Gully’s due date has come and gone, and now we’re just twiddling our thumbs; or rather, I’ve re-read the Twilight series on my Kindle and our complete back-log of New Yorkers, and Joe has started playing Starcraft. Maybe she’ll be potty-trained by the time she wants to make an appearance! There are things I could be going full-throttle at, like studying for the boards or writing an essay to apply for this health services research fellowship that I should really do, but mostly, I’m trying to not be uncomfortable. Carrying an overdue fetus and an extra 30-odd pounds in the hottest July ever is not fun. My feet are so swollen that I can’t wear shoes anymore. My girth is so large that it cuts off circulation to my legs when I sit upright. I’m so edematous that my nasal passages are continuously congested. All in all, being overly-pregnant is not fun.

Joe mentioned this before, but it didn’t strike me until today when I noticed my new employer’s logo on the signage in front of the hospital…the logo looks remarkably like a famous banana distributor’s logo:
    ?=?  

Very different, of course! But it’s blue and ovoid, and usually printed small on ID badges and letterhead and such, so I can see where the confusion may lie.

Clinic makes me anxious for my fellowship to truly start. I’m seeing all these former premie babies in their full toddler glory in outpatient clinic, and while it’s interesting, it bothers me that I’m in clinic and not in the ICU. It’s amazing that I’ve already made the transition in my mind from resident to fellow. As a general peds resident, I was happy to learn about anything and everything related to children of all ages and shapes and sizes. As a fellow, I’m feeling the pull to really only think about the ICU management of sick babies - I don’t care about ear infections or Crohn’s disease or acute lymphoblastic leukemia anymore because those things don’t affect newborns. Give me ventilator settings and hypoxic-ischemic encephalopathy!

In other news, Gully is still lodged firmly in the womb, and we haven’t picked a middle name yet. My dad tried enlisting the help of my relatives in Hong Kong for this, but no one had much interest in this, the rationale being that she’s an American kid, and any Chinese name will be bastardized anyway. In fact, their favorite name involved the syllable “Ga,” which means “family,” but the endearing name would be “Ga-Ga,” just as my family calls me “Ying-ying.” “Ga-ga” just doesn’t go well in the American vernacular, particularly now that we have Lady Gaga parading about in popular culture. At this point, my mom and dad are throwing together sounds (yes, just plain old Chinese sounds, not even words with meaning) and seeing if Joe can pronounce them or not, and if he likes how it sounds and we are sure that her school teachers won’t completely butcher it and embarrass her, then they will dig around to find a meaning to fit the sound.  I think it’s the equivalent of parents picking out make-believe names that we often see plastered around the NICU, like “Leileyiki Rose” (”I just wanted something Hawaiian-sounding.”)

Okay, so apparently pregnancy symptoms can get worse. These last few weeks of pregnancy, I feel more like an old man. Perhaps this is exacerbated by the fact that I am spending my off-time around the house waddling around in an old gray tank top (i.e. wife-beater style) that only covers half my gut, an old pair of Joe’s boxers and compression stockings, and half the time, I have water stains or crumbs sitting on my belly from meals that occurred hours before (I didn’t say a “distinguished” old man, more like a slovenly, crazy old man). However, this is the most comfortable state of being when it’s 90 degrees outside and the air conditioning in our apartment is broken. Also, this child is sitting so low in my pelvis now that when I sit down, she cuts off circulation to my legs, leaving them tingling and numb. And for some reason my coccyx is very bruised. And the sciatica, oh, the sciatica - like someone stabbing you in the back and having the pain shoot down your hamstrings into your feet. You know how they have those signs on the bus that you should offer your seat to old or handicapped people if they board? I have been tempted to ask people to let me sit down on the ride home from work (people are too damn rude in Boston), but my asinine pride gets in the way. And if I sit down, I have to think twice about it - are there places I can grip with my hands to pull myself up once I’m down? This is something I remember from my one day doing a geriatric home visit in medical school.

I had one, single, lone contraction for about 20 seconds (these things never pan out to true labor for me) while presenting a patient to the neurology attending yesterday, and I guess the pained expression on my face made the whole neonatal neuro staff kind of flip out. Also, when I say good-bye to the staff at the end of the day, they’re all like, “I hope I don’t see you again,” in the nicest way possible. Two weeks into my new job, I could take this to mean “I hope you deliver soon and don’t have to be here,” or “we hate you, you’re the dumbest fellow we’ve had in a long time so don’t come back.”

I should try to focus on the positive, I know, I really should. The one cool development is that this kid is very strong and active. I’ll be sitting there in conference, and suddenly my abdomen is lurching around with her kicks and wiggles, and the whole baby bump has swung to the left, then to the right, then to the left again, and I’m listing off my chair because she really wants to hang a left for some reason. Gully, don’t you know it’s really hard to make a left hand turn out of my womb? The exit is downwards. And once you exit, I promise, there’s TV and candy and toys on the outside, oh yes: it’s much, much more fun.

So Gully was breech, and now she’s probably not. This week, I had a cephalic version, where they briefly sent me to the hospital, gave me a shot of terbutaline, and rotated the baby so she can be head down in anticipation of delivery.  There’s a YouTube video (not me!) that shows the procedure - it works only about 50% of the time.  It was not as relaxed or as comfortable as that woman on the video makes it appear.  In fact, it required three tries before she actually flipped, and I was grimacing and holding back tears the whole time.  Afterward, they keep you on the doppler and toco monitors to make sure the baby is okay - that it didn’t cause placental rupture or cord compromise or anything else.  I was extremely exhausted after that, I think because the terbutaline had worn off by the time I got home, and took a nap.  In the middle of my nap, I felt sudden extreme pressure in my belly, awoke from the pain, and saw her kicking and struggling in there - in my half-asleep state I couldn’t tell if she was trying to turn herself back into the breech position.  At this point, there’s a hard part up near my ribs, and a hard part down by my bladder, but I can’t tell which one is the butt and which one is the head.  So now I am not sure if she is still breech or not.

Mostly, though, this show needs to get on the road.  Given how ridiculously dramatic Gully’s been, she will probably take her sweet time and won’t come out until it’s time for high school.  I will be pregnant forever.  The most annoying symptoms are the ligament laxity, being slow, and not being able to pick shit up off the ground.  This week, I was examining infants from a multiple birth who were placed on a play mat on the ground of the exam room, and I had to get down on my hands and knees to examine them because there was no way I could bend down to pick them up onto the exam table one at a time.  Once I was down there, though, I had some major difficulties getting myself back up again, which must have looked extraordinarily graceful and professional to the parents.  Yes, I am a slow, fat clown these days.

I’m tired, but mostly my pelvis is tired, which is probably too much information.  You see, fellowship orientation started this week, and while the majority of it has been about meeting new people and becoming acquainted with the different hospitals I’ll be working at, 50% of my time has been about walking back and forth to various buildings all over the Longwood campus trying to obtain badges for each of the hospitals.  And I’ve discovered that walking, while all my ligaments are stretching and compound joints are becoming all undone due to this pregnancy, is tough on my pelvis.  Word to my pelvis: stop hurting, please! I still have another handful of days of badge acquisition and walking to do.

I also wish I had some profound thoughts to jot down, but I don’t.  Today, we had NRP review at this state-of-the-art simulation center using a wacky super-fancy neonate dummy.  (NRP is the Neonatal Resuscitation Program, which is a protocol for resuscitating newborn babies.) The neonatal dummy, NewB (pronounced “Newbie,” ha) was pretty cool - she cries, she breathes, she develops perioral cyanosis, she can have a heart beat and pulse; she has an umbilical stump that you can catheterize.  The only profound thing I learned from our mock code was that on the video replay, I talk too softly and I am really humongous at this stage in my pregnancy.  And I make funny hand gestures, apparently.  The video replay was quite informative.

Trading in my pedi stethoscope for my neo stethoscope…even tinier!

Random and semi-random strangers sometimes feel the need to comment on my gravid state:

PARENT IN ROOM 3: (in Portugese) “You’re having a boy! When are you due?”
ME: “Oh, I’m having a girl! In about a month!”
PARENT: “No, you’re having a boy! Because he’s all out in front! That’s a boy for sure!”

Or, as I am slowly making my way around the Charles River for a “walk,” i.e. slower-than-slow ramble round:

DUDE ON BIKE: “Whoa, easy there, girl, don’t want you to pop as I fly by.”
ME: “No, worries, you can pass.”
DUDE: “No, I don’t want to be responsible for your water breaking or nothin’.”
ME: “Um, ok, thanks.”

Or, at clinic:

TEENAGER: “How many months are you? 3 months? 4 months?”
ME: “About 8 months.”
TEENAGER: “No way, cuz, like my sister, she bigger than you and she only 6 months!”
ME: “Well, everyone’s different.”
TEENAGER: “I want me a baby, too, you know.”
ME (inner monologue): “Why is this conversation going this way? I need to get her on birth control.”

Alternatively, random comments from family members:

BROTHER: “Your feet are disgusting.”
ME: “I know.”
BROTHER: “They look like Hobbit feet.”
ME: “No they don’t. They’re not hairy like Hobbit feet.”
BROTHER: “No, they’re Hobbit feet. They are exactly the way Tolkien describes them in the book: small and swollen.”

Fortunately, I only have one more shift left, and the nice thing about working in the ED is that it’s shift work. That makes up for the 10 bajillion other issues that make it difficult. The weirdest thing about seeing patients in the ED is that you’re only seeing a tiny sliver of the patient and family dynamic, usually at their worst moment. Because, you know, they’re in the ED, and you only go to the ED (supposedly) when you’ve got an emergency. And how many people do you know who are at their calmest, most communicative, friendliest, smartest selves when they’re in the middle of an emergency, or occasionally, an “emergency”?

Also making it hard to work is my ever enlarging girth in the setting of physically demanding spaces, which the ED is all about - it’s an ergonomic challenge, to say the least. Doing lumbar punctures and IV’s and catheterized urine samples kind of sucks if you’re not comfortable.  The other day, I started a cath urine on a (very strong, extremely wiggly) kid and started having a contraction right in the middle of it. Fun! Also, if I don’t drink at least 3 liters of water a day, I start having contractions, and (a) it’s hard to drink 3L of water in the ED, and (b) it’s hard to pee that much when you’re in the ED. I’m tempted to just roll around with my own IV bag and IV pole, although again, how am I going to do lumbar punctures or suture a laceration with an IV in my own arm?

Oh, and I forgot to mention, I’ve “graduated” from residency. We had a graduation ceremony and an end-of-year party to close out the year, and I was tempted to get all nostalgic about my last three years or at the very least, excited about moving on, but really, I’m just too tired to care. Honestly, what would make life easier these days:

[1] normal sized ankles that are not made of memory foam.
[2] someone to make me a real solid dinner every day, instead of stealing ginger ale and crackers in the ED and eating pre-packaged pineapple chunks and chugging milk from the container when I get home.
[3] a real pineapple-fruity alcohol based drink instead of pineapple chunks.

I might have even put on that wish list that I just want this pregnancy to be done and over with, but that’s not true. Gully needs to stew for a little longer because I have to get through new-fellow orientation and some clinic time in July which I have a feeling I’ll enjoy, but honestly, if she wants to be a late pretermer, I don’t mind one bit - their outcomes are apparently ok, despite all the recent hub-bub about neurodevelopmental outcomes in late pretermers.  The nerd-bomber in me has already lovingly cleared a space in my file cabinet for my NICU fellowship and labeled a new file folder “late preterm - dev outcomes,” and I’ve packed a few articles into it; not that I’ve actually read the articles. Does this count as “nesting”?

As for the actual physical nest, I think it’s almost done, mostly thanks to Joe, who assembled the crib, purchased a twin bed (for nights when cluster feeding shouldn’t prevent the other parent from getting a solid 4-6 hours of sleep or when my mom or dad will be “taking call” with Gully when I’m on call at the hospital and Joe’s in California), hauled furniture around, hung curtains and pictures, washed all of the clothes we’ve amassed, and tucked little diaper inserts into her tiny little Gdiapers. He even bought diaper wipes and butt cream. I think he’s more ready than I am - as evidenced by the fact that he will bend down and tell my girth, “hurry up, I want to meet you!”

Last week, I meant to call Joe for a “check-in” conversation (only because we hadn’t talked to each other in 72 hours), but we both ended up getting very worked up about health care costs for some reason.

I don’t remember how it came up, but for example: do you know how much it costs, in your state, for you to get an x-ray if you break your ankle? You probably don’t. Because it isn’t listed anywhere that is particularly easy to access. And I don’t care if you’re a liberal or a conservative - aren’t you even curious about how much it costs?

Now that I’m 3 years into residency, I am amazed that I know how to suture a laceration but I have no idea how much that service, plus the sterile drapes and lidocaine and suture material, costs. This has come up maybe only twice in my training.

Once, a family from France was visiting Boston, and they needed to have their daughter’s foot laceration repaired in the ED. They asked me how the hospital would be able to bill them for the service once they left Boston, and if they could just write a check right then and there for the service.

Another time, I was a third year medical student at SFGH, on a trauma surgery rotation, and a woman visiting from China rolled in strapped to a gurney, after having been badly injured in a car accident.  Through the medical interpreter, she wanted to find out how much a chest x-ray would cost before they x-rayed her; she explained that she had used up all her savings to come visit her daughter in the U.S., and wouldn’t have any money to pay for this accident.  The senior trauma resident rolled her eyes and said to the interpreter, “Explain to her that in America, we save lives first and worry about the cost later.”  I think that despite the patient’s furious protestations, she was wheeled into an OR anyway to stop her massive internal bleeding.

The lesson learned here - maybe people outside of the U.S. are more cost-conscientious about health care than we are?

I am very much in favor of universal health coverage, and I do understand the argument that if you’re in a real pickle - if you are so unlucky as to be a victim of a massive car crash, or your son develops leukemia - you really don’t want to have to worry about the cost of your medical bill.  You don’t want to even be unfortunately jobless and have to see your primary care doctor for a nasty cough and fever - because what if you have pneumonia, and have to pay for a chest x-ray and antibiotics? (And not knowing how much this costs beforehand can be really scary if you have no income but a potentially huge bill looming).  So why can’t we make costs just a little more transparent?

I start in the ED this week, and I just know something about cost containment and the ridiculousness of the ED will make me have a conniption.  (Although there are plenty of other things about the ED that I know will make me have a conniption, but that’s another story…)

And now for a completely separate topic…In more amusing news, Joe and I went to our “birthing class” over the weekend (cost: $185.00! Insurance reimbursement? Questionable!) and Joe learned that amniotic fluid is fetus pee.  “What’s in it that makes it okay for the baby to breathe it in and swallow it?” he asked me later that night.  I really wish he had asked the RN teaching the class instead, but then he pointed out there was another couple in the class with an annoying engineering husband who was asking annoying technical questions, and Joe pointed out “it’s people like him who give nerds a bad rep.”

ME: “It’s got hormones and nutrients and proteins in it that are important for growth and for their lungs to mature. I think.”

JOE: “Okay, but, still, it’s got waste products in it.”

ME: “Yeah, but it’s sterile, not like our urine, because the whole womb is sterile.”

JOE: “Okay, so if I, like, microwave my pee and drink it and aspirate it, will I be okay?”

ME: “Uh.  By all means, give it a shot.  I dare you.”

Not that I’m complaining (well, actually, I am complaining) but I would really like a tiny break between residency and fellowship instead of an overlap.  It is not a huge overlap - just 5 days - and fortunately, it’s just a few days of adolescent medicine clinic that I’ll be missing to attend orientation for fellowship.  But it’s enough of an overlap to create a likely adjustment disorder in my mind.

The scheduling powers-that-be have been sage enough to put me on “back up call” and “clinic” on my first month of fellowship in July in case I deliver early, which means that with some advanced warning, I can get called in to take call or cross-cover someone who may be sick or otherwise ill-disposed. However, I’m not sure how that will work if I’m unfamiliar with the NICU that I’ll be covering in.  Because I hate the fact that I will be brand squeaky new at my job and will not even know where to find scrubs nevertheless intubate a premature 28 weeker (haven’t done this since my second year of residency) or place a chest tube in a baby (haven’t done this ever), or….lots of ridiculous skills that I wish I were more confident with.  I know that’s part of the point of fellowship training - to get better at this stuff - but I also know that the first year of fellowship is going to be harder than intern year.

At this stage of residency, however, I am also extremely mentally exhausted, and I want a small break.  A long weekend in Vermont, or something equivalent would have been nice.  The one weekend that that I had off where this was possible is now being eaten up by a semi-baby shower that my in-laws are hosting; neither Joe or I wanted this, and we should have been more adamant in refusing, but now we are stuck.

I think this pregnancy is also making me tired.  My feet have swollen width-and-length wise to the extent that I needed to buy new shoes that are a whole size and a half larger because the only shoes that fit now are my Crocs.  Also, the joints in my hands hurt like arthritis because they are so swollen.  I wish my physical limitations didn’t make me so cranky!  Fortunately, I only have 8 more weeks of this.

I was going to write a post about woe-is-me, I hate being tired and pregnant, but then I started doing some research on diapers, and this is infinitely more fascinating.  Joe and I had the chance to see the movie “Babies,” starring…well, some babies (truth be told, it was kind of a boring movie even if the babies were cute).  In one scene, a naked Namibian baby poops on his mom’s knee, and she wipes it away with a corncob, and it dawned on me at that moment, “shit! I have to think about diapers.” I bet that Namibian baby won’t have diaper rash, but here in the U.S., we encase infant bums in multiple layers to catch that damn poop and hence, have to deal with the consequences of needing butt paste, changing tables and disposal systems for said human waste.

“You need a Diaper Genie,” someone told me, and I think I heard those words and wanted to die.  Mongolian babies don’t need Diaper Genies!  Apparently, this is a a foolproof disposal system that seals each dirty diaper in its own plastic bag so that it doesn’t stink up the whole house.  The tremendous amount of waste, human waste combined with plastic and paper waste, that disposable diapers generate is environmentally horrific.  So I looked into cloth diapers, but I can’t fathom washing all those diapers plus being a working resident and fellow.  And then I looked into local diaper services, but there aren’t many available nearby where we live.  One of my attendings swears by Gdiapers, which is a partially disposable/biodegradable system that you can flush down the toilet, which seems appealing, but I’m loathe to employ anything that requires a yuppie-hippy-dippy system.  Another friend says the most relatively economically efficient and somewhat environmentally friendly thing is just to get Seventh Generation diapers, but when you look into how these diapers still go into the landfill, I’m not sure if it has that much less of an environmental impact.

I think that despite the start-up costs, maybe Gdiapers strikes the best balance between efficiency (I don’t have to wash cloth diapers) and environmentally friendly (flushable inserts as opposed to plastic diapers that get chucked in the trash).  However, when Joe and I finally decided we’d like to try this, the company is telling us they are out of the newborn baby starter kit! Crap. Now that they are telling me I can’t have it, I want it!  Maybe I should move to Namibia or Mongolia where babies’ bums roam free?

Now that I am rendered virtually immobile and very slow by my ever-increasing and annoyingly active girth, I am having dreams about exercise. My dreams for the last three nights have featured in their own little mini-movies: yoga, skiing and running. In each movie, I’m doing each activity, then find I have to pee really bad and can’t get out of the activity fast enough to ski to a lodge bathroom, to walk out of yoga class to the locker-room, to run to the nearest port-a-potty…and then I wake up and have to pee for real. It takes a real heave-ho to launch myself out of bed because my abdominal muscles are all loosey-goosey and no longer bound by a linea alba.

Last night on call, I was “rushing” to catch an elevator and three surgical-looking residents managed to hop onto the elevator, and the doors closed just as I was approaching them. I was really jealous because they actually weren’t walking all that fast. Even the patient wheeling around her own IV pole managed to walk past me and get on that elevator.

I’m also jealous of the Title Nine Sports non-model catalog models. There was a Title Nine Sports catalog in the mail today, which I seem to now receive after buying one pair of stretchy yoga pants that since pregnancy have been my go-to pants for non-work use (”Everyone fits into yoga pants,” Joe pointed out) and there are all these healthy non-model looking women who are modeling their clothes. The caption reads: “Katie keeps busy during ‘business hours’ as an architect, but spends her ‘off-hours’ cycling, running, surfing, canoeing, or sushi making!” and lo, there’s a picture of Katie sporting a stretchy athletic top and making sushi. I want to be cycling, running, surfing and canoeing! I also want to be an architect! And eat that sushi she’s making (sushi - another thing I miss). The sporty top she’s wearing is only so-so.

Ideally, though, this pregnancy is going to last another several months because I need to have this kid marinate for longer. Which means no sushi or cycling. And letting everyone get onto the elevator before me.

I used my spam email account to sign-up for weekly updates from BabyCenter.com. At the beginning, it was kind of cool, because week-by-week it would tell me when Gully was growing ear bones or ovaries, and when she would be the size of a pea, then a plum, then an eggplant. But then last week, the email notification suggested that I start working on a “birth plan.”

Do I have to? I was dragging my feet about signing up for a birthing class until my Ob sort of laughed at me and said that I should just do it, if not for me, at least for Joe. I’ve been called to enough deliveries where I am holding my little blue towel under the infant resuscitation warmer for what feels like an eternity as the mom gives these tiny little ridiculous faux-pushes and the perinatologist wanders by to shake her head at the fetal heart tracing…well, I’ve been to enough deliveries to kind of know what’s expected, but I guess Joe hasn’t. And I guess I should know what to expect from the patient-end of things. So I signed us up for one through this company that has a monopoly on birthing classes in the Boston area, Isis Maternity. The woman I had to register through tried to convince me to take an extended course on “natural birth” rather than the regular birthing class. She also started lecturing me on the rate of c-sections and whether or not I had selected a doula. I almost wanted to tell her, “girlfriend, I hain’t yet started cuttin’ back on my crack and tobaccy!”

So the other thing I am reminded of is that April is apparently Caesarian Awareness Month. There are women out there frantic over the high rates of c-sections in the U.S. (it hovers around 32%, as opposed to the WHO recommended rate of 10-15%) and who are also frantic over a woman’s “right” to VBAC (vaginal birth after c-section), the rate of which is apparently very low. While I am all very much in favor of vaginal deliveries (there is no doubt about it that a c-section is truly massive abdominal surgery, and taking care of a newborn after major surgery is kind of sucky), I also have to say that the rate of c-sections will not drop unless women stop demanding a less-than-perfect newborn outcome. Of the 9 most common reasons cited for obstetric malpractice suits, 6 are for not performing a c-section or not performing a c-section fast enough because of a concerning outcome with the neonate. And who wants a less-than-perfect baby because you wanted a perfect natural birth delivery? The malpractice argument is all very nicely laid out in this opinioned post, which I entirely agree with.

As for my “birthing plan,” I plan on Gully staying up in there until it’s go-time in a few months, then magically transferring the pregnancy into Joe, and he will then somehow give birth. No, but seriously, I just want everyone to get along and communicate well. It’s going to be some freshly minted first year ob/gyn resident (July is newbie season) who’s going to be poking around my hoo-ha, and some first year anesthesiology resident with an intention tremor who’s going to eventually place my epidural, so I want them to be very carefully monitored by their attendings. I also want our family to be extra-nice to the nurses so they don’t talk smack about the probable circus that will occur in our labor suite. Communication, folks, lots and lots of it!

For our fourth wedding anniversary this past week, we went to L’Espalier to celebrate, and I’ve come to the conclusion that I hate dressing up to go to dinner.  Fancy dinners, yes, I like very much because I like to eat well and eating is something I do well.  But here on the east coast, there’s this expectation that if you go out for a “fine dining experience,” you are also expected to dress well, whereas in California, Joe and I could pop into a 1-or-2-star Michelin restaurant and I could wear nice trouser jeans, a cute top and heels, and that was the extent of “dress up:” clothes I normally own and will normally wear. The problem with “dressing up,” is that it feels exactly like that - like you’re supposed to rise to the occasion sartorially because you’re not normally an “up” person, although class-and-status-wise I’ve never felt like a ”down” person at fancy restaurants, but only begin to feel that way when forced to dress “up.” 

Behavior-wise, you can always tell who goes to nice restaurants on a regular basis and who doesn’t.  The people who eat at nice restaurants regularly behave like their normal selves, talk to the servers like normal people, ask normal questions about foods they’ve never heard before or wines they’ve never tasted.  People who don’t go to restaurants like this regularly - people who have to “dress up” - put on their “best manners” and get all quiet when reading the menu and are weirdly overly polite.  This is what happens to me when I have to “dress up” - I am wearing panty-hose and all of a sudden, I remember some arcane rule about not putting your elbows on the table because it’s rude, and then I feel like I can’t put my elbows on the table anymore and that, in the end, does take away from the eating experience. 

The other issue is that I have no preggo “dress up” clothes.  I tried to squeeze into a stretchy black wrap dress that night, and after 4 courses, felt like a sausage in a casing that was going to burst. 

The sartorial issue aside, the food was pretty good, and I was particularly happy with the juice pairings they offered me instead of wine pairings.  Now I am going to have to recreate the cherry-lime rickey they served so I can make it at home with my Top Ramen and mac n’ cheese. 

This weekend, a family member who is not in medicine casually pointed out to me that my difficulties with this pregnancy thus far and our daycare woes might have been alleviated had I “waited until [I] became a real doctor” before having a baby.  It took all of my energy not to burn a hole into her forehead with my fiery stare, because oh boy, how many problems are there with this thinking?

(1) Being in training does not make me a fake doctor.  So the next time you want someone to put an IV into you, call the resident who does this 3 times a night, not the attending who hasn’t snaked an IV into a 4 year-old since her training 15 years ago.  (Better yet, call the nurse, who probably does this 3 times a shift).

(2) My training won’t end until I am officially “advanced maternal age.”  If I wait until my training ends, I will be the age of some of the grandmothers of my patients.

(3) The 80 hour work week of residency only turns into the unprotected 100 hour work week of young-attending-hood in some specialties.  Time off only becomes more difficult with the more responsibility you have.

I know, I know, I know, I know I should be Overwhelmed With JOY at the Upcoming “Blessed Event,” (as it has been called by Joe’s grandmother) but quite honestly, folks, I’m nervous as balls.  For starters, I have already started having contractions, so the threat of “modified bedrest” and lately, “strict bedrest” has been hanging over me, and I am going to go ape-shit if this does in fact end up happening.  Finishing residency on time is a goal I’d like to reach, but certainly not at the cost of giving birth to a 25-weeker (oh lawdy, Gully, please stay up in there for a while more, I promise you more yummy ice cream into your veins if you stay put.) Also feeding into the anxiety is this blog I like to read called “Mothers in Medicine,” because it has been giving me a window into the work-family challenge that I am undoubtedly going to face.  “It just works out because it has to,” one attending told me, which is reassuring, but also a little depressing in a way, because obviously, all things ultimately “work out” in the end.  We live down the street from a fire station that has a very prominently displayed neon sign affixed to its brick exterior designating it as a “safe drop zone” to drop off your baby, no questions asked, if you can’t handle it.  If I end up dropping my baby off at the fire station, does this count as “working out”?

I was going to make this a post about how much paperwork being a physician generates, but somehow moms in medicine seemed more apropos.  This weekend I had the luxury of having an entire call-free weekend - no pager, just two normal days in a row to do normal weekend stuff, and it was fantastic.  At one point, I had two loads of laundry running, was freshly showered and relaxed in yoga pants, making soup and chicken salad in the kitchen, and Joe came over to to hug me and commented, “you look like a mom.”  I was briefly a little impressed with myself for just a second, and then briefly jealous of people who do routinely get to this on all their weekends.  I mean, not that it would be easy to be a stay-at-home mom, but wow, how cool would it be to have the chance to take my kid to baby yoga class, and drink coffee at the park in the mornings with my baby, and Make Things in the Kitchen, and take my kid to mommy-and-me book club, and (because this is 2010) become a snarky commentator on some mommy blog?  And now I want to cry, because it’s my own fault that I chose to rack up some ridiculous medical school debt and spend a bajillion years in training and have a distinctly nerdy interest in esoteric doctor-y things.  Now excuse me as I return to more paperwork and reading about lupus and feeling sorry for myself.

I distinctly remember the day I decided NOT to go into internal medicine was when multiple “influential” family members of this patient I was taking care of swooped into the hospital one day to take control of his medical planning - he was dying of pancreatic cancer, and was a drug-addict to boot, and I think his care ultimately suffered because none of the family members could agree with each other what was best for him, and he certainly couldn’t advocate for himself because he was so snowed with opiates all the time. Of course, I’ve witnessed similar scenarios in pediatrics, so what I’ve come to learn is that (1) death is unavoidable in all settings, no duh, and (2) horrible deaths can occur in all settings.

Joe and I talk about advanced directives all the time, I think, partially because of my horror over how horrible many deaths are, and I think it is never too soon to talk this.  I also think that too few people know what needs to be discussed when talking about advanced directives, partially because our medical system really sucks at this, but also partially because people are afraid to talk about it.  This article got me thinking about how a discussion about advanced directives should occur.  In my dreamiest of dreams:

1) The patient, along with a family member who will likely be the primary medical decision maker, will meet with the patient’s doctor over a series of 1-3 meetings to discuss advanced planning.

2) They will talk about the patient’s health and what kind of things could happen at end-of-life care.

3) They will talk about respirators and cardiopulmonary resuscitation.

4) They will talk about tube-feeding and other matters around prolongation of life.

5) They will talk about pain management.

6) They will talk about the settings in which all this may occur - in the hospital, in a palliative care suite, in a hospice care setting, at home; hopefully, not in an ICU.

7) This will all be documented in writing with the caveat that nothing is binding.

I think about this stuff because ever since getting knocked up, I’ve been seen as a patient more frequently, and worry that if anything ever goes wrong, I have no idea how comfortable Joe will be with managing the medical system.  (I worry about a lot of other ridiculous stuff, too…polymicrogyria! What if my kid has polymicrogyria?!)  And even though my parents are quite healthy right now, I wonder how I’m ever going to broach the topic with them.  When my dad underwent some minor eye surgery last year, I wanted to talk to him about advanced planning, not that I had fear that things would come to that from a little laser debridement of his eyeball and some conscious sedation, but he brushed it off.  It’s certainly not a comfortable subject, but it’s so important. Of course, there’s lots of stuff that he likes talking about that I hate talking about, too, like traffic, or pharmacodynamics, and Costco deals on ham.

I can’t help but think of George Costanza’s shouty argument in Seinfeld, “we’re living in a society!” when I think about health care reform.  Today, I was lucky enough to get a seat at a talk by Atul Gawande on health care disparities, and then in the afternoon, I got to listen to lecture on childhood obesity.  During both talks, the issue of individual freedoms came up in both the truly individual sense, and in the larger, health policy-and-mangement sense.

First, health care reform: one of the first thing I hear people complain about (patients’ parents, even some nurses I work with, conversations on the T) is that they don’t want to pay for other people’s ill health.

Second, childhood obesity: there’s an ad that’s aired in Texas that frames the obesity issue as a consumer rights issue - don’t take away our right to eat ice cream and drink soda.

The absurdity of both arguments - which are really one argument - makes me want to knock some heads in.  The idea that individual health is the individual’s responsibility is only partially true.  People feel that sick folks should pay more for their health insurance because they didn’t “protect” themselves and it’s partially their fault that they got sick.  Sure, maybe a little bit; maybe that guy down the street’s obesity and associated heart disease and diabetes-related vascular disease could have been avoided if he took more responsibility for exercise and eating well.  But we all know it’s a lot more complicated than that.  We all know that there are (1) genetic predispositions among certain populations towards diabetes/hypertension/obesity, (2) it’s friggin’ hard to lose weight even if you have the motivation and the means to do so, (3) we live in a society that is pushing more soda, juice, and pies in larger portions than ever before.  We are a society that likes to pretend that your disease is your own business, and that your health exists in a vacuum of personal choices or occasionally, genetic mishaps.  But come on, people.  We know that this is simply not true.

Okay, I need to get off my soapbox now, but bottom line - I don’t mind paying a little more to close the gap on health disparities knowing how complicated “being healthy” truly is, and I wouldn’t mind the government shutting vending machines out of schools and implementing healthier school lunches, because come on, we live in a society, folks.

Can I just sleep, please? It’s not as if I’m the most stressed out, sleep-deprived person out there, but everyone else’s March-exhaustion is making me tired.  It’s nearing the end of vomit/bronchiolitis/prime pediatric admission season and everyone is really tired and just had it.  All you ill children, stop being ill and stop making your parents cry!  Plus, we take far too long to round in the mornings.  Come on people.  I am going to have to buy clogs a size up because my feet are so swollen after rounds.  Well, my feet are swollen anyways because of this darn kid.  I feel like she’s pressing down on my ileofemoral veins or something because I’ve got 1-2+ pitting edema even first thing in the mornings.

Last week, I made my first baby-related purchases:

Yes, it’s a Threadless onesie (did you know that Gerber has trademarked the name “onesie”?), but don’t worry, we are not trying to make Gully an emblem of our wannabe-hipster-irony, so yes, I also bought a couple of not-so-offensive onesies.  This onesie matches a t-shirt I already own, so we can wear coordinating mother-daughter outfits!  The weird “nesting” instinct I guess has started to take root, which prompted me to go out to visit my parents in the suburbs and take my mom with me to Babies R Us, which, by the way, is pure evil.  The aisles were filled with overwhelmed parents clutching scanner guns to stockpile supplies for their imminent bundles of joy.  All I wanted to do was see a breast pump and a car seat up close and personal.  Strangely, Joe was on the opposite coast in Sunnyvale, doing the same exact thing, except that he got a step further than me and actually figured out how to work the damn car seats.  “Everything’s so much more complicated but probably safer,” my dad commented, and pointed out to Joe over the phone that when we were kids, there were three choices of stroller, not seven hundred.  And because there are so many choices, this means you have to research all the products rather carefully. After having first looked into strollers, I have absolutely no energy left to research the other essential crap.  Fortunately, Joe has actually read the “Baby Bargains” book almost cover-to-cover and knows what mattresses and pacifiers and such to get, and again, went one step further because he bought a bunch of heavily-researched stuff online later that night, including the big items like the crib, mattress, stroller and car seat, which luckily saves me the trouble of having to do this.  Still, though, I don’t think we should be buying this stuff until the kid’s actually viable, which won’t be for another few weeks, and even then, I want the kid to be truly, truly viable which isn’t until another month or so.

The difficulty in the whole “nesting” experience is that although we kind of have crunchy-granola leanings (and the baby product world is ripe with all sorts of very expensive products for parents anxious to raise their child in an organic-soy-hemp bubble) we also have kind of cheap tendencies, too.  Take, for instance, the stroller.  The one item that every parent seems to have a preference and strong opinion about, and I’m told that the American parent today owns, on average, 3 strollers.  We happened to pass a baby store when I was 15 weeks pregnant, and we saw a stroller in the window-front that was half-price off, which was the immediate appeal; the second most-immediate appeal was that it was lightweight, compact, and looked somewhere in between the (1) crazy $700 space-aged strollers and (2) the cheap plastic-y huge ones that don’t seem to fold very compactly.  We decided to pass it up, though, because 15 weeks was too early to be buying baby stuff, but that stroller stuck in Joe’s craw, and he has to have it.  I did more research, and started thinking, oh, maybe I need a stroller system (don’t even ask), and then, oh, maybe I want something with bigger air-filled wheels for the bumpy Cambridge/Boston streets, and then oh, I want to find something that folds up even smaller, and the price ranges oscillated between $23.99 and $900, but what it boils down to is that I really, really, really don’t want to own 3 strollers (plus, we have no room to own three strollers much less even squeeze a crib into our apartment), and Joe has to have this stroller, so Joe wins, and he gets his stroller.  I hope this means we don’t have to buy any other strollers, but I’m worried.  Also, I hope the baby actually likes it.

All right.  That’s enough about baby crap.  Not to make the poor cats feel left out, I bought them a new cat scratching tower to replace their old messed up one.  At least I know they appreciate things like that.  We don’t even know if Gully is going to appreciate her modestly luxe stroller, or if she’ll hate me forever for making her wear a onesie with a talking bar of soap on it.

Wow, I can’t recall a time in my adulthood where my intestinal system has taken a beating like the one I’ve had this past 36 hours, but I think I’m in the clear now.  I should have known: the first sign was that I wasn’t hungry, hence, something felt “amiss” like when the ocean looks far too calm and there are no seagulls in the sky and the air is too still.  Monday night, I just felt “tired” - maybe daylight savings stole an hour from me, so I went to bed early, only to awake an hour later, grateful that there was actually an emesis basin on the floor next to the bed (don’t ask).  We’ve been taking care of a lot of little patients with some kind of gastrointestinal ailment or another, and all I can say is: sanitize your stethoscope and wash your hands with soap and water - Calstat does not kill the bug!

I’m feeling way better now, but stupid occupational health won’t let me go back to work until I’m symptom-free for 72 hours - 3 whole ridiculous days, which is putting a squeeze on the back-up system, no doubt.  Sorry colleagues!  Now that my intestinal tract is entirely cleared of any and all debris, I can more accurately say that I feel Gully movements.  Even at my last ob appointment, the RN was kind of miffed that I didn’t feel any movement.  I couldn’t quite tell - everything felt like digestion or gas to me, but then Joe pointed out, “Who feels digestion so much?”  Last night, sipping on some Gookenaid (a Gatorade-esque concoction that Joe bought at some orienteering meet, great for rehydration), I definitely felt something more like small limbs akimbo rather than “digestion” on my right side.

I finally had a chance to look into daycare stuff in between bathroom runs, and we are of course late to the game - there’s a two-year long waitlist for the daycare near our house, and an 18-month long waitlist at the daycare affiliated with my next year’s workplace.  Suffice to say, if it weren’t for the generosity of my parents, I don’t think we could technically have kids until I finished fellowship.  I’m still going to be taking call at the hospital every 4th night for the next 3 years, and with Joe’s business travel to California, there was the huge issue of how we were going to take care of an child at night every 4th night of the next three years.  And when Joe’s away, my hours aren’t exactly compliant with daycare hours; I will typically have to be at work by 6:30AM or so, and most daycares don’t open until 7:30 or 8 AM. I entertained the idea of live-in nanny, but that requires having a stranger living with you, and I’m not sure I’m so into that.  I told Joe that maybe he would have to limit his travel just a bit, and that was immediately nixed…”You ruined my life by moving to Massachusetts, so I’m taking the baby to California with me,” was his answer.  He has this vision of Gully being a “1K United baby.”  He has it all worked out so that I will FedEx him weekly supplies of frozen breastmilk for the full duration of the AAP-recommended year of breastfeeding.  I’m still not convinced of the practicality of that, but maybe there’s less of a waitlist for daycare in California! And he won’t have the problem of finding overnight-care since he doesn’t ever have to work overnight.  Given the constraints of my work, Joe’s idea doesn’t actually sound half-bad. He just has to start looking into daycares in Mountain View.

A solution that’s becoming more concrete is my parents.  My dad is in semi-retirement right now and even before I was pregnant, he offered to do the job, and my mom is just freakin’ good with babies.  She loves babies; she’s like the Baby-Whisperer or something, because other people’s babies just miraculously stop crying when she holds them or they find her silly games The Most Entertaining Shiznit Eva.  I explained to them my call schedule, and they were like, “no problem. You and Joe are so busy, we will just take the baby, and you can come visit when you’re not so tired.”  They are entirely nonplussed by my stressed out search for babycare.  So maybe this is slightly better than stranger-nannies taking care of our kid, and maybe on-par realistic with Joe’s frequent-flyer baby plan.

These days I’m supposedly the teaching resident at Outside Hospital, and while I feel like patients here get super-duper really excellent care, I don’t feel like I’m contributing to the educational milieu or learning much myself.  I need medical issues to arise or at least just plain old problems to pop up in order to learn something and hence, teach about it.  I’m starving for something interesting to arise, and things here have been relatively straight-forward basic stuff. Which makes me nervous about my stint next week as the teaching resident at The Mothership hospital.  I’m finding that I’m only a good learner on “active” problems or cases.  How do I make it a good learning experience for others if I can’t find an “active” case or problem?

Mental starvation aside, I’m also really hungry all the time, and have discovered the breakfast egg-n’-cheese sandwich on English muffin.  Outside Hospital has generally given us meal tickets for breakfast, and I’m spacing out my 8 breakfasts here well, because those tasty, tasty egg-n’-cheesewiches really kick the hunger and keep you going through rounds until lunch time.  So it’s no surprise that I’ve gained 5 pounds in the last week, and I can feel shift in weight distrubution and balance in even the little things, like picking up my bag, or reaching for stuff on a high shelf.  I went to my first prenatal yoga class and I was the only lady there who rolled off her balance ball…and I was the least pregnant one there.  This does not bode well for Gully.

Oh, and we found out Gully’s a girl! Big surprise because I was convinced it was going to be a boy and was kind of hoping for a boy if only because the name game wouldn’t have to kick in.  A boy would have been easier - he would have just gotten Joe’s ridiculously uber-Italian name with a big ol’ “the Fifth” attached at the end.  Not that he’d even be 1/5th Italian, but just 1/8th Italian.  The certainty of a boy’s name was so absolute that it was almost like an unspoken law when we got married.  “What if we don’t ever have boys, then what happens?” I asked once, and Joe very matter-of-factly said, “Well, then I’ll have you beheaded.” 

If that’s the case, then we should name our girl Elizabeth, but we’re actually toying with two-syllable names.  Because we like shorter names, okay? Just because.  And we actually have a “secret” girl name that we’ve liked since forever and ever, which we’re 75% certain might be the name, which might not be so secret soon.  Unless it’s taboo to announce the name…but I think it’s not, right?  That’s just what people do, if they don’t hold out on the sex of the baby, then they hold out on the name, just because they feel like it, right? Not because of some weird fear of a mystical curse or anything right?  Because I hate secrets, and I want to tell everyone the name!  I think we’ll announce it as soon as she has a middle name, too, because she’s getting a Chinese middle name, which my parents are going to figure out.  Right now, our placeholder middle name is “Bing-Bong,” which is ridiculous yet not too far off from my actual given name, which is Bik-Yin (yeah, Miranda is only on my birth certificate as my middle name).  So she’s Gully Bing-Bong Onorato until we otherwise come up with something that sticks a little better. 

Everything makes me cry these days. I would like to blame it on my exhaustion from being on the wards, but I should probably also blame it on the crazy preggo hormones.

That Canadian figure skater’s performance in the Olympics? The one who’s mom died only days before she had to skate? Who I didn’t even know existed before I watched her short performance? Yeah, I cried.

That Pampers commercial they’ve been airing during the Olympics? The one “dedicated to moms”? Big big tears.

And this movie I saw last night.  Best child actors ever.  Sobbed so hard that my face was puffy this morning.

Okay, so all these things kind of feature moms or kids, but then today I was throwing out some old med school notes on reading EKGs so I could use the 3-ring binder the notes were stored in, and reading my old tips on non-reentrant supraventricular tachycardia made me absolutely nostalgic and weepy.

But it’s not just sadness that is set at an extra-high voltage level, it’s also super-omigod-hyper-happiness and incredible-hulk-rage.  Post-call at the vets office looking at all the cute animals in the waiting room? I love the world and all the wonderful pets in it!! Torrential rain outside my window as I’m snuggled under a fleece blanket? Nature is so beautiful and majestic! Crazy parents who insist their child will not be monitored overnight or only allow one needle stick for a difficult blood draw? I will cut you, I really will.  If I were inclined to write poetry, as I was wont to do as a teenager, it would be fabulously flowery and hormonal. In fact, I am inspired to write a haiku:

Pregnancy hormones.
Why, cotton IS the fabric of our lives!
How soft.