Okay, so I whine about how tired I am, and of course, on my one day off this week, I wake up at 5:30a and can’t fall back asleep.  This is what happens when my body adjusts to crack-of-dawn awakenings, and so I ended up getting up and doing all the stupid things that aren’t fun and that I can’t do during my week: pay bills, take out trash, clean litter box, go jogging (only because I’m bored, and it fills some time), start laundry, shower, groom my eyebrows, then decide to groom the cats (or rather, chase them with a brush and fail to actually groom them), and damn, it’s only 11:00a.  Then I realized I could clean out the refrigerator.
A week ago, Amy shared this picture show documenting the refrigerators of people, which I found fascinating.  So, I decided to take stock:

This week, the refrigerator looks like a relatively normal person’s, but only because I haven’t had time to cook much, and hence, leftovers aren’t ballooning out of tupperware.  Notice the stockpile of caffeinated diet sodas.  And to balance the acidity that caffeine brings, I think I compensate with milk and kefir and yogurt.  And there is actual fruit in there!  Although it’s partially rotting because I come home, take one strawberry out, wash it, eat it, and thus I end up throwing away a significant portion of rotting fruit. Way in the back, there were some rotting chickpeas and an open bottle of wine that’s been in there since January or February.  Lucky for you, you can’t smell this photo, either.

Here’s the thing: I would like to be all worked up about California and prop 8, and I would like to be ardent about Sonia Sotomayor’s nomination, but I’m too tired to get my panties bunched up about these things.  I get home and I read cheesy chick lit or recommended stuff from Oprah’s book club.

And yes, it has made me dumber, but I am too tired to care anymore.  I didn’t realize how tired I was until this morning, during rounds. In the mornings, we walk-round in the PICU with COWS, which are “Computers on Wheels” - essentially, laptops on wheeled stands that we can roll in front of ourselves so that we can type notes and enter orders as we go from room to room talking about patients.  This morning, I was leaning on my COW with my head down, and while my co-residents were busily looking up the diverticulum of Kommerell, and updating discharge summaries and entering orders, I was sneakily reading xkcd comics on my computer.  Life is just too much to bear these days.

I think part of my tired-ness is due to my shoes.  Rounds hurts my feet, despite the fact that I wear the clog-wear that is standard for most residents.  I think I need to wear sneakers.  Too tired to care anymore.

Joe isn’t at home right now, so I can eat whatever I want.  We have very different tastes and very different takes on food.  What I’ve realized is not only do I eat much less when he’s not around, but I also manage to plough through the leftovers and pantry foods because I don’t mind leftovers or pantry foods.  Also, I like grains such as quinoa, and he doesn’t.  I have had two very good “leftover creations” in the past week that weren’t half-bad:

Tuna-Asparagus-Quinoa Medley

Ingredients: 1 can of tuna, a quarter-bunch of asparagus, 1 cup of quinoa, 2 tablespoons chopped Italian parsley, half of stalk of green onions, half-handful of chopped walnuts, stone-ground mustard, mayonnaise, salt and pepper to taste.

Instructions: Cook quinoa according to instructions.  Chop asparagus into 3/4″ inch lengths and steam.  Chop green onion and parsley finely.  Toast walnuts.  Mix all ingredients together.  Serve as is, or on toast.  I think instead of walnuts, this would have tasted good with cashews.

Tomato-soup-black-bean-quinoa medley

Ingredients: Boxed tomato soup, canned black beans, 1 cup quinoa, shredded Monterey cheese, salt, pepper, Italian chopped parsley and Tobasco sauce.

Instructions:  Reheat tomato soup.  Drain black beans, rinse, and reheat. Make quinoa according to instructions (I already happen to have a stock of this).  Mix together and season with salt, pepper.  Top with shredded cheese and parsley.  Wish I also had some edamame to toss in.

I have found myself surprisingly busy on call-free elective, but not busy enough to not notice this picture on one of my favorite gossipy websites, people.com.  Okay, I don’t even know who these people are but they are complete morons.

They are “Heidi Montag” and “Spencer Pratt” — self-important reality-TV idiots or maybe soap opera stars, I have no idea, vacationing in Cabo San Lucas.  And they are doing this in the middle of the swine flu epidemic, while all “non-essential” travel to Mexico has been recommended to be suspended by the U.S. government.  First of all, I am not sure if a “pre-honeymoon vacation,” which is what this trip was described as by my illustrious internet news source, counts as “essential” travel to Mexico.  Maybe it’s important for B-list celebrities to do such “essential” business travel.  Second of all, they are wearing “protective” masks while near-naked on a sandy beach.  As if that were going to save their lives as local indigenous workers who lost their farms and had to get a job at this energy-sucking resort are coughing into their margaritas.  Oh, and that towel-boy who handed you your towel as you stepped off the beach into your private cabana-suite?  His mom just died that day of swine flu.  Third: what the frak are you doing prancing about on vacation in skimpy clothing while the country around you is dealing with a pandemic?  I am overwhelmed by the magnitudes of error in this tableau.

In matters related to popular culture and music, I am usually three or four seasons behind, and in most cases, I am never caught up.  For example, Rihanna? I’ve heard about the whole domestic violence thing, but other than that umbrella-song, I haven’t heard much of her music.  “You have to listen to her stuff really loud,” Joe announced to me one day.  The he demonstrated his back-up dancer moves to “Push up on it.”  Not sure if that’s the title of the song, but that phrase is a main element of the chorus.  Thanks to Joe, we own her latest album.

I will be traveling a lot this month, and after realizing that I can only tolerate “Spy Kids 3″ and other airplane movies so much, I decided to download the whole first season of “Battlestar Galactica.” Yes, I realize the series is over, and yes, I realize it was AMAZING, but the series started during med school, and I only caught a few episodes of the first or second season before I descended into the gory depths of Step 1 and my clinical rotations, so tant pis pour moi.  Until now.  I watched the first two episodes on the flight home from Tahoe, and then proceeded to watch the rest of the season through the week.  After this weekend I polished off the miniseries that proceeded the Sci-Fi channel series.  And finished the first three episodes of season two.  What’s missing in this picture?  Nothing, except my sleep.
The problem is, almost every episode ends with a cliffhanger.  I need to know that Commander Adama pulls through!  I need to find out what happened to the pregnant Cylon-Sharon! When will Starbuck and Helo make it back to Galactica?  Why don’t we know anything about the other twelve colonies?  How did Number Six get into Baltar’s brain?  Not only is it serialized in a deliciously tantalizing way, it’s well-written, it’s plot twists are complex and engaging, it holds a mirror up to what would have been the current events of the Bush era, and it’s as nuanced as any good text.  Like all science fiction, there are obvious loopholes in it’s “science,” but it’s easy to suspend disbelief because of all the humanistic (and humanoid) drama.

Of course, BSG isn’t considered as pop culture-ish as other things I know little about, like “Dancing with the Stars” or those yellow rubber Livestrong wristband thingies (I assume a lot when I say these count as “mainstream”).  It’s more like periphery-pop culture.  But who cares, it’s really fracking good.  My only worry is that after I complete my BSG binge, I will feel hollow and lifeless inside, much the same way I felt after watching the complete “Lord of the Rings” trilogy in one sitting, or even after reading Twilight in one sitting.  Can life go on after BSG?  I need to find out.

Some of my friends have moved into the “Expectant Parent” category of life now, and as if they weren’t already getting a boatload of unsolicited advice from parents, friends, and random strangers in the grocery store who want to touch their pregnant bellies, they have very kindly been asking me advice on how to choose a doctor for their child.  First of all, mazel tov! Second of all, please get some advice from someone else as well, preferably someone who has meaningful advice.  Because I am only a second year pediatrics resident, someone who has not yet completed training, someone who does not have “FAAP” at the end of their title, someone who does not have years of kiddie-wisdom stored behind graying temples.  With that caveat, here are some pointers:

Get a pediatrician, not a family practice doctor! To all my family medicine colleagues out there, sorry.  Unless your mom, your dad, your brothers and sisters and your brothers’ and sisters’ children have all gone to the same beloved family doctor for 35 years, and she’s wonderful and kind and intelligent and resourceful and has never-let-you-down, you will want someone who has had specialized training in the illnesses of children.  A family medicine-trained physician has about 3-6 months of formal training focused on children, whereas a pediatrician has at least 3 years of formal training focused on children - and unless your family doc has been taking care of children for generations, they will not have seen the volume and range of illness a pediatrician has seen.  Unless you have a trusted family doc already, I would say you have a much better chance of finding your child a good doctor if you narrow your selection to the kiddie-pool, not to the “general swim” pool.

How much experience should they have? I have heard complaints on both ends of the spectrum.  You don’t want someone who is naive enough to think every rash needs a biopsy and a derm referral but you also don’t want someone who is so old-school that they aren’t keeping up to date with the most recent evidence-based medicine (e.g. docs who still think it’s okay to lower temperatures by giving alcohol baths).  They should be board-certified by the American Board of Pediatrics, too.  I think what’s telling is not so much the individual experience of a practitioner but more the collective years-of-experience the whole practice has: how many pediatricians are in their group practice, what the range of experience is amongst all of them, how many total children does their practice serve? More likely than not, your child is not going to see the same pediatrician for all their sick visits unless it’s a solo practice, and more likely than not, if there’s something unusual about your child’s case, they will likely bring their colleagues in to examine your child, too, or at the very least, use their partners as a sounding board for management advice.

Find out about how they handle 24-hour emergencies.  If you call at midnight with a question, will the phone service direct your call to a nurse triage line, will they page the physician on-call for you, or will you just get an automated voice message that tells you the office is closed, please call during business hours, and dial 911 if it is an emergency? At the very least, you want a practice that uses a reliable phone triage system, that has one physician on-call every night (your particular pediatrician might not be on call every night, but might have a group practice where they rotate through call nights), and that has good recommendations for which emergency rooms to use because each emergency room will have varying levels of experience with pediatric patients and different admission policies.

Find out about office hours and how easy it is to get in contact with a pediatrician in your practice.  You will need a practice that can accommodate your schedule: do they hold office hours at night or on weekends, when most parents get off work? Are the pediatricians available by phone or email?  (A lot of pediatricians aren’t, because they’re seeing patients all day; they do not have time to sit at the computer and respond to email questions all day long).  The other thing I’d be suspect about is how long you have to wait in the waiting room — do you get there for a 3:30 pm appointment that isn’t really until 5:30 pm?  This isn’t fair to the patient, and it is telling of how well an office functions or how overbooked it is.

How do they refer patients when they need a specialist? Do they work with university or children’s hospital specialists? How do they handle children with special needs?  Not that your child may ever need this, but it’s important to know if they have a reliable and often-used network of specialists they can rely on, because it means they are that much more aware and up-to-date with the resources around them.  Also, you don’t want a pediatrician who will just hand-off your child’s special needs to a specialist and not follow-up on management issues.  You want someone who actually reads the letters that specialists send to them after they see your child, and at your well-child check-ups will ask follow-up questions and make sure you understand the care plan or tests that the specialist has requested.

If you can afford the time, interview pediatricians in your community before picking one.  This is the most important thing I can think of.  Most will not charge you for it, and most welcome it, because it’s about finding the right fit for your family’s needs and for your personalities.  Bring a list of questions.  See if they will offer you the chance to talk to other parents who use them, because it will be mostly by word of mouth that you find someone who is right for you.  You might have specific questions about vaccination schedules and holistic medicine practices and beliefs around co-sleeping or breastfeeding or whatever, and you will want to hear your pediatrician’s take on all of it.  Most importantly, you will want someone or a practice who will be an ally in helping you raise your child.
It is excruciatingly hard to find a “good” doctor - it’s not like finding a reliable store to buy pants (although that is hard, too), or a dependable dry cleaners because there are so many factors that make finding a “good” doctor hard, including just having information available.  What’s “good” to one person may not be considered important at all to another person.  And I know parents worry.  One careless comment or suggestion can make make parents stay awake with worry for nights on end - at a delivery I went to, as a father came over to snap pictures of his new baby, he asked me why the baby’s head was cone-shaped and I said, “And all babies who spend a lot of time in the birth canal have heads shaped like this, it’ll just take some time to straighten out.”  It was only later when the pediatrician told me that the dad spent a significant portion of time worrying over exactly how long it would take for the baby’s head to no-longer be cone-shaped and whether it would be cause for developmental delay that I realized that the lifelong worrying of parenthood begins immediamente.

Recommended resources for how to choose a pediatrician:

Your Baby’s First Year has a good checklist for what to look for when selecting a pediatrician.
Visit the American Academy of Pediatrics to search for a list of board-certified pediatricians in your area.

I hadn’t really noticed the flowers starting to bloom amidst the April showers n’ all, because the telling sign of spring in the city is the arrival of Peeps at the drug store!

Joe’s comment on this picture was: “What is Mr. Fur staring at?  Notice that he’s not interested in the peeps because they aren’t food.  (Eat food.  Not too much.  Mostly plants)”

We decided to take two days of snowboarding lessons, and my butt, knees and wrists are now very sore.  I’ll spare you images of these sore and bruised bodily regions but here’s a humorous bum we saw at The Naked Fish, a sushi place in South Lake Tahoe:

There were lots of good sunsets while we were up there:

And a few good powder days:

Lunch breaks are also email breaks:

And here’s a sign that Joe stopped to read, since he apparently does, in fact, read signs:

All in all, a good snow vacation.

Plus, I learned a whole new way of describing snow.  Eskimos have multiple terms for snow, as do bonehead skiers/riders.  Freshies refers to newly fallen, powdery snow; The Goods refers to new snow, usually in the trees; powder, of course, means light, dry snow; spring conditions is when the snow is hard in the morning and slushy in the afternoon.  When we got back to the Bay Area, we decided to go ahead and buy beginner snowboards on clearance (no reason to ever buy full price).  I am very excited about learning to ride next season.

So we managed to get out to Tahoe for some spring skiing, and the moral of the story is that I am old and confused.  Joe caught an edge and sprained something in his calf muscle, and so he took the rest of the afternoon off, and I decided to go skiing by myself.  I did a few practice runs down Olympic — an easy, uncrowded trail.  Then went over to ski some trail that I had fallen on before, and after satisfactorily making it down without falling, I felt like I could call it a day.  I called Joe at the bottom of some lifts to tell him I was ready to go.  He asked me: “Do you know how to get back?  You need to take the California Trail.”  I glanced at the map behind me and identified some trail marked “California Trail.”  “Yeah, sure, I can do it.”  “Okay…” he said, sounding only half-convinced, and we hung up.  It was almost two hours before I finally was able to meet up with Joe, and it was because of this:

Apparently, my stellar sense of direction, combined with my amazing map reading skills only took me all over the mountain before I was able to find the gondola and call Joe to tell him to pick me up.  I accidentally went down Mott Canyon (how does one accidentally go down a run that has about twenty warning signs that say “expert only”? It’s easy when you apparently don’t read signs) and managed to sprain my thumb on the way down (not exactly sure how that happened, either.)  Vowing to never do that again, I found myself at the bottom of some lift called “Sky Express” about three times.  This was supposed to magically transport me to a clearly identified “California Trail,” which I think I managed to be on about 40% of the time but always ended up back at the bottom of “Sky Express.”  The problem, I think, was two-fold: one, I refused to go on any trail that looked super-flat, requiring me to push myself along in the spring slush, and two, afraid that I would encounter super-flat stuff at slow speeds that would require me to push and walk, I probably managed to ski past well-marked signage that would have led me in the right direction.  Actually, the main problem is that I don’t read signs or maps very well and I have no sense of direction.

“How do you get on in life?” Joe asked me in a sort of incredulous tone.  I have often times wondered that myself.  I have no internal map of any sort, and apparently, external maps are of little help.  This is obviously a brain problem.  Even with the navigation system in our car, the little computer says “re-calculating route,” about every 10 to 15 minutes, indicating to me that I am always making wrong turns, and it turns a 30 minute drive into a 45 minute one.  The other thing is, I am perfectly content not knowing where I am.  While skiing, I am happy just spotting a pretty view of the lake or making it down a steep patch with nicely linked turns, and I really don’t care where I am.  In driving, I am satisfied that I shifted well on a hill, or pleased to discover a new KFC that I hadn’t noticed before, nevermind the fact that I am in Dorchester and not near West Roxbury where I need to be.

I am not a post-call go-getter like some people who I know, nor do I have a real life rescuing HIV afflicted children, thus, the the hardest decision I have when I wake up from my post-call naps is: Law & Order marathon or TLC with my toast and peanut butter? TLC has apparently found their captive audience in me, their target demographic: I don’t enjoy anything that they air, but at the same time, I can’t turn away from anything on it, particularly the wacky medical mystery specials they air, like the one about the Treeman, or the strange Joan Benet Ramsey show, “Toddlers and Tiaras.”

I already ragged on that show about the naggy wife and her husband and their eight children, but the newest and most easy-to-target series about gi-normous families is about a family in Arkansas that has 18 children and adheres to the Quiverfull movement.  They are a conservative Christian family who are refreshingly nice to each other, unlike that other show.  But they also terrify me.  As well as their lifestyle and doctrine work for them, it is not a responsible way of life for the majority of the world.  There is the over-population argument; then, there is the octo-mom argument (i.e. y’alls just plain crazies); of course, there is the obvious feminist argument.  Didn’t the 21st century already happen, and didn’t we already establish that women are more than their reproductive capabilities?

This leads into the subject of multiple births and premies and the ethics and cost-benefit analysis of NICU care, which I’ll get into at a later date…

I need to read something that will cheer me up.  The selection of reading material in my house and backpack has either gotten too grim, or I am such an emotional wreck that everything puts me on the brink of tears.  In just the last few weeks:

Diary of a Bad Year, by J.M. Coetzee.  His characters are so pathetic, and the way they intersect with each other so sad, and the way they assert themselves in political terms so depressing…but I guess all his books are depressing.

The Last Lecture, by Randy Pausch.  Based on the last lecture this computer science professor gave, and it is sad because he died.  Whaddya going to do, death is sad.

A short story by Alice Munro, wherein a character recalls how unforgiving children are of each other.  This, too, can kill you.

Catching up on a backlog of New Yorkers this past week, I read this article about kids in the slums of Mumbai.  Unending poverty will crush your soul.

Reading about “The Match” and talking to friends who just “matched”.  An old classmate recently published a book about it (that I did not read), and my first thought was, “why would you want that self-centered piece of nerve-wracking history to be documented for posterity?”

I also read about a recent case of Hodgkin’s lymphoma that presented as constant itching (the kid died), morbidity and mortality statistics in Japanese NICUs (better than the U.S.), neurodevelopmental disabilities in late-preterm infants (nearly as bad as very preterm infants), increases in meningitis caused by non-vaccine serotypes (just plain scary.)  I think it’s a given that my medical reading is usually kind of ho-hum — interesting on a please-satisfy-my-curiosity kind of level and dispassionate on another.  But lately, it has just been plain depressing.

Not even this giant bag of Sour Patch Kids has cheered me up (cereal box next to it for scale).  A string of depressing reads, a giant bag of candy…apparently, I do nothing in moderation.

Finally.  I sleep.  And dream.
We were in San Francisco over the weekend for a friend’s wedding, and my plan was to sleep until the very last moment before any of our social commitments.  This worked out pretty well, minus Joe’s early morning exuberance which consisted of turning on every light in the hotel room, yelling “wake up, wake up, wake up,” and trying to hurry me along after showering by turning on the blow dryer and aiming it at me.  Yes.  The most effective alarm clock in the world is Joe, because he is good at being annoying.  But this (very fun and needing to be awake) weekend was followed by a long, painfully slow day on elective, and an always-panic-inducing night on call at one of our outside hospitals, which meant even more hours that I needed to be awake.

Fortunately, sleep did come after my last meconium delivery at 2:30 am, and boy, did it come: right before I nodded off to sleep, I finished reading an article that mentioned Mollaret’s meningitis, and had a dream that I managed to get a really good deal on a case of Mollaret, an Argentinian malbec (doesn’t really exist, folks)…

then I woke up and signed out to the morning team and went home to sleep some more…where the dream continued in the galley of a kitchen where I was making rosettes out of carrots and failing miserably at this task as chef of Momofuku Saam Bar David Chang was cursing at me for wasting precious time, and oh no, time was up and I hadn’t even finished pre-rounding, and the intern is telling me the baby is still wheezing, and damn, I forgot to get a chest x-ray, so I page my co-resident to ask her if they managed to get an x-ray today for a first-time wheezer…and then I fall asleep again (or maybe I dreamed that I paged that resident? I can’t remember)…and dream about being in a yoga class where the instructor looks like and talks like Justin Timberlake, so it might be a joke yoga class, and we’re all wearing black leotards, but someone must be playing a trick on me because why would I be in a dance class with Beyonce and Justin Timberlake? Oh, because I’m not in a dance class, ha, ha, thank goodness, it’s only a celebrity sighting, I’m in a bar in the Mission district with a bunch of friends and they are only playing that Beyonce song, and I order a beer and something Mexican with beef in it, and damn, that beef smells good…

Okay, and now I’m really awake, and it’s dark and snowing outside.  And it smells like beef because the neighbors are making something really yummy right now.  And I’m a little confused because what day is it? This has been happening to me a lot, recently, where I wake up confused and can’t figure out what time or day it is.  And that dream was so exhausting, I think I’ll just lie on the couch a little bit more and sleep even more…

One of the board review questions that came up today included this lovely picture:

Yes, tick removal.  The thing that kills me is that you would never be able to find tweezers this fine in the doctor’s office or the emergency room where parents take their children for tick removal, so to all parents out there: look, you got over the heeby-jeebies of changing poopy diapers, so you can get over the heeby-jeebies of using your Tweezerman to remove a tick.

These days, I am on night float, which means I have hooker hours: I wake up when the sun goes down, work all night long, and go to bed after breakfast.  It doesn’t feel normal; I can feel the vitamin D leaching from my bones from lack of sunlight, and since I don’t sleep well during daylight hours, I just don’t sleep.  I am starting to feel like a vampire, but not of the Twilight-genre, no, more of the 90’s Buffy-Vampire-Slayer-Angel kind. 

The admissions I’m getting also feel vaguely made-for-TV, and the whole scene in the hospital at night has that surreal-this-is-not-your-real-life kind of quality.  Maybe because everyone is awake when they shouldn’t be and therefore, human interactions are all that more bizarrely technicolor. 

And speaking of TV, ABC is apparently making a documentary TV series at our hospital, much like that series, Hopkins, and they are looking for residents to follow in the next month!  Too bad I am going to be at an outside hospital next month (Outside Hospital: Just When You Thought Your Health Was in Jeopardy), so I will be missing all the action.  Although, never having seen the series, I don’t know if this is a good or a bad thing. I can’t possibly imagine how interesting it would be to follow a typical call night, although they will probably edit together all the Medflights, crashing patients, and gory OR scenes, so it looks more exciting than it really is.  The lovely possibilities of an edited version of reality.     

I came home, didn’t realize that Solo was fed as he meowed his head off at me like he’s NEVER EVER been fed before, and I fed him a second dinner.  And my mom doesn’t always leave notes every time she pops in, so I presume he gets double dinner every once in a while.

Speaking of moms, a bunch of people have sent me a link to this awesome website, and I have been WAITING for the perfect encapsulated moment to send in a post about my mom and her vitamin advice.  Typical scene:

MOM: If you eat yogurt or cheese, you should also be having at least two cups of milk a day for calcium.

JOE: Okay.

MOM: Well, three cups.  Because you’re tall.

JOE: Um, okay.

My last phone call with her (which seems like every phone call with her, in addition to talking about football/baseball/basketball/sport-of-the-season-that’s-currently-on-NESN):

MOM: You should take a multi-vitamin every day.  Do you also take calcium?

Moving on from the holiday season always feels anti-climactic, not that the holiday season is climactic in any way, but 2008 did explode on me at the very end.  How?  Let me count the ways:

1. I worked like a dog up to and through the holidays.  I feel permanently tired.
2. I turned 30.  Nothing dramatic happened. I tried celebrating, but in an overly-friendly gesture towards my semi-English speaking PICU fellow, ended up buying him take-out dinner at a restaurant of his choosing, when all I wanted was some frozen yogurt before call ended.
3. I had a miscarriage.  While being on call in the PICU.  This was also not very dramatic, but it felt odd that I was celebrating the first day of being 30 years old by trying to expel the products of a failed pregnancy, post-call.
4. As a consequence of that not working, needed a D&C.  Not dramatic, either, but most definitely dramatic in my head.

Actually, 2008 was quite okay and quite fun, just this last month has been hard.

Read the rest of this entry »

Lately, work and career-planning has been chipping away at my soul and sucking my energy.

I can’t keep it straight - ampicillin in neonates should be q6h not q8h, and why am I looking at my wicked old NICU dosing card anyway? Get it straight. And, why am I only getting bloody taps (lumbar punctures, for those not in the know) in the last two weeks?  Jeez, Miranda.  And why won’t my letter writers get their letters in so I can start applying already for fellowship?  And why can’t attendings who I respect and desire feedback from give me the feedback I need to get better?  The devil is in the details, and either I am tired and missing all the details, or the details are not forthcoming.  All of these things are accumulating to make me feel like a mess of a resident, and maybe while I am meeting low-level competency expectations, I really do want to be a better doctor for my patients, I want to not be too tired to learn something new, and I want to be rid of this feeling of low-grade fury mixed with anxiety.

I don’t mind the intensity of the residency experience, but right now, after a shift in the ED that almost put me over the edge, I really, really, really wish I owned a piano so I can practice scales and do finger exercises or something so that I can focus all this detailed nervous attention and physical energy on something semi-productive.  Alternatively, I guess I could do a self-imposed Iron Chef session and try to do “Figs” in three main courses and a dessert in under 1 hour.  I need outlets, people!

This past week, there have been a bunch of interesting articles in the Health section of the NYTimes regarding doctors’ sleep, courtesy, and meanness.

On Sleep

The Institute of Medicine just released a new report affirming the 80-hour work rule and additionally recommending some strategies to introduce sleep into the residents’ hospital schedule.  This sounds nice, but I also know it introduces problems into the already chaotic resident scheduling system.  For some people it might be nice if it were built into their schedule to take a nap, as sleep makes them more functional, but I know for me, if I am working 24 hours straight, catching a 1 hour nap on call only confuses me — I wake up completely confused (huh? wuh? where am I? did Xavier die? did so-and-so nurse page me or did I dream it?), in a panic that I missed a page, unable to put together two thoughts about the patients I am covering.  And if I were required to take a longer nap — good luck trying to wake me up.  Being tired, on the other hand, makes everyone prone to making mistakes, which is never good, but I’m not sure a mandatory nap-on-call makes everyone a better doctor.

On courtesy

Dr. Michael Kahn recommends that physicians follow some simple etiquette rules, like knocking on the door and asking if it’s OK to come in to the patient room (duh?!) and introducing yourself, pointing out your name on your name tag and explaining your role on the patient’s medical team (if they don’t know already).  Really basic stuff that makes patient care better, and I’m not surprised we often times forget to do this.  It’s much easier to remember all this stuff in clinic (I point to my nametag a lot there), but in the hospital, where you’re rushing, rushing, rushing to get a quick physical exam, or to quickly check a patient’s vital signs on her monitor, I admit, I probably forget to do this.  And even when I do introduce myself carefully and with consideration, I am not surprised at how easily patients forget who I was even 2 hours before, because they have to meet so many nurses and physicians and other members of their care team.  “Weren’t you the nurse who promised my son Valium two hours ago?” a father angrily asked me as I walked into a patient room for the first time to meet them.  I couldn’t even introduce myself in any courteous manner — the father was just too upset.  And when you walk into a room where the patient is not breathing, you don’t really have time to ask them or their parents how they feel about being in the hospital; your number one job is to get that patient to breathe again.

On Abusiveness

This article horrified me.  Where does some jerkwad resident come off telling a nurse she has no skill in recognizing signs and symptoms?  Unbelievable.  Pediatrics is fortunately not stocked with swelling egos and soul-crushing mockery, but I remember these were things that I was sensitive to in medical school and made sure to steer away from.  As a sub-intern I once had a senior resident who treated everyone like they were the enemy, and at the end of the month, I was feeling very indifferent to both the insults that he hurled at me and to the concerns of my patients - on my last day, a patient incidentally mentioned to me how her left leg would occasionally feel crampy and tingly when she went running, which I shrugged off in my review of systems as I presented her in the morning; after I left the service, I later heard about her suffering from a DVT (a blood clot in her leg) after her abdominal surgery, and that she had May-Thurner syndrome — something I might have been able to address had my senior resident not yelled at me, “yo, med student - pertinent positives only.  Pertinent positives.” You lose perspective of what is pertinent when you are worn down to a defensive shell of emptiness.  I do not ever want to be in a lackey position that prevents me from thinking about a patient as carefully as I can.

About half of my post-call days I have enough energy to cook, and about half of them, I just need to sleep and sleep and sleep.  Today, I am wishing I had Thanksgiving leftovers because the internet is covered in leftover recipes that are making me salivate.  But I’m too tired for cooking today.  For example: turkey tacos with cranberry salsa.  This sounds easy to make and better to inhale.  Also turkey white chili, which sounds perfect on these colder, wetter days.  Chez Pim has a chicken soup for the American soul that might be good with leftover turkey.  This agave-balsamic squash recipe sounds really good, if only I had some leftover butternut squash.  And this pork & pumpkin lemongrass curry is not turkey-specific, but dang, it sounds good.   

Joe finally figured out what he/we wanted to do with the yearly gift certificate to Williams-Sonoma that his mom gets us for Christmas (last year’s Christmas certificate) and we bought a meat grinder attachment to the Kitchen Aid mixer.  He bought some good chuck over the weekend, and we had home made, home-ground hamburgers that were very tasty and moist.  Home-ground meat barely has the chance to oxidize, so it tastes way better.  Maybe I should make a meatloaf today, in celebration of the new kitchen gadget.  Need a good meatloaf recipe, though.

Pediatric deaths are far and few in between, so when they happen, they are very sad.  One of my sickest patients died last night, horrifically, dramatically, both quickly and slowly.  I’m sad.  But weirdly, I’m also okay.  Despite how depressing it was, I still liked the pathophysiology, the thinking, the strategies we use to fight off impending refractory septic shock/acute lung injury/cardiac failure, i.e. total body failure.  My attending ran the codes calmly and efficiently, and I thought, “I can do that someday soon.”  I saw my attending with the sobbing family in eerily lighted moments, and thought, “I want to be in that position.”

Additionally:

1) I’m grateful to the residents who could be there for my patient (because I was in clinic.  Oh my god, what I would have given to be there for my patient and not in clinic.)

2) I’m thankful for a quiet day in the PICU on Thanksgiving.  Let’s hope it stays that way (unlikely given my luck, but let’s hope.)

3) Thanksgiving food abounds in the hospital!  I have multiple opportunities to gorge myself on stuffing today!

4) I finally have (a) a functional sink, (b) a functional bathtub, (c) a functional toilet all in one room, i.e. a bathroom, and it’s LIKE NO JOY I’VE EVER EXPERIENCED BEFORE.  Thanks, Joe (not Joe the Plumber, but Joe the Husband).