Dear Emi,

You are one month old today! Well, technically, you were 4 weeks old, or 28 days old, several days ago, but mommy is generally behind on all things these days. You are a fantastic baby, and your parents are still amazed to have you. Sometimes, mommy still wonders if she will wake up from one her brief naps and find out that you were just a very long dream. You are a very good natured baby with a very easy temperament so far. In the words of your pediatrician, you have “very slow state to state transitions,” which means you are a very easy-going baby. It also means your crazy mommy still works very hard to wake you up to feed you every 3-4 hours 80% of the time, otherwise you won’t wake up to eat. But you’re growing, nonetheless. Mommy has trouble looking over your head when she pops you in the Ergo because your torso is so long (you have your father to thank for that).

So far, you’ve started to be more alert, particularly in the late morning/early evening hours, which is fun for mommy and daddy - it means more time just playing with you. At this point, that means flashing black and white cards and mobiles at you, and trying to get you to make eye contact either with us or at yourself in the mirror - because that’s what babies do at this stage. Sometimes it means taking a lot of goofy snapshots of you. Sometimes it means we give you a sponge bath (again, your crazy mommy is still worried about your umbilical cord). You seem to like warm water on your head and the sound of running water. Sometimes if we play with you too much or too long, you do tend to get cranky and start crying from overstimulation. We’re sorry! But you’re so cute.

The other thing that’s happened is that you’ve gotten a cold (thanks again to your crazy mommy, who’s been fighting the same cold since giving birth to you), and have a lot of congestion, which again, doesn’t help the feeding issue. I’m sorry for squirting saline into your nostrils and bulb suctioning your nose. This is one of the other times you cry big tears. Thankfully, you don’t have a fever with this.

What else can I tell you? Your grandparents are head over heels for you, too. Your cat sister and brother, Manzie and Solo, are slowly getting used to you. Solo tries to find ways to cuddle with us when we’re breastfeeding, but mommy’s lap is too small. Manzie is kind of scared of you, but you’re trying to make friends with her, as daddy makes you pet her every day.

I guess I should also tell you that your mom and dad are really trying hard to keep it together for you. We’re new at this parenting thing, and we’re sorry if we don’t know all the answers for you! We are also working hard at trying to adapt to this new normal, which is hard for both of us, and I’m sorry if that upsets you, too.

We love you so much!
Mommy & Daddy.

Taking care of Emi, I have daydreams about having a voice-activated omni-present computer like on Star Trek Next Generation. Like when Picard goes, “Computer, Earl Grey, hot.” Or when anyone on STNG asks the computer anything. Because Emi is a grazer breastfeeder and she likes to be held and bounced or rocked when she’s awake, 80% of my waking hours involve holding her, and I can’t do much else (she needs 4 hands to make her do her job, which is to eat or burp!). So I want to have a computer do everything else for me.

“Computer, check the weather for Hurricane Earl’s estimated arrival in Massachusetts.”

“Computer, I need to dictate this email to my program director. Begin dictation…”

“Computer, why is Emi fussing?”

“Computer, peanut butter and jelly sandwich. And feed it to me while I hold Emi.”

Then I realized, maybe Emi is like me…a partially ineffective multi-tasker. While she is supposed to be breastfeeding, she is also looking around and learning, or trying to relax and sleep, or concentrate on pooping, or getting all worked up about gas, all of which affect her latch, breathing, suck and swallow; hence, slow breastfeeder! She’s a partially ineffective multi-tasker, too! Maybe she’ll like Star Trek someday, too.

Motherhood has imposed new (lower) standards of cleanliness.

(1) Dirty laundry = stuff that has major spit-up or vomit stains

(2) Semi-clean wearable/usable = stuff that spit-up but does not smell completely rancid yet or at least doesn’t look stained

(3) clean = actually not worn or used before.

I spend 90% of my time in category number 2. Gully spends 90% of her time in category number 2, although I’m trying to be better about it, really, because I’m holding off on baths since her umbilical cord started bleeding, and she kind of stinks of spit-up and sweat (she’s a very sweaty baby).

We went to our first mommy-baby class together, and it was quite an outing, involving packing 80 bajillion things. It was nice to get out of the house and hear other first time mom’s experiences and see their new babies, and I would like to just relax now and enjoy how lovely that two hours was, but now I’m all worried about the germs. Germs! Granted, they make you take off your shoes before you enter the classroom, but still, a whole cohort of unvaccinated babies in one contained space!!! Aaaarrgh!

Warning: this is yet another depressing newborn baby posting.

Someone I trust very much called the first two months of you and your baby’s life “the fog of war,” and I find this to be very true. Granted, it’s not like real war in Afghanistan or Iraq, which I imagine to be infinitely more horrible, but there’s something about the combination of day after day (after day after day) of sleep deprivation, combined with the singular, prison-like time cube of your baby’s “feeding schedule” that makes everything…well, foggy.

Plus, I am a worrier. So I worry about whether Emi is getting breastfed enough. Continually. Endlessly. Almost shamefully so. Because even though she’s gained weight, she is still a little jaundiced, and she likes to fall asleep at the booby. Then wake up squawking if she didn’t get enough. Then fall asleep again when I re-plug her in. The only time she seems satisfied is when Joe gives her a bottle of expressed breastmilk.

She’s a hard baby to read because she’s such a good baby. Emi rarely cries, and when she does, it is sort of low-decibel and difficult to decipher. She’s also a very grunty, squawky sleeper, so half the time, I can’t tell if she’s stirring awake for a feed or just being a noisy sleeper. Then there are those moments when she just lays awake in my arms all googly-eyed and occasionally yawns or starts to make grunting/rooting/mouthing faces that mean “could be hungry, could be bored, could be sleepy - mommy, you have to guess because I sure as heck don’t know.”

In a way, the breastfeeding issue is almost getting in the way of me bonding with her. Joe gets to hold her and cuddle her and bottle-feed her - all while I have the chance to pee, eat, pump. Makes me very nervous about him returning to work because in some ways, she needs 4 hands, not just 2. We are going to do a trial run tomorrow, where Joe will return to the Kendall Square office for work tomorrow just to see if I can swing it alone for the day-time. We’ll see how it goes…

We are still getting adjusted to our new life roles, i.e. parenthood. It’s exhausting for a variety of factors, but let me count the ways:

1. I am The Boobalator
Gully/Emi is what I would describe as a slow-poke grazer. We didn’t do too great with the initial breastfeeding in the hospital, and she was jaundiced and losing weight. Fearing another admission for hyperbilirubinemia (our hospital experience made us want to avoid a re-admission at all costs) and in my deliriously sleep-deprived and physically incapacitated state, I let the nurses talk me into SNS (a supplemental nursing system). You can look this up yourselves, but the bottom line is that it’s a humongous pain in the ass. We gave up on that after 24 hours, and just started supplementing with formula via bottle after every attempt at breastfeeding for the next few days. I started pumping to get my milk supply going, and my breastmilk was in by day 5. I went to a lactation class with Gully and we got an in-home lactation consultant to come see her feed, both of which were only partially helpful because Gully performed like a champion feeder both times, which was highly unusual. At best, Gully is still a very slow feeder/grazer - it takes her anywhere from an hour to two hours to feed, and she’s additionally cluster feeding as well. We don’t have a schedule down yet because of these issues. This leaves very little time to sleep. Right now we’re trying to do only 1 bottle per 24 hours as a compromise between nipple confusion and sleep for Miranda and teaching Gully to perform on the boob, but this, for the past 2 days, has resulted in a very alert baby who wants to start cluster feeding.

2. Da Blues
They say that around 50-75% of women experience the “baby blues” (separate from post-partum depression), after the massive shifts in hormone levels after giving birth, and I think this, combined with my exhaustion, is why I am crying every day at either trivial things (”I dropped the burp towel and can’t pick it up because of the flailing, crying infant in my arms and my stitches, woe is me”) to chronically worrisome things (”Shit, there’s no way I can study for the boards with Gully feeding like this,” or even the ridiculous “what if I only love her because it would be sad if her mommy didn’t actually love her?”) Joe, I think has some paternal version of the baby-blues, too, because the other day, we went for a walk in the park and saw a 2 year-old playing, and he commented, “I would dig a hole and pour money into it if it would get her to age 5.” He’s been a tremendous help around the house with chores, cooking and running up and down the stairs getting things while I sit there ensconced with an infant in my lap, but I think the dad-role can be remarkably frustrating when your kid’s only job is to sleep and breastfeed, both of which require only peripheral help from a dad.

Joe also commented that he can’t wait to get back to work - not that he doesn’t love his baby - and part of me envies him for his ability to do that sooner than me. I would love to get back to some semblance of my old life, but my old life is really f***ing hard and stressful, and I can’t handle that right now. My new life is one continuous marathon cycle of breastfeeding and skin-to-skin, where the clock resets every 2-3 hours, and I have to figure out when in those cycles I can have a moment to pee, eat, nap, shower, have visitors (meaning I gotta put some clothes on, because to maximize effectiveness of breastfeeding they suggest you and your baby be “skin-to-skin”). This kind of life means that I don’t have time to study and be adequately prepared for the boards, which are in October, and to make life easier for myself, I just decided to forgo the boards until next year. This feels very much like failure for me, which only compounds my guilt. As for returning to work in October…I just gotta compartmentalize and think about that later.

3. There is no normal, i.e., this is all normal
In my type A kind-of-life, there are measuring sticks big and small to track progress, and typically, I am mindful of these things to make sure I’m doing an adequate job. However, in newborn care, the only thing that I feel like I have to track Gully’s progress and my progress as a mother, is if she’s eating or not and if she’s gaining weight. All the fun developmental stuff comes a little bit later. And so, I am not sure if I’m supposed to enjoy this or not, but I’m pretty sure a lot of new parents do not enjoy the first few weeks to months of new parenthood.

This is the story of Emi’s birth (more to come about Emi and parenting later). I talked to a lot of people and read a lot of people’s stories about their labor & delivery, and I think it’s really useful to know how different everyone’s labor can be so different and yet everything can turn out just fine. Bottom line is: they don’t call it labor for nothing. If you are not interested in the gory details, skip this post, but if you think you need to know this information, keep on reading:

Emi was born on August 5, 2010 at 1:09 pm. I went in for induction for post-dates at 41 1/7 weeks on August 3 at 8:30 pm, and was in active labor for about 40 hours, which included about 1 hour and 20 minutes of pushing.

Day 1:
We walked into L&D at 8:30 pm. They started my IV, checked my cervix which was 1-2 cm and still long, and her head was was +2 station. I got Cytotec to ripen my cervix and start dilation. By midnight, I was having irregular, mildly crampy contractions ranging from every 30 sec to 1-2 minutes. They weren’t painful, just crampy and annoying, and I tried sleeping through them, but couldn’t.

Day 2:
At 2:30 am, they noted my contractions were still too irregular and too frequent to start me on Pitocin, so they let me just contract a little longer. Around 4:30 am, my cervix was not dilating. At this point, the contractions had died down to 1-2 minutes apart, and were still crampy enough that I couldn’t sleep. They started the Pitocin around this time at very low doses, which made my contractions very painful, but then they were very irregular - I would have 2-3 in a row every 2-4 minutes, a pattern that again made it difficult to increase the Pitocin dose. Meanwhile, Emi’s heart rate on the monitors were tolerating this all quite well. Around noontime, they checked my cervix, and I was still at around 2 cm, 50% effaced. At this point, we decided to do a balloon catheter to dilate my cervix, and they turned off the Pit (thank god, it was soo painful), and inserted a balloon catheter to dilate my cervix. My contractions died down to every 3-4 minutes or so, and were less painful, but by 5 pm, the balloon catheter had fallen out, and I was 5 cm dilated. After the catheter fell out, they restarted the Pitocin, but I requested to have an epidural if they restarted the Pit (sooo incredibly painful). The epidural went in around 9 pm, and it sucked - took two tries, and I was having contractions through them, and then even after that, it still didn’t work.

Day 3:
Still hadn’t gotten any sleep because the epidural was doing a great job of numbing my legs, but wasn’t working to ease the pain of the Pit-induced contractions, and for some reason, we were not increasing the pitocin through the night. I received several boluses of fentanyl/bupivicaine through the night that did little to relieve the pain, then finally a lidocaine bolus that semi-worked and I was dozing every 1-2 minutes and waking up for every contraction that occurred every 2-3 minutes apart (still irregular, too!). At some point in the middle of the night, they also broke my water. By morning time, it was just too f***ing painful, and I hadn’t slept in over 36 hours. My Ob walked in that morning and squeezed my hand, “I’m so sorry, this is just one of the worse inductions” or something to that effect. I don’t know, I was delirious from lack of sleep and pain. The new Ob on service that morning decided we should go ahead and ramp up the pitocin to slightly above maximum doses, while receiving more boluses of pain meds via epidural, and this is when I was crying almost continuously for about 4 hours. My temperature spiked up to 102, too, so they started me on antibiotics for presumed chorioamnonitis. We were ready to call it quits at my next cervix check at noon-time, and just ask for a c-section, as dumb as that is, but by noon, they saw that my stupid irregular and infrequent contractions had finally dilated me to 10 cm, got Emi’s head to -2 station, and we were ready to push.

“Are you fucking kidding me?” I think I asked the very kind Ob. I think I pointed out that at this point that I was too tired and in too much pain to push. But since there’s no turning back, something flipped in me, and I just started following the nurses’ orders and just started pushing. About 45 minutes into it, they said “you’re almost there just a few more pushes,” and I think I told them “I don’t believe you,” but by that time, the Ob hospitalist and Ob intern rushed in, and I think it truly was about 4 pushes before she was out.

It was a huge relief. They put her on my chest, and I think I mumbled “warm, stim, dry,” as I helped towel her off. Her Apgars were 9 and 9 at 1 and 5 minutes. Weight was 8 pounds 4.4 ounces, length 21.5 inches, head circumference 36 centimeters. Afterwards, she had to go to the nursery to start IV antibiotics as well.

Days 4, 5, Post-partum:
Family members wanted to rush in at this point, and were delightfully exposed to seeing me being transferred on a gurney, my exposed breasts during breastfeeding (they recommend doing this in the first couple hours of life), and skin-to-skin kangaroo care with Emi. No one tells you how busy it is, with people constantly checking in you, nurses wanting to do vital signs all the time, pediatrician and ob and anesthesia and everyone else trying to talk to you (so you still don’t have time to sleep), and no one tells you how difficult getting the breastfeeding going is, particularly as your body just isn’t cooperating. It was 24 hours before I could pee on my own, and getting in and out of a chair or bed was just not happening gracefully or pain-free.

Tidbits:
Medical students: I feel bad that I was so rude to them (there’s always a teaching moment at a teaching hospital) but I was so delirious from the pain that I couldn’t take it when one of them confused me for another patient that I requested no medical students on day 3.

Fluids: 5 liters via IV total, which resulted in massive swelling in my legs and you-know-where, making it hard to go to the bathroom. Also want to remind folks that throughout this, you can’t eat, you can only have clear liquids, and I was strangely starving the whole time, despite being in pain.

Family visitors: we made the mistake of letting them come too early, despite all their good intentions. Give yourself some time to rest and start immediately bonding with your baby before they descend and sit there twiddling their thumbs and staring at you all swollen and shocked in your hospital bed.

Husband: Absolutely amazing through all of this.

More to come about bringing Emi home…

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.