Puzzles and tricks

Last week Alex promised Allie more Sam videos, so here ya go! Replete with our standard gold-plated production values, to say nothing of the editing botch job. Eh. Good thing the kid's pretty cute.

Blogging fail

I can’t help thinking that when I read back over these posts next year, it will seem like my intern year was composed entirely of days off spent at the spa. I’m off today, sitting with my post-pedicure toes under a dryer, wondering how many minutes are required before I can safely slip my sandals back on.

It’s early in the afternoon, but already, it’s been a productive day. Since Sam went to bed last night, I’ve performed the final post-mortem on our Thursday night dinner party (read: two hours of scrubbing dishes, the stove, the kitchen floor), done three loads of laundry, finished up a few nagging research details and sent them to my advisor, planned our family menu for the upcoming week, gone to three grocery stores and dropped off a donation at Goodwill. Now Sam is napping, and I’m blogging. I’m hoping my toes dry in time for me to get in a short nap myself before he wakes up.

I love not being at the hospital. Oh, how I love it.

But that’s not what I wanted this blog to be about. I wanted this blog to be about my life at the hospital and about my patients. It’s not that there’s a scarcity of stories to tell. Just in the last couple of weeks I’ve dealt with addiction and psychosis, sepsis, flash pulmonary edema. I’ve called strangers in the middle of the night to tell them a loved one is unexpectedly dying. Alcohol withdrawal. Heart attacks. But I’m finding it very hard to find the space and the energy to tell those stories.

On a lighter note, Sam loves to watch Brian in the kitchen lately, which Brian facilitates by letting Sam stand on a dining room chair so he can see up on the counter. Downside here, obviously, is that Sam tends to fall off the chair. I've been thinking about buying this:

... but the $200 pricetag has dissuaded me. So tonight while I was napping on the couch, Brian fashioned a solution out of a dining room chair, an old bike tube, two C clamps and some zip ties:

Aaaaaand now I'm thinking $200 sounds like kind of a bargain, now that you mention it.

In order of awesomeness

Things that are awesome:

1. Chicken schwarma for dinner
2. Pictures of Sam on the Golden Gate Bridge
3. Three tickets to Tuscany for my vacation in April
4. A day off from night float

In no particular order

Things that suck:

1. Night float
2. Night float
3. Night float

Night float

It's almost 2 AM and I'm camped out in what passes for a "hotel room" in our hospital. It looks more like a drab dorm room: narrow twin bed, non-functional lamp, cramped desk. Even the alarm clock is broken. Tonight's my second of fourteen nights on night float and my pager has been relatively quiet but I can't sleep because a) ever the pessimist, I drank an enormous quantity of coffee four hours ago and b) I'm waiting for a repeat hematocrit on a bleeding patient, anxiously refreshing and refreshing my computer screen.


Night float is a necessary evil in medical training. In years past, before new limits on duty hours for residents were adopted, the on-call resident handled cross-cover and admissions, but this genius system resulted in marathon shifts lasting far longer than the supposedly enlighted 30 hour maximum that's the current standard. So now we have night float and for the next two weeks, I'm it. My shift starts around 8 PM and lasts until the primary interns and residents return to the hospital in the morning to resume care of their patients. I cover patients for 12 doctors overnight -- typically about 80 -- but I'm not responsible for admitting new patients. All night long, I answer pages about Ambien and hypotension, I follow-up on recommendations made by subspecialty consultants, and I see and evaluate patients for whatever comes up overnight: pain, agitation, abnormal vital signs.


Night float is generally considered to be a pretty miserable time, and so far, I'd say that's right. It's lonely, it's boring, it's annoying, it's frightening. The good stuff about residency -- the honor of a patient's trust, the commaradie among residents, the satisfaction in mastering a new skill -- is essentially absent. What's left is the chaff of residency: paperwork, a never-ending succession of pages, uncertainty and inadequacy. For instance, I just took a break from writing this post to see a patient downstairs who's nauseated and vomiting. I have no idea why he's vomiting. A quick review of his chart reveals that the vomiting is a new problem for him, so the doctors who know him well haven't left me any clues. He could have an infection, or the vomiting could be the result of his kidney disease, or maybe it's from the medicines we're giving him. I suppose he could have an entirely new problem: heart attacks and pancreatitis can cause vomiting. So can a million other conditions, like migraine headaches, toxic exposures, small bowel obstructions. But my patient doesn't have a fever or an elevated white blood count. He's getting regular dialysis that appears to be adequate. He has no additional symptoms like chest pain, abdominal pain, headache. So here I am. Other than medication to treat his nausea and a couple of simple blood tests that I don't expect to be spectacularly revealing, I'm not sure what to do. It's now 3 AM and frankly 7 can't come soon enough.

Day off

Yesterday morning, post-call and semi-delirious, I was rushing around the hospital to examine each of my patients before our early rounds in the CCU. One of my patients this week is a lovely woman in her mid-50s with radiation-induced pulmonary fibrosis and severe damage to her heart from chemotherapy many years ago. The radiation and chemotherapy cured her cancer, but that's small comfort now that her heart and lungs are failing. She's been virtually confined to bed for years, but lately she's taken a turn for the worse. Her left lung is full of fluid and she can't so much as roll over in bed without becoming severely short of breath. Making matters worse, several times each day, her heart goes in and out of a very fast rhythm that exceeds the upper limit of her pacemaker. After listening to her breathing (crackly in some regions and eerily silent in others) and her heart (fast with a loud whoosing murmur), I started to leave her room, already ruminating on my next task. Once I was halfway to the door, I thought to turn around to ask my patient if there was anything I could do for her before the day got underway. "Just enjoy your life," she said sadly.

Whew.

So today, my first day off in ten days, I am determined to do just that. I started the day with an early morning hot tub soak and massage, then biked home to play with Sam and feed him lunch. This afternoon, my sister and I will pick our youngest brother up at the airport and I'm hopeful that we'll have time to take Sam to the park before the gang of us go out for dinner. Maybe after Sam's in bed, we five can sit in the backyard and share a bottle of wine. There's laundry to do and dirty dishes in the sink, but they can wait. Today I'm enjoying my life.

Insomnia

It's 3 AM and I can't sleep. This almost never happens. There was one night in college when I rolled around in bed for most of the night and for years afterward, I refered to the experience as "that time I had insomnia". Generally, I fall asleep as my head is hitting the pillow, if not before. Tonight, though, I woke up a couple of hours ago to the sound of Sam having a nightmare, and although he fell asleep again almost immediately, I haven't been so fortunate.

Here's what's bothering me: what if I'm making a terrible mistake?

I start Saturday in the CCU, which means for all intents and purposes, I start internship on Saturday. And suddenly, I feel sick to my stomach. I am reasonably sure -- as sure as you can be, I suppose -- that Sam will make it through the year unscathed. But will I? Earlier today, Brian and I talked (calmly, rationally) about how he and Sam will likely go to Oregon for Thanksgiving and Christmas, leaving me here in California alone. (Thanksgiving = VA wards; Christmas = University hospital wards.) So I will miss my baby's second Thanksgiving and his second Christmas.

Oh, nuts. Now I'm crying.

More than the holidays, though, I'm going to miss a thousand ephemeral moments with my tiny son over the next year: swinging at the park, snuggling on the couch with a library book, hanging out laundry in the backyard. And I just wish there was some way to know for sure that it will be worth it. I wish there was some way to look forward to the future, to the time when I envision meaningful work matched with ample time to mother and ask my future-self: was it worth it?

I've thought this issue through from every side, talked about it with friends and family until there's nothing left unsaid. I'm desperate to make the choice that will most bless my son, my husband and myself, over the long term. Caitlin Flanagan famously wrote that "when a mother works, something is lost." What she failed to mention is that something is lost either way. If I don't complete an internship, I'll leave behind a career I've worked years to build. Doctoring offers me the opportunity to set an example for my impressionable son, flourish in the public sphere, nurture my peer marriage, maintain my economic independence. A second income will give my family security in uncertain times. More important, I'm good at it. More important still, it needs doing. But at what cost?