April’s Highlights

We’re in our dream house, our house for the boys to grow up in, our house (*maybe*) to grow old in, our house that is currently making us very house-poor but is VERY worth it. April 3rd was moving day and it’s been crazy ever since.

I’ve been too busy moving to blog, but my boys haven’t stopped with the noteworthy milestones and stories.

Here are the highlights:


GRAHAM

Since I last blogged, sweet little Graham has just had an explosion of development:

Little man is now talking… "Mama", "Dada"," bye-bye." He actually said "MAMA" before he said "Dada." This is rare for kids, but my boy is SPECIAL. He is definitely a little Mama’s boy.

Now he eats big boy food… ANY big boy food he can get his pudgy little hands on: Pizza! Chicken Nuggets! Mac & Cheese! His two favorites are strawberries and mandarin oranges.

He holds his own bottle and can drink from a tippy cup.

The biggest news is that he’s learning to walk. Now he walks with a walker... or with anything about his height that is not firmly fastened to the floor. He pushes around chairs / barstools / toys, with his little legs motoring away and this look on his face that's a blend of excited, determined and proud. May 24 is his first birthday and he may be REALLY walking by then. (He’s walking sooner that Cole, who was just walking with a walker at his first birthday and then first REALLY walked at 13 months).

He also got his first haircut this past weekend, and he’s looking VERY handsome.

All of this in a few short weeks. He’s come so far he’s like a different baby from this time last month!

He still idolizes big brother Cole. He follows Cole around and wants to get into whatever Cole is doing. Even when Cole doesn’t want to be bothered and is pushing him away, Graham thinks it’s a game and laughs hysterically. One of the things that I don’t think Dan or I will ever forget about Graham (because it happens EVERY night) is how he loves to steamroll over the books we read Cole at bedtime. Since we can’t exactly climb into the crib with Cole, we lay on the floor with him and put the book on the floor where everyone can see. Inevitably Graham crawls into the middle of the book and sits his little ass right in the middle of the page. Either that or he’ll start grabbing wildly at the pages, sometimes ripping them. It’s to the point where Graham usually has to be removed from Cole’s story-time for bad behavior! He’s very assertive and gets into whatever is going on.

Mostly he’s still happy and good-natured and seldom cries. He’s mama’s little ANGEL.


COLE

My big boy is personality PLUS.

He just got moved up to the next class at daycare because he was "bored" (I think that’s Goddard language for acting out.) He had been in that room so long that he was the oldest and biggest and smartest kid and wasn’t getting challenged enough. His teacher called him "The Ringleader." So he’s on to bigger and brighter things. He loves school and gets all excited when the car turns down the road to The Goddard. That makes putting him in daycare 5 days a week a hell of a lot easier.

Cole is a riot. He’s getting so much more sophisticated with his language that he can tell us what he wants and what he’s thinking now. Here are a few of the recent funny Cole stories:
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One of the "acting out" offenses that has been a problem at daycare has been "spitting." (Really spitting = making raspberry sounds, i.e., "pfffft," when he’s pissed off. I think it’s better than blurting out obscenities the way adults do, but if daycare doesn’t like it, we can’t tolerate it.) So we’ve been working on him about "no spitting." He gets time-out when he makes the raspberry sound. He’s doing much better, but every once in a while when he gets tired and has a melt-down, he’ll start doing it. He was doing it in the car the other day, which is the worst place, because I can’t exactly put him in time-out while I’m driving and he’s strapped in a car seat. He did it even after I had told him to stop, and he knew he was in trouble when we got home. So out of the blue, he said to me, "No tell dada. No spitting." Damn if he wasn’t already worrying about Dada finding out before I even mentioned Dada. Pretty smart for 2!
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Here’s another one that made me laugh: Cole accompanied me to the grocery store one morning and we were wheeling around the fruit section and I asked him, "Cole what’s you’re favorite fruit?"

"MAC AND CHEESE!" He shouted.

"No, Mac and Cheese is not a fruit. Strawberries, blueberries, watermelons. Those are fruits. What’s you’re favorite fruit?"

"MAC AND CHEESE!" He shouted excitedly.

"No," I laughed. "Mac and Cheese still is not a fruit. Look around. We’re in the fruit section. Do you see Mac and Cheese here?"

He looked and thought, thought and looked. "Mangoes" he said tentatively.

"Yes, sweeties. Mangoes are fruit."

So Cole’s favorite fruit, according to him, is Mac & Cheese. According to me it’s Mangoes. I’ve been buying a lot more mangoes since then.
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I get a big kick out of how Cole blames Graham for all of his shits. With everything else he’s very honest and will pretty much tell on himself. (For example, Just the other day I caught him pushing Graham down and went to address it and said, "Cole, did you push your brother down?" and he matter-of-factly answered "Yes." Or often he’ll come running to me and announce, "I made piggy mess.") He’s not manipulative enough yet to lie. But when you smell shit in the air and wonder whose diaper it’s coming from, Cole will always tell you it’s Graham:
"Ewww who has poopy?" we'll ask.

"Gi-gi made poopy."

At which point we’ll sniff both butts and determine that Cole is the offender. "No, Cole. You made poopy."

"No. Gi-gi poopy," as if we’ll take Graham and change his diaper instead.

It happens every time. Too funny.
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And for the final Cole story… the other night Dan was bathing him, and he had Cole do his usual routine of standing up to get his pee-pee washed and then turning around to get his butt washed. Cole did it and got cleaned then sat back down in the tub and looked at Dan and said "Thank you, Dada."

"Thank you for what, Cole?" asked Dan.

"Thank you wash my butt."

You gotta love our little Mr. Personality!
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Overall, as the boys grow and we discover their personalities, it seems like Cole looks like Mama and acts like Dada, while Graham looks like Dada and has more of Mama’s personality. They are so much fun!

Making his father very proud.

Graham is sick again. This time he’s got the gastroenteritis that’s going around… this is after two recent ear infections. The poor boy has been sick more than he’s been well lately.

I’d rather an ear infection to the stomach flu any day. At least with an ear infection you can give antibiotics and it gets better. There’s no real cure for the stomach bug… just "supportive care," i.e. keep them hydrated by mouth the best you can and if they are puking absolutely everything up and looking too dehydrated get them an IV. The worst thing about the stomach flu is the projectile, high-volume, exorcist-style puking.

Graham started this bout of gastroenteritis with a bang, by puking in Dan’s mouth… and the puking hasn’t stopped. It’s to the point where Cole has seen us spray the red can of Resolve and then blot the stain up with towel over and over and over.

Last night Cole was in his room reading books before bed and I was trying to deal with Graham in the nursery and I got a shower of formula puked all over me. I called to Cole, "Cole, mama’s gonna be another minute. Gi-gi puked and I need to clean it."

Cole came running in, all excited. He brought me the Resolve and said, "Mama do it." I dutifully removed the cap and sprayed down the puke stain on the carpet. He looked at the white foam all over the place and said, "I need paper towel." I handed him a dirty bath towel from the hamper and left him to have a field day while I ran to my room with Graham to change my puke soak sweats yet again.

Within 2 minutes I was changed and went back to the nursery, and Cole was standing at the door waiting for me with a big grin. "I cleaned Gi-gi’s puke!" I looked at the spot on the floor where the puke had been, and sure enough… the carpet was clean.

He is his father’s child.

Want to turn a nice guy into a prick? Send him to Police Academy.

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It Takes a Real Man.

It’s official – We’re moving Cole away from his little girlfriends across the street.

Here’s why:

Cole wants to do everything Abby does, and the other night, much to Dan’s chagrin, Abby was trying on her pretty new party dresses. Next thing we knew, Cole was demanding a dress for himself.

What you can’t see here is the twirling…. Abby start twirling in her dress, so what do you think Cole started doing?

In his defense, he is just beginning to learn about boys vs girls. He DOES know he’s a boy, believe it or not. That night we had the "boys don’t wear dresses" lesson. ("Except for fraternity rush week", commented Abby’s dad… Now there’s a thought I really needed. THANKS.)

All I can say is that it takes a real man to pull this look off… And no one is more secure in his studliness than our little man Cole.

I know Cole will miss his estrogen connection, but, alas… mama and dada found their dream home in another neighborhood across town.

Moving day is April 2nd!!

Sweet G

Sweet G is on the move more and more. This month he's hit a few milestones:

Several weeks ago I walked into his room in the morning and found him sitting straight up in his crib, just looking at me with a big shit-eatin' grin across his chubby cheeks, like "Hey Mama... look! I can sit up now." I'm sure it doesn't sound particularly overwhelming to read it, but to walk in and expect to see your little baby on his back the way you left him and then to see that, like a little magician, he's gotten himself upright... it really makes an impression.

And then from sitting up to pulling up... Little man will commando crawl to anything taller than him (bottom stair, Cole's chair, couch) and pull himself up to standing. He even does naked pull-ups in the bath on the side of the tub, quite a feat considering how slippery it must be for him. He's ready to move! Gi-gi will get himself wherever the hell he wants to be... I'll leave him with some toys on one side of the house and go to do something on the other side, and if I'm gone too long I'll hear grunting and look up to see my little determined man commando crawling to get me, sometimes from several rooms away. It is very endearing.

All of this motoring, sitting up and pulling up means he was dangerously close to flipping himself out of his crib. I had Dan drop his crib mattress to the lowest level this past weekend, so we don't have a repeat of what happened with Cole...

When Cole was beginning to do the same things Graham is, we were a little slower to lower his crib mattress and he DID flip himself out. Fortunately Dan was standing right there and caught him when it happened.

My boys are fearless!

Brotherly Love

Monday Cole gave me another early sign we're doing something right.

I was picking both boys up from daycare, and I carried Graham into Cole's classroom and sat him in the middle of the play area while I put Cole's coat on and collected his things. All the other little 2-year-olds were gathering around Graham touching him and asking me about him. I told them all, "This is Graham. He's Cole's baby brother."

Cole was standing about 5 feet away just watching, and I asked him, "Cole, are you proud of your little brother?"

Cole walked right over to the group of his little friends and looked at them all as he proclaimed, "I LOVE MY BROTHER."

These heart-melting moments are my favorite part of motherhood.

The Trouble With Surgeons - UPDATE

My write-up reporting the incident with the on-call surgeon who wouldn't come in for the emergency splenectomy made it's way to hospital administration and the shit hit the fan. Within 72 hours of the incident, the surgeon had "resigned."

Really he had been under scrutiny for some time for similar occurrences, and my incident with him was just the straw that broke the camel's back. But, nonetheless.... Don't mess with Doctor Mom!!

Within a week of hearing about the surgeon getting the ax, I had another coup in the continual struggle against grumpy specialists: This past Friday in the middle of the night an ambulance brought in a little 7 months old girl who had stopped breathing in her sleep. She had no spontaneous respirations and no pulse and, to make a long story short, I got her back in a resuscitation effort that I'm pretty proud of. We have no pediatric ICU (PICU) in my little hospital, so it was a no-brainer that she needed transfer to a facility with a PICU since she was on the ventilator. I called the helicopter to come get her and simultaneously began calling around for an accepting facility. Any facility with a PICU bed is legally obligated to accept her since they offer a higher level of care. The first place I called had no available PICU bed. The second place I called had a bed, so that should have been the end of it -- accept the patient and let me send her. But they gave me the royal run-around. The pediatric ER doctor wouldn't accept and referred me to the pediatric ICU doc. She accepted the patient but only after asking me 101 ridiculous questions about what the patient ate for breakfast, what her favorite color is, etc., etc. (Okay, maybe not that painful... but nothing I said was going to change her management at that instant and the fact that she was keeping me on the phone playing 20 questions when all the patient needed was to get flown out was ridiculous) and THEN... Then she reamed me out on the phone for launching the helicopter BEFORE I had an accepting physician. Hello! If I waited to jump through all the hoops these docs were giving me before calling the helicopter, the baby's transport would have been delayed an hour or more. Besides, it is totally the standard of care to call the helicopter first and figure out were you're sending them second if the patient is unstable. So she REALLY pissed me off by fussing at me, especially because everything I was doing was in the patient's best interest.

Well, lo and behold, the following night toward the beginning of my shift this doctor called me back and said "I owe you an apology"!!!!! She ate a big piece of humble pie and told me I was right and she was sorry.

What a rare pleasure for an ER doc to have this kind of validation... two times in one month!! Next time I'm getting an earful from a grumpy specialist, I'll think about these two coups and keep my chin up!

Feast your eyes --

Here's the latest professional photo shoot of my handsome boys. We went to Portrait Innovations again. I still highly recommend it. Here's the 11 best shots.

(You'll notice there are more of Graham. This is partly because Graham was a lot more cooperative than Cole, who wanted to run around the studio like a wild man. But mostly it's because I put Graham in the blue overalls and had several pictures just of him, since Cole got a whole session by himself in the same outfit when he was that age.)

Feast your eyes and eat your heart out!

**Notice Graham's two little teeth!

And early sign we're doing something right

Dan’s in Atlanta this week (or "Lanta," as Cole says), and Cole’s been a little more difficult with his Dada gone. Last night it was all I could do to get him across the street to have dinner with my friend and her 2 little girls. He showed up with no shoes on, only one sock, and tears all over his face after a temper tantrum in the car. I was worried about what the rest of the week has in store until Dada comes home.

Fortunately, Cole perked right up when he got around his little girlfriends.

I don’t know if he knew I was nervous and wanted to reassure me, or if he just wanted a free pass for more difficult behavior later, but my little man really poured on the charm as I was sitting at the table with all the kids and Michelle was passing out strawberries for dessert:

First Cole got his plate full of berries and requested a fork, which Michelle dutifully gave him. Then I got my plate full of berries and began eating them with my fingers.

"Mama need fork."

"Thank you, sweetie, but I’m okay using my fingers."

Cole put down his own fork, got up from the table and walked all the way over to the drawer where Michelle keeps her utensils. He looked up at Michelle who handed him a grown-up sized fork. Then my considerate little chivalrous man brought the fork right over to me at the table, just like a short little waiter and proudly said, "Mama fork," with the sweetest smile.

I don’t know if it was the relief at that moment that the tantrums were apparently over for the night, or the sheer sweetness of the gesture, or the realization that my little man was worrying about his mama, but my eyes welled up with tears. Those were the sweetest strawberries I’ve ever eaten. Moments like that are what it’s all about.

As Mastercard would say:

Strawberries: $4.00

Fork: $4.00

Realizing your little man is looking out for his Mama: PRICELESS

The Trouble With Surgeons

This post is actually something I wrote for my own purposes, documenting an incident that occurred during my overnight shift on Saturday. Even with my matter-of-fact reporting and medical jargon, the drama of the moment is more than apparent, so I decided it would make an interesting blog entry. I've gone through and made annotations in green for all my nonmedical friends.

Saturday night a 23-year-old male presented to the ER with progressively worsening shortness of breath and low-grade fever following several days of febrile illness and flu-like symptoms. On arrival to the ER he was supremely tachycardic (fast heart rate) (150’s/160’s - normal is less than 100), tachypneic (fast respiratory rate), unable to urinate (from decreased kidney perfusion, I thought at this point from dehydration), and intermittently hypoxic (inadequate oxygenation). I treated him for dehydration with IV fluids, ruled out pneumonia and then, when he remained tachycardic and dyspneic (short of breath), ordered a PE (pulmonary embolus, i.e., blood clot in the lung) CT. I had initially noted diaphragmatic tenderness, possibly secondary to coughing. Around 2am while waiting for the PE CT results his mother came out and said he was having left shoulder pain (Many things can cause this, but it is significant here because in retrospect this guy had referred pain from his diaphragm and spleen, which often goes to the shoulder). It was around 2:30am when the radiologist called with the results of the PE CT: Lungs were clear but there was fluid around the spleen and under the left diaphragm, from a ruptured or lacerated spleen.

I immediately went back to the patient's room to repeat his abdominal exam, and he had increased peritoneal signs (usually indicating a surgical emergency in the belly) compared to his exam on arrival hours earlier, with pain in all 4 quadrants, guarding and rebound (these would be the peritoneal signs). He also was still tachycardic in the 130’s despite aggressive fluid hydration (over 3 liters by that point). I immediately called the surgeon on call (Dr. X), and I ordered O neg blood ("universal donor" blood -- can be given to anyone regardless of their blood type in an emergency), a type and screen (to determine his blood type for type-specific blood transfusion), a monospot (the test for mono infection, which causes enlargement of the spleen and makes it more prone to rupture), and a repeat hemoglobin (blood count).

Dr. X didn’t call back. We wondered if there was a mistake on the call schedule, as is often the case, and paged Dr. Y. Dr. Y immediately called back and listened to my brief case history. He explained that he wasn’t on the call schedule, but agreed to come in given the patient’s emergent medical condition and our inability to contact Dr. X. I continued to page Dr. X. It was just before 3am when Dr. X called back, and I gave him the same case history I had given Dr. Y. Specifically, I explained to him that I had a patient with a ruptured or lacerated spleen, diagnosed by PE CT, and that the patient needed a surgical evaluation as soon as possible because of his worsening peritoneal signs and hemodynamic (related to blood circulation, as determined by pulse and blood pressure, among other things) instability. Dr. X was incredulous that I had called him regarding a splenic rupture diagnosed on PE CT and told me neither he nor any other surgeon would operate on a spleen without an abdomen pelvic CT. I assured him that I was not asking him to operate without an abdominal CT, and re-iterated how the atypical presentation had led me to make the diagnosis via a PE study rather than an abdominal scan. Dr. X asked more questions and focused on the fact that there was no history of trauma and that the patient’s hemoglobin on arrival was 18 (Way above the normal value of 12, though this guy's hemoglobin was probably concentrated from his severe dehydration). I kindly reminded him that I was the one at the bedside with more intimate knowledge of the patient’s condition, and he therefore should defer to my clinical judgment. I urged him to come as soon as possible, offering to get the CT while he was in route or to re-discuss the existing CT images with the radiologist. He stated that it would be unacceptable for him to wait in the ER if the CT wasn’t already done by the time he got there. He was so irate that I had called him without an abdominal CT that he requested the name of my medical director. I gave him his name, and he hung up on me. (Later I found out that instead of coming to the ER like he should have, he proceeded to call and wake up my medical director at 3am to scream at him like a prima donna. My medical director totally had my back, though.)

Just after he hung up on me, the nurse informed me that the while I had been on the phone the patient’s blood pressure had dropped to 80’s systolic (too low... you want that number to be 100 or more) and the repeat hemoglobin had come back at 12 (down from 18 hours earlier). I rushed back to the bedside and found the patient with a systolic blood pressure of 60. I had considered transferring the patient to a more accommodating surgeon, but did not feel he was stable for transport at this point. While we were securing more IV access for even more aggressive fluid resuscitation and blood, Dr. Y, thankfully, walked into the ER and assumed care of the patient. His blood pressure began to respond to fluids. He remained tachycardic, though, and his abdominal exam continued to progress.

Dr. X called back closer to 3:30am, and I updated him on the patient’s status and told him Dr. Y had assumed care. At this point Dr. X said that if it were up to him, he would have advised me to do a DPL on the patient and call him back. (Diagnostic peritoneal lavage: an obsolete procedure in which you cut a small hole in the belly wall, squirt saline into the abdominal cavity and then suck it back out to see if there is blood in it. If there is enough blood, the surgeon needs to take the patient to the OR. They don't even really teach this procedure in residency any more... that's how obsolete it is. It would have been an unnecessary and unsafe delay to definitive treatment for this patient.) The recommendation for DPL was despite my explanation that the patient was unstable and that there was an obvious bleed both by CT and by my clinical assessment. I chose not to dispute this point with Dr. X, but if there had been any doubt in my mind that this patient had intra-abdominal bleeding, the FAST bedside ultrasound exam (a quick and easy 4-view ultrasound of the belly looking for free fluid) would have been the preferred screening modality, not the DPL. He said it was a mute point by then and I agreed. The patient went to the OR for an emergent splenectomy with Dr. Y not long after. (I was 100% right... He HAD needed a surgeon stat.)

If Dr. Y had not come in, this incident could have been detrimental to the patient. Other patients could have been adversely affected as well, because at the same time this incident was occurring, another patient with chest pain was ruling in (having a heart attack) by Troponin (the enzyme that is elevated in your blood when there has been cardiac tissue damage, usually associated with a heart attack) and needed my critical attention as well. (So take all this drama and double it.)

I hope in the future the surgeons on call to the ER will be more willing to render their services emergently and without delay when the ER physician expresses an acute need, regardless of what imaging has or has not been done at the time that they are called. (Translation: Quit whining, get off your ass, and come in already!)

Let me just rush RIGHT into that patient's room to see.

A quote from a nurse tonight in reference to a man who was brought in by his mother because he hadn't shit since Christmas:

"Doctor, the patient in room 11 is saving his stool to show you. You will not believe what came out of that man's rectum. There is no way it's going to flush."

Another satisfied customer.









Okay, now that you've appreciated the humor just in what the nurse said alone... there's more:

Let it be known that this man actually came to the ER HAND-CUFFED!! IN POLICE CUSTODY!! with an ECO (emergency custody order) for medical treatment. I saw him cuffed and assumed he was suicidal or homocidal. So my interview went something like this:

"Do you want to hurt yourself?"

"No."

"Do you want to hurt anyone else?"

"No."

"Why did the police bring you to see me today?"

"I haven't pooped since Christmas."

Hand-cuffed for constipation. That's a first. Apparently this man didn't want to see the doctor because he hates enemas, so his mom actually had him dragged in by police so we could have the pleasure of birthing has baby-sized shit. Before you get any ideas, you can't just call the police to drag whoever you want to the ER... this guy has mental retardation and therefore limited insight into his medical condition. It all worked out for him, though. He was as proud as a new papa of those big turds that clogged our toilet. Go fleets enema, go.

Our Little Parrot

Cole is hysterical these days. He absorbs everything, and as his language skills grow, so does his ability to crack us up.

Before I realized Cole was retaining my word choices, I used to scream down to Dan from the nursery about the status of Graham's diaper as I changed him. "Eewwwwww.... runny shit," or "patty shit" (the hard rock-like kind), or "green shit," or "BIG shit."

I stopped this when Cole started to echo "BIG shit" back to me. Recently I've been trying to say "BIG Poopy" in front of Cole, but it's too late.

The other week Cole came running over to me, smelling obviously like he had just dropped a deuce, and he put his hand on his butt and informed me, "Mama, Big shit." Great. Bet that's a hit at daycare.

I tried to correct him, "Big POOPY, Cole," but it did little good.

This morning I put him on his changing table for his morning diaper change and tried to reinforce "poopy" as the appropriate term. "Okay, Cole, let's clean your POOPY."

Cole simply corrected me. "Big shit, Mama. Big SHIT."

Two-Toothed Crawling, Babbling Wonder

Little Big Graham is speeding through all his baby milestones. Now he has his two front bottom teeth. They're charmingly lopsided right now since the left one came in first, and the right one is just barely peeking up through his gum.

Just around the time his teeth came popping in, he began dragging himself around in search of things to bite. No longer does he sit and cry for stuff that he can't reach, or even try to log roll over and over until he rolls into it. Now he commando-crawls wherever he wants to go. We'll see him set his sights on something and then slowly and steadily drag himself with his big chunky arms across the floor on his belly and elbows until his supreme determination pays off and he gets what he wants in his fat little hand. Half the time he has gone after something Cole was playing with and then, after all that work, Cole looks down at him and says "No, Gi-gi" and takes it away. Poor Graham! He just keeps practicing and goes after something else. He's working on staying up on his hands and knees. Right now he gets up and as soon as he tries to move he does a belly flop, but it won't be long until he really crawls!

He sure has had a lot to say about all these new developments. The last week or so he's discovered his voice. Now he babbles so expressively that even Cole is inclined to answer him. He mixes it up between "BaBaBa", "WaWaWa," and "YaYaYa." A few times I thought I heard "MaMaMa." (Maybe I'll get lucky and Gi-gi will be one of the rare babies who says Mama before Dada. It's a known phenomenon that babies usually say Dada first, because it's an easier sound for them. Cole said Dada months and months before Mama. But Gigi has been working on "MaMaMa" and hasn't said anything resembling "DaDaDa," so I am optimistic.) The boy has got some lungs on him and will belt out his new syllables quite loudly. He tends to do it when he's pissed, so half the time it sounds like a little baby swear. "WaWaWhere's MaMaMy F***ing Dinner YaYaYou BaBaBitch?" Or something like that. Graham's a trip!

Whatever Works

It’s February. It’s freezing out (high of 32 here today). It’s cold and flu season. So people are getting sick and they’re coming in mass to my ER, where many are getting admitted to the hospital with things like pneumonia. The other weekend between the other ER doctor and myself, I think we admitted 20 patients to the same on-call internist. I was working overnight and I swear I called this poor doc every 2 hours all night long, and he was remarkably gracious about it.

I had heard some of the other ER docs complain that this internist and some of his colleagues can be difficult when you call them for an admission. This is not entirely uncharacteristic of internists… There is a constant war of wills between ER docs and internists – We call them to admit patients and they get annoyed because they don’t always agree with our plan and instead think the patient can go home, etc., etc. BUT they are not the ones at the bedside and can’t really make that call over the phone from the comfort of their couch, so they have to either get off their ass and come in to see the patient or give telephone orders for admission and then suck it up and take charge of the patient’s care upstairs. So you can imagine that sometimes they are not too fond of us, since we create a lot of work for them. Although, on the flip side, they are the ones sending us all the patients who call them with anything that might sound remotely concerning… basically when they get too busy to see their own patients they tell them on the phone, "Just go to the ER." So it works both ways. But you can imagine it could be grounds for some conflict every now and then.

One thing I like about where I work is that, personally, I’ve found the group of internists to be very agreeable. They seldom give ME a hard time about admitting patients. I joke that I could call some of them and say, "I’m sending a young healthy person with a hangnail to the ICU," and they’d respond "Sure, Dr. So&So."

So the other night I wasn’t too terribly surprised when this poor internist that I was hammering was so gracious. I felt bad about torturing him all night with admissions, but it was just one of those shifts when everyone was sick. The next morning one of the nurses was teasing him: "Dr. Mo, What are you trying to do? Admit the whole town?"

His response maybe explains some of the reason I don’t seem to encounter too much resistance when it comes to admissions. I wasn’t there for the comment, but the nurse passed it on to me the next time I saw her. He answered: "It’s Dr. So&So. She’s so damn cute, I just can’t say 'No'!"

Hey, cuteness isn’t at the top of the list of what is supposed to make a good doctor, but if my cuteness helps get my patients admitted when they need to be, I’ll take it.

One-Toothed Wonder

Special Milestone: Graham got his first tooth one week ago today!

And not-so-swift Mom and Dad were not even the first ones to appreciate it. Graham’s note from day-care Monday night said, "Graham loved showing off his new tooth today." When I read it, my heart sank because no one is supposed to have to point it out to you that your own child got his first tooth.

Ironically, Dan and I had just discussed the night before that his tooth was working its way up. I had felt it there under his front lower gum a couple of days before, and then Sunday night Graham had a fit of inconsolable crying which is not like him at all. He went to sleep for the night only after Tylenol, so we figured that a little tooth was cutting through… but I guess neither one of us had clean hands at the time to be poking in his mouth. In my defense, I went to work Sunday night after he went to bed and didn’t even see him Monday morning. The tooth made its debut at day-care Monday, so the ladies at Goddard got to tell us about it, instead of the other way around.

Either way, Graham is proud as a peacock! Go, Graham, Go!

After working Tuesday, Wednesday, Thursday 2pm-12am & then unsuspectingly showing up Friday morning to daycare

"Honey, why were the ladies in the infant room getting such a kick out of a picture of Gi-gi with a silly grin holding a $5 bill?"

"What did they tell you?"

"Something about you and strippers."

"Oh. Well… I showed up Tuesday night and told Graham it was just us boys for 3 nights and so Dada was gonna get them some strippers."

"Nice, honey. And the $5?"

"I gave it to him to stuff in the stippers' G-strings. At first I was going to hand him one-dollar bills, but that wasn’t enough for MY boy. The ladies thought it was hilarious and took a picture of him holding up the money."

"Right."

"What did you say to the daycare ladies when you saw the picture?"

"I told them to keep Gi-gi away from sex, drugs and alcohol."

"What did they say?"

"Just say no, Gi-gi! Just say NO!"

Hello, My name is Pain In The Ass.

Schedulers control my life, so I was glad when my ER’s new scheduler sent each of us an e-mail asking about our overall schedule preferences. I was all too eager to tell her exactly what works and what doesn’t work for me… So I answered her with a lengthy description, which I’d normally hold back for fear of seeming like a pain-in-the-ass, but Hey! -- She asked for it!

I chose to include it in my blog because it really sheds some light on the chaos that defines our family schedule.

Hi Michelle. Looking forward to working with you.

Thank you for asking about our scheduling preferences, because getting a schedule that works with my family has such a positive effect on our quality of life. I'm thrilled to tell you all about what I prefer. I'll start out by answering your fourth question ("What are your scheduling likes and dislikes"). Do you have kids? If so, you may understand a lot of this.

My ideal shifts are the 7a-5p shifts. I LOVE those. I especially love week day 7a-5p shifts. Generally, the more I get of those, the happier I am.

I have two baby boys -- 24 months and 8 months, and a husband who works full time 8-5 and no live-in nanny and no family in the immediate area (my parents are three hours away, so they at least can come in a pinch), so on a daily basis it is up to my husband and I to provide child care. The boys go to day care M-F 7-6, so the more I can work when they are in daycare, the better. It's very hard on my husband and typically a challenge to find childcare assistance when I work nights and weekends. I understand it's part of the job, but that is why I strongly favor 7a-5p shifts.

For similar reasons, when I have to work 9p-7a I prefer them to be anything other than Friday or Saturday, because there is no sleep to be had in my house on Saturday or Sunday with the two babies at home. Any other shift on Fri or Sat is preferred over 9-7.

Except for those Fri and Sat 9-7 shifts which I can never recover from because I can't really sleep, on Sun-Thurs I don't think nights are that bad because they allow me to be home for family time at night. On Sun-Thurs if I can't have 7-5 I'd prefer 9-7 (confused yet?), because then I can be home for dinner, putting kids to bed, etc. The worst shifts on weekdays for me are the 12-9, 2-12, 5-1 because I miss family time at home.

Obviously, like everyone, I don't like weekends. I'd like at least one weekend a month where I'm off the WHOLE weekend. (Lately I've been asking for specific weekends to ensure this, like I have for March.)

Those are my utopian preferences. I know reality and fairness interferes with what you are able to do about them, but I appreciate you at least asking.

Here's my answers to your other questions.
1) How many shifts do you prefer to be scheduled in a row?
I'm flexible here. By the fourth shift I get to be really tired, so three is probably enough. But, honestly, I'm not as concerned about how many shifts in a row as I am with getting the "right shifts" (see above.)
2) How many night shifts in a row?
Two seems to be just right for me, but again, I'm flexible. I'm more concerned with getting nights that aren't Fri or Sat.
3) How many shifts do you prefer to work each month?
130. Maybe throw in an extra shift when it's a 31 day month to make 140.
4) What are your scheduling likes and dislikes?
See above!
5) Anything else that I should know about you that would affect how you are scheduled?
My "boys" (Husband Dan, 2 year old Cole, 8 month old Graham) are the most important thing in the world to me and 99% of my scheduling requests revolve around them. Sometimes Dan has to go out of town for his work (He's a V.P. at Suntrust bank), and so sometimes I ask off for that.

Thanks again for asking those questions and allowing me to voice my preferences, Michelle. Just so you know, we are having a minor logistical crisis in the Simons household, because Dan's work just mandated that he go to Atlanta for 2 or 3 days every week for the next 8 weeks! This is not typical and is NOT going to extend beyond 8 weeks (if it does... either he or I will be looking for a new job, because you can imagine the logistical nightmare.) I don't know if or how this will affect my schedule requests. We are looking into finding someway to get childcare the evenings he's gone. The only reason I'm telling you now is that I may have a few more schedule requests for March. I'll let you know soon if there are.

Thanks again.

Hopefully she’ll be kind.

No He DIDN’T!

Next time you visit your local ER, please remember your doctor is human and try not to be a jerk. The other day the jerk-to-reasonable person ratio in the ER was astronomically high. Everyone thought they were the only patient, and I was the only doctor for all 20 of them. I was getting slammed and the shit was flying.

The older docs I work with reminisce about the times when doctors were treated with some respect. I’ve never known those times and just have accepted that being an ER doc and getting bitched at go hand-in-hand. Usually it doesn’t phase me; partly because I do understand that whatever brought people to the ER is stressing them out, but more so because when you get bitched at everyday, you have to find a way to ignore it if you want to stay sane. But the other day this guy somehow managed to get under my skin so much that even the next morning in the shower I was still fuming about what an asshole he was.

His wife came into the ER by ambulance after a minor fender-bender and went straight to room 6, not even realizing she had bypassed the 4+ hour wait time for patients who did not come by ambulance. My first clue that she wasn’t too seriously hurt was that her biggest complaints were related to being immobilized in a cervical collar on the backboard. I understand those things are not particularly comfortable, so to the extent possible I try to get to such patients as soon as I can and get them off the backboard. Maybe I took a little longer with this lady because there were so many REALLY sick people who came in at the same time, but I explained and apologized as soon as I walked into her room.

As I examined her, she never jumped or winced but complained of tenderness EVERYWHERE (another clue she wasn’t too seriously hurt, because pain will usually localize at least to a general organ system if there’s a serious conditions). When I went to clear her out of the c-collar, she said her mid c-spine was tender right in the center, but unfortunately the one place she wasn't tender was on the sides of her spine where the paraspinal muscles run (which maybe would have allowed me to chalk it up to just a sprain / strain or spasm). I doubted the lady broke her neck , but I ordered x-rays to cover my OWN neck.

Then, not too worried about her, I left her in the room, ordered her some pain meds, ordered her x-rays and went about my business… which – I should mention – at that moment happened to include intubating and stabilizing a nice lady with lung cancer in acute respiratory failure. By then, it was around the time the cafeteria closes, and I was starving because of my new diet. So once I knew everyone was at least stabilized, I ran to the cafeteria and grabbed some food and brought it straight back to the nurse’s station, holding it in my hand as I checked a few things. Then I disappeared for 5 minutes to wolf down a bit.

When I emerged, the administrative head of the ER found me to ask what the delay was in bed 6. Generally she shows up only when people ask to speak to "whoever is in charge." The fender-bender woman hadn’t even physically been in the ER for 2 hours at this point! (I’ve had SCHEDULED non-emergent OB appointments longer than that!) I told the administrator that I hadn’t checked the x-ray yet because I was taking care of sicker patients, and she went off to her room to smooth things over.

Not too long afterwards I checked her x-ray, which, of course, was negative, and then I went to discharge her. I AGAIN apologized for the delay, and no sooner had the words come out of my mouth than a grumpy old man growled from the foot of the bed an extremely accusing and sarcastic, "How was DINNER?!"

My jaw hit the floor. The nerve of some people. I mustered a smile and made a joke out of it, trying to keep it light… "Don’t even give me grief for eating," I teased. "You don’t want a doctor taking care of her who doesn’t have any fuel in her brain!"

He became less growling and less accusing, but still continued, "I wish WE could eat."

"You can."

"The cafeteria’s CLOSED now," he snapped, like somehow I have control over the cafeteria hours, or the fact that he wasn’t resourceful enough to run down there when they were open and bring something back.

"Well, there’s a subway just across the parking lot and that’s probably better than our cafeteria food anyway."

"Well, WE’VE been hungry for hours." He gave me a how-dare-you-feed-yourself-when-my-wife-is-waiting glare.

I exercised a great deal of control and instead of going off (I won’t even put into writing all the things I wanted to say to him), I politely and pleasantly said, "Well, then, let’s get you discharged so all of you can get out of here and go get some food." I couldn’t get out yet another apology for the delay… even though I could tell they wanted one. (This asshole wouldn’t have been happy unless I knelt down and spit-shined his shoes while groveling.) As I fled room 6, they were right on my heels, chasing down the nurse for her portion of the discharge papers. Then they hovered around the nurse’s station, just glaring at everyone until her nurse succumbed and stopped in the middle of doing something for one of the other sicker patients to give them their papers so they could finally leave. I was so relieved to see them walk out of the ER.

Ever since then I’ve been eating in stealth, hiding out in the doctors’ lunge. I’ve learned my lesson – I don’t dare let my patients know that I actually stop to pee… and sometimes I even EAT!

Graham's Symphony

Mark my words. Graham is going to be musically inclined. My little man sings and coos to me like a little bird, or sometimes like a little dolphin baby. He loves the sound of his own voice and takes great pleasure in chirping to himself in varying intonations, as if he’s trying to find his favorite melody. He even provides dinner music – a deeply contented medley of "mmm-mmmm-mmmmm"s and "aaaahhh"s as we shovel in the baby food. And then, when he’s had enough, it’s the raspberry – "ppfftt," which started out meaning "I’m done, Mama" but has recently been extrapolated to just about any time he’s feeling displeased: "Get me out of this high chair" or Get me out of the car seat" or "Get me out of my crib" or "No, not formula! I want SOLIDS." For someone who doesn’t know any words, he sure is vocal.

Not only is baby G making noise with his voice, he’s found all the kiddy musical instruments in the house. He won’t leave Cole’s Sunshine Drum alone.

At daycare, his favorite toy is the maraca. He will fight the other little babies for it and shake, shake, SHAKE his little heart out. In fact, he will repeatedly shake or clank anything that might have even the remotest chance of making some noise. Some sounds in Graham's Symphony:

• His fingernails scratching across the lining of his car seat,
• Two of Cole’s building blocks clanking into each other,
• The wrist button on his dress shirt tapping against the kitchen table as he repeatedly slams his fat little hand down,
• The tinkling of his multiple rattles,
• The crinkling of paper as he balls it into his tiny fist,
• The clap of his stackable plastic cups knocking against each other.

I bought him a Little Tykes Piano for Christmas, and he takes it VERY seriously – pounding away like a little virtuoso. And that’s just a warm-up… then he steps it up a notch and steals his brother’s toy keyboard and makes music on that. He truly is a musical little baby.

Look out American Idol 2025!

What It Means To Be A Parent

Usually I blog about being a doctor or being a mom (I didn’t title this blog "Doctor Mom" for nothing), but I take exception for exceptional circumstances. Today’s blog is about parenting… PHENOMENAL parenting, but not by me.

I haven’t written about this because it’s not something that can easily be summed up in a blog entry or two. For the last 8 months, our thoughts and prayers have been with the Fish family, who’ve been going through very difficult times, to say the least. Fish is Dan’s oldest and best friend. (Here are Dan and Fish with their new babies, Graham and Ian.)


Fish’s oldest son, Kyle, was 5 this past May when he was diagnosed with Myelodysplastic syndrome with monosomy 7, a rare form of leukemia. Sine then, their world has been turned upside down. We’ve been following along vicariously, trying to empathize but not really being able to even fathom the hell of having a child get so sick.

There’s no bright side to the situation, even for me, a glass-half-full kind of person, but there is a lot of inspiration in the way the Fish family fought so valiantly – inspiration about the phenomenal strength of little kids and the true devotion of parents.

After being diagnosed, Kyle was rushed to Yale and then spent May through December in the hospital, first at Yale and then at Duke, after Fish’s relentless search for the best care for Kyle’s condition led him to doctors in Durham. The feedback from his medical staff was that there wasn’t a stronger child than Kyle. He was a model patient. I’ve seen grown-ups melt down over a needle-stick, but not Kyle. He underwent what seemed like umpteen million medical procedures (some so uncommon that even I had to look them up) with more tenacity than the bravest, toughest man. Fish, ever the golf fanatic, said he couldn’t have been more proud of Kyle, "even if he won the Masters, US Open, and the British all in one year." It’s hard for me to even type how Kyle’s battle ended, but sweet little Kyle died late December after the most valiant of fights.

The reality of losing such a pure and innocent child who, as his father told us, just wanted to make it downstairs to the gift shop, literally makes me sick to my stomach. I thought being a doctor and dealing with death at work made me strong, but I’ve never had this same kind of visceral gut-wrenching reaction at work… Partly because, no matter how moving the circumstances, I’m always the doctor… And partly because I see my patients for only a handful of hours on one given day in the ER and don’t have the same degree of emotional investment. When it’s personal it is infinitely more devastating. I think about Kyle every day. His fight inspires me to live in the moment and to appreciate every single breath. Needless to say, I’m giving Cole and Graham many more hugs, kisses and snuggles lately, inspired by Kyle.

I also think about Kyle’s parents every day. What they have done the last 8 months has been a beautiful example of parental love. There can be nothing worse for a parent than not only losing a child, but first watching him suffer, not knowing if he can ever get better. Yet they somehow stayed strong, because their baby needed them. Every time I talked to Fish throughout the last 8 months I was overwhelmed by his strength. I must have said to Dan more than 100 times, "Fish is a Rock." If you believe people are defined by how they deal with adversity (which I do), then Fish has shown himself to be a pillar of strength and love.

From the moment Kyle was diagnosed, Fish put all of his New York-style pushiness to good use. If there’s anyone more aggressive and more outspoken than Dan, it’s his best friend Fish. When we first heard of Kyle’s illness, one of our first responses was that Kyle was lucky to have Fish as his advocate, because if there was any possible way for Kyle to get better, Fish would make it happen. As expected, Fish went on a relentless search for the best doc with the best track record for Kyle’s diagnosis, which was how Kyle ended up at Duke. Fish then left his home and his support network in Connecticut behind, moved to Durham into Kyle’s hospital room, and rarely left the hospital until Kyle died. It was Fish who was keeping the doctors on their toes and speaking for Kyle when he couldn’t speak for himself. I know this helped, because I’ve been the one on the other end having to deal with concerned and over-attentive families of patients, and I know that if a doc has 10 things to do (in the absence of any medical reason to prioritize), she’ll take care of the most vocal people first to get them off her back. Thankfully, persistent Fish was probably one of the squeakiest wheels that hospital ever saw.

The real reason Fish never left Kyle’s side, though, was because all he wanted was for Kyle to enjoy his time in the hospital. He gave up everything else (probably even eating, as evidenced by his new 30-lb-lighter physique) to be there playing games on the computer, drawing, going to activities (art, science class, bingo, etc.) Dan was able to get to Duke several times and always said that Kyle seemed like a normal kid – happy and playing—thanks, for the most part, to his devoted Dad. And then when Kyle got too sick to play, Fish was there remaining optimistic and keeping Kyle surrounded by the positive thoughts he needed. Fish was a rock.

Meanwhile, Donna (Mrs. Fish) was back and forth between CT and NC taking care of their second son, Evan, and GIVING BIRTH to their third son, Ian. Yes, that’s right… Donna was late in her pregnancy when Kyle was diagnosed. (As was I; and, needless to say, it gave me a lot of perspective about what REALLY constitutes a rough pregnancy and significantly curbed my own pregnant whining.) Throughout the 8 month ordeal we didn’t keep up with Donna as much as we did with Fish, but she made a huge impression on me in one single day with what she found the strength to do at Kyle’s funeral. In the middle of the ceremony, in front of a huge church-full of 5 or 6 HUNDRED people, Donna got up in her orange (Kyle’s favorite color) sweater and spoke for Kyle. It was amazing that her legs even carried her up there. The second she stood up several people around me gasped in disbelief. It was more amazing that she got through her entire tribute with only one little crack in her voice at the very end. She and Fish had asked several people to speak, and each one declined for fear they wouldn’t get through it. But Donna had no fear. He was her baby, and she was going to speak for him if no one else would. Her display of maternal love touched me so deeply that I will never forget it.

Kyle’s funeral was 2 weeks ago today. It was an unspeakably hard day. The Catholic Priest did say one thing that provided some comfort – when children die they automatically become Saints. So Saint Kyle is now up there watching out for his amazing Mommy and Daddy. They need his help right now. I cannot imagine their overwhelming grief. I know, though, that years from now as they heal more and more, they will look back and be proud – proud of themselves and their inspirational devotion as parents, and especially proud of Kyle.