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.