Well, i'm really good at spelling. I was one of the finalists in my elementary school spelling bee but I lost on the word 'bizarre'. Not because I didn't know how to spell it, but I failed to ask for the definition and spelled the word 'bazaar' instead. I'm still beating myself up about that one. I have a picture of myself with Steve Kerr, you know the Chicago Bulls star from the championship era? Only I was in sixth grade and looked like a boy so I am ashamed to display it publicly. I had some serious fashion issues back then. Haunts me still. When I hear the sound of silverware clanging together I want to suck my teeth out of their sockets. I find it hard to believe that I am the only one who feels this way. Speaking of teeth, I am looking for the perfect time to use the word 'toothsome' in a sentence. That word has been banging against my lips for days, begging to be let out. Well, that's about it in a nutshell.

Them: Fabulous! We think you're perfect for the job. We'll be sending a contract your way. Welcome aboard!

I'll keep you posted on my ongoing job search. And if I do have an interview like this? Oh yes, you'll be the first to know.

I'm Watching You December...

December is a mere 2 weeks away. How can that be?! It seems like just a few weeks ago I was telling you about all my summer discoveries. I'd like to bury my head under my pillows and wake up when it's spring again. Of course, here in the windy city, that might not happen until June. How did you sneak up on me December? Did you push November into the slot normally reserved for October? Because I have to say, I don't remember October having much of a presence this year. Hmmm, I am giving you the stink-eye December. Don't think I don't remember how you tried to imitate February last year with all your snow and freezing rain. Even shoving your holiday cheer in my face won't make me forget wrapping my living room in saran wrap just so I could sit on my couch and STILL freeze. Damn you.

When I introduced myself (and this blog) to you I mentioned that I was from Arizona. The first question I get, after a look of amazement, is "Why did you move here??". I have answered this question so many times over the last few years that I feel I have it down to easily digested little nuggets. Here are the highlights (expounding to be done at a later date):

• I moved here because someone I respected and trusted said it was a good place for me to be.
• I moved here to explore a passion.
• I moved here because I thought I would fit in and be successful anywhere, no matter how far from my family and friends and familiarity I traveled.
• I moved here to discover that things don't work out just because you want them to. Really badly.
• I moved here to remind myself that I make mistakes, I am far from perfect and that is ok.
• I moved here to experience the dissolution of a dream and an identity and to create new ones, however different and unfamiliar they may appear to me still.
• I moved here to rely on the company of myself and my dog when things got lonely, and learn to be ok with that.
• I moved here to discover what I really want to be when I grow up.
• I moved here to eventually take a job that would push the limits of my confidence and hold a mirror to the ethical principles in which I truly believe, as unpopular as they may be.
• I moved here to meet my husband and his dog.
• I moved here to grow and struggle and be lonely and make friends and be a pediatrician.

Now you know.

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.

Winds of Change

At what point does one go from being "with it" to being "old school"? I guess I should know the answer to this question because clearly I passed it a few years back. Let me paint the latest scenario for you...I taught my first Problem Based Learning (PBL) session today for second year medical students. What a fun experience! It was so refreshing to be among students who really get excited to use such terms as tachycardia and hypotension and who volley back and forth the merits of exotoxin vs endotoxin in the production of fever with as much fervor as a Wimbledon match. I sat back in my chair beaming like a proud grandparent much of the session. But the fact that I am a good ten years older than all of them doesn't bother me, I hardly notice. No, here's what did it. We had a tutor kick off meeting before the actual sessions began. The PBL coordinator started talking about different technological resources to utilize in order to enhance our interactions with the students. Then, out of her mouth came the words Twitter, mesh terms, portal, and RSS feeds. I know about half of you reading this blog are thinking "Yeah, so what?" and the other half will understand when I say I began to feel like I had missed that lecture and there was now going to be a quiz.

I know what Twitter is. Scratch that, I've heard of Twitter but never actually used it. I find it vaguely uncomfortable to say things like twitter and tweet and take myself seriously. Thus, I have found a way to exist happily without it. And that's not all. I only recently created a Facebook page after increasing levels of peer pressure. Mostly I look at other people's pictures. I did not have a Palm Pilot in medical school or residency. I do not have a Blackberry, iPhone, iTouch, and only use my iPod on shuffle when I run. I prefer books and paper to screens and stylets. My white coat pockets were always stuffed with reference books and notes and never once did I fall victim to a dead battery when I needed information. My cell phone does not have a camera, a keyboard, internet access or the ability to make playlists. In fact, it was free with my phone plan and was once lost by Wrigley Field and returned to me the next day by someone who tracked me down. The thing is the size of a stick of butter and indestructible.

I used to snicker at my parents and grandparents for being so overwhelmed at the thought of using the internet or paying bills online or downloading pictures from a digital camera. And now I am that person who is frightened by this 'new fangled' technology. When did this happen?! Apparently, if I want to continue down this road to being a clinician-educator, I need to open my mind to the wonders of modern communication. Ok, i'll embrace change if it makes me a better physician. But don't expect me to tweet. That's where I draw the line.

Love Is A Battlefield

A recent New York Times article shed light on the phenomenon of post traumatic stress disorder, or PTSD. What made the topic unique was that it referred to a study from Stanford that looked at the incidence of PTSD, usually seen in survivors of war, rape, extreme physical trauma, etc, in parents of infants who were hospitalized in the NICU. Their symptoms, after leaving the NICU with babies in tow, included avoidance, hyperarousal and flashbacks or nightmares. One woman in the article is quoted as saying "The NICU was very much like a war zone, with the alarms, the noises, and death and sickness." Geez. That's harsh.

I've been thinking about this war zone analogy. Where do we as physicians fit in? I suppose we'd be like the generals, leading the weary soldiers through the battlefield, making strategic moves and countermoves, reconnoitering, losing some battles along the way but not for lack of a valiant effort. Are we then, the ones responsible for leading these parents into battle in the first place? I've written before about my struggle with knowing how much is enough or more than enough. In the NICU, this is an ethical dilemma played out on an almost weekly basis. Infants who are clearly not ripe for this world nevertheless are 'incubated' in our artificially created environment until their lungs can breathe air, their skin can protect vital organs, and they can process life sustaining nutrition.

Most level 3 NICUs will resuscitate infants down to 23 weeks gestation. In the case that delivery is inevitable, we are often asked to speak to the parents and give them outcome statistics and discuss their 'options', one of which is to only provide comfort care and not proceed with aggressive resuscitation. We ask them to make a decision, to tell us what to do. I can't imagine how unbelievably agonizing this choice of theirs must be. Or maybe it is an easy one, because how could a parent not want everything done in the hopes that their child will fall on the rare side of the statistical teeter-totter? But, we have an n = hundreds and they have an n = 0. The soldiers bravely follow the generals into battle, with limited understanding and information but with the desire to continue fighting for what they believe in.

We are so focused on caring for these infants that we often neglect the emotional trauma the parents are going through on a daily basis. And what about when the baby is ready to go home? Amid the joy and relief at finally being able to have their infant home comes the realization that they now have to care for an infant on various medications, juggle multiple specialist appointments, become proficient at tracheostomy care and be hypervigilant for any respiratory illness that might compromise their tenuous breathing. If they are lucky, they have the support of a partner and family close by. But not always. Thankfully, there is an online support community at shareyourstory.org through the March of Dimes. Check it out.

The Virtue of Regimentation

The other night at work, a very astute nurse came to me with what appeared to be a medication error. The dosing seemed strange so the resident and I sought to find the reason for the anomalous dosing. Here's what we found: When the patient was initially admitted to the general peds floor for respiratory distress, the dose of this home medication was ordered as 3mg. Now, looking through the patient's discharge summary from his previous stay in the NICU, it appears that he was sent home on 0.3mg which was the recommended dose for his weight. For reasons completely unrelated to this medication, this patient's condition worsened so that he was transferred back to the NICU (he is a former premie, hence his previous stay with us) after 3 days and when this medication mishap was discovered, had been in our unit for another 3 days. In other words, he had been given this 10 fold dose of medication for a week while in the hospital.


It is tempting to look at the original admission order writer and place blame there. But, that is an oversimplification of the checks and balances that are supposed to be in place in hospitals to prevent medical errors. The collective "we" failed this patient on many levels. This dose got by the doctors, the nurses, the pharmacists, the computer ordering system on a daily basis. For a week. Why did this particular nurse decide to check the dose before giving the medication that night? Was she just being diligent? Was she following a protocol that says that nurses need to review medication doses periodically? I have no idea. But I do know this. Mistakes happen, we are human after all. Therein lies our responsibility as the deliverers of healthcare to police ourselves. Yes, its nice to expound on the 'art of medicine' and to delegate our brains as the keeper of all minutiae pertinent to our respective fields and maybe even deem ourselves a bit above 'following the protocol'. But is that best for our patients?


Atul Gawande, a physician writer and a man I credit for opening my mind to so many things in medicine, wrote a fascinating article about the value of checklists in the ICU and the resistance to implementing such a simple change. Checklists, he postulates, are a way to assist memory recall for mundane matters that are easily overlooked in patients undergoing more drastic events. In our patient, his home medication had nothing to do with his breathing issues and his subsequent transfer to the ICU. But, it was an error nonetheless. There are multiple checkpoints in place to catch these errors before they ever reach our patients. But, checkpoints and checklists are only as good as those enforcing them. Kudos to the nurse who that night, considered diligence a worthy endeavor.

You Say Hotcakes, I Say Heaven

One of my fondest memories of my childhood involves pancakes. My mom used to make me pancakes as a special treat in the morning before school. Mmmm, I have clear visions of their thin pale yellow buttery goodness. All she had to say to get me out of bed was "Do you want pancakes?". Occasionally, she would go so far as to put chocolate chips in them. How many kids get to have homemade chocolate chip pancakes before heading off to school in the morning?! Not many I bet. I'm a lucky girl.

You can imagine my disappointment when I learned that my husband hates pancakes. With a passion that I cannot fathom. So, pancakes aren't a welcome guest in our house as often as I would like. BUT, my grand plan is that our children will love pancakes. And then he'll be outnumbered won't he? I imagine weekends filled with the smell of homemade (with real buttermilk) pancakes. Blueberry, banana, whole wheat, peanut butter, oatmeal, chocolate chip...yes, all kinds of pancakes smothered in real butter.

Did you know that kids can develop a taste for things that their mom ate during pregnancy? Yeah, now you see how my plan will unfold right? Check out this great article in the Miami Herald about raising "foodie" children. What was I doing reading the Miami Herald you say? I say, why not?!
http://www.miamiherald.com/living/story/1182212.html

Lonely Sandwich Hater Seeks Same

So I have this thing. You know how everyone has at least one food that they really really hate? I mean can't even stand the smell of? Mine is peanut butter and jelly sandwiches. Hate em. Can't force myself to eat one. Get nauseated at the smell of them. I can't even stand when my husband gets a bit of peanut butter in the jelly jar. As far as I know, I am completely alone in this hatred of mine. PB&J might as well be the American flag, I feel so unpatriotic hating it. Others hate things like brussel sprouts, mushrooms, stinky cheese, asparagus. But those people can usually find a handful of others just like them without trying too hard. Heck even cilantro haters have their own website! I'm lonely. So i'm putting it out there...are there any other PB&J haters?

Let me take you one step further into my psyche. I've been thinking a lot about professional isolation. What causes it? What does it feel like? How do we prevent it? Here's where I'm coming from...I work in a NICU, at night, as the only physician in house. As a matter of fact, I am the only non-neonatologist or neonatologist-in-training on the medical staff in my division. Yep, the lone general pediatrician. I see my professional colleagues briefly at the beginning of my shift for sign out and at the end of my shift for the same. Occasionally, I am lucky enough to be on with a resident. Professional isolation does not only refer to geographical isolation, although this is the easiest to define and understand. I am not in a rural practice. I am not a senior physician who has loads of personal experience to draw from and an aversion to technology. I do not have a narcissistic personality disorder or practice some obscure form of alternative medicine. These are all risk factors for feeling professionally isolated. Yet that's how I feel. I miss working side by side with other pediatricians more than I can express. My colleagues in the past challenged me, made me laugh, bored me to tears, ruffled my feathers, pushed me beyond my comfort zone, and competed with me in a way that made me a better physician, a better teacher and a better learner. Willian Osler wrote in 1897, "The medical society is the best corrective, and a man misses a good part of his education who does not get knocked about a bit by his colleagues in discussions and criticisms."

Fairly recently removed from residency, I did not consider isolation when accepting this position. Would I have done anything differently? Probably not, considering all that I have gained from doing what I do. But, I would caution a young physician from isolating themselves from their professional colleagues and mentors. The learning curve is still so steep that it would be a shame to not have senior brains from which to pick. I look forward to the day when I can jump back into the mix and "get knocked about a bit".

In the meantime, here's how I cope. I am an active member of the AAP both nationally and locally and hold a position with the Section on Young Physicians. I try to attend 1-2 conferences or professional meetings a year. I am on the Section on Hospital Medicine listserv. I volunteer to teach medical students Problem Based Learning. I remind myself that this experience has forced me to trust my judgement and function independently and confidently while practicing within my limits. And I write this blog. So thanks for listening (reading!).

Food for Thought

As I've said before, I love food. Everything about food. I watch the Food Network while I'm at the gym. I read Food and Wine magazine. I have a cadre of recipe websites that I check daily. I shop at farmer's markets and purposely buy something random and then try to find a way to use it in a recipe. I test said recipes on my poor unsuspecting husband. For example, over the weekend I decided to make my husband a vegan chocolate avocado cake with avocado buttercream frosting. My husband is neither a) vegan or b) a fan of cake or avocados. But, it seemed like a great idea at the time. The result resembled 2 soil-colored discs with a sinkhole in the middle covered with a gelatinous supernaturally green ooze. Picture asphalt covered in the "ectoplasmic residue" made famous by the movie Ghostbusters. Go ahead, i'll wait. Got it? My dear husband gamely ate a slice and then said "Well, I think I'm put off food for the next couple of days." Eh, you win some you lose some.

Because of this divine appreciation for all things edible, it becomes necessary for me to remain physically active virtually everyday. Lucky for me, I like exercise. BUT, as I get older my metabolism tends to go on holiday more and more often (I fear the day it retires) and this combined with the looonnng Chicago winters finds me digging at the bottom of my motivation well more often than I care to admit. So, in a moment of wisdom I bought a treadmill! I want to name him, because I have a feeling he and I are going to become good friends, but I haven't thought of anything suitable yet. My theory was that if the opportunity and means to exercise was sitting right in my apartment, how could I ever resist? Because it was available to me, I would use it more. Right?

Ok, I admit it. I trapped you a little bit. Did you think this blog post was just going to be about me and my treadmill and avocado cake?! The reasoning I used above can actually be extrapolated to demonstrate a theory called "moral hazard". Moral hazard, in the context of healthcare, is an idea that economists put forth to postulate that health insurance can change the behavior of the person being insured. I liken this to an all-you-can-eat buffet. Have you ever seen the waste that goes on in those places?! Just because we can? In other words, if universal health insurance were provided, the citizens of the US would just use healthcare willy-nilly. Thus, the "lack of enthusiasm" some display for universal healthcare. To look at it another way, those who are un- or under-insured are actually efficient users of healthcare. Make sense? No, I don't think so either. This presumes that people will treat healthcare like they treat a buffet. And have you ever known anyone who would rather check themselves into the hospital for a host of painful and invasive tests than go to the beach? Or wait in the waiting room of an ER instead of watching a movie on the couch with popcorn? Just because it's available? Me either. Here's a link to an article that describes this myth much better than I.
http://www.newyorker.com/archive/2005/08/29/050829fa_fact

Food for thought. Food for thought.

On Dreams and Discoveries

I have this recurring dream. I am in a hurry, on my way to somewhere. I come across an all-you-can-eat dessert buffet. I try a few things and they are so good that I want to taste more. But I don't have time because I have to be somewhere else. I am filled with disappointment and longing. And then I wake up. Hungry. Weird huh?

It's amazing what you can discover when on your way to somewhere else. Here's a few things I've discovered this summer.

Garlic scapes- These guys look like a cross between a plant and an octopus but are actually the above-ground chlorophyll colored stalk of the garlic bulb that we know and love. They have an amazingly fresh and mild garlicky flavor and you can use them as you would garlic. My favorite is to make a pesto sauce out of them (no need for basil!). If you see them at your local farmer's market, grab some. You won't regret it.

Brown butter- Or Buerre Noisette if you're sophisticated in a way that I most definitely am not. This is actually a way of cooking the butter that completely transforms its taste. Heat butter over medium heat in a stainless steel pan. It will melt, the top will turn white, it will start crackling, then the magic happens. It quickly turns a shade of light brown and that is the time to remove it from heat. You've just turned the milk solids in the butter brown and created a wonderfully nutty earthy sauce. I used it in a blueberry muffin recipe and they were like rich cakey dessert muffins. Mmmm, big fan of this ingredient that can wear a sweet OR savory hat!

Rose wine- Ahhh, the perfect summer wine. Not to be confused with "white zin", the sweet gateway wine that marked my entrance into the wine-drinking world but that now I wouldn't drink if I had a choice between that and Nyquil. A rose is a beautiful deceptive pinkish-red color that surprises your palate by tasting dry like a white with a hint of deep red berries like a red. It is served chilled so is great for toting to the beach or drinking on your porch on a hot steamy summer night. I can't believe I've lived this long without it!

Columbus, Ohio- What a gem of a city! I loved the wide streets, the green trees, the cute neighborhoods, the field of cement corn cobs, and Graeter's ice cream. Let me say that again. Graeter's ice cream. I ventured out of Chicago and discovered that the rest of the Midwest might not be so bad. Who knew?!

The Pediatric Hospital Medicine conference- Have you ever felt like a stranger in a strange land? And then discovered a group of people who thought like you, spoke like you, and had the same vision as you? Then you know how I felt at this conference. I came back intellectually stimulated and excited about my career and future all over again.

On a side note, this weekend is my husband's birthday. When we met, my impetus for moving to Chicago had not turned out the way I planned and I was in a rush to head off to somewhere else. I 'discovered' him while I was in the midst of this transition. Now my reason for being here is completely different (and infinitely more satisfying) than what brought me here. But sometimes, if you're lucky, that's what happens. Take a pause and linger at the dessert buffet. You might be glad you did.

Cool Party Tricks for Cool People

I know, I know, I've been MIA these last couple of weeks. I figured my last overly lengthy post would tide over my faithful readers for a least a good week. I've also been traveling for the past week and have had spotty internet access. That said....I have some good bits of gristle to chew on since coming back and I hope you'll stay tuned!

I visited my good friend in Ohio and we had the chance to catch up on our lives, personal and professional. After a year-long stint as a pediatric hospitalist in an academic center she switched over to the general peds division and did outpatient clinic, adolescent medicine, and staffed the juvenile detention center. In an unfortunate maelstrom of events, the division decided that they could no longer support one physician's salary and since she was the most 'junior' person, she was told that at the end of June her contract would not be renewed. So much for job security! My friend, being the resilient and laid back person that she is, decided to take a 'forced sabbatical' and hang out at her parent's house for awhile to see how the other half lives. Hence my minibreak in Ohio. Let's face it, it's no fun being unemployed by yourself. My friend (let's call her Janet) became my rock during residency and one of the people I credit for keeping me from needlessly clouding my life with regret by acting on completely irrational urges. Everyone needs a friend like that, don't you think?

Anyway, we're similar in so many ways except how we view our entry into the world of medicine. Medicine found me on my way to law school. Really. I remember sitting on the floor of my dorm room and brooding over the course catalog and asking myself "Which of these series of classes feels the most right?" In other words, when I close my eyes and picture myself doing one or the other (law school vs med school), where am I most at peace? It felt like a key sliding into a lock and turning smoothly. The answer was clear and I have never looked back. Hearing the answers from my heart was so much easier back then as my voice of doubt had not yet found its stronghold. Medicine was and always will be the career that I chose for myself. The tenet along which I've aligned my life, for better or worse. Such is not the case for Janet. Her older siblings are both in medicine. When she graduated from undergrad she wanted to join the Peace Corps. Her dad told her to wait. So she went to med school. When she graduated she wanted to join the Peace Corps. Her dad told her to wait. So she went on to residency. After that she did a chief year and then you know the rest. Since I've known her, she's always had a sense of restlessness about her. Contrary to some beliefs, you don't have to love medicine to be a good doctor. She is a great doctor and one who practices diligence at a level I aspire to. But she doesn't love what she does. Over a glass of a really smooth Zinfandel she explained to me how she feels about medicine. She said it's the same as how she feels about playing the piano. It's a great skill to have and to pull out when you need it (like at parties, or on an airplane when someone is seizing) but not something you want to do day after day. Hmmm.

I feel like I understand her better now that she simplified it for me. And that makes me all the more grateful for listening to that feeling I had sitting on the floor in my dorm room. As someone who is quickly approaching a crossroads in her career, I only hope that I can sift through the static and that damn voice of doubt (why is it so loud?!) and find peace again when the time comes to make a decision. As for Janet, I hope that she finds her passion. But I think that for now, she's still waiting for it to find her.

A Day in the Life

As I've said before, lots of people cock their head at me when I tell them that I'm a neonatal hospitalist. So, instead of trying to explain what I do I thought I would share with you a little slice o' my life. During my last 24 hour shift, I kept a diary of my time at work. Lucky for me (and you) there was no shortage of activity. Here it is...the first installment of A Day in the Life.

830am: Rounds start and our team gathers around computers on wheels. The resident reads off numbers and tells us what happened with each baby during the day and night before. I enter orders into the computer (so convenient!) and the attending writes their note. Everything is electronic which is supposed to make things streamlined but not without some hair pulling and keyboard jabbing. You know, the harder you hit the enter key, the better the system works.

11am: Rounds wrap up and I'm thinking about what I'm going to have for lunch when I get called into a room because a breathing tube has slipped out of a premature baby who in fact, does need that breathing tube to live. These things happen sometimes which is why we have experienced respiratory therapists who never leave the unit. They have a new tube ready for me before I even walk in the room. Breathing tube replaced, crisis averted. Mmm, now for lunch.

1230pm: We get called to the delivery of a 33 weeker whose mom was induced 2 days ago (yikes!) for high blood pressure. The baby comes out stunned and not at all happy to be born. So unhappy in fact, that she refuses to breathe for a good 2 minutes. I know she'll come around eventually so I support her with positive pressure ventilation (oxygen by bag and mask) while the nurse stimulates her and dries her off. She gets the whole breathing thing down and we put her little hat on and show her to mom before we whisk her away in her isolette (a heated incubator). I get her settled and draw her blood which involves a radial arterial puncture. So far everything is going smoothly in NICU-land.

7pm: The afternoon has been filled with a smattering of issues here and there. Most of my attention is focused on a baby with suspected Noonan syndrome. She has a heart defect that causes her oxygen depleted blood to mix with her oxygen rich blood coming from her lungs. She also has RDS (respiratory distress syndrome) due to being a bit premature and kidney issues. She's currently on a high frequency oscillating ventilator so we are checking blood gases every few hours. Her big brother and dad visit and I answer their questions as best as I can. Her brother asks me if he can touch her and I want to give him a big hug and tell him that everything will be fine. But I don't, because I don't think it will.

830pm: We are called to a delivery because the OB is going to use the vacuum to help this woman finally have her baby after 5 hours (oy!) of pushing. The vacuum is attached to the top of the baby's head and the OB pulls and pulls and the woman screams and screams and finally this 10 pound baby is born and is pink and fat and doesn't need us at all. I decide to have an elective c-section when the time comes.

9pm: We get a call from labor and delivery that they are going to take a woman who is 27 weeks pregnant for a c-section because she has a placental abruption and is bleeding. I ask when and they say in the next couple of hours. Thankfully, I know not to trust pregnant women who are bleeding. I rally the troops and get a breathing tube ready, order up surfactant and scan through the mom's chart to see what we are dealing with. Her water broke a week ago and she has been on bedrest since. Uh oh. The longer the mom has been ruptured the higher the stakes for the baby.

920pm: See, a couple of hours turned into 20 minutes. The woman began bleeding more heavily and now they are taking her for emergent c-section. We're ready. The baby is larger than we expected (good!) and tries to take a few breaths on her own. I intubate her on the first try (I must be feelin' it tonight) and the resuscitation goes smoothly thanks in no small part to the team of experienced nurses on with me tonight. We take her up to the unit and prep her for line placement. I insert catheters into one umbilical artery and the umbilical vein. Her first blood gas shows that she's doing well and I don't suspect she'll need the ventilator for very long. The whole process takes a couple of hours but without any issues yet, I think she'll sail through the night.

Midnight: Oh it's my lucky night. The nurses are having a party for the July birthdays and there is a potluck going on in the lounge. A snack is just what I need right now. There's nothing that quite mimics my enthusiasm for potlucks in the middle of the night. Ritz crackers and cheese have never tasted this good.

1am: I'm done with my night rounds and find that the sickest baby needs one of her umbilical lines adjusted a bit. Meh, no problem. I'll do this and then head off to bed. Ha! Famous last words. In the process of mucking around with the line a hole appears and the line starts leaking. Please tell me this is not happening. I ask the nurse what meds are going through that line. She says "everything". You know how people say "you are your own worst enemy"? Well not tonight. I know by the way that nurse looked at me when I told her I somehow poked a hole in that line. I take a deep breath and gather all the supplies I need to replace the line. My plan is to thread a new line right beside the old one so that the vessel doesn't close up when I pull the old line out. Seeing as how I haven't had to do this often, I'm a little nervous. But, what can I do? I have to solve the problem I've created. After an hour and a half of MacGyver-like maneuvers I successfully replace the line and everybody is my friend again. I'm bone tired and sweaty but so relieved I almost skip to my call room to take a well earned nap.

230am: On the way to my call room a nurse stops and tells me the micro lab called and one of the babies has a positive blood culture. Ooohhhh darn. I review the baby's chart to see why the blood culture was drawn in the first place since I knew he had been pretty stable. Turns out he had some apnea the day before and as a precaution the team drew a blood culture and complete blood count. Well, now we know why he had apnea. I ordered antibiotics and did another radial artery puncture to send more blood for testing.

330am: Whew! Everything seems to have quieted down and my eyes are getting scratchy. I notice that my stomach is rumbling again but I have neither the desire nor the energy to go in search of food. We are called to a delivery for meconium. The baby comes out not breathing and covered in poo (for lack of a better description) and I intubate to suck out any that might have dribbled below his vocal cords. Nope, nothing there and the intubation was sufficiently obnoxious to him that he lets out a lusty cry and our services are no longer needed. We clean him off a bit and hand him over.

4am: As I cruise back into the unit a nurse stops me and says that the baby we delivered earlier, the 33 weeker, has a positive blood culture for gram negative rods. I'll be honest, I'm a little deflated at this point and hope that she's joking. She's not. Because this type of bacteria can also cause meningitis in neonates, I have to do a lumbar puncture. Did I mention this baby weighs 1200 grams? No probably not because I didn't expect to have to stick a needle in her back! Now, my tried and true method of LPs in infants involves inserting the needle as slow as you can. And then slower. Doing it this way, I rarely go through the space creating a bloody tap. My favorite NICU attending in residency showed me this and I am forever indebted to him. However, the nurse holding the baby in position is not a huge fan of this method. Sorry, getting spinal fluid trumps your charting. I'm feeling a bit tart at this point in the night, errr, morning. I also do an arterial stick for a repeat blood culture and order up some antibiotics.

530am: Getting into my call room bed as the sun is coming up is pure joy. My feet are throbbing (I need to start gellin') and my eyes feel like they are sunken into my head. I have a sour stomach and even more sour breath. I am sticky with dried sweat. Yum.

620am: My alarm goes off and all I can think of is putting both feet on the ground and moving forward or else I'll roll over and close my eyes against the bright sun and even brighter lights of the unit as the day shift nurses roll in with their freshly washed hair and casual chatter. I feel like a troll. I sign out to the oncoming resident and attending. As soon as we finish there's a call for a delivery. I look at the resident and say "It's your turn now." I gather my things and head for the train that will take me home. Home sweet home.

A Letter of Gratitude

Dear Father Who Thanked Me For Being At His Child’s Delivery,

Remember when you said to me “Thank you for being here” and I just looked at you and smiled and said “Sure thing”? Well, here’s what I really wanted to say to you, only I didn’t realize it at the time. I’m not very good at ‘on the fly’ and ‘spur of the moment’. As I said before, I’m a planner. Anyway, I wanted to thank you for acknowledging my presence at your child’s delivery in what must have been a moment of extreme fear and stress for you. Rarely do parents think to do that and I never expect it. I wanted to tell you that this is why I became a pediatrician. To help parents escort children through life until they can pave their own way. Your gratitude was beautifully heartbreaking and I carried that with me for the rest of my shift. You made me feel like I make a difference each and every time I attend a delivery whether I give oxygen and chest compressions or simply dry the baby, wrap her in clean blankets and hand her over to mom and dad.

Your baby did fine, didn’t even need me after all, but I’m glad we were there. More for my sake than yours. See, you gave me such a gift that night. I’ve been walking a little taller, feeling a little less run down, and generally feeling a sense of peace about my career path that I haven’t felt in awhile. So, although I will never see you again, I want you to know that as much as my presence impacted you that night, yours had the same effect on me. Thank you for being there. Thank you for your unabashed sincerity.

Best,

The Pediatrician At Your Child’s Delivery

New Year's In July

My favorite time of year has always been the Fall. Fall meant that school was starting again and I had another year to prove myself and do things right. I usually started the school year with a handful of resolutions. You know, like ummmm, try to be in the cool crowd. For once. The first few weeks I would carefully model myself after the pictures in my Seventeen magazine and slip into my 'bubbly' persona as soon as I walked into the building for my first class. Year after year I tried this and inevitably would settle into my less-than-cool self which was much less time and energy consuming. But, so much more rewarding. In hindsight.

Nowadays, I have those same feelings in the beginning of July. No not the "please let me be cool this year" feeling. The anticipation of something fresh, something better. A chance to renew my commitment to my profession and make good on those resolutions. Only now they are more along the lines of 1. Read Pediatrics EVERY month 2. Answer my PREP self-assessment questions online weekly 3. Peruse the current literature on clinical scenarios I encounter at work 4. volunteer to teach PBL for the medical students 5. Push myself to teach the residents I work with at each and every opportunity even though I only see them at night and all they really want to do is get through until morning.

I couldn't wait to get to work tonight and meet the new residents. The memory of walking into the hospital at 5am on my first day as an intern is seared into my brain. I love that memory and I love realizing how far I've come. So here's to a new year's worth of resolutions. I just hope I'm more successful with these than with that 'learning how to knit' resolution....

What Do I Keep Pinned to the Strap? Beepers.

The second best thing about my current job is that I don't carry a pager. Yep, that's right. No pager. Even when i'm working I carry a phone but no pager. And when I leave? I hand off that phone and walk out the door. Remember when you were in med school and were handed that luscious inviting black rectangle of plastic? Oh, the possibilities were endless. I would actually feel deprived if I didn't get paged for an entire day. What, no one needed me?! I ignored the fact that I was still in classes and the only people who paged me were members of the 'back row posse' as we liked to call ourselves. Then came our clinical rotations and the pages were a little more frequent but no less exciting. A page usually meant there was something for us to do or see and in our world, that was big time. Upon entering residency, I was given a pager with a gold chain on it to provide an extra layer of security when attached to my body. I was too legit to quit. Nope, nothing was going to separate me from this baby. Pages in the middle of the night became the norm, signaling an admission, a tylenol order, or a 'critical lab value'. Eh, not so bad. As we moved further up in the ranks of residency, we wore pagers like boy scout badges. The more the better. If your scrubs kept slipping down and your silhouette was reminiscent of Stephen King's The Gunslinger, more power to ya. Turning in my pager that last day of residency, I felt I was saying goodbye to an old friend. So what happened?

I quickly became reunited with a pager when I started fellowship. When on service, we were on call night and day for a month at a time. My pager never left my hip or my nightstand. It came along with me to dinner, on dates and to the movies. It sat expectantly on the floor during hip hop dance class. It vibrated gracefully during yoga and lit up while on the treadmill. It did not care if I had just called an old friend or was on hold with the cable company when it sang it's little tune. My pager came with me on my first date with my husband and perched itself on my sweaty hip while I trained for the Chicago marathon. My pager invaded my dreams, my meals, my sanity. I heard my pager even when I wasn't on call. I heard it on the bus, on the radio, when a flock of birds flew by. Instinctively, my breath caught and I reached for my invisible holster. When I wasn't on call, I would bury my pager at the bottom of my bag, as if I didn't want its plastic green-glow eye to be able to see me enjoying my freedom lest it become jealous and call me back to the phone. It's been a year (tomorrow) since I carried a pager. Yet still, whenever I hear that piercing bleat my heart speeds up and I feel...hunted. Seconds later I realize it is not mine and I go back to work. I work all night alongside the nurses and patients who need me to be fully present. And when I get home, I recharge so I can do it all over again. I know I will carry a pager again someday and I will see it not as a necessary evil but simply as a necessity. Until then, I will make my peace with the past and know that I am important. Despite being pager-less.

Planning Makes Perfect

"One day at a time". That phrase really gets on my nerves. And here's why. I'm a planner. Always have been, always will try to be. I get the benefit of living in the moment, taking things day by day, not worrying about things that haven't happened yet, etc. I get it. But, I enjoy planning for the future. It is immensely satisfying for me to feel like I have things figured out 'just in case'. Haven't you ever been in a situation where you thought "Gosh I wish I would've thought about making those awesome cupcakes for my birthday party instead of scrambling around and buying 'two bite brownies' at the last minute."? No? Well, you get my point.

Sometimes remembering what got me jazzed up in medical school and residency is enough to kick me in gear and start making a plan for my ideal career. Planning to accomplish everything I had hoped to back then gets me through the occasional days when I realize I am not quite there yet. So today, I challenge you to do one thing for your future. Your future can be next week, next year, or your 80th birthday. Stay connected to your future. That is where some of your best moments are yet to be realized. That said, I'm going to try out that new cupcake recipe. I might need it someday...

You + Me + DC?

Hey there! I'd like to cordially invite you to attend the AAP National Conference and Exhibition in Washington DC this October. If you're already planning on going, great, reading ahead is optional. If you've always wondered what that NCE thing was all about, or if against all odds, you've never heard of the NCE, do yourself a favor and keep reading. That is if you're not turned off by my apparent love of commas.

The NCE is the AAP's official meeting and is held every year in some awesome city in October. To call it a bountiful feast of education, networking, socialization and pride in all that is pediatrics would almost do it justice. Almost. My first NCE experience was as an intern. All the shininess had worn off intern year as had the novelty of being a doctor and I was looking for a shot of inspiration to get me through the cold hard winter (Ok, I was in Arizona so the winter wasn't that cold, but you get it). I tend to do that a lot. Look for injections of inspiration that is. Following my heart is both a blessing and a curse at times. But I digress. Our program was already funding someone to go so I paid my own way and dragged my mom with me on an impromptu vacation in New Orleans. This was pre-Katrina so the French Quarter was in full force. We packed our weekend full of Bourbon Street, the French Market, the trolley cars, Haunted Places tour, Cemetery tour, and of course, beignets at Cafe Du Monde. And that's in addition to going to the conference! I attended the Section on Residents (now known as the Section on Medical Students, Residents and Fellowship Trainees) educational program. I have to tell you that that experience was one of THE defining moments of my life. The excitement and motivation and pride I felt at being a pediatrician has been unmatched since that day, but it set in motion a sequence of events that changed the trajectory of my career. I have continued to be heavily involved with the AAP since (including authoring this blog) and it added a dimension to my residency training that few were lucky to experience.

Disclaimer: Results not typical. Now, I know that not everyone had the cosmic turn that I did and not everyone can expect a life changing experience by attending the NCE. Just like I know that not every bad day can be made better with a little wine and chocolate. But you never know so why not try, right? I'll see you in DC. Do it up. Do it up right.

When is Enough, Enough?

Inevitably when practicing medicine, one comes across ethical dilemmas that may or may not serve to frustrate and stir up a little angst about doing the 'right thing'. I've had 2 patients in the last couple of weeks that have made me revisit the medical ethics teachings of my school years if only to remind me that I am not alone in this conundrum. I'll share their stories with you...

YA is a full term infant girl born to parents who are first cousins. She did not breathe after she was born and has yet to take a breath on her own as she remains on a ventilator. She can not see, hear, or move freely as her arms and legs are tightly contracted. Should her breathing tube come out, an emergent call would be placed to anesthesia for assistance as her airway anatomy is such that intubating her without flouroscopic guidance is next to impossible. Her chromosomes are normal and basic lab tests are unremarkable. For the past 3 weeks, we have been her lungs, eyes, ears, and advocates. Our last diagnostic effort was a muscle biopsy, which I am sure caused her considerable pain. Yet her parents are not ready to let her go.

JH is a former 33 week premature infant born to 18 year old parents. He has lobar holoprosencephaly and ventriculomegaly, essentially a small rim of brain and a head filled with fluid. He has a cleft lip and palate so he can't eat. He has no eyes and can't see. His brain is not developed enough to allow him to hear. No surgeon will attempt any procedure because they rightfully will not cause pain in the face of futility. His head is getting bigger by the day and he is starting to have short periods of apnea. We've touched on the subject of a DNR order with the parents but they firmly believe that "he will pull through". So we continue the tube feeds and basic care and hope that he does not put us in a position to have to resuscitate him while we wait for his parents to let him go.

Ethics in the NICU are difficult mainly because neonates have no way of representing themselves (no way for us to allow them autonomy) and proxy decision making is unavoidable. Thus, the decision making lies with the parents with help from the physicians. Ideally, these decisions would be made with the baby's best interests in mind, both current interests and potential interests for development. Occasionally, we as physicians must wrestle with the pressure from parents to do what is the wrong thing for the baby, whether that be overtreatment or undertreatment. We are asked to evaluate the baby's 'quality of life' but what exactly is the state where that quality is no longer worth achieving? A child's parents may have a very different answer to that question than the physician caring for him or her. There is a principle called the principle of double effect. This refers to an action that leads inseparably to both positive effects and negative effects. Relieving pain but hastening death for example. Or, in the examples above, relieving the suffering of these infants will indelibly mark their parents' lives with grief and loss. Such is the burden of the physician caring for critically ill infants.

Each time I walk into the unit and I see those babies still lying in their cribs I feel a twinge of sadness that they are still with us. And then I feel more than a twinge of guilt for that very same reason. I don't know how to ensure that we are doing the 'right thing' for every baby that crosses our path. But, I am so grateful that I still have the motivation to try. Thankfully, there are professional guidelines for us in our neverending quest for compassionate care. If you are so inclined, check out the AAP's policy statement on Noninitiaion or Withdrawal of Intensive Care for High-Risk Newborns in the February 2007 issue of Pediatrics.

Struggling is the Sign

Whew! Time has flown by and I apologize for not blogging sooner...I guess my excuse is that I was enjoying the not-so-warm weather in Chicago. So, my husband and I were having an interesting debate the other day and i'll share it with you. The topic was passion (no, not that kind) and if everyone 'gets' to have a passion in the 'life purpose-fulfilling-career-sense'. The way I see it, some people don't have a passion and don't really care either way. They are perfectly happy. Some people however, feel the tug of something and are not fulfilled until they satisfy that need. They struggle to find their passion and live out their life's purpose. Those who don't have a passion, don't struggle. Herein lies our debate. My parents and my husband's parents, like many of their generation, did not go to college and view raising a family and bringing home a paycheck a worthy enough undertaking. This in itself could be viewed as a struggle. But, did they struggle with that cosmic pull of finding something...more? I would argue that most of us who entered the field of medicine did so in response to a calling. I would also argue that we chose pediatrics in response to this calling. We had a gift in doing what we loved. In essence, we made a selfish choice so that we could perform selflessly.

My good friend's husband just graduated from medical school and is preparing to begin residency later this month. As a young physician I am not so far removed from that heady experience that I can't distinctly feel the nervous excitement and incredible honor at finally being a doctor. I remember the sense that the opportunities were endless. But, I must admit that too infrequently do I nurture those sentiments and cultivate that sense of pride and optimism in my day to day life. After finishing medical school and residency, how many of you landed in a place where the struggle ended? How many of us are still looking for our true passion? 

Less is More...or do I mean Fewer is More?

I know most of you are winding down on this Sunday night, the last night before we wake up to June, and psyching yourselves up for the week. For those of us with irregular work hours, Sunday nights don't hold the same melancholy nor Monday mornings the same manic. However, I do remember those days and in honor of the weekend wind down I'd like to give you a little treat. I prize efficiency...at work, in the gym, in the kitchen. But sometimes we have to slow down and smell the cookies baking in the oven. So, here is a recipe for deliciously decadent and fabulously simple peanut butter cookies! Have one with a tall glass of milk for dessert...or breakfast before facing the week. Enjoy!

Flourless Peanut Butter Cookies
1 cup all natural smooth or chunky peanut butter (use organic if you can, none of the cheap stuff)
1 cup sugar (1/2 cup brown, 1/2 cup granulated)
1 egg
1 tsp baking soda
Preheat oven to 350 degrees. Grease a baking sheet with butter and set aside. In a mixer combine PB and sugar until well combined, about 2 mins. Add egg and baking soda and mix for another 2 mins. Roll into walnut sized balls and create criss cross pattern with a fork. Bake for 10 mins until lightly browned. Cool on a baking sheet for 2 mins, then eat! You can also add chocolate chips to this recipe if you are so inclined.

A Worthy Endeavor

The word o' the day is diligence. Diligence is defined as "persevering and careful in work, hardworking". Alternately, as defined in Atul Gawande's Better, "the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles". According to Gawande, diligence is both central to a physician's performance and very difficult to accomplish on a day to day basis. I would have to agree with him. How many obstacles do we as physicians encounter on our quest for diligence? Let's see...fatigue is a biggie. This one is near and dear to my heart because, i'll admit it, at 3am (which will hereby be referred to as the witching hour) I am struggling to put out fires and keep everyone alive until the reinforcements show up. The only obstacle against which I'm trying to prevail is the mud in which my thoughts have become hopelessly tangled and mired. Not that I don't try. There have been plenty of times when I lay down to catch that 1 precious hour of sleep before morning labs come back and I think "Is that baby peeing enough? Well, the nurse would tell me if she isn't. Wouldn't she?". I put my shoes back on and leave my dark call room to check on that baby's urine output. But does that happen every single time?  Another obstacle is time. I know from my clinic based colleagues that having enough time to give the patients what they need AND get what you need from them AND write orders AND document AND communicate with staff AND breathe is next to impossible. But I know they do their best until that last appointment of the day. For residents, the duty hour regulations presents a double edged sword. They have the same amount of work to do in a shorter period of time. They have to be even more efficient in their work and pay even more attention to detail because there are so many patient hand offs these days.  A study published by Landrigan et al in Pediatrics in 2008 showed that after duty hour implementation, there were no changes in the rate of medication errors and a borderline increase in resident ordering errors. Are we as their mentors teaching them how to be diligent while maintaining efficiency?

Consider your own obstacles to diligence in your career. Do you strive to be diligent in what you do every single day? Why not? As physicians, what are our rewards for diligence?

Putting the 'soul' in soldier

Its Memorial Day, a holiday meant to honor those who serve our country and to mark the beginning of a new season, Summer. In light of this, I want to share one of many 'NICU stories' I have saved in my mental filing cabinet under Times I Had to Choke Back Tears at Work. The story involves a mom who is not a soldier per se, but someone who has weathered a battle in the process of bringing a life into the world and has not finished fighting. At 25 weeks gestation, this 50 year old first time mother (yes you read that right, 50 years) came to see her OB because of persistent bloating and abdominal pain. After a physical exam, the findings of which I do not know the details, the decision was made to ultrasound the abdomen. Multiple lesions of unknown etiology were found on her liver in addition to an abnormal appearance of her omentum. A biopsy showed the lesions to be a metastatic small cell adenocarcinoma of unknown origin. She was admitted to the hospital for palliative chemotherapy but the cancer was considered terminal. The baby arrived at 30 weeks due to a placental abruption and was immediately sent to us for further care. This mom is bedridden and on a constant infusion of narcotics for pain. She is unable to come to the NICU to see her baby boy and is not alert enough to receive updates. The nurses take digital pictures and send them to her room in the event that she wakes up and is able to see this life she has created. According to her history, she has been married for only 2 years and conceived this baby through a donor egg and implantation. Because the medical chart is devoid of emotional backstory, I create my own. I imagine after years of independence and a life full of friendship and family she had resigned herself to spending her years without finding 'the one'. And then this amazing person walked into her life and swept her off her feet. They couldn't imagine not creating a family together and despite the odds found a way to have a child. She felt like all of her prayers were answered and she was the luckiest person in the world to have found all that she had found. But in an instant, the path she saw unfolding before her turned and she finds herself fighting for a chance to see her husband and child for just one more day. When I care for that baby I am looking at a little boy who will not know his mother as she will likely be dead before he even leaves the hospital. But, he will know that his mother embraced her dreams and squeezed as much out of this life as she possibly could against great odds. She fought the good fight and I salute her.

I Heart Caffeine

This will be short and sweet as my internet is out at home so i'm sitting in a Starbucks. Seriously I can only take the grinding of the grinder for so long before I want to scream. Being here reminds me of the wonders of caffeine. By some miracle, I made it through medical school and residency without drinking coffee. Not that I didn't want to. Everyone gets so excited about coffee and its various permutations. And its almost always free isn't it? It's not hard to find the ubiquitous 'coffee cart' whenever you're forced to wait somewhere. Smiles are spread and spirits are lifted at the mere mention of coffee. I simply don't like the taste and the fact that it leaves me with dirty mouth. So, i'm left with iced tea and diet Coke.

Most of the time I enjoy caffeine as a byproduct of whatever i'm drinking. However, when i'm at work I use it like the drug that it is. America's most popular drug. As I said before I work nights and weekends. During the week, my shifts are around 15 hours long and on the weekend I work 24-25 hours. Over the past year, I have tried to figure out a way to feel alert and chipper and by all means competent once 3am rolls around. I've tried to stay up really late the night before a shift in order to sleep in the day of my shift but I am a die hard morning person and ended up feeling sad and unproductive sleeping all day. I tried getting up early on the day of my shift and taking a nap later but inevitably by forcing myself to try to nap my body rebelled and I just ended being really tired by midnight. Now I just wake at my regular time and go about my day until it is time to go in and know that I will be exhausted at the witching hour. Everytime I feel that bandlike tension around my forehead, the sandpaper feel of my bloodshot eyeballs, the nauseating hunger rolling around my stomach, the inability to multitask effectively, the quick irritation at questions (and then the guilt for being short with the staff) and the long pauses in my speech (much like absence seizures) when I'm having word-finding difficulty during signout I wonder....am I sacrificing my own health for the sake of my patients? When my heart is doing somersaults in my chest from caffeine overload and i've eaten more vending machine crap than I ever would during daylight hours in order to fuel my beaten brain I promise myself that as soon as I get some sleep I will work out and drink water and eat healthfully. Until my next shift.  

Check out this link to learn more about sleep deprivation and patient safety. http://www.aap.org/saferhealthcare/webinar_06.html 

Our First Date

Take a deep breath...this is my first ever blog post. I never saw myself as a 'blogger'. As a matter of fact, I never saw myself as a neonatal hospitalist either and here I am. If I am being really honest, I never saw myself as a pediatrician. Not even when I couldn't think of anything else i'd rather be doing with my life. I fought it tooth and nail because I had never pictured myself as someone who put Disney stickers on my nametag or called my patients Pumpkinhead or took off my shoe and pretended it was a telephone. Hmmm, years later and I am still learning that the grand plan in my head is not necessarily where my heart will lead me. But I digress.

Let's start with the basics. I am a neonatal hospitalist working in the Level III NICU of an academically slanted community hospital in Chicago. Yes, it's a mouthful. Most of the time when I tell people my title I get the slightly open mouth head tilted back "Ohhhh". And then silence. If I am surrounded by other physicians I get asked if I am in fact a neonatologist. The answer is no. The next question is if I am a neonatal fellow. Not exactly. I am a board certified pediatrician who cares for neonates unfortunate enough to find themselves in need of intensive care. There are a small but mighty number of us who work in NICUs of all levels. Some work alongside neonatologists to relieve some of the patient load, often taking on the "feeders and growers". Some cover mostly normal newborns and sicker near term babies with the back-up of a neonatologist. Some preside over a team of residents and act much like a fellow would in order to ease the workload of residents and provide some continuity of care in the "duty hour limit" era. Some take overnight and weekend call with neonatologist back-up by phone to provide 24 hour physician coverage in the NICU. I am part of this last group. A level III NICU as defined by the American Academy of Pediatrics is "a hospital neonatal intensive care unit organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness." Our NICU can provide comprehensive care to extremely premature infants (less than 28 weeks), advanced respiratory care, advanced imaging, and access to various subspecialties. In essence, I spend my nights and weekends at work in a perpetual state of catecholamine release, kicking myself for not paying closer attention during my residency NICU rotations. That said, after almost 1 year in this position, I find myself with a newfound confidence and a tentative peace in knowing that I am right where i'm supposed to be.