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.