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.