Mishmash

I just finished day 14 of 26 in a row. Because I just got off night shift (no weekends while on night shift) and because I chose to work Xmas instead of NY, I’m working many days in a row.

Today I broached the subject of the divorce with my kids. It is not something that they’ve really wanted to hear about before but since their dad is coming out here again in a few days and since it was a HUGE elephant in the room that caused all manner of psychic distress for my kid, I thought we should at least start a discussion. I think it took nearly this long for me to be able to have this conversation and be as fair as I needed to be to my co-parent in explaining the whole thing to them.

I studied today for CREOGs. This is an annual exam we take in January to evaluate our knowledge of the content you need to know to be an Ob/Gyn. It was a day that was busy in pieces, but gave me time to answer questions and review my notes. Not as many deliveries in the last couple of weeks, but I’m in for the long haul, I can wait.

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Been feeling pretty crappy lately but it turns out I wasn’t burnt or depressed, I was just in need of a damn day off. Mercifully, once I figured out that I was working 26 days in a row, we were gifted with the world’s slowest Monday on L&D and my chiefs let me go home for the day. I walked my dog, cleaned my room, did some fun errands, made dinner, did stockings with the kids and baked peanut blossoms. I didn’t swing a nap but the day was great anyway. Only 2 weeks (well 12 days) until my next day off. Can’t wait to do it again.

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Every service has its upsides and downsides. When I’m on an L&D rotation I’m reminded what a creature comfort predictability is for me. On L&D from day to day, hour to hour, you never know what you’re going to get. I guess that you can remember that Tuesday is high risk clinic day and to expect a bunch of you-know-what to hit the fan in the afternoon - patients coming for extended monitoring, to rule out pre-eclampsia, ultrasounds, EKGs, etc. The sucky part is when that semi-reliable day happens in addition to a bunch of walk-ons with all manner of complications. Life on L&D is like a box of chocolates, you never know what you’re going to get. And sometimes it just kicks your ass.

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We got an admission recently that is making everyone varying degrees of sad and angry and frustrated. A patient with a terribly sad, avoidable outcome has been handed into our care by an out of hospital birth attendant who works in the area. This is my own personal first horror story of tragic, avoidable outcomes due to this person’s poor standard of care but I understand that it isn’t likely to be my last. There have been reports to the medical board, by patients and doctors, yet somehow this person is still peddling their toxic product. I have known that there were people like this out there - allowing women to get sick or permanently injured and babies to die (I’m not exaggerating) and still offering substandard prenatal care that doesn’t provide recommended evidence-based surveillance or have necessary back ups in place. 

I can only imagine safe out of hospital birth when it is coupled with seamless integration into higher levels of care - knowing when you are performing at the edge of your scope and where to get the next level of care and accessing it quickly. I think the thing that bothers me the most about this is that even in the setting of harming women and babies, this person sets themself up on a pedestal, revels in the title of “infamous” and considers themself the one true champion for women & babies in Western North Carolina.

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I get a lot of feedback. My actions are under a lot of scrutiny and that is right and good. I need to be careful, precise and as correct as possible in my actions and decisions. I accept this as necessary. At this point, I’m not (usually) a danger to patients, so the feedback is mostly fine tuning. It seems to be having unexpected consequences on my psyche.

I get correction from 3rd & 4th year residents frequently. Sometimes we have responsibilities that overlap. So I might see a note or orders placed by someone who is also responsible for making sure I do my job correctly. Because they are also still being trained and learning, they do things incorrectly as well. Also because they are human. None of these things are dire or consequential. Like much of the feedback I get.

There is this little “first thought” that I get that is a petty “A HA!” when I see a mistake made by an upper level. As in, “Not so perfect, are you?!?” I’m immediately layering a second thought that gently reminds myself that they never claimed to be perfect and to stop being petty. But the first thought is there and I need to recognize it so I don’t let it sneak into my attitude and relationships with my co-workers.

Halfway

I feel like I haven’t published in a million years but I see that it has been less than 3 weeks. (It's been longer than that by now but it was about 3 weeks when I wrote this)

I noticed recently that my posts that talk more about work seem to get more views and I was trying to think of things to say about work but having a little bit of writer’s block for lots of reasons.

Today I managed a 16 week loss. The patient was admitted and stable when I came on this morning but she was going through something called an “inevitable spontaneous abortion.” The pregnancy wasn’t over yet, but we knew it was just a matter of time.

This wasn’t a situation where the pregnancy was no longer viable, when there’s no heartbeat and we’re just waiting for the body to notice that it was no longer gestating. This wasn’t a “passenger” problem, it was a “passage” problem. These sorts of problems can be infections, very early rupture of membranes, labor, painless cervical dilation to name a few. In these cases, there’s still a heartbeat and if we were cruel enough to put an ultrasound on the uterus, we’d see it. And the fetus moving, oblivious to the looming danger.

In these situations, there are a few ways we can manage things but before I do I want to state very clearly that this is a pregnancy that Is. Going. To. End. 100% chance of miscarriage. No chance of survival. No chance of waiting until the fetus is big enough to be viable and benefit from a neonatal intensive care unit. This is a hard, hard day, for everyone involved. It is heartbreaking and tragic and absolutely no one’s fault. It didn’t happen because someone was fat, used drugs, had bad teeth, didn’t pray enough. ANYTHING. I really don’t want some anti-abortion troll to find this post randomly and call me a baby killer.

Patients need some time to come to grips with this reality. It doesn’t fit in a brain - the baby is alive, but it won’t be for long, and there’s nothing I can do about it except choose the manner of its passing. Sometimes while they are coming to grips, the situation changes and our path is limited by the circumstances - bleeding, infection, retained placenta. This is exactly what happened today. Our stable, very sad patient was taking some time with family to mourn when her body decided it was time.

Had we not had our hand forced by our patient’s uterus, we would have offered her 3 different options: (continued) watchful waiting, induction of labor or dilation and evacuation or a D&E. I think a D&E is what is known as a “partial birth abortion” in political spheres but I couldn’t honestly tell you because there is NO SUCH THING as a partial birth abortion. It is a made up term used by non-medical people to misrepresent a heart breaking and sometimes life saving medical procedure.

We know some things about placentas in the middle of pregnancy - they are now big enough to do work and pool blood, despite what else is happening. And they are often still very adherent to the uterus, if they don’t come out all the way, we need to go in and get them or they cause deadly trouble. If a patient is already sick or just doesn’t want the risk, a D&E is, hands down, unquestionably the safest way to get to manage a second trimester loss. The downside from patient perspective is that they don’t have a baby to hold, For some people that is very important and they are willing to risk needing manual extraction of a placenta, a D&C, a blood transfusion. It isn’t a guarantee but it is common.

You may have noticed that this is a fairly clinical description of these events. It was an oddly clinical day for me - I kind of forgot to be sad about the baby dying. I was thinking about managing a sick patient who was not conveniently (or as it turned out, safely) located relative to the supplies, staffing and OR. I was deciding about when to give her medications, how much to give and what signs would mean I needed to do something different. I actually had to make an emergency call at one point. People were moving slowly toward a goal and I said “We need to go NOW” and what do you know, people reassessed their needs and moved a lot faster after that. This was MY patient. I managed her (with help, guidance, supervision, of course), I counseled her, I met with her family afterward. I was very busy and it was a huge growth experience for me. But I forgot to feel sad. And now its been a few days (I’m finishing this post up a few days later) and I don’t think I can unpack that sadness at this point. Maybe later, when managing the medicine is not as new and intense, I’ll be able to hold sadness while getting shit done. Life goals.

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Today in clinic I helped a experienced nurse practitioner diagnose an unusual problem she encountered in a postpartum patient visiting for an IUD. Bodies are weird, this one was doing unusual things and she couldn’t make heads or tails of it. I did an exam and identified and evaluated the problem. Then I put in the IUD. Proud little “I’m becoming the next level provider” moment.

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Had something of a personal curveball last week. I’m on a leave from work for the last 7 days, will probably be heading back in about 4 days. It wasn’t my curveball, it was a parenting curveball. No, I’m not going to say more about it than that at this point. When your kids get older, the stories aren’t really yours to tell anymore. This is going to be one of those things that comes out over a series of small posts, peppered throughout my blog. Stand by for more.

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I've not been feeling great recently, realized that I haven't been reaching out, not trying to talk to friends, just keeping my head down and moving forward. Feeling a bit out of sorts. I'm publishing this stuff that I've already written so that I can clear the plate and maybe do some blogging again. I need to get back to the quick vignettes so it can feel more accessible to blog. My life is hard but my life is also amazing. I need to remember the second part a little more readily. 

We're about halfway through 2nd year and it has indeed been a tough year. Last year I liked the second half a lot better, I sure hope that's the case this year too. 

Clowns to the left of me, jokers to the right, where the heck am I?!?

My life is so topsy turvy, I don’t think I should try to make sense of it. I think I need to just grow sea legs. Some good things happened today for my daughter, some things made me realize that my son was having a harder time than he lets on with his teflon smile. I had a pretty chill day at work, which is a nice change and helps me get some administrative stuff done and be rested so I can have some active recovery time this weekend. I’m lonely for friends but don’t have much time to arrange social events and I rarely know when I’m going to feel up for the adventure of hanging out. I love my job but it is so...consuming. I am consumed.

The bullshit that is happening in the Senate judiciary committee this week is not helping me. Like many (most?) women in America, I’m a sexual assault and trauma survivor. I don’t think about it a lot but it’s there and it has come roaring back to my front burner this week. I’m dreadfully proud of Dr. Ford, not just that she came forward, but how she did it and how she comported herself during the process. And the whole damn thing is triggering, a word I don’t particularly like, but it’s appropriate in this context. I feel like I’m listening to a loud drippy faucet ring out in a quiet night while I’m trying to sleep. Just as I’m drifting off *PING* there it goes again and my adrenaline surges. I want to do something incredibly restorative and self-soothing tomorrow but I’m not sure what it would be. A hike someplace beautiful, maybe. Where I can get my feet wet if I were so inclined. Western NC is known for its beautiful waterfalls. Hmm. That sounds very grounding. Bonus if I can take the cute pup with me. 

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I am now one-quarter of the way through what is arguably the most inhumane of my 4 years of residency. This year I will have 12 weeks of night call, much more frequent weekend coverage, the god damned 24 hour shifts (those don’t go away). This job is back breaking, it is destructive to one’s psyche and it is murder on any notion of balance. Despite how upsetting it might sound, I state this without emotional distress. The material is difficult to master and it should require superhuman effort to do so. We hold life in our hands. We have to know our shit. And despite all those practical and logistic realities, it is not an abusive environment. The superiors are supportive and there are many structures in place to help diffuse the hardship. I don’t feel like I’m on the receiving end of a psychological beating. I’m just really fucking tired.

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I have been delayed gratification girl for so many years. I have recently been prompted to make more declarative statements to someone about “what I want.” This person is not necessarily in a position where such requests/demands are going to be met but it has gotten me thinking. What holds me back from really living, and not just surviving. I’ve been in survival mode for so long, I need to deliberately break out of the mindset, it isn’t just going away. Conversations with people who ARE on the inside, who get to hear my process and know my heart, have helped me realize that I have a great big psychological boogey man standing between me and my goals. I have a Dweller on the threshold and I’m calling it the “BUT HOW.” Because when I think about things that I want - friendships, romance, socializing, etc. I get a huge BUT HOW thrown in my face by this archetype in my mind that I cannot yet get around. I don’t know how I could fit one. More. Fucking. Thing. into my life, but I still want things! Like many problems at this point in my life, this is not a new issue, this is just a variation on a theme. I must know the whole path before I take the first step. Obviously I’ve gotten over that compulsion or I never would have gotten married, had children, gone to medical school, gotten divorced, moved across the country so many times, etc. But here I am, thinking about what is missing from my life, wanting to make a plan to add it, and the BUT HOW is standing in my way.

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My co-parent is planning a visit. As a result we are thrust into conversation more frequently. I’m not enjoying how these talks are going. I value having him more present in the kids lives, but it is hard for us to navigate this stuff. We cohabitated (so awkwardly) then I left, the kids followed suit shortly after. We haven’t had to manage family sharing much beyond managing vacation times. I want him to come see his kids. I want them to have time together. I’m pretty sure it is going to be painful and hard for me. I still want it.

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If all goes well, I am going to have 3 days during this rotation at a local FQHC that has services for trans patients - I’ll be shadowing and learning from an MD and a PA, and they have a support group that I’ll be attending as well. I’m trying really hard to get some experience that is going to be helpful for my eventual post-residency career. Plus I get to queer up the residency program. Win-win.

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I miss being in the OR. That is an unusual sentiment for me, I was kind of surprised by how much I like surgery. I always thought of it as a means to an end (the end being patient care) but the fact is I actually like OR days. The work is gratifying.

That being said, I’m still chipping away at my emails and just finished 2 writing projects that were anticipated several weeks ago. I am enjoying having my brain back and being able to see my kids more. So all OR all the time, not really what I’m looking for either.

Nighty night

I just finished my first of 3 weeks of night for this rotation. I’ll do this 3 more times before next July. I’m so ridiculously tired right now but it’s 11pm and my body clock is all messed up so I’m just going to journal for a while while the melatonin kicks in.

I was a bit anxious about how much awake & home time I’m missing as a parent. And this is only the 2nd week of school. I’m already gone by dinner & bedtime, I’m not home yet most mornings when they leave for school. I tried to prep the kids as much as I could, but as they are 15 and 17 now (D’s birthday is in 2 days, A’s was on Labor Day), they know much more than I do and have assured me that I am, in fact, overreacting and quite foolish. (insert eyeroll emoji here)

Halfway through the week we had a demonstration that adolescent brains are not the same as adult brains. Independent of each other on the 3rd or 4th day of my week, during the after school period we have together, they both made incredulous comments about my schedule. And the amount of sleep I’m (not) getting. I chose to find it heartwarming that they noticed and not irritating that they didn’t believe me the dozen times I tried to warn them about it before the rotation started. But we’re all on the same page now, it seems.

The work itself has been amazing. It is rare that I have time to sleep any amount that really matters. Maybe a 5-10 minute power snooze with my head on the table. Sometimes I do so much, I can’t keep patients straight (obviously I take good notes and rely on my team to help me, I don’t actually get anyone’s care confused!). I did 3 c-sections one night. Another night I was in the main OR doing urgent gyn surgery for 5 or 6 hours (ectopic pregnancies and septic abortions and torsed ovaries). Some nights I just managed sick people and didn’t do any deliveries or surgeries. And then there was a night that we had (on either side of midnight) 2 women roll in and deliver babies very quickly. As the 2nd year, I usually get the sicker patients, but when the intern on the team is a relatively new family med intern and we have to deliver a preemie baby for someone who’s been in the hospital 15 minutes, that counts as complicated enough to be in my wheelhouse. At night we sometimes take care of some things the day team didn’t have time to get to - consenting postpartum patients for tubal ligations, reading the daily fetal monitoring for patients who are in hospital for many days or weeks, following up on hypertension/pre-eclampsia management changes.

This week I decided that I’m going to try managing my pre-eclamptic patients with treatable BPs with nifedipine instead of labetalol. The science is basically the same but the meds are dosed a bit differently (1-2 times a day vs 2-3 times a day, 2 dose options vs a large range of doses) and I’m wondering if starting with nifedipine will enable us to shorten length of stay and titrate an effective treatment faster than starting with labetalol. This is one of those things we call “practice variation” which means there’s not a good reason to do one over the other, but individual doctors still have preferences.

I have the weekend off, a little bonus to working nights. I’m very happy to have 48+ hours off in a row after a week of 5:45pm to 8am work (bonus on Fridays - didactics until noon). 2 more weeks of this then I have an Outpatient rotation which is a luxurious 8-5 job!

One of the ways I’m coping with the arduous role of a 2nd year resident (really the workhorse year of our program) is by breaking the year up into fractions. Recently I “celebrated” the completion of ⅙ of the year. This week marks the 4th of 6 weeks of this rotation so I’m two thirds of the way through. Breaking things into smaller manageable chunks makes the whole year stretched out before me a bit less daunting.

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And I just finished my last week of nights for this rotation. I’ll do another 3 weeks of nights in 7 weeks. After that I have a longer break and then there will be 2 more 3 week stints in the spring & summer. I am consoled by the fact that though I have 12 weeks of nights this year, I only have 7 next year and 5 the year after that. It all comes out in the wash. “It’s a 4 year program” is one of the truisms we use to remind ourselves of patience with our own learning and to get through the times when our schedules are harder. I’m very tired and I miss my kids. They’ve done a great job but taking care of themselves - a lot of frozen lunches, yogurt and bowls of cereal. The dog has been walked, the homework has been done (or so I’m told) and life has gone on. With the night shift schedule, there’s not really enough time to do anything other than come sleep and have about 20-30 minutes to do something else - shower, eat, see the kids. Pick one.

Labor & Delivery has been an amazing place to work the last 6 weeks. The team I was working with gelled really well and I cannot express how much I have learned, what a better doctor and surgeon I am now. I’ve taken care of some really sick women and participated in some amazing births. I’m a lot faster at doing c-sections now and I was the person who did things for the intern when they couldn’t manage - breaking water, checking a difficult cervix, helping to make a plan for a patient with an unusual presentation. More often than not, I’m able to deliver the fetal head in a c-section (this is harder than you’d think) and I rocked c-section breech birth maneuvers several times. I still need a lot of help and there were some times I had to turn to my chief to do things for me - breaking water, making treatment plans, some hard surgical stuff. I was present with women when they delivered babies born still and took care of some sick women who ended up losing their uteruses or being told that pregnancy was now a life-risking endeavor that they should not undertake again.

Next week we have a short week of filler stuff - all our rotations don’t divide evenly into 52 weeks so we have several “freak weeks” - at the end of the year when the graduating chiefs aren’t around, during orientation for the new interns, this week when more trainings happen and 2 weeks over the winter holidays. After that I have 6 weeks of outpatient clinic - heaven is a job from 8 to 5!

Each one, multitudes

Things you may not know about surgery/medicine/humans: 1. Blood congeals really quickly. This knowledge has started to inhibit my ability to enjoy a good police procedural. 2. It is pretty much universal for people’s guts to stop working when they have abdominal surgery. And there’s not much that we can do to get them going again. Patients think it is really weird for their doctors to ask them about farting every day. 3. Different tissues have different smells when treated by electrocautery. Blood & fat together is my least favorite. Muscle is the most confusing, it smells like you are grilling.

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The way we can take care of all our patients, but especially patients who are really sick, who need real doctors, while we are learning: layers. There is a team taking care of every patient “I” see. There’s a chief resident above me, there’s an attending above her. I talk to my chief and my attending about my patients. Sometimes I ask if I should do what I think I should do, sometimes I tell them what I’m doing. Often I am confirming what I know and they are refining my understanding.

This is all information the front of my brain knows.

The inside of my brain, however, is pretty heartbroken today. It thinks that learning medicine is pretty shitty when you have to almost kill someone to learn things. My basic instinct brain thinks I’m essentially an attempted murderer. Today has been a hard day.

The truth is, I didn’t miss something. I really don’t think so at least. I think one of my patients had early symptoms that resolved while I was caring for her and then acutely had some really bad shit go down. Women really do die after having babies. It’s a thing.

She didn’t die but she was and is very unwell. There are implications for the rest of her life. I didn’t miss it when I saw her yesterday afternoon, because it wasn’t there yet. But this morning she was whisked away from our care and sent to the intensivists, to the ICU, where they will hopefully stabilize her.

I will never ever forget this constellation of symptoms and circumstances and I will work hard to catch it sooner next time. If it could even be caught any sooner. It is quite possible that the complications were caught as soon as there was something to catch, that her body was hiding the problem even from trained eyes, that there was no telling that she was going to go into that level of distress based on any information we had at our disposal before she actually crashed.

I can’t save everyone. Today I am confronted with that reality and it hurts. 

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Today I delivered a baby that weighed a pound and a half.

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After work today I was too keyed up to go straight to the Mom Duties that await me. It was also warm enough to consider a swim so I invited the kids to join me and my daughter and I went for a quick dip. When you have a pool at your immediate disposal, you use it differently than how I used to think about going to the pool. It can be a quick 15 minute dip, floating in the water, staring at the sky, or maybe swimming a few laps to get some pent up energy out or practicing cannonballs and somersaults. Then you just head home, take a shower and make breakfast burritos for dinner. Onward and upward!

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Today I delivered a baby that was alive yesterday.

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My son made dinner tonight. Wouldn’t let me into the house when I got home (our main door is through the kitchen) so I sat outside on the porch with my feet up and listened to music. And had a delicious dinner delivered to me! Don’t let anyone tell you that raising boys is easy or that young men have simple emotional lives. This kid contains multitudes and he’s amazing.

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One of my children or the other has lost their temper three times now and and damaged a piece of my home. All the pieces are repairable, but it is still a huge pain in the ass. They need to reign in their tempers a little bit. At least the latest one is an easy replacement part (door shelf on the fridge) and I can charge Little Hothead for it. Good thing they made all that money this summer!

Personal life? What personal life?!?

I’m having something of a parenting challenge right now. Teenager’s brains are difficult to live in and difficult to live with. My son is man-sized. I have to regularly remind myself that he is NOT a man. And I have to check my own issues with male anger and avoid getting worked up when he’s worked up. He’s working through some very appropriate and very complicated emotions but, like most men-type people, he’s lacking some of the emotional intelligence and self-regulation to really experience and process his emotions. Walking him through this process is sticky. It’s really REALLY hard to see the 10,000 foot view.

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I’m coming out of a place in my life where I performed hypervigilance in response to someone else’s emotional state and needs. As such, I’m having something of a backlash against expectations that I read people’s minds. I don’t mind hard work, I don’t mind staying late or staying up late to help you with your problem. But don’t expect me to intuit your problem. I’m more than a little bit psychic but I’m still a terrible mind reader. 

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Back on the dating horse - we’ll see how it goes this time around! 

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Had a good conversation with my son to work toward helping him with some of the things that are holding him down right now. It was a successful conversation and forward steps have been made in the process. It is hard to blog about these huge aspects of my life because I want to respect my kids' privacy and right to own their own digital identity. I want him to get help. He’s got a lot of emotions tucked inside but anger seems to be the door we need to go through to get to them. I think we've found  the start of a solution.  I love it when I’m able to navigate the psyche of a teenager and it goes well. 

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I absolutely cannot stand gossip. It is right up there with mind reading. Once my ex remarked to someone that something he liked about me was that I wasn’t catty or gossipy. I was surprised, I guess it was a little like someone complimenting me for not being an aggressive picker of lint off of the clothes of strangers on the bus. Of course I don’t do that! Why the fuck would I want to do that? I don’t get any joy from talking about people behind their backs. It is malicious and poisonous.

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I have shrines that want constructing and it is making me sad that I can’t get that done. I need a few little bits for one of them - some nice paper & an hour of internet research and printing of things, plus someplace to put the things I print (I’m thinking tiny picture frames). The other I think is just a matter of cleaning off a shelf and rearranging things that are in other places in my room. I also want a full moon calendar. At this point, I should probably just wait and get a 2019 one, but dammit money is always tight around the holidays and I forget to get it in the new year. These are things that will make me feel more centered and authentic in my home. Lots of little shrines and a full/new moon calendar as art. Life goals.

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There are many areas of my life where I am full of curiosity. Curiosity helps me understand people who are different from me. It helps me parent. It helps me do my job and it helps me learn and grow as a human.

I get texts from people I’m dating, asking about my day or sharing some tidbit and it occurs to me, I may be crucially lacking the curiosity about that person’s life for casual dating to evolve into actual relationships. I’m not sure I have space in my life right now to care about another person. I care about so many already!

Summertime, and the livin is easy

I just had the best vacation! It involved a lot of driving that mercifully went very smoothly. Every single day I was gone I was able to visit with wonderful friends. Some friendships were formed in the crucible of parenthood. Somehow it is more incredible to me that these children are young men and women than the fact that my own children are. My friends are doing our part to bury the Mommy Wars - we have all made different decisions about how to raise our kids and we respect each other’s paths as right and good. And we can be honest about our doubts about raising teens and the troubles that entails as we were when we were uncertain about toddler temper tantrums and daycare and nap time. It is important to have friends you can be honest with. I did some very Maryland/DC activities while I was there - a visit to Great Falls (wow the Potomac was raging!) and played tourist at the Supreme Court and the LIbrary of Congress. I know that you can’t go back to places and times you’ve lived but I think I might find myself moving forward to a new life in Maryland. It has ocean, mountains, cities. Ample communities in the shadow of our capitol that need doctors. I’m familiar with the politics, the terrain, the culture. There is a good bit of time between now and when I need to make my What’s Next plans, but Maryland is definitely an option.

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Three years ago today I was making a mad dash across the country in what turned out to be a futile effort to be at a dear friend’s deathbed. He sickened and died very quickly but was held close and sung home by the very same people I would have at my side when my time comes. Wicca is a relatively new religion and we are learning and creating rituals for ourselves. With Keith’s passing, we hit on something old and familiar. Many have taken up the commitment to build our end of life traditions and customs as a result. Though I missed the end of his life, I was able to be part of the next steps of preparation of his remains. Death is a Mystery but dying is a human act that should be discussed, anticipated and witnessed. Know what you want at the end of your life. Talk to your loved ones about it. Don’t leave them with the burden of uncertainty during that painful time. I still feel waves of grief from the loss of Keith. But I don’t ever wonder if we did the right thing, in the decisions of his last days, in how we sang him Away or in how we dealt with his possessions afterward.

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Sometimes the surreality of my life hits me at the must mundane moments. Today it was while I was gloving up for surgery. I’m almost 45, I have teens about to turn 15 and 17. I’m a 2nd year resident. I do surgery. I’m an effing doctor.

When my son (the almost 15yo) was in 2nd grade we decided that what he needed was to be in 3rd grade. It took some doing but it worked and he went from being old for his grade to being young for his grade and has been just fine with that ever since. But one of the things I remember thinking, calculating, considering, when he was in SECOND GRADE (he was 8) was that if everything went my way, he’d graduate from high school the same year I finished my residency if he moved up a grade. I have been doing this for a long long time.

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Did you ever listen to the NPR show Car Talk? Two of the funniest, smartest guys on a radio show. They used to have all sorts of people call with problems with their cars they KNEW were caused by a certain event that correlated with the onset of the problems. They were pretty unabashed about telling people when they thought, in their expert opinion, the 2 events were actually not related at all. They could be pretty funny about it.

Humans are trend makers. We look for patterns, in the stars, in chicken entrails, in our lives. People in medicine are no exception. There are all sorts of superstitions about saying that things have been “quiet” on the floor and people often label each other as Black or White clouds, leading to doom or peace. Our patients do the same thing. Very often someone will associate getting their tubes tied or some other event with other problems in their lives. And no one else knows your body like YOU know your body. But as someone who knows BODIES in general better than the average person, I often don’t agree with their assessments of cause and effect. I have learned not wish co-workers a “quiet shift”, instead I say “smooth” and mean quiet in my head. And if you insist that while we are taking out your uterus, we need to get your tubes too because of an association between your tubal and your skin rash, I’m not going to try to dissuade you of that notion. Respect the patterns, people. Otherwise it’s all just chaos.

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My kids are home! They are jet lagged and a bit feral but they are coming back into house manners quite well. I hope they will re-learn the skill of putting themselves to bed. They are loving the dog, fixing meals and today they helped me assemble a futon frame. Actually, I would say that I helped them. I read the instructions and they did the work. The worked well together after their summer of construction/handyman work with their dad. I wish I had an ongoing need for home improvement tasks so they could continue to work together. And tonight they are celebrating their accomplishment by playing GTA, sitting on the futon together.

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I was going to comment on a friend's FaceBook post but didn't want to get off topic of her own adventures with a ketogenic diet. Ketogenic diets sound frighteningly complicated. Likely complicated enough to trigger my eating disorder but *maybe* going gangbusters on it would just re-direct all that dysfunctional eating into something that was less unhealthy (and a good bit more creative) than just eating fewer and fewer calories each day.

I spent 4 months not eating sugar (well no desserts or sweets, but not monitoring hidden sugars in foods, which are myriad). I think that most of that time I struggled against the urges of my eating disorder. I had this overpowering drive to add more rules, change my exercise habits, set goals and critique my body in such self-hateful ways. I fell off the wagon for a vacation, and I don’t regret it. And though I am making some subtle efforts to reduce my bad food choices again, I am wary of making declarative statements about my eating. I’m pretty annoyed with the weight I’ve gained in the last 18-24 months, but I am leaning more toward buying clothes that fit instead of trying to lose the weight.

I hate that I’m so limited in my food management options. I really walk a narrow, potentially dangerous space between disregarding all limits (and therefore gaining even more weight, which would put me closer to a health-debilitating BMI) and imposing disordered eating upon myself. I wish I didn’t have this particular mental hiccup. And I want a pony.

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Yesterday I worked 11 hours then came home and made dinner - pork chops, couscous & peas. I cook, you clean up - house rules. I don’t care if it gets done right after dinner but it has to get done. This morning when I walked into the kitchen at 0530 to go to work the dinner pans & dishes were still there. I woke up both kids and put them to work. To their credit, they got right up and did it. To my credit, I did not harp on them or lecture about it. I have a penchant for lecturing.

I also put tracking and blocking apps on my kids' phones this week. They are pretty pissed but I don't really care. I know that their shiny new iphone 8+s are going to be a major distraction when school starts and I'm not going to be around to tell them to get off the games and videos. They are going to have to learn to manage their tech, yes, but expecting 2 teens with ADHD and very little parental oversight/micromanaging to just figure it out is not reasonable. I hope that these tools will ultimately be useful. Their dad has concerns about taking the learning away from them and I appreciate and respect that opinion. I may be hindering them. But I also don't want them to have to learn from mistakes that involve failing classes and harming the trajectory of the next 5-10 years of their life because they have the whole of the internet at their fingertips without limits.  My goal is to make it a conversation and learning experience. 

Around we go

The Wiccan calender is all about new beginnings. Yeah, Samhain is the "new year" for most of us, but really the whole frickin' thing is about renewal and fresh starts. Now I have another New Year celebration - July 1st. Thus begins my second year of residency. Happy New Year. 

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I’m now 3 weeks into second year and I can report a couple of things: I like not being new at my job, surgery is fun, complicated pregnancies are complicated.

I’m on the benign gyn rotation during the week but second year involves lots of weekend call so I’m also spending time on L&D. I had an absolutely insane shift the first time I worked a solid 24 hours (we don’t do 24 hour shifts as interns, a hold over from some old duty hour restrictions that got lifted but our program kept them. I’m eternally grateful). The second 24 I worked was THIS weekend and it was a bit different, I worked my regular day shift job and then showed up on L&D to take report from the day team and work a second shift on L&D until morning. I managed to sneak in about a 40 minute power nap prior to my shift and the night was a steady stream of busy but not the insanity of over a dozen deliveries, half done by me, that last weekend brought us.

I have admitted a couple of people with some interesting problems to our Maternal Fetal Medicine unit on my weekends on L&D. It is interesting how much of a Black Box Warning pregnancy is for every other kind of medicine. If someone happens to have something else going on - Lung infection? Cellulitis? Broken bone? Odds are good that we will either be called to consult or be asked to admit a person to our service even though we have no idea how to manage the medical issue that brings her in! We had someone who was miscarrying recently and still the medicine docs would not recommend surgery for an unrelated and REALLY IMPORTANT problem she was having. Instead they opted for “conservative management” which involved NOT fixing the problem that they wanted to fix surgically before they realized she was pregnant. The consult note from my gyn-team colleague had very explicit ALL CAPS instructions about recommending “DO WHATEVER THE HELL YOU WOULD DO IF YOU DIDN’T KNOW SHE WAS PREGNANT!!)”

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Two small raccoons, one lying, still, on the side of the road. The other approaching carefully, tentatively forward from the tall grass. Nose to nose. Heartbreak in a flash of my headlights at 5am

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Laparoscopic surgery is a different kind of frustration. There are issues of dexterity and muscle memory with all surgery but this year I’m getting more exposure to laparoscopic surgery. It’s making me wish I’d played a LOT more video games in my youth! It is so frustrating to be looking at my tools on a screen, trying to grasp and maneuver, find the right angle.Trying to make the tools do what I need them to do, while remembering they are on a fulcrum, that levers move backwards (If I want the grasper to go up, I move my hand down). And on a 2 dimensional screen. And that is real tissue you are grasping, so don’t pull too hard, watch where the instruments are going, and please for the love of everything holy, do not require us to open because you perforated the bowel or tore open a blood vessel. Also, I’m trying to remember crucial details like the names of the different types of graspers and when you use them, a Maryland is different from a Prestige which is different from a Hunter Bowel (really, you have to know what to ask for. Often the scrub knows what I need before I ask for it, but sometimes s/he is wrong and I need to adjust my field of view. AND I need to remember the steps of the surgery - DON’T FORGET TO INJECT THE DILUTE VASOPRESSIN!!!!! WHY DO I ALWAYS FORGET THAT STEP?!?!?! Sigh, anyway, it’s July again and I love my job but I am going to be a LOT better at it in six months!

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I just had an amazing half day in clinic. As I think I mentioned, as a 2nd year a lot of your responsibilities increase. We have a lot more people on our clinic schedule and they can be more complex than return OB prenatal visits. This time, I had 8 patients on my schedule - and they all came!! That in and of itself is a little unusual for me. I usually have at least 1 no show to give me a little breathing room. Today I had 3 Spanish speaking patients, 3 return patients, a consult for PCOS, a woman needing a new contraception plan (one of the Spanish speakers), a woman with gestational diabetes who wanted a trial of labor after cesarean and didn’t have her sugars with her and didn’t know how she was supposed to be testing her sugars (also a Spanish speaker) and what turned out to be a VERY complicated IUD removal. I didn’t get a single note done before the end of seeing patients, but I got all the prescriptions done as I went, I had all the salient details either in the notes or in my head or written down someplace so I could write my notes afterward. My last patient had a 4pm appointment and I walked into her room at 4:22. That is running spectacularly on time in a resident clinic! Then I stayed after work and finished my charts before heading home. I’m getting good at this!

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I’m on vacation as of this afternoon.. I haven’t started packing yet. I need to be at work in 40 minutes and I’m still in bed. I will be driving to DC at some point today. I should probably get up!

Highs and lows, but mostly highs

I just had the best day ever!!!

It started with an interesting surgery, that I did not actually do but rather watched 2 community docs work together to do. It was interesting because of the problems of approach and there were some techniques that were used to accomplish the surgery that were the very definition of mastery. The problem was not one either had exactly seen before, the situation required flexible problem-solving, innovative application of familiar surgical techniques and a good bit of communication and collaboration. It was an interesting bit of medicine. And an interesting bit of people watching, to see a relatively recently graduated physician (it was his patient) work with one of his more experienced partners.

After the surgery, I found out that I PASSED my Step 3 exam! Last hurdle before I abandon general medicine and start focusing on Ob/Gyn stuff exclusively!! The stupid exam administrators send you an email, make you log into a rarely used account, download a score report and THEN open the report to find out whether or not you passed. Believe me, doing all that shit then seeing the word FAIL on your score report is heartbreaking. But no more!!!

Then I did a cool ED consultation for a patient who needed to be admitted. I got a lot of the workup right and learned a lot about managing this diagnosis. She’ll be my patient for the next few days.

In the afternoon, I got to do a cool in office procedure that we have done exclusively in the OR until very recently. It was a boatload of fun. Then I put in an IUD, and THEN I put in a Nexplanon. Birth control!!!!

Then I met the boy who is dog sitting for me and found out that he and his mother are lovely and are going to watch Bear for me while I’m on a 24 this weekend. I had dinner with my dear friend Christy from Portland who is here with her extended family on a vacation. She dragged them from Nashville for the week so that we could hang too! Efficiency!

Finally, my swipey app has born some interesting fruit and I’m enjoying some texts and planning some dates. This has been an all around amazing and fun day. Yay!!!!

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I think it is safe to say that I’m having a good week. I’m so fucking relieved not to be an intern anymore I can’t even tell you. I underestimated what a difference it would make to my coping, my mood and my performance. Being just a resident (well and a dog mom) is so much easier than being a singlemotherresident. I had aspirations of getting some home updates done but I find I’m not focusing on that as much after all. The time I’m not parenting, I’ve filled with other things. I’ve done some administrative and educational tasks, I’ve done a few things around the house, I’ve spent some time with friends & on dates. But honestly, I had a lot bigger to do list than what I’m accomplishing. Part of the issue is that I’m saving money for my vacation, part of it is that if I have time, I’m choosing to use it to relax or have fun. Errands and buying house fixer upper things is not as entertaining.

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I worked a 24 hour shift this weekend, something doesn’t happen in intern year in our program, but will happen a LOT this year, and continue but to a lesser extent for 3rd and 4the year. It is actually more than 24, I started at 6am on Saturday and left around 8:15am on Sunday. It was an absolutely insane night after a series of what were apparently record breaking days on L&D. I personally attended 6 deliveries, was primary surgeon on 2 cesareans, assisted another, and did 3 vaginal deliveries. I could have done a cesarean delivery of twins too if I hadn’t felt like I was losing my mind by that point. Plus the 2nd year answers the answering service pages and there was a fair amount of helping the intern figure out how to do her job. July is a nutty time. I am a bit intimidated by the 24 hour shift. I am worried it is going to kill me. That is only a little bit of hyperbole.

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Power napping seems to be a crucial element to managing my new weekend work schedule. I took a 20-30 minute nap the 2 days following my weekend and I was able to go to ballet class and take the dog to the vet and make dinner (well dinner happened on the not-ballet class night at least). I set my timer for 30 minutes and just let myself drift off. I don’t think I slept hard but it was very restorative!

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I’m only going to parent full time living with me children for another 3 years. One of my kids only has 2 years left on her lease. I can’t believe it is almost over! Thank goodness for the dog.

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Until recently I was struggling with temptation to suggest reconciliation to my ex-husband. To be clear, the idea is a product of a tiny minority portion of my mind. The rest of my mind is working on bringing her around, but she’s pretty stubborn in the notion that the only happiness in my future lies in the past. and is gone now. When I realized how such an action would be repeating self-defeating behaviors of the past, a lot of the wind was taken out of her sails and she’s been pretty quiet since for a few weeks.

But right now my co-parent is with the kids, staying with my parents at a property that we have in Northern California. A place my children will someday own. He’s helping clean up from a tragedy there and doing traditional fun things - swimming hole & soft serve - with the kids. So last night that tiny short sighted part of my brain did something only your brain can do. It delivered unto me a dream, full of visceral, physical sensations. Reminding me what good parts of a long marriage include. It wasn’t a sex dream. That I could handle. It was a dream of walking next to someone, hands gently intertwined, feeling their breath on your neck. The comfort, familiarity, intimacy were overwhelming. But it was a dream, the reality was starker. My body aches for something it hasn’t had from my ex in years. My stupid brain doesn’t care how long it’s been, it’s so sure we could have it again if only I would…

Even in the dream I managed to stop myself. I left the room, I tried to walk up stairs but they were covered with obstacles (tiny stupid part didn’t want me to leave I guess). I’m left this morning with the aching feeling of a missing touch. Grief is a circle.

(Has anyone noticed I have 2 terms for the same person? He is my ex-husband when we are talking about the relationship between us that is gone. He is my co-parent when we are talking about the relationship I still have with him. That’s deliberate)

Summer snippets

I wondered how I was going to manage with meals while the kids were away, cooking for one and for my own tastes & preferences is very different from cooking for myself & 2 teens. It’s been going pretty well. I think I may have mastered the pork chop! I made 2 the other night and it gave me 2 meals worth of main protein source. I’ve been eating a LOT of broccoli & cauliflower. I’m struggling with reducing my portion sizes (to reasonable sizes, not diminutive ones, fear not) so I’m trying to fill up on veggies and water if I find myself wanting bigger portions, carbs, seconds or dessert. I bought a Brita water pitcher, I think I have FINALLY tired of drinking only seltzer water. I need to get a new water bottle too, the handle of my current fave is broken. Also the charger for my computer finally kicked the bucket (it’s been frayed and precarious looking for a while) so I’ll need to get one of those soon. And I need a shop broom so I can sweep water out from under my carport where my fancy new outdoor seats are. It’s been rainy in the afternoons the last few days and it is pooling and cramping my style. This evening Bear and I sat outside together for a bit next to the big puddle, I didn’t make him go out in the rain again!

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I wrote about my chronic occasional health thing recently. I just realized that the likely source of my recent remission was my abstention from alcohol. I didn’t drink from January through April. In the last 2 months I have had more symptoms despite being okay during spring allergy season and while sleep deprived. I am going to start a new experiment. It’s not super complicated: I’m going to stop drinking again and see how I do. I’m pretty irritated but on balance I would much rather not drink than have the annoying and often debilitating symptoms I have to deal with. I’d be curious if the aforementioned provoking factors would still provoke symptoms if I’m not drinking at all. I look forward to this new era of discovery. 

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Today I started my second year of residency. It was mostly a fun day. Figuring out how much time I had to teach and how much time I had to do my own work was something of a task. And watching the new interns work gave me a little PTSD flashback and I had to remind myself that I never had to be at the bottom of that learning curve again. It was a little like the feeling I had during my second pregnancy when I viscerally remembered the experience of labor and was like “Oh SHIT” about having to do it again. Except this time it came with the happy reality that I DON’T have to do it again. Second year will be hard in a different way but it won’t be hard in the myriad of ways first year was hard. Learning to be a doctor, manage orders, notes, pages, locating places in the hospital, meeting my superiors (literally everyone on the care team) and managing expectations...breathe, breathe, breathe. Anyway, suffice it to say that it’s a new year and I’m pretty happy about that! 

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Today I went for a swim after work. It was perfection, floating on the cool water during a hot evening, staring up at the puffy clouds in the sky. I almost went to ballet but I decided against it. The class tonight is a 90 minute class. Not sure I’m up for 90 minutes of ballet just yet. Maybe next week! 

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I have gone to 3 ballet classes during my “summer vacation”. Last night I inspired 3 of my co-workers to go with me to that 90 minute beginner ballet class. It was a good class! Not too many jumps (which I have to sit out due to old injuries I’m not quite ready to poke) It is also closer to my house. I liked it a lot! And it was fun to go with friends. Ballet is hard but also something I feel competent at. It challenges me but is also meditative. 

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That person I was falling out of interest with ran out of patience for my schedule so they have been “archived” per their request. But now I’m back on one of those swipey dating apps and I’m surprised by how much choice I have in dating options. I’m quite limited by my own availability but otherwise I feel really good about my options. And I continue to be completely unapologetic about my availability or lack thereof.

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Until recently I have been overwhelmed by an urge to act in a way that is contrary to my best interests regarding my ex-husband. I know that these urges are part of the grief process and that I shouldn’t act on them. Last time I was bowled over by these desires, I also realized that if I were to cave into them, I’d be investing emotional labor into a relationship that already showed me that my emotional labor did not bear fruit. Something about that realization has helped free me from the fantasy of reconciliation. Also I’ve had a few opportunities to cry about the whole thing that have been very cathartic.

Fewer children, more blog posts

This evening I had a massive craving for chocolate. But I don’t have any in the house. The craving was strong enough that I drove to the grocery store with my mind’s eye specifically on a raspberry dark chocolate I am a fan of. I walked through the bakery, considered some dangerous things, turned the corner to the cookies & candy aisle (conveniently located together, right next door). I walked between the mint oreos and the chocolate bars (alas, no raspberry dark chocolate bars). I felt like I was playing with the tip of a knife on my skin. I walked out without buying anything. 

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Maybe it is a product of the individual, maybe it is a result of where I am in my relationship arc, but right now, I’m falling out of interest in someone I’ve been seeing. This is a perfectly nice person, and someone who is doing interesting things with their life. But if they were to spontaneously not exist on this Earth, the greatest loss for me would be the occasional opportunities to scratch an itch. While I have enjoyed time we’ve spent together, in no way do I crave their attention, time, conversation, company. I have no idea if I will at some point develop those feelings toward another person. I’m sitting with this emotional place and letting it be. I will date when it is fun, stop when it isn’t, and not make myself go out to dinner with someone when all I want is to make a pork chop and hang out with my dog. I have a huge hole in my heart & soul. This is not a hole that can be filled by pouring someone else into it. It has to heal by secondary intention. This is a slower path, it requires me to create MORE of myself to fill the hole. Why isn’t there a Spiritual WoundVac?!? I wonder what my emotional & relationship landscape will look like when I am healed. From where I stand right now, I can’t imagine loving someone else again. I can’t imagine craving someone’s presence in my life. I’m have faith that it may happen, because I have enough trust in the infinite capacity for healing for the human spirit. But I’m not there yet. 

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My dog has gone completely soft. It was lightly raining this evening and I took him out and he was like, NO I WILL NOT. Refused to walk, tried to go back under the carport. When I managed to get him around the side of the house, he went behind some bushes to a space under the neighbor’s walkway and sniffed around and peed UNDER COVER. He’s completely abandoned his PacNW roots. 

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A few times a year it becomes necessary to take a chunk of our residency team out of commission. We run skeleton crews and mostly throw the rotation schedule out the window. We call these weeks Freak Week. Some people find their existence stressful. Probably because they have more responsibility than I do. This week, our 4th years are graduated and getting ready for written boards which are the last week of June for all Ob/Gyn program grads. Our new interns are still in orientation. Yep, it’s Freak Week. I’m in clinic 2 days and on L&D for 4 (I’m working Sat but not Sun). Then next week starts our first rotation of the new year. I’ll be a second year on the benign GYN rotation. This week I’m an intern plus. Or a second year light. Everyone is anticipating the move up to the next rung in the ladder.

So, me too, I guess?

Big test starts tomorrow. I am ready. I have been performing adequately on the practice questions, I have worked out the kinks (mostly) for the simulator for the cases (that’s Thursday). I have the address and my testing permit printed out up on my desk. By this tie, much of the prep is pro forma, I know what to wear (layers, comfy), what to bring for lunch (turkey sandwich) & snacks (chocolate for a PM pick me up), how to spend the night before (a tiny bit of studying, mostly resting). In the past, I had an inkling that I wasn’t ready for exams but I took anyway. This was universally a mistake, bourne by my fear of admitting weakness or denial of the possibility of failure. So now I just reflect, do I feel ready? Does the objective data demonstrate that I am ready? Yes, I am nervous, but it’s going to be just fine. I look forward to being on the other side of this.

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Kids have been gone a week already! I am slowly chipping away at the list of things that I wanted to get done. And forgiving myself for not being nearly as driven as I imagined I was going to be. I’m getting things done, to be sure. But it turns out I’m not nearly as interested in working out in the morning as I am getting an extra 45 minutes of sleep! I’m eating more spinach and fewer carbs (it helps that I’ve eaten everything up not am buying more!). I predict this 8 weeks is going to fly by. It seemed like such an eternity before they left.

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Apropos of nothing, I have a story spinning around in my head that I recently thought about in a new way. A couple of years ago, I went to a beer festival at Tom McCall park on the Portland downtown waterfront. I was a PSU student at the time and had a bus pass and ended up taking a bus home from the event (this was the days before Uber came to town). If I walked over a bridge and caught a bus away from the event, it would be the bus that took me directly home. It was a frequent flyer so I didn’t worry about when the next bus was coming, I just finished my night and then headed up to the stop on the bridge.

There were 2 drunk guys up there. I think they were also waiting for a bus, maybe they were just fucking around. (You can already see where this is going, can’t you?) One in particular wanted to chat me up. My usual cold, terse responses were not effective in getting him to leave me alone. In fact, they riled up the classic “She owes me something because I complimented her body” responses. He was “just being friendly,” why didn’t I want to talk?!? While he was making me VERY uncomfortable, it wasn’t too late out, it was a well lit, high traffic area with cars and foot traffic. Because of the beer festival, lots of people were walking across the bridge to their parked cars in East Portland. He didn’t touch me. I wasn’t in physical danger. But it was one of the more unpleasant drunk asshole confrontations I’ve ever had.

I haven’t thought about this event very often, and in the rare occasions when I have thought about it, I haven’t thought much about what came next. On the bus, away from the drunks, another guy sat near me (the seat behind mine) and talked to me. He had been at the bus stop. He had been watching what happened. He wanted to commiserate about how inappropriate and drunk and aberrant those guys were. I’m sure he was trying to put me at ease, chatting me up in a friendly, non-threatening, not drunk way.

But lately I’ve been just as pissed off at that quiet, nerdy guy who didn’t speak up while I was being harrassed. Who used my discomfort after the fact to make himself separate from Those Kinds of Men. He was invisible to those guys (though not to me because I had been surveying the terrain and I saw him hovering on the other side of the bus shelter), and he didn’t say a damn thing to endanger his anonymity, his comfort or his safety while I was being involuntarily drunk dialed while waiting for a bus. The more I think about this guy, the more pissed off I become.

Feminism has reached the end of what it can accomplish in the changing of women’s lives. Now if we want our lives to be better, men need to step the fuck up and change things on their side of the court. I’m not here for your entertainment, for your viewing pleasure. And I’m NOT here to make you feel better than the guys who think that I am. Unless you are actively and loudly rejecting that behavior in public and private, you are just as much of a problem, as far as I’m concerned. Time for the men to clean their house. We’ve done what we can to change ourselves. Your turn.

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I have this little health problem that bothers me very rarely. I take a daily medication to manage it (well, the allergy meds are a crucial part too though for a separate issue) and beyond that, there’s very little I can do. I will either have symptoms or I won’t. There are a few provoking factors but few palliating ones. Once it starts to bother me, I just have to ride it out. If I have to beg out of things, I usually claim a headache. It’s easier than explaining. I mention it because I’m bothered by it today, because of an unavoidable obligations that was a provoking factor. Now I’m begging off some social fun because it will be loud (which will makes things worse) and my head hurts. I’m trying to be zen with the reality of my limitations but it’s hard.

Have I used "This Too Shall Pass" as a blog title before? It probably won't be the last time...

This weekend made me feel really good about my kids being settled in Asheville. Duncan is hosting a series of friends at the pool in our complex, he’s got a core group and they have friends who come too. Only 3 or 4 friends at a time to comply with the HOA policy and they are doing a great job following the rules and being good neighbors while there. On Saturday Ainsley went to Queer Prom, sponsored by a local LGBTQ youth organization. But before that she had a friend come over and help her dye her hair blue. And then this evening she went to an outdoor performance of Midsummer Night’s Dream with some friends (where other friends were performing).

Also I learned where a bigger Target is, and there’s a Big Lots and World Market right next door. So Ainsley got a new Pride tank top (Target has Pride wear and they get so much of our business because of it!) and I found a relatively inexpensive set of outdoor furniture that we put under the carport - 2 chairs, a loveseat and a table. And a nifty outdoor rug/mat as well. All it’s lacking is a citronella candle! I had a portion of my state tax refund that I wanted to use to get some outdoor furniture. I always think of my friend Shannon chastising me for giving the government an interest free loan (that’s what tax refunds are, apparently) but given the tight margins of my life, I wasn’t going to save on my own so instead I’ll just thank them for the service and appreciate my new outdoor space!

Of course, the kids are leaving a week from tomorrow, they’ll be gone for 8 weeks. Just as they are getting really settled in! But the pool with still be here, the outdoor community theatre will still be here, they will come back and maybe plug back into their lives pretty much where they are leaving off right now. That’s my hope, at least. We’ll see. It won’t be as hard as last year!

I got a haircut! I heard about this salon and this gal from a few people, it was very reasonably priced and she cut curly hair very well. It’s funny because I didn’t get a lot of length taken off but when I got up there were PILES of hair at my feet! I have soooo much hair! But now now, now I have a reasonable amount of hair. It’s been about 14 months since I got a haircut but this place is inexpensive, really good, and you can make appointments online so I’m optimistic that I’ll be able to be better groomed despite my busy schedule!

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This is the kids’ last weekend in NC for a couple of months, mostly they are enjoying being done with school while packing and cleaning at a snail’s pace. I’m distracted by studying for Step 3 so they’ve got some slack to work at their own paces. Their rooms & public spaces are slowly getting clean, laundry is getting done and packing prep is starting to happen.

Unfortunately blogging about parenting a teen means there are parts of the story I can’t tell because they aren’t mine to share. I’m having a bit of one of those times with one of my kids right now. It is something of a big deal but a lot of it will be taken care of by the temporary displacement they are about to experience. I have had more conversations with my co-parent in the last week than probably the last 6 months combined. He was a bit taken aback by the news of teen drama and the notion that that they were going to be out there “just for a visit” was shattered mercilessly. I mean clearly he knew that the honeymoon phase would not last 8 weeks, that there will be snark, PMS, hangriness (dear lord, this family is full of people who are terrible about self-regulating our blood sugars!), irrationality, health problems and moodiness. But knowing that there was a pretty big issue he was inheriting right off the plane, that was harsh. He took it well. I still have to tell him that we had lice and he will need to do head checks next week. I should get on that… :-)

I’m grateful that my troubled child is going to get some time with Dad and that the impetus of the end of the school year stress and the imminent departure was able to unroof some poor coping and existential pain. Admitting you have a problem is the first step right? So we’re on to step 2 now. Fortunately for this particular flavor of problem, co-captain and I are firmly aligned. The messaging will be united and the East coast/West coast plans for addressing the issues will dovetail nicely with each other.

I’m looking forward to having a break. I will miss my kids like gangbusters, but I am also pretty excited to go on dates, clean my house, get some residency shit done, study and get started on my new life as a Second Year Ob/Gyn Resident without the omnipresent distraction of daily parenting.

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One of the things that is harder about blogging honestly like I was in the beginning is that I feel less anonymous. I know there are people reading this, including people who I work with. I have been hesitating about pushing into this latest soft spot and digging around because I don’t want people at work to think I’m pathetic, that I’m not handling my life as well as I want them to think I am. I don’t want pity, but I want a place to speak truth to my hardship. So don’t pity me, I’m just more honest about the hard parts of life than most people. We’ve all got ‘em. Here’s some of mine.

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Today I’m remembering what it feels like to be relocated for a year. I remember that I felt like I should be more settled than I am. I remember thinking that I didn’t have the friends, networks and connections I wished I had. I remember thinking I’d feel more settled than I do now. I remember that eventually I realized it really takes a few years (in Portland I settled in 3, it took 3 years to get settled in Portland), more than I wanted it to take.

So today I’m sad that I don’t have friends, I don’t have people to spend time with when I’m not working or parenting. I’m tired of having to do the work to make friends. The constant putting yourself out there, asking people if they are available and for some reason or another not connecting. And working not to take it personally. I’m lonely. Maybe my co-residents don’t invite me to socialize with them because they think I don’t want to. Maybe they don’t want me to. Maybe I really don’t want to. Who knows. But they don’t ask. At least I don’t think they do. Maybe they did in the early months when I was overwhelmed and couldn’t leave lonely kids to have my own life while they were isolated and sad. Maybe I missed it and now it’s too late. There are a few people who aren’t residents who I have connected with, but they all have full lives that were going strong before I got here. Trying to merge into their flow often means they are not available when I am and when they are available, maybe the are making plans with the people already in their lives, but whatever they are doing, they aren’t connecting with me.

It takes longer than a year, that’s what I’m remembering. And that’s okay. It doesn’t mean it isn’t going to happen. It just means it hasn’t happened yet.

This too shall pass.

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Like I said a few days ago, I’ve been talking with T (that’s my co-parent) more this week than I have in a while. We’re talking a lot about the kids but there have been personal conversations as well. I really missed the easy communication between us. Now that we are not as wrapped up in how much the other has disappointed us or not met our needs, we are able to talk more like the old friends we are. When you’ve known someone 25 years, there’s an ease to talking. And some predictability too. He’s working a lot. Which means he’s skipping meals and being hyper-focused on work. Which doesn’t bother me the way his poor self-care when he’s busy used to. Why did it bother me so much? Because it scared me, if he wasn’t going to take care of himself, then maybe he’d die, or at least not live as long as he could. There was an aspect of my control and co-dependency that was triggered by something as little as him skipping lunch. If he didn’t do it, it was one more thing that I had to do. Did he ask me to do it? No! In fact, we probably would have been better served if I had not taken psychological ownership of things that were clearly his to take care of. Now he tells me he skips lunch and I find that reaction has been deactivated. It isn’t that I don’t care about him, or that I no longer want him to live as long as possible, but that wasn’t ever really a rational fear. We were too closely intertwined. It held us both back. Together we became better versions of ourselves than we probably could have alone when we were in our 20s and 30s. Now in our 40s we are becoming better versions of ourselves than we could while we were together. Not going to lie, watching him become better fills me with pride and deep sadness. It makes me miss those great decades when we were able to grow ourselves together. I’m never not going to be sad that we had to part for each of us to be our best selves. The rough edges to the sadness are slowly smoothing over time. Every so slightly, it isn’t as hard to be sad now as it was 6 months ago.

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Something great is happening at work: I’m getting good at my job! I did a repeat cesarean recently at which I got only positive feedback. Even with regard to one part of the surgery that I’m still working on. I’m doing everything right, the muscle-mind connection just hasn’t clicked yet. (Getting the baby’s head out the uterine incision is a specific combination of wrist movements, flexing the baby’s head, being a lever and a shoehorn that I understand in theory but just can’t quite put together unless everything is perfectly aligned) On the theme of anniversary reflections, I remember what it was like to do a cesarean last year, I had the stamina to do about the first half of the surgery, then when I had revealed the uterus, I was HAPPY to pass off the scalpel and have someone else finish. It taxed the limit of my stamina and concentration to get that far. Now I can do the whole thing, ask for the instruments, even figure out which suture we are using and how many knots it needs (except PDS, I still can’t tell PDS from monocryl, but I do know it needs more knots!).

And during that same shift, I cut my first episiotomy. This tiny infamous procedure looms large in the psyche of women. In this case, it was a very necessary intervention due to specific details relevant to that patient. And even though I’ve never done one, I realized it was going to be necessary, mentioned it to my attending, who listened to my whispered diagnosis and did her own assessment and agreed with my recommendation. My only reflection is that we did not have time to talk it through more with the patient. That place where babies are on the brink of being born is a tenuous one, it is hard to monitor their heart rates, they often experience the most stress we see and we often have to act quickly to get babies out. Given the totality of the details of that case, the episiotomy was a small matter. In reality (it was only about a centimeter long) and symbolically (there were other things that happened that mattered more to her during delivery). But it was a big deal for me to be able to see something I’d never seen before and successfully evaluate and address it!

Catharsis

I haven’t written much the last few months. In part because I’ve been busy but also because I’ve had this huge 800 lb gorilla standing in front of my view, blocking the flow of any simple, smaller vignettes that might want to come trickling out. And until I get rid of the gorilla (don’t worry, I’m only going to write her away), I’m stuck. So here she is…

I hate the health care system.

This may not sound shocking and it may not sound debilitating but it is tripping me up. I am a “work within the system” sort of woman but right now I'm having a hard time seeing my path. I want to go "Hulk smash!" on the whole damn thing. Which isn't productive for a number of reasons. 

The thing is, I don't feel disillusioned about choosing to revolt from within. I have few illusions about the difficulties that entails. I’m not romanticizing how much of a difference I can make or how much I can even change said system. But the realities of the role of physician as cog in the wheel are pretty fucking demoralizing. In time, I will arrive at a place where I have power and influence (to a limited extent) within the system. Until then, I’m at the bottom of the pile (can’t say bottom of the totem pole anymore, even in hyperbole, since I learned that’s where the important folk go). And the bottom of the pile is a shitty place to be.

During my brief 2 year stint as a public school teacher, we had some union troubles. Just short of striking, we adopted a “work to rule” position for some time. We came to work, we did our jobs, but only what was required by our contracts. The point, I suppose, was to show the powers that be just how much they were already getting out of us.

If physicians were to “work to rule” the entire health care system would grind to a shocking halt. The things that are required of us, they are not actually possible for a human to accomplish.

There’s this thing called the Hidden Curriculum of medicine. People have varying opinions about what exactly this curriculum teaches us but it is the implied undercurrent messages that we absorb as we progress through our training & careers. The problem with a Hidden Curriculum is that there’s no telling what people will learn from it. The lessons aren’t explicit and a great deal of one’s own personal baggage informs one’s lessons from the Hidden Curriculum. Handling criticism, giving feedback, working in teams, managing colleagues and underlings, these things are not taught in medicine but they are key, KEY parts of your work as a resident. If you internalized self-loathing (not hard to do) from the Hidden Curriculum, then you are going to be a crappy manager and mentor. But there isn’t a lot of room (like, any) in the Hidden Curriculum for self-examination, self-reflection, self-awareness. We aren’t encouraged by the system to reflect, just push on through and Do. The. Job.

(Parenthetically reminding everyone that I work at a fantastic residency program where these sorts of things are things we can address, we talk about respect and teamwork and we have opportunities built into our curriculum to reflect with our class and plan as a cohort for the next year. I never violate duty hours, we have great administrators. And I’m doing okay, this isn’t a desperate plea for help or a cry of despair. This is observation, reflection because I’m incapable of NOT navelgazing, this is me coping with the reality of the broader system I am becoming a part of. I’m just writing away the 800 lb gorilla that is blocking my Qi)

My plan will allow me, ideally, to live apart from this hierarchy someday. I’m going to open a community based clinic, it is going to have family medicine services, Ob/Gyn services, birth & abortion care, trans care, it is going to have a community board that helps us run it. It is going to be constructed specifically to deconstruct colonialist, patriarchal, capitalist power structures that oppress, oh, just about EVERYONE. I’ll get there. I’ll have my ideal clinic someday. Because I have a plan, I will have the skills, the connections, the capacity, the social capital and the power to create this sort of existence. I’m really looking forward to it. But to get there I’ve got to get through several years of learning from, working within and tapping into the current resources available for my training (and a few years after that to get financially stable after hundreds of thousands I had to borrow to get here at all). These all require me to work in a system I HATE. Most of the time I’m totally okay with that. Fight the power. From within. Change the system. From within. Often I forget that to do that, you have to KNOW the system. You have to be able to function within the system first. I can do that.

Bye-bye Gorilla.

Some stuff about work

On Fridays we have a procedure clinic where women who have had abnormal pap smears come for next level cervical biopsies called colposcopies. This clinic is busy with lots of patients and often lots of residents. It is an anticipated clinic as well as it is considered a straightforward office visit (we aren’t addressing ANYTHING else usually) and the documentation is easy to get done as you go. Unfortunately for me, I’ve had a bad run of luck in colpo clinic - difficult cervixes: to find or to biopsy. I am NOT superstitious about my work flow (I generally don’t believe the notion of a person being a “black cloud” or a “white cloud” and I’m not afraid to say that a service is looking QUIET for fear that the heavens will open on our heads) but I feel like I’ve been cursed in colpo clinic this year. The interns do colpos during 2 of our 4 rotations so we spend half of the year doing colpos on Fridays. After tiring of always having such a hard time, I have been collecting advice from upper levels and troubleshooting my technique with people. Today for the FIRST time, colpo clinic didn’t suck in its entirety. Of course I’ve had a few easy biopsies, but not even enough to count on one hand. Today I took bigger samples, I squeezed instead of pulled, I turned the Tischler (the tool that takes the biopsies) so it was oriented a particular way relative to the lesion I was biopsying. And I finally get it why people like colpo clinic! Part of my issue is that I can’t believe we are taking tic tac sized chunks out of people’s bodies without any anesthesia. Part of my issue was a steady stream of rubbery cervixes. And honestly my technique was faulty. I can do a stat cesarean section but until today, I couldn’t do a colpo with any sense of confidence. Huzzah! Intern year must finally be almost over, I’m finally getting the hang of it!

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My kids are almost done with the school year. We have 2.5 more weeks until they are done! A few days after that they are going to SF to stay with their dad for about 8 weeks. That is longer than our agreement lays out but they wanted to spend a lot of time with him, he could manage it and I didn’t want to refuse any of them the opportunity to be together. I’m pretty upset about the idea of them being gone for 8 weeks, I’m going to miss them so much! And because the human mind is a vast and infinite place, I’m also really looking forward to having the break. I don’t get weekends off, we don’t share parenting time, it’s all Larissa all the time. It is fucking exhausting. I don’t know exactly how I’m going to handle it (though I’ve got the dog walking figured out) but I think 8 weeks is enough time for me to be at loose ends for a little bit and then get into a routine on my own.

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Did I tell you I did a stat c-section recently? A stat is a circumstance where, likely, the baby is not looking great and needs to get born quickly. There are a few things with regard to the prep and the equipment that are different (so we can be ready faster). The surgery is basically the same except you worry less about going through the tissue from skin to uterus carefully and do it quickly then if there are problems, you fix them after the baby is born. And you don’t get to use the nifty tube retractor (it’s called an Alexis retractor and I love it) because it takes too long to set up. We still have time to administer anesthesia, scrub our hands & prep the patient, then we get down to a baby as fast as we can and hand him over to the awaiting NICU team. 11 months ago when I started doing surgery, I could handle about half a cesarean before the adrenaline would fade and I’d wilt. Looks like I’ve learned some things this year after all.

Regarding delivering the baby during a cesarean:

In that stat section, I did everything in the delivery as the primary surgeon except delivering the baby. I probably could have done it but it is a task that takes attention to detail, awareness of passage of time, physical effort and finesse. I started to try but after 10-15 seconds decided to let my upper level do it. There are a lot more things to think about than just sticking your hand in a uterus and lifting a baby out. We make the smallest incision possible (there’s only so much room between the Uterine arteries) and babies can wedge themselves in there in a myriad of different ways and it is pretty important that we flex the head in a way that makes it possible to lift.

On the latest cesarean I did, I explicitly told my upper level I was going to work on delivering the baby until he took it away from me. Having that explicitly stated gave me the freedom not to worry that I was taking too long. I knew he’d take over if it was time. Turns out, I was able to do it. Practice practice practice!

Almost none of this is work stuff, even the work stuff

Sometimes I look at ADHD life hacks and realize how many of these things I have already crafted into my life. Just watched one that suggested:

• Wear a work uniform: for me, when it isn't scrubs, it's black pants, a shell and a cardigan, I love the ease and reliability of it!
• Eating the same thing every day: Right now there are 5 Ball jars of yogurt & 5 sandwich bags of granola in my kitchen!, 
• Apparently hitting snooze causes decision fatigue and makes ADHD brains tired. I don't hit snooze anymore though I do have my AM blue light which helps me with the sleep-to-awake transition. In my experience, changes in body/mind states are hard on ADHD folks, and I struggled with the snooze button every morning when I was a teen and in my 20s, my daughter struggles with it now,
• To reduce strain of thinking of meals, have themed dinner nights (like "leftover mondays" and "mexican tuesdays"): that isn't quite what I do, but I do make sure I have the stuff for a week’s worth of meals and I post the things we can eat on the fridge, then I just have to decide any given night which of those things I feel like making. I often have frozen pizza, wontons, tamales, etc. that I can make instead if I decide the things on the list are too labor intensive for my energy level,
• They had things to say about grocery shopping, keeping a list and all that. I use an app called Picniic that has a number of family coordination tools. My kids are not as enthusiastic about them as I am but I paid for the upgrade so we could all share shopping & to do lists, calendars and other features that I’m still working on maximizing. 
• I also have a bowl where I keep my keys, right by the front door, no thought involved, keys go in the key bowl. End of story. 

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Working with a private doc in the community today and I saw that he has his own order set in the computer. Got me thinking about my orders and how I customize them and what I’d do it I were writing my own order sets. Some of the things are really technical and not interesting except to other people who need to write orders. But one of the tangents my mind explored was the communication between L&D nurses and doctors, what needs clearance to order and what gets done and then told to me later. I’m thinking of epidurals. It is really common for a patient to get an epidural and then I’m told about it afterward. I wonder if I would like to know this beforehand when I’m in private practice - managing patients who I know, with whom I have a relationship and have had a chance to do some prenatal education. I’m super supportive of people getting epidurals. I just think we don’t do a good enough job talking about how they change labor. I want to do a better job as a doctor and as a patient advocate. I know I’m not a doula anymore and I won’t usually be able to help manage the moment to moment, contraction by contraction experience of labor. I just want to be sure my patients are clear about what they want, what they get and how decisions influence the unfolding of events. 

Clearly this is not a fully formed thought, but it is where my mind went this morning.

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I’m back in a missing being married phase of mourning. It is tough, and I’m feeling the loss of something that I had for a long time- a partner, a helpmeet, a friend. Someone to roll their eyes at our kids being obnoxious teens with. Part of my pain is due to my own healing, I’m dating, it’s going well, but it is still dating. Getting to know people, deciding when I feel like spending time with or communicating with a near stranger. Also this is an anniversary time, of graduation, of moving arrangements, it was all so fresh and raw and painful last year, and I remember that. I miss what I wanted to have here. And some of my reaction is due to things happening in my coparents life - decisions he’s making and that make me think “if only” and why did he have to decide to do these things now and not 2 years ago, when there was still time. Why? If my study of the human body has taught me anything, asking why humans do anything is a question destined for dissatisfaction. Whether it is inquiring why a body develops autoimmune responses or why blood vessels clog or why the mind thinks anything at all, who knows why? No one knows and asking is just inviting frustration.

But why? Why can’t I have a life, the life I wanted. Why? I am a cope-er, and a survivor and even at times a thriver, so I’m going to be just fine. I’m going to fix things and I’ll be okay. But I can’t stop asking why.

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Regard something you know about yourself that you just know. You don’t think about it, in fact, it is just there. Your toenails grow, you have all your fingers and toes, knees bend, ears on each side of the head. Something like that. Something that is bedrock to your existence to the point that you don’t think about it.

Here’s what I know: my body is disgusting. It just is. I know this with a fundamental certainty that you take for granted regarding your toes. Sometimes I have feelings about it, sometimes I manage not to think about it, sometimes I even put lipstick on the pig and feel pretty satisfied with myself. I mean nothing in the world is all bad, so my body grew and fed people, has been fit and active, and while it is relatively deconditioned right now it has been capable in the past for sure and I’m sure will be again someday.

Let me be clear: I’m not saying this to garner pity or attention, or to get you tell me your opinion of my opinion or worse, your opinion of my body. I’m not saying this to GET anything. I’m saying it because I’ve only recently realized that this bedrock assumption exists and is different from how other people view their bodies. I spent a few days kind of rocked back by the insurmountable reality of it. I have deeply internalized that while I may be more disgusted with my body right now than I have been at times past, there really is no point in the game when I get to be happy with it, only varying degrees of displeased.

In a way, this is a victory. In the past I have set bars for myself, if I were to fit into those clothes, do these exercises, weigh this many pounds, THEN I would be okay. But now, I realize, that was a finish line I was never going to cross. There is no moment in time where I say that I have arrived, I have achieved the body that makes me happy, makes me feel satisfied. I can stop trying to come up with the perfect set of circumstances under which I will be satisfied. Sure I am disgusted, but I’m also free.

On vacation

I’m on vacation right now. Sitting in my dear friends’ home looking out the window at a sunny day getting ready to go to the beach with my kids. Except it is 8:30 and they are still sleeping! Maybe I’ll go for a bike ride first then wake them up at an hour decent for teenagers.

Yeah, I pulled my kids from school and lied about it. I don’t feel even a little bad. I was vague and the secretary at school filled in blanks to mean “something along the lines of an ailing grandparent” and I did not dissuade him. I said it was a “planned, medical, necessary absence.” Because mental health is you know, medical, and the stress of our lives and the difficulty we have forging connections with things like regular meals and family time is real. My kids and I need to bond, we need to relax. We are going to the beach. We will get ice cream, we will play mini-golf, we are going to do an Escape Room. We got assignments from teachers before we left and they know they are going to spend some time doing homework. But this week is going to be a little break from reality.

Since you heard from me last, I had my Gyn Oncology rotation and an OB rotation. Now I’m on a Benign Gyn rotation. This rotation has me in clinic about half the time and I really like it. I miss being in clinic. I like seeing patients. Onc and OB are tough rotations for different reasons and it was hard to have them back to back. Next year is going to be hard for lots of reasons but one of the nice things about the schedule is that it rotates reliably between OB and outpatient or benign gyn (no Onc for 2nd years, mercifully). We’re switching (back) to 6 week rotations (apparently the 4 week thing was an experiment that didn’t work out) so I’ll have 3 weeks of night, 3 weeks of OB days then 6 weeks of either OP or GYN.

I’m talking about next year’s schedule to avoid processing this year. First step is to see the hole. Maybe next time I write I’ll shine my light down in it. But for now, vacation time.

Admissions

I’m halfway through my Gyn Oncology rotation, which explains why I haven’t been writing. Like many other things in the second half of the year, it is not as hard as it was last time around. It is a lot of work, early days, sick patients, daylong sessions of time in the OR, but it isn’t as intimidating as it was last time. I’m MUCH better at presenting patients, which I kind of sucked at last time. And I’m faster enough with the process of seeing patients in the morning that I can come in a little bit later than 5am unless our service is expansive. Unfortunately we had a record-breaking increase in our census at the beginning of this week - 5 admissions in one day and NONE of them from the OR.

There are a few different ways you can become a patient in the hospital. One is to come in for surgery and stay for recovery. The length of your stay will depend on the complexity of your surgery, how sick you were beforehand, what they found when they surgerized you and how your body recovers from the process. If we went into your abdomen, chances are your bowels will stop working for a time and we will have to wait for them to wake up again. If it takes a long time, then you have something called an ileus. If this is all you have, and not a bowel obstruction, then the only thing to do is keep you NPO (nothing by mouth) and give you IV fluids and wait. We had someone recently who took 8 days for her bowels to wake up. We’ve also had people who take 2 days for the same result. There’s really no telling which it is going to be.

Another way is to come in through the ED. If you are a cancer patient, are undergoing chemotherapy, have some sort of complication related to your cancer or are showing signs of recurrence, then you are likely to end up on our service. We see women who have anemia, thrombocytopenia and pancytopenia, who have partial bowel obstructions, who have new metastases, failure to thrive, wound infections and a myriad of other complications. There’s a pretty low threshold to admit a cancer patient who comes in through the ED.

If you are a patient of our oncology attendings, you might live very far away from Asheville. So instead of coming to our ED, you might go to your local hospital, which will either transfer you directly from their ED or admit you for a few days and try to tune you up before they decide to transfer you to us. Direct transfer from an outside hospital (OSH in our lingo) is another way to get to our service. This can be a little confusing because your OSH may not share electronic health records with us so getting the details of your stay there has to wait until you show up with the paper records and a CD of imaging for the radiology department to upload. Then you may be very sick or you may not need much. But likely we at least know you from a previous admission or surgery so we have some sense of who you are. There are times that we get new patients through an OSH who have a diagnosis of a new complex pelvic mass (pretty clear sign of a Gyn oncologist appropriate surgery if not actually cancer) then we don’t know anything about you. It is kind of a mystery.

Between 3:30 and 5 in the afternoon, I might get a page from the staff at the Gyn oncology outpatient office telling me they are direct admitting a patient (if it happens earlier in the day, they usually go directly through the attending who is there that day and they end up telling us about it before the page comes through). Often we get patients who are having complications from chemo this way. They go into the office for an outpatient check up a week or so after a chemo treatment and are found to be intractably nauseated or frighteningly anemic or in a lot of pain. Often chemo makes things worse before it makes them better and that can be hard for someone who wasn’t very healthy or who’s cancer was quite advanced on the outset.

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I’m doing pretty well with my sweet-free dietary changes. I continue to be able to stay away from bags of chocolates passed around during didactics, the desserts in the cafeteria, the many, many options at the grocery store and even the ice cream in our freezer. I’ve also started doing a 30 minute yoga workout I have on DVD twice a week. I had aspired to 3 times a week, and a 10 minute ab workout at the same time, but I have decided to move the finish line and call this a victory! I am doing the abs about once a week and even with working overnight this weekend I did the yoga as well. By doing the same workout over time, I can measure my progress. It is starting to get easier! I’m in my 8th week of the diet changes and my 3rd week of adding exercise. Taking a long view is easier now than it was a few weeks ago, when I felt like I needed to add rules or changes to what I was doing. Now I’m at peace with the idea of these two small, lasting changes being something I can stick to. Maybe in May or June (at 4 or 5 months) I will consider adding one more small change - maybe an addition instead of a subtraction. Maybe adding a trip to the salad bar at work or something. We’ll see. For now, I’m content with the idea that I’m making lasting habit changes without spiraling into disordered eating.

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It’s really lonely to be in a bad marriage. My friends & family in the know couldn’t really help. Most of my local friends didn’t know how bad things were. I had too many “we” friends. Now all the friends are MINE (mwahahaha!) and I can be however I want with them. I’m still lonely but now it’s more like the quiet solitude of a rare weekend afternoon alone. Before it was like being alone in a crowd, screaming but no one noticed. This is another area of my life where I’m exerting patience. I am making friends, bonds are building, but it takes time. I will have a full and vibrant social network here in town before too long. Hopefully long before it is time for me to leave!

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I had a great conversation with 2 co-workers today that helped us get to know each other and I hope, will help me relax a bit around them. I was telling stories about myself and realized that I have been reconnecting with parts of me that have been long dormant - like the little girl who cold called the neighbors to see if there were any other girls to play with when we moved to a new house when I was 5. She’s the same kid who struck up conversation with two strangers who came to take free moving boxes off my hands this summer. “I feel like we should be friends” were actual words that came out of my mouth. And now we are. Wow.

While we were talking (my co-workers, not the Craigslist friends, I recounted the 4 (at least) friends I have made in town. They are all busy people and we don’t hang much but they are great and I’m happy to have them in my life. Al & Rebecca - of the random Craigslist meet cute, Bridget - a friend of a friend who proves that awesome people know awesome people, and Raven - who is as busy as I am but throw regular international travel into the mix, so we don’t see each other often. And maybe a couple of others brewing: Sam, who I met randomly on a neighborhood walk, who recently moved to town and used to be a photographer with National Geographic. and Byron: a local pagan leader/author. We know a lot of the same people in the broader community but haven’t managed to connect socially outside of ritual space yet.

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There are a lot of people who changed me for the better and made me feel good about myself because of their contribution to my life. I’ve been thinking about two of those people recently and felt they deserved a “shout out” even if I can’t find a way to get the word to them myself. Maybe the universe will hear and it will echo back to them somehow.

• Mrs. Majeski: My 3rd grade teacher, she tried to motivate me with carrots, and I think that was the first time in my life someone tried something other than a (figurative) stick. She noticed me. Granted, it was usually for not being able to do my work or having a frighteningly messy desk, but her efforts were kind and stick with me to this day. I remember my report on Jane Addams and Mrs. Majeski incentivizing my performance in school with a special prize: lunch with the teacher. Again, carrots. 
• Ms. Hayden: My freshman year drill team coach. I know that we aren’t supposed to tell women & girls to smile, and that was Ms. Hayden’s primary message to me my freshman year of high school when I was on her JV drill team, but again, she seemed like the first person to notice that I was quite miserable as I was moving through the world (also, as it happens, I have quite a resting bitch face and had no idea how it was affecting my social interactions but that is another issue). Ms. Hayden seemed to care that I was unhappy, she was nice to me.

I’ve actually tried to find these women out there in the world, but my google-fu is weak and I couldn’t afford the PI I approached. Maybe someday I’ll be able to tell them that even though they were only in my life for one year, they made a difference in my life. Until then, telling you will have to suffice.

Whatever the opposite of a “shout out” is, here’s one of those:

• My sophomore geometry teacher who’s name has been deemed unworthy of memory by my mind: He was a jock, he was a dick, he thought it was really funny to call me “Larry” (short for Larissa, like Lari, get it?). And he was a great demonstration of the kind of grown up I did NOT want to be. I was an awkward, socially anxious self conscious 14 year old. The attention I got from him made me dread math class. Like I needed another reason to dread math class.