2 Advent

My favorite thing about finishing a wards month is being back at church. Today, the second Sunday in Advent, I served as subdeacon. After the service, we gathered to celebrate the recent ordination of a member of our parish, and to decorate gingerbread houses. Sam took to the task with enthusiasm and his house is now proudly displayed on our dining room table.

In unrelated house news, our house buying situation remains maddenly up-in-the-air. It appears we'll close a day or two after my three weeks of vacation end, just days into my ICU rotation. Ugh. But at least some needed repairs are moving forward relatively swiftly; the house is tented for termites as I type; tomorrow the roofers arrive, weather and G-d willing.

The upside of the delayed closing, of course, is that I'll get a real vacation this month. Sam and I plan to spend a few days in Seattle watching on with excitement as my sister chooses the dress she'll be married in come June. Otherwise, we'll be at home. We'll nap/park/library when it suits us, maybe do some holiday baking should the mood strike ... and that's about all I have "planned".

Heaven.

The break also affords me the chance to reflect on my first month as wards resident. The job entails running a general medicine wards team, responsible for supervision and teaching for two interns and two medical students. I, in turn, was supervised by an attending physician, but that person was only in the hospital intermittently, and generally left diagnostic and treatment decisions to me. It marked a big change from internship for me, and I'll freely admit that I was nervous about the new responsibility. But the month went well: we took good care of our patients, my team and I. We learned from them and from each other. We even had some fun.

One call, the night float intern poked her head into our team room. She had an EKG in her hand and a worried look on her face. "I need a little help," she said and handed me the EKG: wide complex tachycardia. I was out of my chair before she could describe the patient. Together, we pushed adenosine, called a code, prepared for cardioversion, and sent the patient, a cachectic woman with lung cancer, to the ICU. A few hours later, I found a little note taped to my keyboard: Thanks for the back-up.

Ahhh. This job is starting to get good.

New house

Today was my day off from the wards and Brian and I took the chance to meet with our realtor and sign our names about one billion times each. We're in contract to buy a house in Sunnyvale and so far it seems that everything is on track for an early December closing. Pinch me! The virtual tour is still available online here. The house itself is quite modest but the yard, neighborhood and excellent public schools are a dream.

Picture drop

Brian's taken some really lovely pictures of Sam lately.

I was on call for Halloween (again!), but Sammy dressed as a firefighter:

The following weekend, I missed a train ride:

And some bed-jumping:

Five more days on the wards!

Adventures in potty training

Daycare has its perks, I admit. One great thing: they (help to) potty train your kid. Downside is, you have minimal say on the timing, at least at our daycare center. Sam's on the potty training fast track these days and it's not because he's a bladder control prodigy. Nope, it's because, you know, there are tiny infants in our neighborhood whose moms and dads need to go back to work in January. So if Sam doesn't get his literal you-know-what together, there won't be space in the two-year-old room (sunshines!) for all those one-year-olds (moonbeams!) who are getting displaced to make room for ... the infants. It's somewhat surreal to me that my son has to give up his diapers because a stranger just had a baby, but there you go.

On the upside, he's looking forward to being a !starlight. (I know, I know. Ridiculous.)

Having said all that ... the potty training ... it's not going so well. The other day I sailed out of clinic early to pick him up for some much-anticipated library time. I found him sitting on the potty, singing a little song. After 20 solid minutes of, ahem, no productivity save that song, we left for the library. Once there, I plopped him back on the (cute, toddler-sized) toilet for another 15 minutes of nada. But five minutes -- FIVE minutes, people -- in the picture book room and he managed to pee on the floor and poo in his superhero underpants.

Whoever those new parents are, enjoying their babymoon, putting all thought of January and the end of parental leave out of their minds ... I kind of hated them in that moment.

Inservice

Yesterday was my inservice exam, an annual test required of internal medicine residents. I'm a fast reader and was completely clueless about far more questions than is strictly optimal (second line therapy for psoriatic arthritis, anyone?) which meant I finished the morning session with more than an hour to spare. To kill time, I wandered over to Nordstrom in search of new shoes, something I very much need. But I'm pathetically out of practice when it comes to shopping. I wander aimlessly, I can't settle on any particular object, I get overwhelmed before I try anything on. So after a quick look through shoes and around sweaters, I spent the hour eating nicoise salad at the Nordstom cafe, bent over the new Jonathan Franzen novel. I'll curse myself Monday morning when I still have no suitable shoes to wear to work.

Work this month is the "same day" clinic at the veteran's hospital. It's like urgent care and so far, I like working there, for the simple reason that I never get in before 8 AM and I never leave after 4 PM. (If I had known, eight years ago, that my criteria for professional satisfaction were so simple, I could have saved myself a lot of trouble.) But I do find myself amazed on a near daily basis by the complaints that bring patients to the doctor. Two days of mild cough. Intermittant toe pain (that's not even happening right now). One guy came in Friday because he'd changed his mind about that prostate biopsy the urologist offered him nine months ago. I met a woman last week who was having a mild sore throat and "when I stand up, I get nauseated". I'll admit I have limited tolerance for this sort of thing. Brian likes to joke that my favorite clinic patient is actually dead, holding a slip of paper with the diagnosis. What a trouper!, he says, mimicking me. I don't think that's entirely fair, but I do get annoyed with complaints that any reasonable person would treat with common sense and patience. Sometimes, I want to tell my patients, people cough and then a few days later they stop. Once in awhile, we all get a headache. And I bet if I got a new fitness machine, my knee might hurt a little the next day too.

On the other hand, some patients are too stoic or too scared for their own good. Last week I saw an elderly man with shingles in his eye; he'd waited six or seven days before coming in. I suppose he was thinking, whatever it is, maybe it'll go away. And it probably will, but it may take the eye with it. Or the 85 year old woman, coughing for the past three months and losing weight despite forcing herself to eat, who just casually mentioned that her mother died of tuberculosis. Or the obese smoker with a family history of early heart disease whose worried wife hauled his butt in after three days of left-sided chest pain that started when he was cleaning a pool. Our exchange was mind-boggling. "I don't understand why this is happening to me," he kept saying.

"Well," I said, "for one, you're fat. For two, you smoke. Your mother had her first heart attack in her 40s. Your blood pressure is 175/95 and God only knows about your cholesterol."

"OK," he said, "but why is this happening to me?"

We went around like that for several minutes, until finally, I said, "I don't know why this is happening to you. Sometimes people get chest pain. And sometimes it's nothing, but sometimes it's a heart attack. Please let me take care of you."

And you know, it's taken a long time to get to say that. Four years of undergraduate education, five years of medical school, a grueling internship. But finally now, ten years in, I can look my sick patient right in the eye, and offer to take care of him, and actually mean it. And that exchange -- of help offered and help accepted -- is exactly as satisfying as I thought it would be. So maybe same day clinic isn't so bad.

Unrelated: we went fake-real camping two weekends ago (where you sleep in a tent 10 feet from the car and eat steak and drink beer and drive into town in the morning for a decent cup of coffee, not to be confused with fake-fake camping, where you stay in a hotel and tell Sam, "We're camping!"). Brian is begging me not to share these pictures with you until he has a chance to process them, but too bad for him.

Endocarditis

Another perk to my temporary life as a cardiologist is that I don't need to arrive at the hospital before 9 or 9:30, so I've traded gigs with Brian and have been dropping Sam off at daycare in the mornings. We've already developed a weekday routine that involves a morning coffee (for me) and a morning scone (for him). Yesterday as we were walking toward the coffee shop, we passed one of the baristas, empyting the garbage. "Stay in school, kid," he said to Sam. "You don't want to spend your life empyting other people's trash."

Yeeeeeeeeeeesh.

Speaking of gratitude, here's a story for you. One aspect of modern medical care that I suspect many non-doctors don't fully appreciate: the log-jam. I recently helped to care for a patient at our veterans' hospital with so many medical problems, it is almost impossible to treat him. Poorly controlled diabetes earlier in his life resulted in kidney failure; a decade ago he underwent kidney and pancreas transplantation. Unforunately, his shiny new kidney was infected with a virus and was subsequently removed and he is now a dialysis patient with permanent vascular access. But his borrowed pancreas still functions, and he remains on immunosuppressive medications. (Note that permanent vascular access + immunosuppressive medications is a bad, bad combination.) He rolled in to our VA emergency department four or five days ago with a high fever and severe back pain. An MRI showed a large abcess in his lower back, tracking along his spine. The next day, his blood cultures grew Enterococcus and an ultrasound of his heart revealed a infectious goober flopping along on his aortic valve. The valve itself is no longer functioning adequately; he is increasingly short of breath and hypoxic as a result. Treatment for an epidural abscess? Surgery to drain the abscess. Treatment for bacterial endocarditis causing heart failure? Surgery to replace the valve. But the heart can't be fixed before the back; can't put hardware in a patient with an active septic focus. And the neurosurgeons are -- how to say this? -- declining the opportunity to operate on this man's back due to his kidney disease and overall clinical instability. "Poor surgical candidate," they called him. ("Poor non-surgical candidate," the medical team noted.) In the meantime, his fevers and rigors continue despite horse doses of antibiotics and all the while he remains paradoxically on medications to suppress his immune system. The whole situation is a complete snarl and the patient is desperately, desperately sick. I'm not sure what will happen for him or to him.

Cardiologist for a day (month)

This month, I'm on the cardiology service at our veterans' hospital. Among other things, the new rotation means WEEKENDS OFF. My first so-called "golden weekend" (known to non-residents by the common moniker, "weekend") was last week. Brian, Sam and I celebrated by spending the weekend at Lassen National Park. Despite a Bay Area heat wave earlier in the week, it actually snowed in Lassen over the weekend. Snow! In August! Even with the incement weather, we had a wonderful time. On Sunday we hiked to the top of the Lassen cinder cone for a view of the painted dunes and lava beds. It's quite a steep climb and poor Brian carried Sam on his shoulders the entire way. When we got to the top, Sammy announced, "I HIKED!" Um, sure, kid.

I'll post pictures of Sam "hiking" and "camping" (technically, a hotel, but what does he know?) when I can.

August update

Still here, still alive.

This weekend, Brian and Sam are in Oregon, throwing rocks into the Rogue River and catching up with old friends. I'm in the middle of a run of night shifts in the emergency department at our university hospital, so I got left behind. What this means is that, for the first time in over a year, I have an entire day to myself.

Sleep until I wake up, check. Coffee and the NYT, check. Pedicure, check. Eating ice cream in bed while I update my blog, checkity check.

Emergency medicine has been an interesting experience so far. As a medical student, I felt reasonably certain that the specialty wasn't for me, so I didn't bother to do an emergency rotation; this month is my first exposure. While my time so far has confirmed that emergency medicine isn't a fit for me (noisy, chaotic, waaaaay too much psych and OB), I'm enjoying myself. Nice people, interesting cases, shift work.

Last night I met a 59 year old woman who was billed as "headache, vomiting" and triaged to the less-acute area of our department. I strolled in, expecting a migraine or maybe meningitis. But from the doorway, it was obvious that my patient was much sicker than advertised. She was slumped to her side, shuddering and moaning. Three hours earlier, her son explained, she had argued with a neighbor, then been struck suddenly with an overwhelming headache. She fell to the floor, unable to stand or walk, and proceeded to vomit again and again. When I met her, she no longer recognized her son and she couldn't look at me, answer any of my questions, or participate in my cursory neurological exam. After surveying the scene for about a minute, I had heard all I needed to hear; I called a stroke code and 10 minutes later, I was standing in the control room for a CT scanner across the hall with the on-call neurologist, looking in horror at images of a brain filled with blood. We wheeled our patient back to the emergency department, pushed mannitol and 23% saline to prevent her brain from swelling, then waited for the on-call neurosurgeon to make his necessary arrangements. I suppose it's a sign that I don't belong in the emergency department that when my patient left for the operating room -- no longer my patient -- I wanted to go with her. To be sure, I am not the doctor she needed that night, but it doesn't sit well with me to triage and stabilize, then hand off care for my patients to other physicians. I'm glad I'm not an emergency medicine resident.

On a happier note, here are some pictures of Sam at the science museum in San Francisco.

Photography

Brian's been making noises lately about "needing" a new camera. (Note to self, this must be where Sam learned to use the word "need".) I am having trouble being supportive of this need. His collection of camera equipement is already a) extensive and b) expensive. Does he really need another DSLR? Wouldn't life go on, just as it has, without the capacity to shoot HD video? The camera he has his eye on isn't available yet, so I have a temporary reprieve, but even so, I admit to a bad attitude about spending $2K for the latest version of what we already have.

Having said that, Brian was processing some pictures last night and had this to show me:

This shot completely captures my memory of our trip. I suspect I'll look at this picture again and again over the decades of my life and be transported back to a moment so flawlessly happy, it's almost a miracle.

Which makes me think I shouldn't interfere with Brian's pursuit of his photography hobby.

PS. In case it's not obvious, that blur in Sam's hands is a little wooden sword.

Limping

It's been an eventful week. For starters, on Tuesday, Sam developed an atraumatic limp. By Thursday, the limp was worse and both my brain and stomach were churning (!sarcoma! !leukemia! !septic joint!) so we piled into urgent care where Sam limped obligingly up and down the clinic halls, giggling. The ped, thoughtful and thorough, sent us home with reassurance. But the next day his limp was worse yet, so back to urgent care we went. This time: plain films of the hips, knees, ankles and some basic blood work. All blessedly normal, and today the limp has more or less disappeared. I am relieved, but still a little rattled.

It's always interesting to me to be a patient -- or worse, a patient's mother. There's this out-of-body thing that happens: helpless, I watch myself morph into the kind of patient who drives me bonkers. I'm irrational, I cling to my own explanations, I demand needless intervention.

All very humbling.

Work has been less humbling. It's near the end of intern year, and I can feel myself starting to get cocky. After ten months as an intern, I can write an H&P in 20 minutes, I know where the radiologists hide in the middle of the night and I actually remember which carbapenam doesn't cover pseudomonas. I know how to distinguish between right and left atrial enlargement on an EKG, how to triage respiratory distress, how to perform a thoracentesis. I have the pager number for the on-call ICU fellow memorized. I even know where the obstetricians stash their free hot chocolate. I've got this down.

Anyway, I'm working this month on the private hospitalist service. The schedule is more or less the same as for the university wards -- Q4 overnight, roughly 80 hours/week -- but interns work directly with attendings. Some of the attendings are micro-managers and others don't seem to care at all what I do for our mutual patients so long as everyone's alive in the morning. Needless to say, the second type is my strong preference.

I was on call last night with an especially hands-off attending. We admitted a 56 year old woman who for the past four years has been inexplicably unable to walk. Apparently, four years ago, her legs developed intractable spasms and over time, she walked less and less until she became essentially immobile. Yesterday, her husband had finally had enough. He picked her up, carried her to the car and drove her to urgent care. From urgent care, they dispatched her immediately to the hospital for additional imaging of her brain and spinal cord. In fact, when I left this morning, she was in the MRI scanner. I'm not sure what's wrong with her, although the posibilities are numerous and interesting (multiple sclerosis, a severe B12 deficiency, syphillis, diseases that form benign CNS tumors like neurofibromatosis or tuberous sclerosis, probably several other things I haven't thought of), but what's really fascinating to me about this woman is her indifference to the problem. Apparently, years ago, she was a ballerina. But for the past four years, her legs just ... didn't work. And she did absoutely nothing about it. What does that mean?

I dare you

... to keep from smiling while looking at this picture. Can't be done!

Home!

More Tuscany

The last pictures from Italy! We fly to London tomorrow.

This is my favorite shot of Sam, just outside the restored cloister where we're staying:

We spent an afternoon in San Gimignano, amazingly overrun with tourists even in April.

On the way to Volterra, we stopped at a farmhouse for some agriturismo: delicious food and a place for Sam to run.

We were tempted to stay (forever) at the farm, but eventually made it to Volterra.

Today we went to Montalcino, for some famous wine.

Siena

On one of our last nights in Florence, we three got caught in a thunderstorm on the Ponte Vecchio. Dreamy beyond dreamy and Brian shot the perfect picture:

Now we're off to the hill towns. En route to Siena, we stopped in Monteriggioni.

Amazingly enough, Tuscany actually does look like this, from pretty much all angles:

We LOVE Siena. You can keep Florence; I want Siena.

Pearls before swine, redux

Sam at the Uffizi: "I don't want more art. I want more CHOCOLATE." (Yes, that's chocolate around his mouth. Yes, I brought bribe-chocolate into the Uffizi. If you can think of a better way to get a two-year-old to spend an afternoon looking at Giotto, I'm all ears!)