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.