The Sounds of Frosting Holiday Cookies

Hope everyone had a Merry Christmas. Here’s a sample of the festivities at our house:

COLE: ‘Nother Cookie! "Geen!" Red!

ME: Hey Cole, Why don’t you try putting some frosting on the cookies instead of eating it all?

GRAHAM: Coo, Coo, Coo. (Reaching for the array of frosting and sprinkles.)

OPA: Graham wants to help. (Pushing Graham across the table to the bowel of bright green frosting.) Get in there, Graham.

AUNTIE NUSSY: (Handing Graham a knife loaded with frosting and holding up a cookie.) Frost the cookie, Gi-gi.

OPA: (laughs)

AUNTIE NUSSY: I went to a cookie-frosting party and everyone said MY cookies were the best!

ME: Nothing like these, though.

AUNTIE NUSSY: Look! This cookie has Graham’s big finger smear right down the middle.

OMA: Who gave Graham the knife? Oh no… he’s stuffing it down his throat. Oh no… he’s gagging himself. Take it away.

OPA: (laughs)

AUNTIE NUSSY: Graham loves squishing frosting between his fingers.

OPA: (laughs)

ME: Is frosting a dairy product? Graham’s not even supposed to have any dairy until age 1.

OMA: Well, there can’t be more than 20% dairy in there, because it’s mostly sugar.

ME: Oh, that’s much better.

OPA: (laughs)

ME: Whoa Cole, A whole box of sprinkles on one cookie? That’s beautiful. I’ve never seen anything like it before.

COLE: I did it! (Proudly displaying his cookie masterpiece.)

OPA: (laughs)

COLE: EAT! (Leaning over and planting his nose in a freshly frosted cookie.)

Just Shut-Up Already, Whitebread!

Usually while I’m doing procedures on patients, I try to distract them and pass the time by making small talk. Sometimes I end up saying things that seem right at the time but in hindsight are probably just silly. Here are two examples:


1.
When you work Saturday night overnight, you expect a few drunks or a few bar brawl injuries to show up around 2 am as the bars close. This past Saturday night was no exception. Around 3am I looked over at room 3 and saw a young girl holding a blood-soaked rag to her mouth. The chart in the rack listed "smashed in face with bottle" as the chief complaint.

"Doc," she explained as she lowered the rag from her mouth, revealing a huge bloody gap where her two front teeth should have been as well as a badly cut-up mouth, "Someone smashed me in my face at the club. I look horrible, don’t I? Look, doc… I’m a prissy pretty girl, so you gotta sew on me like you’re Dr. 90210, okay?"

None of her lacerations were anything requiring a plastic surgery consult, which meant putting her face back together was all me. "I’ll do my best," I promised.

While I started getting ready to buckle down for at least a few hours’ worth of laceration repair worthy of Dr. 90210, I sent the nurse in with a morphine shot for her pain since she undoubtedly would have had a hard time swallowing a pill. The nurse came out a few minutes later with a smirk…

"Well, I figured out what she was doing in the club. When she dropped her pants to get the shot in her butt, I found all kinds of cash sticking out of her hot-pink G-string."

I was amused, but in an effort not to be judgmental, I tried to erase that mental image from my brain. But by the time I was repairing her 5th facial laceration, I had been in and out of her room over a 3-4 hour period (alternating between suturing her injuries and continuing to care for all the other patients in the ER), and we had already exhausted all the usual avenues of small talk. Plus, I really couldn’t quit picturing her pink G-string stuffed full of dollar bills… So I went there:

"So, what were you doing in the club?"

"I dance. I’m ‘Baby Phat" and this here," she pointed to her friend. "This here is ‘Sweet Baby’ and we dance together."

"Oh… like choreographed routines?"

"No… there are two poles and we each get on one and freestyle… whatever we think is gonna get us the most tips."

"Oh." You could imagine the mental images I was trying to erase from my brain at that point. This is not a subject I’m used to small-talking about… so I responded with the first thing that jumped into my head:

"I danced on a pole at my wedding."

Baby Phat and Sweet Baby just looked at me. Silence.

Nice one, Whitebread. What exactly are you supposed to say to an exotic dancer without sounding like an awkward mom trying to be cool… and failing miserably.?


2.
The next one is even more classic. This happened 2 or 3 years ago during my residency training at the trauma center. One night the red light outside the trauma room began flashing and in rolled 2 shooting victims. The first patient had been shot by the second patient who had then in turn been shot by police.

The first patient died despite our best efforts. The shooter, our second patient, was luckier and managed to remain stable and awake despite a bullet through the top of his left lung, just above his heart. He had a hemopneumothorax (blood and air in his lung), and as I was preparing to put in a chest tub, many of the ER staff were saying he didn’t deserve any analgesia for the procedure since he had just killed the guy in the next room (allegedly, anyway). That would have been malpractice on so many levels. Of course I numbed him up and made him comfortable. The guy was appreciative because he had heard what the nurses were suggesting.

So, having established rapport with the guy, I proceeded to chat him up in my usual manner as I jammed the chest tube between his ribs and into his chest cavity. "You know, if the bullet had been an inch lower you’d probably be dead right now. Someone has given you a second chance for whatever reason. Maybe you should think about that and make a few changes."

I paused. What exactly are you supposed to say to an alleged murderer? In my case, it was the first thing that popped into my head:

"Like, for starters, try not to shoot people anymore!"

Well-said, Whitebread. Well-said.

Music to My Ears

Cole has learned a new word that has changed our world – "OKAY."

For 4 months now we’ve been listening to "No!"… even when he has not been presented with a yes / no question… even when no one is talking to him. It was bad enough that he seemed to think "no" was the only possible answer for yes / no questions (basically, if he DIDN’T say "no" that meant yes), But then he started giving "no" as his token answer to all questions:

"Cole, how was your day at school today?"

"No!"

And then one morning I awoke to "No! No! No!" coming through the baby monitor from Cole, alone in his crib, apparently warming up for a day full of "no"s.

I kept telling myself, "He’s nearly two. This is normal… They don’t call it the ‘terrible twos’ for nothing. This will pass." And sure enough, it has.

This past weekend Cole has started happily answering "okay" instead of "no" to yes / no questions, finally reserving "no" for times he really means "no." Suddenly the ever-disgruntled protestor has become pleasant and cooperative:

"Cole, help Dada vacuum."

"Okay!"

Or "Cole, put that in the trash for mama."

"Okay!"

It is the best word I've ever heard him say.

From the mouth of someone whose brain is worth a small house? REALLY?

Really. I DID go to Yale Med. You just wouldn’t know it by listening to me sometimes. After all, I have been working in a small southern hicktown for over a year now… inadvertently absorbing the southern lingo that all the nurses use.

Two days ago I stood in the middle of the ER, needing to speak to my patient’s nurse, and when I didn’t immediately see her I yelled out, "Where Ms. Tina AT?"

The secretary looked at me in disbelief and started laughing. "WHAT did you just say, doc?" It was only then that I realized how ghetto that sounded. Damn it, I could have saved myself a lot of money in student loans and still sounded as profound. I swear I’ll never let the backassward local colloquialisms rub off anymore.

To add insult to injury, the son of the brain worth a small fortune isn’t doing much better…

He listened to his dad talk on the cell phone to all his homies the whole car-ride back from our Thanksgiving in Connecticut. Apparently he absorbed every word, because 2 days later he came barreling in the bathroom in the morning yelling ‘Hey MaMA!"

I answered "Yes, Cole."

"Hey MaMA!" (making sure I was listening.)

"Yes, Cole," I repeated.

" ‘SUP?!" (Just like Dada’s "What’SUP?" when he talks on the phone.)

So eloquently put. Glad my higher education has allowed me to impart such refinement to my boy.

Rollin', Rollin', Rollin'

Let’s get this blog train rollin’! I’ve been too busy living my life to blog about it lately. But now that I’ve finally shaved my legs for the first time since before Thanksgiving, I’m starting to feel like order is restored at least a little bit, and I can spare a minute or two to blog some of the highlights.

We kicked off the holidays with a five-day trip up to Watertown, Connecticut to spend Thanksgiving with Dan’s family. A five-day trip translates to 7 days of mom time by the time you allow a whole day to pack and a whole day to unpack and get the household back in order. You cannot possibly fathom the high level of orchestration necessary to drive 2 babies 8 hours for a visit with the en-laws. There were actually a few moments when I would have rather been at work… until the vodka kicked in!

My absolute favorite moment of the whole week happened Thanksgiving night… after the Turkey dinner at house #1 (Dan’s parents’) and the dessert party at house #2 (Dan’s sister’s). We were winding down and putting away all the baby paraphernalia from a whole day of hauling the kids around, since we were staying at house #3 (Dan’s other sister’s). I set Graham up on the floor on his back with some toys and left him with Dan who was pitter-pattering around picking up. When I came back into the room Dan was holding Graham up in the air above his head, and both were grinning proudly. "Tell Mama what you did, Gi-Gi," cooed Dan. "One minute he was on his back," he boasted. "The next time I looked over there he was on his stomach." Another Milestone!

Graham had previously mastered the front-to-back roll, but we had never actually seen him do back-to-front. The little man was holding out for a big day… like his First Thanksgiving. Since then he’s been a rollin’ fool. You can tell he gets a kick out of it – Front, Back, Front, Back! Rollin’, Rollin’, Rollin’! Go G!

Green Beans & Peas.... WOO-HOO!

This past weekend, Graham had his first food outside of milk and cereal -- Green Beans! I have video footage of his reaction, which was PRICELESS and involved a funny face and a full body shiver. My thinking is that if I start him with the least appealing things first, he won't expect everything to taste like applesauce. It worked for Cole. Next we'll do peas, then yellow squash, then carrots, then sweet potatoes... and then finally I'll let him have some FRUIT. For those of you nonparents, it will actually be close to 2 weeks before we get to fruit, because you can only introduce one new food every 3-4 days so if they have an allergic reations, you know exactly what the reaction is to. Tonight is the night for his first PEAS! Woo-hoo! It really is amazing that feeding my baby peas now constitutes a rockin' evening for me. I have officially become lame.

Saturday Night Fever, Jr.

This morning Cole and I were jamming out having a dance party in the family room. He busted out all the usual moves (clapping, spinning, moving his head, stomping his feet, rolling his fists around each other). And then all of a sudden without any prompting... he raised his arm and pointed his little index finger in the air, and then he plunged his arm down and pointed his little index finger to the floor, and then back up went the finger again. If you can't picture it, he was doing the John-Travolta-style disco, one of my all time favs (see previous post). I'm so proud to be passing on all my special moves.

Saturday Night Fever

It was a gloriously slow Saturday night in the ER. In fact, it was my slowest night EVER. The timing could not have been more perfect, as this was right at the peak of Graham’s RSV illness, and I was exhausted and in no shape for a hectic shift.

The quiet meant the night nurses had plenty of down time to grumble and groan about their aches and ailments. "Oh my toe. I had an ingrown toenail that I dug out myself at home." And "Oh my back. I think I strained something moving a patient."

At about 4 am, all of us were sitting at the nurses station and the back pain nurse stood up and filled the silence with a painful moan, grabbing her low back. One of the younger nurses looked at all of us and quipped "I need some younger, healthier coworkers. ‘Oh, oh, oh’," she imitated their groaning. "You all are an old and decrepit bunch."

I don’t know what possessed me… Probably sheer delirium from lack of sleep, and the fact that there were only 2 patients in the whole ER, and neither of them were within sight of the nurse’s station. Suddenly I found my self saying "ALRIGHT!" and jumping up out of my chair, running around from behind the physician’s desk and assuming the Saturday Night Fever Pose in the middle of the ER.

Right there, with my scrubs and white coat and stetho-scope, I broke it down John-Travolta-style with some 70’s disco moves. There was no music playing. In fact, it was dead quiet as all the nurses and techs stared at me with surprised faces. "I’M not old and decrepit," I screamed as I jammed out to the music in my head.

They all started rapping "Go Doctor, Go Doctor" and giving me a beat. Finally I stopped with a sheepish laugh. I sat back down, a little red in the face. I’m definitely not used to showing that side of myself at work. I usually try to suppress it for the sake of professionalism, but it had just come exploding out of me.

One of the nurses had been outside on a smoke break. When she came back, she saw everyone laughing and noticed my red face. "What did I miss?"

Back pain nurse spoke up. "Doctor was giving us some Saturday night fever. She’s not old and decrepit… YET!"

Bath Time Surprise

A few nights ago I was in the family room giving Graham a neb treatment when Dan came out from our bedroom, where he had been giving Cole a bath, and interrupted me. "Honey, this is worth coming and seeing RIGHT NOW."

I flipped off the neb and eagerly carried Graham into our bedroom to see what Cole had in store for us. There on the bed was Cole, buck naked, with his hand on his crotch. He was talking to his pee-pee and playing with it: "Hello Pee-pee," pulling it out. Then "Bye-bye Pee-pee," poking it in…. over and over. The thing was all red from being messed with so much. And there was a little baby erection pointing up at all of us.

"How did this start?" I asked Dan, accusingly.

"Honey, I was sitting at the computer with my back to him. All of a sudden I heard him talking to it, and I turned around," Dan explained, "and all I saw was THAT LITTLE BONER!"

Ah, such are the joys of raising sons.

Docs hate cold and flu season, and Moms hate it even more.

So many blog-worthy stories, so little time. In the week since my last blog, life has given me more material to blog about than I can keep up with: Cole shitting all sorts of unexpected places (bath, carpet…); Cole fondling his pee-pee and causing a little boner; A Manhattanite showing up in my little southern ER and getting a dose or our small-town nurses; The nurses at work flattering me to the point of my head getting dangerously large; Trying to trick-or-treat with two babies; and Me after too many sleepless nights busting into a full-blown John Travolta-style disco in the middle of the nurses station in the ER (to the delight of everyone present). Hopefully I’ll be able to catch up in the near future and blog about each of these, but for now, the MOST blog-worthy event is the one that has dominated our life the last week:

Graham’s bout with RSV.
Poor little Graham contracted a nasty respiratory infection at daycare and spent the better part of a week completely miserable and not breathing well at all (which, coming from an ER doctor, means there was some legitimate respiratory compromise). We spent the better part of a week worrying about him and trying to make him well.

I’ve learned two important things from the whole experience:

1) I'M NOT AS NEUROTIC AS I THINK I AM.

When he first got a little sniffly and then initially got sent home from daycare with a fever, I was levelheaded. "Probably viral and will be over in a few days" was my line of thinking. Just in case (since recently at work I HAVE been seeing some pretty severe cases of infant bronchiolitis leading to ICU hospitalizations), I called the pediatrician and made an appointment for 5 days later to have him evaluated if it didn’t go away.

"You have a febrile 5-month-old and want to wait 5 days to have him seen?" asked the receptionist when I made the appointment.

"I’m a doctor." Yup… Doctor Mom was handling it calmly and coolly. That lasted about 12 hours….

Then, in one night, what started out as cold-like symptoms progressed to audible wheezing, severe chest congestion and a respiratory rate of 60 (way too fast – a sign of respiratory compromise). He was not eating; he was vomiting; he had no wet diapers; his fever remained high; and he was so miserable I was unable to put him down from 12:30am to 7am.

"Great. He has RSV, he’s dehydrated, and he’s gonna be hypoxic before long." If Dan hadn’t been out of town, I might have left Cole home with Dan and taken Graham into work in the middle of the night for an IV and some oxygen. As it was, as soon as the pediatrician’s office opened in the morning I was on the phone with them and had Graham in the office one hour later. That’s saying a lot. In all of Cole’s life I’ve taken him to the doctor just one time for a sick visit, because it takes a lot to get me too worked up.

The only appointment they had was with a nurse practitioner, which normally I would have refused, seeing as I prefer someone with at least my level of training telling me what to do with my kid, but I was desperate for ANYONE with objective eyes to take a look and see what they thought, because by this point I was irrationally afraid he was going to end up on a ventilator.

Of course, as soon as Graham got in front of the nurse practitioner he started smiling. There must be something in their molecular structure that makes them well when they appear before the doctor and then sick and miserable again when they leave. Parents are always telling me "He was crying until we got here," or "He had a fever until he got here." Now I can vouch – this really does seem to be a legitimate phenomenon. Somebody with more time than I have should research it.

Anyway, Graham seemed happy and so she assumed she wasn’t too sick, despite my tales of our angst-filled night. She sent him home with a nebulizer for his bronchiolitis and some antibiotics for a bilateral ear infection. I was surprised… I had jam-packed the whole diaper bag in preparation for a trip to the hospital at least for some IV fluids. RSV could potentially be life threatening in a 5-month-old, but she flippantly told me "I’m not concerned" and sent us home.

I thought my maternal neurosis had gotten the better of me. "He must not be as sick as I thought. I’m just losing my objectivity because he’s my son." So I went home assuming I was too neurotic and that she’d been correct and he’d do fine.

Well, he didn’t do so fine. He spent two more nights having a really hard time breathing, requiring significantly more frequent neb treatments than the 4-6 hour interval she had recommended and STILL spiking fevers.

Finally I had the opportunity to speak with another MD about his breathing at work when a 3-month-old with similar symptoms (but not even as severe) came into the ER and had a positive RSV test. "I’ve got a three month old patient of yours here with RSV," I explained to the pediatrician on call.

"Admit her to the hospital" said the pediatrician immediately with no further questions asked. "When they’re that young they’re at risk for hypoxia and respiratory distress."

"I know." Then I went fishing…. "So, if I told you I had a tachypneic (breathing fast) 5 month-old here with RSV, would you admit him."

"Possibly. Even 5 or 6 month-olds could still be at significant risk."

I knew there was more to my angst about Graham than undue maternal neurosis. I told the pediatrician how the Nurse Practitioner I had seen had been so nonchalant. "You should NEVER be nonchalant about RSV in a 5 month-old," was her response. THANK YOU! Never again will I write off good clinical judgment as "neurosis" when it comes to my kids.

2. NOT EVEN THE BEST MEDICAL EDUCATION CAN PREPARE YOU FOR ACTUALLY BEING THE PARENT OF A SICK CHILD.

I know a lot about RSV. I diagnosis and treat it all the time. I’ve seen parents who show up in the ER in the wee hours of the morning after baby has kept them up all night. I’ve given them the instructions about what to do with baby at home. I’ve written them notes for work, understanding that caring for a sick baby interferes with everything else. Before this week I thought I was pretty empathetic towards parents, given my medical education and clinical experience.

But I never really KNEW the overwhelming exhaustion of comforting crying baby ALL NIGHT LONG, giving nebs every 3 hours around the clock, trying constantly to get a baby to drink ANYTHING when he has no interest, keeping track of when it’s time for Tylenol & when it’s time for Motrin, agonizing over how many diapers it’s been since the last time he peed. The uncertainty of "Is he going to get better? And When?" just weighs on you. You are unable to concentrate on anything else when your baby is sick, and you couldn’t even if you wanted to because you are so damn tired. I kept working full time throughout the whole ordeal, and I was just a walking zombie. I am just now beginning to catch up on my rest.

This past week with Graham taught me more than my Yale Medical Doctorate ever could about how having a sick baby at home turns your world upside down. And this was just bronchiolitis treated as an outpatient. I can’t even wrap my brain around what it must be like for parents whose kids are hospitalized, for any length of time. Sometimes it’s good to be reminded that you have no idea what it’s like to go through what your patients do and that you need to have respect for the significant impact of the illness on their life.

The First Counterstrike

Little Graham is getting feistier and feistier. He's also honing his fine motor skills to be able to work those paci's. All of this means big brother needs to be protective of his paci when feisty little G is around.

This past Thursday night we first saw Graham master his paci. For weeks he’d been grasping hold of it and plucking it from his mouth… then he’d try desperately to put it back all by himself only to hit himself repeatedly in the eye, nose, cheek and chin. Finally on Thursday his aim got a little better and he actually put his paci in his mouth for himself. I am so thankful for this milestone, as it means he doesn’t need to cry for me to put it in there for him anymore.

Having conquered his own paci, Graham moved onto Cole’s. Over the weekend he was staring and staring at big brother’s face. So finally I put him right next to Cole on the couch and immediately his little hand shot up to Cole’s cheek…
And after 5 months of being knocked around by Cole, Graham initiated his first counterstrike. He reached and reached and finally got hold of Cole’s paci, then yanked it right out of Cole’s mouth. And so it starts!
Cole was more stunned than angry. He reclaimed his paci and popped it right back in.
Then graham struck again. "Noooooooooooo, GI-GI!" Cole protested. He held his paci in his fist at first, guarding it. Then he put it under his butt and sat on it for maximum safe-guarding. So Gi-gi just started reaching out and poking Cole all over his face. Finally Cole got up and moved away from Gi-gi’s little attack.

It’s On! Don’t mess with Gi-Gi.

Why can’t we all just get along?

"To know me is to love me." I tend to win over people I work with. ER Nurses and I get along fabulously. Even the hardened battle-ax trauma nurses where I trained were sweet to me by the end of my residency, because I was sweet to them. That Golden rule "Do unto others" really does work.

The problem is that auxiliary departments (radiology, lab) are staffed by techs who seem to have a propensity for bitchiness, and I don’t interact with them enough to win them over. My interaction with them is limited to the occasional phone call when I am too frustrated to wait any longer for my results, "Hello, this is Dr. so-and-so. How are you today? Can you tell me the status of my test result please?"

You might expect the techs to be courteous to me because I’m the doctor, but gone are the days when doctors were treated with respect, by patients and by staff alike. Patients seem to think I’m a waitress ("Can I have a coke? Can I have a meal?") or that they are at a healthcare drive through ("I want my CT scan immediately then I want to be out of here 5 minutes afterwards"). One day I’m going to show up to work in a McDonald’s uniform and ask them "Would you like fries with my potentially LIFE-SAVING treatment that I trained 10 YEARS to be able to offer you!?" Even if you get a nice group of patients, there are still some nasty techs in the hospital’s auxiliary departments to contend with. They are nasty to EVERYONE… clerks, nurses, doctors and even their own bosses, as illustrated by what happened yesterday:

"Doctor!" yelled a nurse who had just answered the ER phone, "The CT tech is calling to inform us that they are getting ready to tie up the scanner with an hour-long procedure on one of the floor patients. They want to know if there are any scans we need done before they start." I urged them to do the head CT on my HIV patient with altered mental status, not because I needed the results within the ensuing hour for medical reasons, but as a courtesy so we wouldn’t delay his work-up for a whole hour when there were people in the waiting room waiting for an ER bed. The CT tech agreed to wait for us to start his IV line so he could get the study with contrast to rule-out ring-enhancing lesions.

While the nurses were getting the first patient lined and over to the scanner, they brought in a 64-year-old female with focal neurologic deficits. She probably had a stroke and definitely needed to have her head CT without delay. As soon as I examined her I ran out of the room and told the clerk to call over to CT and tell them I needed another scan done before they started their procedure. He called then said they’d agreed to do her scan too, but they weren’t happy about it.

While they were getting ready to rush the second patient to the scanner, the nurse brought me the chart of the newest ambulance delivery – a patient with brain cancer who was significantly confused with neurologic deficits. As soon as I looked at the chart I had the clerk call over to CT to make sure they also scanned patient number 3’s head first before they closed down the scanner to us for their in-patient procedure. He called and then gave me a look like I had just started World War III. "Now they’re PISSED."

A few minutes later the phone rang and I could hear the nurse explaining why a stat head CT was indicated in the 3rd patient. She sounded frustrated and defensive. "Wait until after your hour-long procedure?" I heard her ask incredulously. She looked at me with exasperation. I decided, as the MD in charge, to straighten the whole situation out. I held out my hand for the phone. "Hello, This is doctor so-and-so. I really can’t wait an hour to know if there’s blood in either of these last two patient’s heads, because if there is I need to fly them to a neurosurgeon immediately."

So much for my authority carrying any weight. The tech on the other end of the phone sassed back with all the insolence of a smart-mouthed teenager, "We have a PROCEDURE we’ve been waiting to do."

"I know you have a procedure, but I have two patients who are critically ill and we need to TRIAGE our care. They go first."

She huffed "Fine. Send them over" and then I suddenly heard dial tone. She hung up on me!

No one at the nurse’s station was surprised. "She’s always that way." I decided to take it upon myself to keep her from being "that way" anymore. I called the radiology supervisor and explained the needless hostility her tech had shown to my nurse, my clerk and me. She very politely agreed, as their superior, to look into the matter.

30 minutes or so the radiology supervisor came and found me in the ER. She introduced herself with an empathetic smile. "I called over to CT," she explained. "There are two techs over there. I didn’t talk to the one who hung up on you. I talked to the other one. She said she was standing there when her colleague was on the phone with you and that what she heard did not sound rude."

Typical.

"But," continued the supervisor, "she was not at all nice when she said this. And then she hung up on ME!"

It really is a wonder to me how these people keep their jobs. Why can’t we all just get along?

You know you’ve had a shitty day when…

Monday morning in the ER – something to avoid, for patients and doctors alike. Studies have actually documented an increased incidence of deaths from heart attacks and strokes on Monday morning. And, no, it’s not the quality of treatment provided by hungover medical practitioners on Monday mornings! To me it seems perfectly obvious that the symbolic significance of Monday mornings and the physical and psychological demands of returning to work at the beginning of the week are to blame. No one has really proved exactly why Monday is a bad day for hearts, but it is. All I know is if it’s a bad day for hearts, it means it’s a bad day for ER’s, and you should try to avoid Monday morning in the ER at all costs.

Unfortunately, people don’t realize this… I’ve noticed the Monday morning phenomenon of well-appearing patients showing up with minor complaints and wanting work notes. They couldn’t be bothered to come during the weekend and now suddenly on Monday morning (when I’m trying to take care of all the heart-attacks and strokes mentioned above) it’s an "emergency." Then they complain when they have to wait for hours! Then there is the other Monday morning phenomenon of somewhat sick patients who were planning to go see their regular doctor first thing Monday morning, but they wake up Monday and call and can’t get an appointment, so instead they come at the ER.

Trust me, you really don’t want to come to the ER on Monday morning unless you are getting paid to do so. This past Monday I was right smack in the middle of the chaos earning every last cent of my salary. I think someone commented at one point, "Wow, I’ve never seen the chart rack BULGING like that." Turns out with enough charts in it, a metal chart rack will actually flex and bulge. Great. That’s really freakin’ amusing when you’re the physician responsible for all the patients in that rack. It was just one of those Mondays. When I finally dragged my weary ass into the house around dinnertime, I was completely wiped out from dealing with so much shit.

As I came through the door, I looked down and there was Cole waiting to greet me. In his little hand was a plunger that he had retrieved from our bathroom, as he sometimes likes to do. He looked up at me and smiled and began repeatedly thrusting the plunger in my direction as I took off my white coat. Nothing could make me forget the crap at work like this sight of my little man, ready to conquer all the shit in the world for his Mama.

Genius, Cole. Positive "plunger sign"! The mark of a truly shitty day.

Fever of Unknown Etiology: The Follow-up.

Last night I talked to the internist who admitted my febrile soldier (see prev post). I had to call him about another patient of his and was planning to ask him for follow-up on the fever guy's diagnosis before we got off the phone. I didn't even have to ask; he couldn't wait to bring it up. "Man, I still don't know what was wrong with that patient. I sent every possible test." He then rattled off babesiosis and several other medical "zebras". "Everything was negative."
The soldier went home after two days in the hosptial. The final diagnosis was "viral syndrome." We are both perplexed. I guess they make tougher, meaner viruses in Iraq.

While other moms call their pediatrician to ask about runny noses...

On my most recent night shift, the first chart I picked up said "Sore throat, fever, headache." I glanced at his vitals and his pulse was racing (100+) and he had a temperature of 103. "Strep?" I wondered. I headed back to his exam room to see.

You usually can tell which patients are the most sick by just looking at everyone as they come into the ER. As I laid eyes on this muscular young soldier, I knew he had seen better days. His bald head was completely coated in beads of sweat and his skin had a sickly pallor to it. He was laying listless on the stretcher, like a wilted plant in need of some serious watering. I knew there would at least be IV fluids in his future.

He told me he had been fine the preceding day, then just woke up that morning with a sore throat and headache and maybe a little cough. His neck also hurt, in the front… NOT in the back (which would have meant a spinal tap to rule out meningitis). On exam he had some swollen nodes under his jaw and maybe a mildly red throat. Last time he felt this way it was strep throat. "Good," I thought. "I can give him a shot of Bicillin for strep and he’ll go home and get better." I ordered IV hydration, pain meds, antipyretics and then sent the strep test and some basic labs, plus a mono test and chest x-ray, just in case.

I didn’t hear anything more from him as I waited for his tests to come back, and I assumed he was back in his exam room getting better with watering. His tests showed an elevated white blood cell count (the cells that fight infection) and dehydration, but there was no strep, no mono and no pneumonia or other airpace disease. Could this all just be viral with a fever of 103? I felt like I was missing something. I went to re-examine him and he still looked like crap and STILL had a temp of 103. I told the nurse to consent him and set-up for a lumbar puncture (spinal tap). Maybe there really was something more to this neck pain...

As I was getting ready to go tap him, he suddenly started screaming out with excruciating belly pain, and vomiting profusely. What the heck? I went and re-examined his belly and it was no longer soft, but firm with guarding…. If his mono had been positive I would have thought he ruptured his spleen. I wondered about appendicitis, cholecystitis, some strange hepatitis? So I sent him for a belly CT scan and added on belly labs to his blood work. Damn if all of that wasn’t normal too.

At this point it occurred to me to ask if he had been out of the country recently, since he was military. Sure enough… he just got back from Iraq 3 days ago. Hmmmmm… could it be some kind of weird travel related illness that you never expect to see in my podunk little ER? I sent a malaria smear and read up on what infections might be indigenous to Iraq… then I sent Q-fever and schistosomiasis serum tests. I decided to proceed with the LP to rule-out meningitis or some kind of funky encephalitis. Now this was getting interesting.

"Interesting" is never good from the patient’s standpoint. And it’s not good from the doctor’s standpoint when she get exposed to the patient’s bodily fluid… especially when the doctor happens to be feeding her breast milk to her baby at home. Until this damn spinal tap, I had never stuck myself or had any type of body fluid exposure in my entire medical career. But I guess I got a little overzealous with the soldier’s subcutaneous lidocaine. In an attempt to make the LP as tolerable as possible for patients, I typically go crazy with the lidocaine – I get extra lidocaine beyond what they give you in the LP kit, and I inject away… subcutaenous tissue, deep tissue, periosteal tissue. It usually works very well – I’ve had 2 patients tell me that my spinal tap was less painful than the having their IV started! On this occasion, however, the lidocaine did me wrong. I was injecting it… a LOT of it… right under his skin. The pressure under his skin got greater and greater and then WOOSH! The syringe came off the needle and pressurized lidocaine sprayed right out of the needle in his back and went EVERYWHERE, including both of my eyes. Shit.

With my eyes stinging, I quickly finished the procedure and then filled out an incident report. I wasn’t particularly concerned because it was such a low-risk exposure… mostly just lidocaine and probably slim to none of the soldier’s body fluid got in my eyes. Plus I’m vaccinated and I know he is too, since he’s military. I was feeling pretty nonchalant about the whole thing… until I thought about Graham drinking my breast milk. Then I became crazy psycho worried mommy… and off went the HIV and Hep B&C tests on the patient. I even had the nurse stick me to make sure my Hep B titer is good. Worrying about your kids adds another whole dimension of stress to what might otherwise been only mildly stressful, and suddenly I was acting like I had injected his blood right into my vein.

I’m still not sure what is wrong with the patient. His spinal tap ended up being normal. I admitted him to the hospital for fever of unknown etiology, and a lot of the test results for the more unusual infections (malaria, etc.) are still pending. I would have followed up on his hospital course based on academic interest alone, but now I have a personal interest as well, and I can’t wait to finally see what’s wrong with this guy. If he has some weird Iraqy infection, what are the chances I contracted it and might pass it to Graham via my breast milk?

Even though I figured chances were quite low, I decided to run it by my pediatrican. So, while other moms are calling and asking about little Jonny’s runny nose and cough, I call and ask (in a nut shell), "If I got splashed in the eyes with lidocaine from a needle in the subcutaneous tissue while doing a spinal tap on a febrile soldier who got back from Iraq 3 days ago, should I worry about passing something to Graham via my breastmilk?" I was not surprised the answer was no. I just needed to hear someone else say it. I WAS surprised that they kept from laughing while they listened to the whole saga. Sometimes truth really is stranger than fiction.

Only me, I tell you. Only me.

Milestone after milestone

Cole was high on life the other night. He was such a whacko during playtime that he reached two new milestones just by sheer uninhibited zealousness…

#1. First actual jump in which both feet leave the ground (as opposed to the semi-jump, in which he cheats and squats down like he’s going to jump to great heights but then just springs up on the tip-toe of one foot while lifting the other way up and reaching his hands toward the sky).
We had gotten used to the semi-jump, so we were pleasantly surprised when he held up a plastic kangaroo and yelled "Hop! Hop! Hop!" and than got actual air with BOTH feet. We kept having him repeat the stunt and got to witness a few cheerleader-looking jumps with some semblance of a split in the air. He’d fall down, laugh and do it again. Finally he stopped the splits and, lo and behold, he landed on his feet.
Keep it up, buddy. May you be fortunate enough to continue landing on your feet your whole life.

#2. First brother-to-brother bodily harm.
Graham was sitting on my lap staring at his brother in amazement. "Will I ever be this hyper?" Cole found a rattle and after giving it a few hearty shakes decided to comply when I asked him to share it with "Gigi." He got such praise for handing the rattle over to his little brother that when he came across another rattle, he got a little overzealous… He looked up and with his biggest proudest smile, he threw the rattle right to Graham. Poor Graham can’t catch and sat there drooling as the little plastic boomerang bounced right off his forehead. He cried. I fussed. Then Cole cried too. Then Dan came in and said ‘What is that Whelp on Graham’s head?"
First of MANY, I’m sure.

OCD, junior

When you marry an anal retentive man, it means you’re going to have a clean house and probably anal-retentive kids.

Every day Cole watches Dada do his Obsessive-Compulsive wiping, swiffering, vacuuming, and now he’s starting to get into it himself. "All Clean!" is one of his proudest exclamations. He’ll abduct a diaper wipe from his changing station to the kitchen and use it to wipe down all the surfaces he can reach – floor, chairs, table, refrigerator. Then he’ll beam at me proudly, "All Clean!" Except really it’s not so clean, since he usually does the floor and then uses the same wipe on all the other surfaces, but who am I to be a stickler for details when the boy is showing enthusiasm about cleaning?

Don't get me wrong, Cole definitely has his moments of smearing chocolate pudding all over everything in site then squealing "Mess! Mess! Mess!" But not only does he enjoy making a good mess, he enjoys cleaning it up. If you give him a wet rag, he’ll wipe the table until the pudding is all gone and clean his hands and face as well.

He’s been pushing a broom or swiffer or vacuum attachment around since he could walk. This month he’s stepped it up a notch and has started removing the disposable swiffer cover and depositing it into the trashcan himself when he’s done. Dan is so proud!

The cleaning ladies are 2 of his favorite people ever. This past week when they came he started shouting "Clean! Clean!" He can’t take his eyes off them. He follows them around and steals their swiffer and their vacuum.

So what happens when such a fastidious child finds himself with his own turd floating beside him in the bathtub? You would think a big brown squishy thing, especially one bobbing in the water, would be fascinating to most toddlers. There is a particularly repulsive story my mom tells of me as a toddler pooping in my dad’s shoe as she was getting my bath ready, then squishing it, smearing it everywhere, even tasting it. Cole is definitely not like me in this regard. This week Oma and I heard him grunting while in the bathtub, then we looked down and saw a man-size lumpfish floating up from under his rear-end. What was priceless was the look of horrified disgust on his face as he laid eyes on his poop, as if he could not imagine anything more repugnant. He sat there stunned, then he let out the whimpering "Nooooo, Noooooo" reserved for the most offensive events, like when I took him on his first ride at the state fair and he got scared, or when he bites into a piece of chicken or waffle and it’s too hot. Even after I swooped in and picked him up out of the turd-infested waters, he was still visibly upset. So I got a plastic (DISPOSABLE!) cup and scooped the poop and carried it over to the toilet. "See, Cole. Poo-poo goes in the potty." Flush! Down it went, and Cole was immediately relieved… as if he knew everything was in it’s place.

Good Boy

Hopefully I'm not jinxing myself with this post, but I have to enjoy it while I can.

This morning I woke up in "mission control" (as Dan calls our bedroom, describing the 2 baby monitors, 2 alarm clocks, carbon monoxide detector, wireless weather station… not to mention TV, stereo, phone on each bedside table, and our computer). Anyway, I woke up in mission control to the sound of baby fussing coming from Graham’s monitor. It was just a gentle little whimper, so I figured he was just waking up a little hungry. I went upstairs and found him with his leg stuck through the crib slats up to his thigh and his head jammed into the corner of the crib! I don’t know how long he had been like that, but he was just laying there patiently waiting for me to help him out. I know if I were stuck like that you would hear not just gentle fussing but full-blown screaming. Graham, however, is just unusually GOOD.

He is so good that when he was first born I was reluctant to put him up in his nursery, because I didn’t think I’d hear him wake up to eat. What newborn do you know that doesn’t cry in the middle of the night? It’s not that Graham was sleeping all night… he would just wake up and move around a lot and breath heavy and MAYBE whimper for the first two weeks. He was right next to our bed those first weeks, yet Dan would sometimes wake up in the morning after a full night’s sleep and not even realize Graham had been up at all because he was so quiet. It was not until 3 or 4 weeks old that he actually discovered he could cry in the middle of the night to get my attention. If you are reading this thinking we got off easy, don’t worry… we definitely paid our dues with Cole, king of colic. This makes us all the more able to appreciate what a little angel Graham can be.

Graham is now so good that we can take him anywhere and everywhere. He is one of those delicious little babies at the Fall festival in the pumpkin hat, the kind that makes everyone else want to get pregnant. We’ve had so many outings recently because Grannie & Grandpa AND Oma & Opa came to town. Graham was packed up, carted all over town and then pushed for hours in the stroller or carried (when we could) all around the zoo, the farm, the airport, the state fair. Did he cry? No. Did he even whimper? Hardly. He just rode around behind his brother with his big angelic blue eyes wide open, checking it all out.


Good job, Graham! They don't make babies much better than you. May you be such an angelic toddler...

Dada's Butt

There is nothing cuter than watching your baby’s vocabulary explode, until he says something incriminating.

It all started out so innocently. Right around Cole’s first birthday, as we helped Cole learn his animal sounds ("What does the lion say?" "What does the cow say?" etc.), we would slip in an occasional "What does Dada’s butt say?" just for kicks. Now "pfft" is in his repertoire right along with "roar" and "moo."

Over the last month, Cole has been saying more and more words, and has started putting words together. "Bye-Bye Dada" was his first two-word phrase, followed by phrases like "More cheese." "Mama, Mess!" "Yellow juice" "Bubble Bath" "Mama’s car" "Mama’s shoes" "All done" "Dada clean."

We’d been eagerly waiting for more three-word phrases and sentences. The weekend before last we got our wish. Cole said his first sentence for Dan and the babysitter while I was at work. Apparently out of the blue he just looked at both of them and said "Dada’s Butt pffffft," flashing his proudest grin. The babysitter about peed her pants she laughed so hard.

Good job, Cole! We would have remembered your first sentence no matter what you said, but you wanted to make it something no one could forget.... EVER!


Update: Since "Dada’s Butt pffft," Cole has come up with sentence after sentence. This week he actually made a compound sentence: "Juice All Done; More Juice, Please."
Go, Cole, go.

Damn Hard To Do As A Working Mom

Graham had another milestone yesterday, but I’m not celebrating…
He had his first bottle of formula.

I wish I could be one of those mothers who give their baby nothing but breast milk for 6 months or even a year.

"The American Academy of Pediatrics believes that breastfeeding is the optimal source of nutrition through the first year of life. We recommend exclusively breastfeeding for four to six months, and then gradually adding solid foods while continuing breastfeeding until at least the baby’s first brithday. Thereafter, breastfeeding can be continued for as long as both mother and baby desire it."
(From The American Academy of Pediatrics Complete and Authoritative Guide to Caring For Your Baby and Young Child, Birth to Age 5) (My child care bible!)

I put a lot of pressure on myself to breast feed, because breast milk really is best (See the American Academy of Pediatrics official Policy Statement on Breastfeeding for all the reasons why), but it’s damn hard to do as a working mom. I find myself resenting the stay-at-home mothers whose milk flows effortlessly, because they have the luxury of being with their child 24-7. (For those of you who don’t know, it’s a supply and demand effect… the more baby nurses, the better your milk supply.)

The solution for having to be away from my baby is supposed to be my Rolls Royce of Breast Pumps. The problem is, I’m not able to use it enough at work to keep up with Graham’s intake. To do that I’d have to pump as often as he eats: every 3-4 hours. My ER is single coverage most of the time (meaning I’m the only doc), so I’m lucky if I get a minute to scarf down any kind of food… let alone 15 whole minutes to to disappear to pump in seclusion. I used to spend the majority of my shift in the ER with painful engorged boobs, constantly trying to get caught-up with patient care enough to go pump, and then constantly having another crisis happen, or, even without any crisis, constantly having at least 3 nurses lined up with "Doctor this" & "Doctor that." What ends up happening is I only get to pump once during the 12 hours I’m away at work, instead of the 3-4 times I should to keep my milk supply up. The nurses have even observed how infrequently I get to pump. The other day it was slow in the ER and I actually got to pump twice, and one of the nurses appropriately commented, "Wow, it really must be slow. You pumped twice today, and I've never seen you pump more than once." I even started foregoing food so I can use that time to pump, which is not helping my milk supply either.

So now, after 2 months of never being able to pump at work, I’m making less and less milk. The good news is I’m no longer in pain from engorgement. The bad new is I’m not making enough breastmilk to keep up with Graham, who is wanting more and more as he starts to turn chub-a-lubby, so yesterday as I packed his bag for daycare I was forced to include one bottle of formula.

Unfortunately, as much as I may try, really I CAN’T do it all. It’s all about prioritizing and making choices. Yesterday I was left with no choice but formula supplementation, and I feel a little defeated. Hopefully, though, my stubborn determination to give Graham what’s best will allow me to keep up with some degree of breastfeeding until his first birthday.

Positive Burger King Sign

Sometimes being a good doctor means being a detective. Usually it’s question-and-answer detective work. A good history will give me the patient’s diagnosis in many cases. Sometimes there are other clues…

I walked into the exam room of a 7 year old little boy whose parents had brought him to the ER for 3 days of vomiting and diarrhea. He wasn’t febrile and his vital signs were stable. He sat there happily playing with a familiar looking yellow ball. "He’s been throwing up for two days straight," said his mother, "and having diarrhea too." The kid looked pretty happy for someone who had supposedly been puking his guts out, and he didn’t look dehydrated either.

I knew being a mom would help me with pediatric patients. Sure enough, the yellow ball the patient had was the same yellow ball Cole threw around the back seat on our recent road trip after receiving it in his Drive-Thru Burger King Happy meal.

"Is that a Burger King Happy meal toy?" I asked the kid.

"Yup!"

"When did you eat Burger King?"

"Yesterday!"

"Did you eat it all?"

"Yup!"

"Did you throw it up?"

"Nope!"

I looked at the Mom for confirmation. "He kept down a Burger King Happy Meal yesterday?"

"Yes," said mom.

Where I trained there was a McDonald’s in the hospital lobby (to keep the Cardiac Cath lab in business, we always joked). This was often problematic in the ER. I can’t tell you how many times I looked over at a poor patient who was being kept NPO ("nothing per oral") and saw family members torturing them by eating a Quarter Pounder right in front of them. Even worse, you wouldn’t believe how many times a patient who came in with "Belly Pain" would be sitting there munching on greasy french fries. The docs training us called it the "Positive McDonald’s Sign": If you were well enough to sit in the ER and scarf down McDonald’s you probably didn’t need to be in the ER.

Well, it didn’t take the aroma of Whopper Junior in my ER to clue in Doctor Mom, detective… all I needed was the little yellow ball. This kid had a Positive Burger King Sign. I reassured the parents, and home he went.

"Mommy and Me" Day -- Busted!

As an ER doc I work a lot of evenings and weekends, but then I get a lot of random weekdays off, when daycare is open and everyone else is at work. This allows me the privilege of taking one son to The Goddard School and keeping the other son with me for some special "Mommy and Me" time.

Poor Cole got the shaft a week ago on his Mommy and Me day. I had a lovely day planned. First we were going to go to Work of Art to paint, and from there we were going to go to Swift Creek Berry Farm to explore the colorful Mum field and bring some Mums home.

Nothing like having perfectly good plans go down the shitter. I had Cole all excited to paint, but when we got to Work of Art, rearing to go, they were closed ("Reduced September Hours. Back to Regular Hours in October"). Just my luck. At least I had a plan B… or so I thought. We drove all the way to the damn farm and there was not a mum, person, or other vehicle besides mine to be seen. It looked nothing like the seductive pictures of bright fields on their website. By this time poor Cole was sound asleep in his car seat. So much for a stimulating day with Mommy.

So we ended up just stopping at Panera and having a little lunch date. You never know what you’re gonna get when you take an almost-two-year-old to a restaurant, especially when the kids meals come with squeeze up yogurt that can all to easily be turned into a squirt gun.
(Here’s a picture from another lunch date with Oma.)

This time Cole managed to spare his face and got his belly instead.
"Mess!" I exclaimed.
Cole watched my every move as I took a napkin off the table and wiped the yogurt off his shirt. About ten minutes later when I busted out the potato chips, he was getting crumbs everywhere. He looked at me, then looked down at the crumbs on his belly and said "Mess."
I was tickled that he had remembered the word. Then it got even better… He picked up a napkin himself and wiped off his own belly and gave me a "look what I did" grin. This little accomplishment was worth every ounce of the frustration I endured that morning. It’s the sweet and unexpected little moments like this that I cherish as a Mom. I agree with Lennon – Life really is "what happens to you while you’re busy making other plans."

And not to worry… We got our mums. We just got back from "Mommy and Me" outing for Mums, Take 2. This time we went for the sure thing – Lowes!

Reality TV Baby

Our family has a dirty little secret. We love reality TV. I give Dan full credit for this. When I met him I was a dorky med student who watched at most an hour or two of TV a week. I started watching with him, and look at me now… I can chat at the water cooler with the best of them about whatever scandal and drama the big networks were able to create the previous night on America’s beloved reality shows.

It’s a sad statement about how addicted we are to these stupid shows when the timeline of Graham’s short life is punctuated in my memory by what reality shows were on at the time. I realized last week as we fed him his first rice cereal (see most recent post) to the premier of Dancing with the Stars, that he was marking his first solid food milestone on the night of both that reality show’s season premier AND another’s season Finale (Big Brother). I suppose this is appropriate for a Baby who was born the night of the American Idol season Finale. (I think the only way Mommy got through that long drawn-out compilation of one cheesy performance after another was the drugs.)

You would expect another milestone from Graham this past Thursday, as it was the premier of Survivor. Of course life did not disappoint:


It worked out that Graham got to meet his Great-Grandma "Mim" for the first time on Thursday. They hit it off fabulously, each laughing at the other (I don’t know who was more entertained.)

Our little road trip landed us right in front of my parent’s TV for the Survivor premier, where we all got our reality TV fix together. It’s not just Dan and I… My parents and Dan’s parents are hooked too. Baby Graham has all four of his Grandparents in various Survivor Pools! Reality TV is a multigenerational guilty pleasure.

Big G Eats

Graham ate his first rice cereal last night.

First he was clueless that the spoon even deposited anything in his mouth and was just grinning at me as if poking the spoon in and out was a game. The more he laughed and smiled, the more cereal came pouring out down his chin:

Then came the instant when he realized, "Oh my god. She just stuck something my mouth! What is this shit?":

He smacked it around in his mouth like a little cereal connoisseur, trying to appreciate every nuance of the sophisticated "simple grain rice" flavor:

He must have liked it, because then he started making an alien face as he tried to suck everything down, including his own two lips. You'll have to use your imagination to envision it, because we were all laughing too hard to get a picture.

You would not think an ounce of cereal could generate so much entertainment. It was gone before we knew it. And thus concludes another milestone. Baby G is growing up so fast!

Time of Death: 1503

When I have a really bad day at work, someone usually dies. Yesterday was a really bad day.

Mr. H was standing at home talking to his wife, and mid-sentence he just fell over backwards and hit the floor. When a 74-year-old with a history of coronary artery bypass graft and an upcoming appointment for defibrillator placement does that, it's never a good thing. Mrs. H called 911 and then, instead of doing CPR, sat and waited 10 minutes for them to arrive.

By the time he got to me he had gotten multiple rounds of code drugs and had been shocked a dozen times or more. His heart was still fighting, but his after the 10 minutes without oxygen before EMS got to him, his pupils were fixed and dilated -- a very poor neurologic prognosis. This is why everyone should know CPR. Hell, I'm even thinking of getting an AED (automatic external defibrillator) for home as Dan starts going more and more gray. (Yes, I do want to keep him around!)

Even though Mr. H's brain was probably gone, I started coding him to try to get return of spontaneous circulation, because that is what we do. Mr. H's heart was stubborn. He had remained in ventricular fibrillation (where the heart muscles beat independently and the heart is a quivering lump that can't get all it's muscles to work together to make a beat and actually pump blood) no matter what EMS tried, and I couldn't get him out of v fib no matter what I did either. I'd shock him and we'd get a few beats of something and he'd slip right back. I got a few minutes of accelerated ventricular rhythm at one point and actually had a pulse with it, but as soon as I got the cardiologist on the phone to tell him I had thought I had something to work with, of course... v fib again. We saw some Torsades and some pulseless ventricular tachycardia (neither of which are compatible with life) briefly, but by and large, the man remained in v fib for almost 2 hours. He was like my science project... We cracked open countless epinephrine doses, atropine, amiodarone, magnesium, bicarb, lidocaine, calcium and even the now-out-dated procainamide ("I can't remember the last time I gave this," commented one of the older nurses). We even had him on normal saline and amiodarone drips. But his damn heart was just too stubborn. It was supposed to either stop fibrillating and go to asystole (flat line) or start beating again. After 2 hours of CPR, 20 shocks, a consult with the other ER doc on duty, analysis of his chest x-ray & labs, a conversation with his primary care doctor and a bedside visit from the cardiologist on call, he was STILL fibrillating. None of us could do anything to get him out of it. So we had to stop CPR.

I was drained and frustrated because V fib is something we're supposed to be able to fix. I think Mr. H's heart and I would have been battling all night if it weren't for (1) both the cardiologist and the more experienced ER doc telling me that there was nothing else left for me to do and (2) the fact that I knew Mr. H would likely never wake up anyway, even if I could get circulation back, because of his devastated neurologic state. I did feel better when one of the nurses working the code with me told me that she hopes I'm on duty if she ever presents in cardiac arrest, because she doesn't want anyone giving up on her too early. She also told me she can't remember the last time she saw a list of code medications given as long as the one I'd just compiled. I honestly can't think of anything else I could have done, but I always wonder, "Could I have done better?"

There is one episode of Grey's Anatomy (one of my favorite shows) in which the resident tells her intern that the reason docs go through such valiant efforts at the end of life, even if deep down we know it's futile is "So we can tell the family we did everything we could." Amen to that. Giving families news like I had to give the H family is the worst part of my job. I tried to prepare them by telling them when he first got tot he ER that I was trying to get his heart going but there was a good possibility I wouldn't be successful. Mrs. H was a sweetheart and grabbed my hand and whispered "It is in God's hands. Try your best." I let her come into the code for a few minutes and explained to her everything that was going on so she could see that we really were doing everything we could. Then I ushered her back out so I could focus. There is a new trend in Emergency Medicine to let families be present for as much of the end of life resuscitation efforts as possible, so when we finally decided to call it, I let Mrs. H and family come in the trauma room for the final minutes of CPR. I explained that there was nothing further we could do, and then we called it, right in front of them. "Time of death -- 15:03." The drama that ensued overwhelmed the whole ER. There must have been 6 family members present; half of them fell on the floor, and half of them threw themselves on Mr. H's body. The wailing and shrieking and "Oh Lordie"s could be heard in the ambulance bay. Not that I blame them. I just question whether it really is better to have family right in there at the bedside for such traumatic moments. It definitely wasn't better for me. Maybe in a few weeks they'll have more closure and feel more at peace (the way research suggests) from having been there with him for the final minutes, but it was rough for all involved yesterday at 15:03 and made me again wonder "Could I have done better?" in terms of easing the family through it.

When I finally emerged from the room, a Nurse told me "You're bright red... even your ears." My face always seems to find a way to express everything I try to bottle up inside, and yesterday the redness was a neon sign to everyone -- "Watch out, I've had a really bad day."

London Bridge

"How come everytime you come around,
My London, London bridge, wanna go down like,
London, London, London, wanna go down like,
London, London, London, we goin’ down like…"

That's Cole's new favorite dance song: London Bridge by Fergie. You have to dance around for him while you sing it, and be sure to poke him in his big belly right when her voice jumps a few octaves on the third "London" ["London, London, LonDON" (= poke here!)].

Mornings with my boys are turning me into a morning person. I work about 13 shifts a month, and those are random smatterings of mornings, evenings and nights spread out over weekdays and weekends. So I usually end up working only about four 7am weekday shifts in a given month and maybe 2 or less weeknight shifts (which keep me in the hospital until 7 or 8am)... meaning Dan only has morning duty about 6 weekdays a month, and the rest of the weekday mornings, while most people are getting up and going to work, I'm getting up and hanging out with my babies. Sometimes it's hard to get going if I've worked until the wee hours of the morning the evening before... but once I see their precious little faces it is so easy.

When I go into Cole's room in the morning he giggles and jumps up and gives me the million-watt smile that I love so much. Now he likes it when I turn on the local hip-hop station on his little stereo and give him a little dance show before I pick him up out of his crib. It's a big bonus when London Bridge happens to be playing and I get to do the Belly Poke. I get a HUGE belly laugh.

He's turning into quite the little dancer, because of course he wants to imitate everything Mama and Dada do... including our crazy dancing techniques. If you've ever seen Dan and I dance, you know the boy is learning some serious moves. He's getting more and more groovy with each family jam session in the living room. This past weekend, in addition to all the arm moves and "loose neck" head-bobbing, he got his legs into the picture... He started moving his right foot back and forth to the beat, and he also spread his legs wide apart and got low like Mama does. 'Attaboy! I've even taught him the joys of car dancing. Yeterday a good song came on the car stereo. I heard giggling in the back and turned around to see little funky white boy waving his hands around in the air, moving his head and clapping "like he just don' care". Go Cole! Women will be swooning in about 15 years.....

Short and Sweet, Please.

I have a VERY short attention span.

This makes me a great playmate for Cole. In fact, sometimes Cole's attention span outlasts mine, like when he wants me to read the same book to him 4 times in a row, or when he wants to build the same tower and knock it down again over and over and over.

It also makes me a good ER doctor. Most ER doctors have short attention spans. We want to get in, get to the bottom line and keep going.

It would not, however, make me a good radiologist. Radiologists are a different breed. They sit in their dark room and spend a long time analyzing and describing an image that can usually be summed up in a few words.

What's frustrating to me and my short attention span is that if I want to get the official radiologist read on an x-ray, I can't just skim a report to get to the "impression" (the succinct summation of the bottom line). I have to call the dictation line, punch in a bunch of numbers, and then listen to the radiologist drone on, rattling off the study ordered, patient name, date, procedure, and then painstakingly detailing every little finding (usually in a slow unhurried tone) until they finally get to the point. In a busy ER, who has time for that? I can't tell you how many times I'll look at one of my colleagues with their ear stuck in the phone and a frustrated look on their face... waiting for one of these long dictations to meander through the long, circuitous description and finally get to the impression. Really, they should just start out with the "impression" and spare us all.

Below is an example of why these radiology dictations are so painful to listen to, excerpted directly from a radiologist's report of an abdominal film at my hospital. This wasn't actually my patient. A PA printed out the the report and brought it to me for a chuckle. I did find it very amusing that radiologist who dictated this couldn't just say "Belly Button Ring."

"A curvilinear metallic radiodensity overlies the region of the umbilicus and likely represents an umbilical adornment."

Just GET TO THE POINT already!

A Parent's Fears

I'm afraid that my spasticity will catch up with me and I'll trip and fall down the stairs while carrying Cole or Graham, sending the baby flying head-first to the hardwood floor below. I'm afraid that Sudden Infant Death Syndrome will keep my baby from waking up one morning if someone lets him sleep on his belly or if bedding obstructs his breathing. I'm afraid of leaving my son alone with anyone who might potentially crack, fly off the handle, and shake the living daylights out of him. I love these kids more than anything on this earth, and I would hate it if anything ever happened to them that was my fault or was something I could have prevented.

It doesn't help that I've seen each of these fears actually happen to babies who end up coming to see me in the ER. This past Friday, Hurricane Ernesto, turned tropical storm, rained down on us all day. Saturday at work I looked up and saw a nurse with a little 2 month old boy, who looked very much like Graham (that always makes it harder for me), wearing a white onesie that was streaked with mud all over his left shoulder and left side of his back. Thankfully by the time he got to me he was quiet and content. Mom had been carrying him outside in the wet aftermath of Ernesto and had slipped on some wet moss, sending both her and baby flying. Baby flew out of her arms and skid across the ground on the left side of his head and torso. He had abrasions all over his head, neck and back.
Then about an hour later I looked up and saw a second little baby, who also looked like Graham, simply inconsolable with bruising and swelling all over his little head. His mom had also slipped and fallen!
I made my colleague see the second baby, because I was a little too empathetic with these poor moms and was already upset after seeing the first one. The second baby got a CT scan of his head because he was crying inconsolably with obvious head trauma. The one I saw had nothing more than scratches on physical exam. Both babies ended up being fine. What was even more amazing to me is that both moms, even after realizing one of my worst fears, were holding up fine too. Everyone knows babies are resilient, but it's nice to be reminded of the resilience of parents.

Even when their children are NOT fine, parents find a way to keep going. Last month I saw a heartbreaking case of SIDS: A 2 month old little baby boy had been put to sleep on his stomach, and when his parents went to get him out of his crib in the morning, he was not breathing. He came to us via ambulance and we tried anything we could to give him a chance, knowing how resilient a baby's cardiovascular system can be, but he was simply gone. I had to tell the parents. They were probably prepared for the news after finding him that morning, but I was still amazed at the strength and courage they were able to muster and the composure they were able to keep. It's comforting to me to see that parents find a way to get through.

Just like any parent, I'll always have that lurking concern that I could trip as I carry baby down the stairs. But my job is a constant reminder that people do drop their babies on their head or worse, and lo and behold... they keep going.

Damned if you do; Damned if you don't.

I decided this past week to look as doctorly as possible. If I look too undoctorly, too many of my patients don't realize a doctor has seen them, and last week one patient consequently became very irate (see previous post). So, this week I busted out a white coat, I picked a subdued blue from my rainbow collection of mostly fun-colored scrubs, and I pulled my hair back. Yes, Everyone was going to know I was the doctor.

Unfortunately, this included the nutjob between me and my Iced Venti Caramel Macchiato at Starbucks on my way into work. As I reached for a straw I could see him eyeing the "MD" insignia on my white coat. Then as I reached for my coffee he exclaimed "Hey MD!" so loudly that half of the coffee shop turned to look at us.
Oh Geez. If this is what I get for busting out my white coat, next time I'm leaving it in the closet. "Yes?" I politely responded to the wacky coffee man who was getting a refill of a huge venti coffee.
"Yeah. Um.... What happens if you drink, like, 12 cups of coffee a day? Do bad things happen to you?"
Nothing like being forced to explain the negative effects of caffeine in the middle of a Starbucks. Ever cognizant of my audience, I answered in simple wacky-coffee-man language. "It jacks you up. You can get really nervous, have trouble sleeping, or your heart can race."
"My heart can race?! So if I have a whole bunch of coffee, I can have a HEART ATTACK!" he screamed. Now the whole coffee shop and the snooty little coffee maids were looking at me in my white coat as if this coffee health alert had come from me, and this was definitely the wrong audience for such a sentiment. Looking undoctorly was seeming awfully appealing.
"Not usually, but it is a stress on your cardiovascular system," I corrected him as I hurried by him out the door to work, where there would be no wacky coffee men soliciting free medical advice and my obvious doctorliness would actually be a good thing.

Boy was I wrong...
In room 16 there was an acutely psychotic manic-depressive who had been acting out that day and was brought in for an evaluation. I went to interview him to see if he met any of the three main criteria for emergent admission to the psych ward: 1) Was he suicidal?, 2) Was he homicidal?, or 3) Was he simply lacking the level of function necessary to care for himself? Turned out he was not suicidal. So, I asked him "Do you want to hurt anyone?"
"Yup."
"Really, Who?"
"I want to kill doctors."
Now it was like a train-wreck -- horrible but you can't look away -- so I kept asking questions.
"Oh, Do you want to kill me?"
"Yup."
"Why?"
"You seem weak."
"Hmmm. What would you do? Do you have a specific plan?" It's always important to know if they have a specific plan or just general ideation.
"I'll slit you're throat."
"Oh..." At this point I was gradually backing out of the room. This is one of the reasons you're always supposed to keep yourself between a psyche patient and the door. "Are you taking your psychiatric medications?"
"Nope." That one was a no-brainer.
"Okay, well, we'll get you some help."
Just my luck. I get the homicidal patient who wants to kill doctors the day I decide to look as doctorly as possible. He went to the psych floor as quickly as possibly, and after he left the nurse found a LOVE note he had left her in the room. Apparently he reserved his death threats for doctors only.

At least I accomplished my goal: Everyone, even wacky coffee man and homicidal doctor killer, knew I was the doctor.

Gratuitous Pictures of my Babies

All of us (even Dan!) went to Portrait Innovations on Sunday morning. I highly recommend it.

We were lucky to get the any shots of Cole and Graham together, because Cole wanted nothing to do with his little brother during the photo shoot. Being a big brother, as far as he is concerned, means gently patting Graham on the head every once in a while, or proudly retrieving Graham's paci, burp cloth & doggy blankie from the baby swing and parading them over to me while I nurse him on the couch. But if Cole goes to crawl into my lap with one of his books and finds Graham already there he gets quite annoyed. One time Graham went so far as to kick Cole in the back when he brought a book into my lap, and Cole whined in protest and reached his little arm back and tried to push him away. And so it started...

Yesterday, at the photographer's request, we repeatedly deposited Graham into Cole's lap and Cole repeatedly screamed "No," pushed him off, got up and walked away. The one shot we have where there is actually brother-to-brother contact was snapped as quickly as possible immediately after putting them on their backs together on a bean bag, just as Cole was sliding away from Graham as fast as he could. Guess we need to practice brotherly love!

Now my count is 3 successes (with actual pictures purchased) out of 5 photo shoots attempted. The 2 failures were Cole at 6 weeks (too colicky to cooperate) and Cole at 1 year (just plain pissed-off that day).

Here are my 7 favorite shots from the latest successful shoot:

Graham's Poop Project

He did it! After greater than a week's hiatus from shitting, Graham dropped a deuce yesterday. I was the lucky recipient of The Big One.

It was an angst-ridden week waiting for the little rascal to shit (See previous post: "Drop a Deuce"). I tried prune juice, Karo syrup, rectal stimulation with a thermometer. Poor Graham took it all in stride. Then I went looking for answers on the net and found this reassuring article, and decided to leave the poor baby alone for a while. He was never uncomfortable until the night and morning before the big blow.

I, on the other hand, was very uncomfortable about the state of his bowels and spent the week neurosing. I had everyone on high poop alert - grandparents, friends, neighbors, daycare, babysitter. I even mentioned it to one of my patients who was asking me about her own baby's 3-day hiatus from shitting. She found Graham's week-long hiatus very reassuring.

All week I kept thinking something was coming because his farts kept getting worse and worse and worse. By the time anything actually happened his ass was releasing the worst Death Bombs you've ever smelled. When I walked by his nursery to Cole's room, I actually got a whiff of it emanating out from under the closed door as he slept...

Finally, yesterday morning, Graham started grunting and straining and looking like he was in pain. Dan had already encouraged me to call our pediatrician if it went longer than a week to see if he had any advice. It takes a lot to get me to call my pediatrician because it's like a sign of weakness -- I'm supposed to know this stuff. But watching him turn red-faced and cry made me pick up the phone. The recommended plan was to pump milk rather than put him on the boob, so I could add dark Karo syrup (1/2 tsp to every 2 oz, if anyone's curious) to every single feed until he pooped. Apparently more than a week without poop is concerning to the pediatrician, so if he didn't poop within 24 hours I was supposed to call back.

Graham overhead the phone call with the pediatrician, and I don't think he liked the plan to not put him on the boob. He made it a BIG project and worked it and worked it, grunting and straining for a good 3 or 4 hours... His timing is exquisite, because just as I was picking him up off the playmat to take him to the store for dark Karo syrup, I not only smelled the Death Bomb aroma, I felt like I was inhaling it. Sure enough, there it was. Now I know what a week's worth of baby shit looks like. (I had typed a description here but deleted it because it was just too gross. It suffices to say it was bad.)

Then the celebration began! "Graham, you POOPED!" You would think the child had just won a Nobel prize. He did look particularly proud, though. I called Dan and left a celebratory message on his voicemail at work. I called my parents and left a "He pooped! Yay!" cheer on their machine as well. It's amazing how parenthood changes what makes you excited. When Dan first bought me my fancy car, I was excited to roll around looking cool. Yesterday, As Graham and I left to get groceries after the Big Blow, the Benz was cruising down the street with the window down so I could scream "He Pooped!" and give the fist pump of joy to the neighbor on the front porch . What could be cooler than that?

Good job, Graham.

Ways to Annoy your ER Doctor

This post is inspired by my not-so-wonderful shift two evenings ago.

Ways to Annoy your ER Doctor:

1) Ask her "When is the doctor coming to see me?" immediately after she finishes doing a history and physical and explaining a work-up and treatment plan for your complaint.

I cannot tell you how many times I have to answer "I am the doctor," or the nurses have to explain to the patient, "You know that little blonde girl that was in here before? She is the doctor." You'd think people might clue in when the first thing I say upon walking into their room is "I'm Dr. So-and-so. Nice to meet you." All my scrubs are monogrammed to say "MD" and I always wear my hospital badge which clearly states my title, but what I really must need is a big bright button that says "I am the doctor!!!"

Apparently my undoctorliness became an issue two evenings ago. I returned to work yesterday evening and the nurse asked "Do you remember the little boy in Room 16 last night?"
"Yes," I answer.
"Did you examine him?"
"What?" I ask incredulously. "Of course I examined him. He was my patient."
Turns out that after I signed out his care to the overnight doc and went home, the patient's mother threw a fit and insisted that no doctor examined her child. Ironically, not only had I done a full head-to-toe exam on him and explained in depth my plan for evaluating his fever, I had then been cornered by the mother in our staff lounge while I was trying to quickly wolf down some dinner and had answered all sorts of questions about his eczema, his eczema creams, his allergies, and his allergy creams. I had even left the prescription on the chart for the new eczema cream that she wanted, even though it had nothing to do with the fever that brought him to the ER. Nonetheless, when his fever work-up came back negative and it was time to discharge him home, she was irate because no doctor had laid a hand on him. Guess I needed my button.

2) Be Agist
Another patient two evenings ago was downright hostile about how young I look. Patients love to comment on how young I look, but most of them manage to do it in a complimentary manner.. unlike this gentleman. He was an elderly gentleman with a laundry list of medicines and an utter inability to articulate his medical history or what brought him to the ER. I was probing by asking questions such as, "Have you been admitted to the hospital here before?" and "For What?"
All he could say was "I been coming here for years." Finally he looked me up and down and asked, "And how long you been here?"
"A year," I responded.
"I been comin' here since before you was born," he scorned.

I wonder, is this more insulting to me or to him?

3) Be Sexist
It turned out this same gentleman needed a rectal exam, because, from what I could ascertain from his vague history, GI bleed was on his differential diagnosis. "I ain't takin' my pants down for no damn woman," he scorned again.
"Well, I'm your doctor and you need this test, so let's get it over with."
"I HATE takin' my pants down for a woman," he complained while begrudgingly assuming the position.
Lo and Behold - he did have a GI bleed. "I told you that you needed this test," I said victoriously.

4) Never be satisfied by anything... ever!
I don't know what was in the air two nights ago. Another patient with pelvic pain was signed out to me at the beginning of my shift. She was waiting on an ultrasound to rule-out ovarian torsion. The other doc thought it was going to be normal, because he suspected she might be drug-seeking. Sure enough, it was.
I went to talk to the patient and her husband and tell them the good news. It's amazing how saying "You don't have an emergent medical condition and are okay to go home and follow-up with your obstetrician" can evoke such rage. "We want a CT scan. We want an MRI. You and the other doctor haven't done enough. I just saw him leaving in his golf clothes," complained the husband, "and my wife is in pain." I reassured him that I'd give her pain medicines for a day or two to cover her until she good follow-up with OB and explained again that there was no indication for an emergent CT. I left the room to do her discharge papers. They were unhappy, to say the least, and while I was writing I succumbed to the fear of lawsuits that plagues all emergency physicians and blurs the line between what we should do and what we actually do. I ordered the CT, rationalizing that she'd be back anyway for the same complaint, and I was doing a favor for the next ER doc who would see her. Hell, it might even be me... this way I could just pull up the CT report next time.
I went back to the room and told them that we'd to the CT so they could rest easy. I then told them explicitly that they'd be in the ER for multiple more hours to get this test. "We don't care how long it takes. We just want the test done."
Multiple hours later, I was in the middle of an acute stroke, a chest pain, a possible central cord syndrome (spinal cord injury), and (my personal favorite) a traumatic ejection from a golf-cart with altered mental status -- all of which had come in within the past hour. I look over my shoulder and guess whose husband is lurking at the nurse's station, just staring me down? Guess who is now pissed that they were in the ER for multiple hours? And guess who, even with a normal CT scan, still won't go home happily? And guess what lucky doctor is still being told "You haven't done enough"?
I had gone out of my way and they still weren't satisfied. Sometimes you just can't win.

Yes, two evening ago I went home very annoyed. Then last night, thankfully, I returned to have a great shift and today am back to loving my job. It all balances out in the end.

P.S. STILL no poop from Graham.