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...