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?