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.

Hitting my stride

I just had a calm conversation with my co-parent, conveying a message from one of our kids that signals what’s likely a lasting fracture in their relationship. I was asked by said kid to convey things that they didn’t feel safe or comfortable communicating directly but that they wanted known. It was a hard conversation and I believe I handled it well. But it is sad and unsatisfying. I want him to be closer with his kids and I want them to be able to connect. I worry that he’s losing them at a crucial time in their development. I never imagined that he would arrange his life in a way that keeps him so far away from his kids. It is an unimaginable choice to me and I keep hoping he’ll change his mind.

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You know the worst thing about bathrooms? The bright lights in your face as you are trying to get ready for bed. You’re all sleepy and ready to snooze but, being the responsible human you are, you go to brush your teeth and wash your face first. BAM! Bright lights, multiplied by their reflection, in your face as you complete your nighttime ablutions. I have fixed this terrible problem in my bathroom by stringing some LEDs on the top of my shower (no tub in my bathroom). The lights are battery powered and the pack is secured in the top of my bathroom mirror cabinet. They are bright enough to shower and brush my teeth and mellow enough to encourage sleepiness. Not that I need much encouragement! As a kid I took ballet lessons several evenings a week and got in the habit of showering at night. I like not having to get up any extra minutes early too, now that I’m back on Gyn Onc and my day starts at 5am.

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I may be the last person in America to do so but I downloaded Candy Crush onto my phone a couple of weeks ago. While I like the Match 3 games, this one is a bit of a racket. They have so many in app purchases and features. It is really hard to progress in the game without them. At level 98, I may have reached the end of my Candy Crush experience. There’s these bombs that go off if you don’t match them away and they keep exploding less than half way through the level. I am down to trying the level once or twice a day and if I don’t get through, I just quit and play one of my other off-brand free phone games that don’t try to squeeze me.

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There’s a significant amount of muscle memory involved in mastering the surgery basics that I’m working on as an intern. The pressure you apply to a scalpel to cut through the layers of the skin appropriately, given the location, size and shape of the incision, the tissue underneath, the goal of the incision, the age of the patient and the condition of her skin. Today I was able to get through skin and into subcutaneous fat in one stroke. It has taken me 7 months to get that just right. It isn’t hard to stab through skin, but it is hard to smoothly, consistently apply pressure to skin so that it is separated evenly. And I can do that!

Also there’s a wrist action that you do when suturing and a way to hold a needle driver that maximizes fine motor control (hint: it doesn’t involve your fingers or thumb being in any of the finger holes). Today I felt that wrist action consistently. Not every time, but many times. Perhaps even most. I did 5 surgeries today. And I did more than half in each surgery (except lymph node dissection, I don’t do that part yet. Cancer surveillance is pretty important).

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I have several friends whose main job in our relationship for the last several years was to allow me space to vent and process about my partner. Okay, maybe not their main job, but it certainly felt like what I did in most of our conversations. Because brains are kind of stupid about changing their ways, my brain has continued to try to bitch to these friends about things. Get one of them on the phone and my brain wants to give them an update on the latest stupid thing my co-parent has done, tell them about my frustrations and disappointments and generally dominate my half of the conversation with talk of someone I haven’t seen in months or spoken to in weeks. Bad brain! No donut! I’m making a deliberate effort to talk about other things in my life with these friends. Now we talk about my dog, the weather, how awesome my job is, how effed up the health care/education/political/just about any system is in the US, how awesome my kids are, my vacation plans, parenting, or just about anything else. My conversations are light hearted and funny, poignant and personal, filled with talking and listening, generally amazing interactions.

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Today my daughter said “maybe North Carolina isn’t so bad afterall.” And that it was beautiful here, she can feel it in the wind.

Snippets

My parents are in town this weekend. There’s a tennis tournament here and my mom got tickets for my step-mom for her birthday. Venus & Serena are in town! The tournament was 2 days and my mom gave D her ticket today so he could go (he had previously declined their offer of a ticket and had not-buyers remorse). My mom & I had a great day together, we explored an herb/aromatherapy store, had a long lunch, got her some clothes and picked up groceries. I love that we are close enough to spend this kind of time with them. 

My kids’ spring break unfortunately coincides with my last week of night shift for the year. Instead of staying home quietly while I’m sleeping all day and then hanging out by themselves while I’m working all night, they are going to go to Florida and hang out with Grandmas. We are going to meet them in Savannah and explore for a day and then I’ll go home and work. It isn’t much but we will get to see Juliette Lowe house and eat at the Pirate House for dinner. My parents are going to take the kids to see Cape Canaveral and they are going to help with some bathroom remodeling that requires more hands on deck to complete. They’ll get to go to the beach, sleep in and hang out with a different, larger set of dogs.

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I find it hard to justify the expense of greeting cards. Why should I spend 4 or 5 bucks on a card that someone is literally going to read for one minute. Of course, I can think of times they are relevant but for little holidays like Valentine’s Day, it was not something I was going to invest in for my kids. I got them a couple of little chocolate things a few weeks ago when I was out running errands and tonight I printed cute little cards from a free online card site (greetingisland.com if you are interested). They are half sheet little cards that you can customize the insides on and print out at home. For the purposes of this holiday, they are perfect. When the kids were little, I used to use our art supplies and make them homemade cards with notes in them about how awesome I think they are, in a specific and individualized way. It is fun to highlight the ways I find my kids amazing for their consideration.

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Valentine’s Day is actually my wedding anniversary. I spent about 10 years hating that fact and wanting to do some sort of vow renewal thing to re-adjust our anniversary. I found it cheesy and faux romantic to be married on Valentine’s day. Finally I came to appreciate having an industry reminding us of the date, as neither of us were particularly sentimental about actual dates. I’m doing surprisingly well today, the eve of my 20th wedding anniversary. I was very sad several weeks ago and spent a lot of time anticipating the event. Now that it’s here, I happen to be in an “all for the best” headspace about the ending of my marriage. It was sad, it was not what I wanted for my life, but it was what needed to happen. I hope that the ending will bring us both more lasting and authentic happiness. 

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We had a Spring day today, it was nearly 80 out in the peak of the afternoon. It surprised all of us, we were all wearing sweatshirts and extra jackets and winter stuff. But this is what I missed in Oregon, the erratic but generally upward trend of temperatures heading toward summer. I gave the kids explicit lessons in climate trends outside the PacNW and they responded predictably. He was very accepting and she gave a “but that’s not how things are” response. I love Spring!

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I have had 2 tasks on my mental to do list for many weeks. Both of them required multiple steps but neither was technically complicated or difficult to accomplish. I just wasn’t doing them. Recently I realized that they really are the last 2 marriage-related chores I have to do. I mean there are a couple of ways we are still entwined - obviously the kids, but also taxes. I’ll be paying the IRS for years but the payment plan is set up and that is just an ongoing bill. These 2 tasks were the last things that tied me to my marriage. I don’t think I was holding onto them to prolong the process. Maybe I was just leaning away from unpleasantness. Either way, as soon as I made the connection, I finished them in less than 5 days. It is time to move forward.

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Today was a hard day. I wanted dessert. I wanted it badly and for no good reason. I wasn’t more hungry, tired or stressed. I just wanted it more. I was thinking about it more. And then I walked into a break room to get a drink of water and there they were. I could smell them when I walked into the room. 5 different kinds of dessert, all with chocolate. I got a glass of water and went and ate an apple slice. And then I ate a slice of cold meatloaf when I got home. Now I’m at Whole Foods while D is at soccer, mooching their free wifi. I treated myself to a bottle of Lime Mint Elderflower sparkling water. And that’s it. It is hard, but I’m building my capacity. 

I’ve been struggling, pretty much since I wrote that I wasn’t struggling, with jumping ahead of myself. I’ve been trying really hard not to think about the “next thing” I’m going to do to change my diet. I don’t need a next thing, I’m still working on this thing. I’m trying to keep my change horizon extended to the end of residency. By the end of residency, I would like more control over my diet. I would like to be able to fit into my clothes again. Probably not ever those size 8 cords I’ve had in my closet since first year of med school, but the stuff I was wearing a year ago, 2 years ago. I don’t need to make all the changes right now to make this happen. In fact, I know that if I try to make too many changes at once, I will just spiral down and end up in a really bad place. Better to be content with my little victories over the surprise break room finds and daily choices stick to my goals. And I’ve been exploring the idea of an OA meeting. I’m really not down with the 12 steps, but maybe some support would be useful.

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By this point in my training, I’ve had a few opportunities to take care of women who were incarcerated. Whether at the hospital or clinic, they are accompanied by a guard who is armed. I have some pretty visceral feelings about the guards that I am having to pay close attention to. While the individual women working as guards are personable enough and at least on the surface they seem to have a good report with my patients, I find myself carrying a great deal of resentment and suspicion toward them. I really dislike doing exams and having conversations about medical history with the guards in the rooms, even if they are behind a curtain. The individual guards I have met have seemed like kind, respectful women but the inherent power differential is something I cannot ignore. Prisons and our justice system are such broken, dysfunctional, skewed, manipulative structures. The culture of guards and our clinic has been such that they are not asked to leave any rooms and I honestly don’t know if the would or if such a request would be supported by our practice. I have worked with incarcerated women and with people who have worked with incarcerated women before, but doing it as a physician is a new experience and brings with it new questions about boundaries, roles, options and more.

Dessert-eaters Anonymous?

Let’s start with this: I have an eating disorder. 

I don’t usually exhibit disordered eating, but the disorder is always there. For years I was able to cope by ignoring my eating habits. While that worked in my 20s and 30s, as I have progressed through my 40s I have been struggling to find a new way to relate to food and eating so that I can maintain a healthy, active body that will allow me to do the things that I need and want to do. I’ve had a few pitfalls as I’ve tried to turn back toward thinking about food, including a really bad stretch where I ended up eating fewer and fewer calories each day. It didn’t take long to get my calorie count so low I was unable to function. Turns out, starving your body also starves your brain, which made learning next to impossible. Despite knowing this was horribly unhealthy behavior, I required medical intervention to break the cycle and regain my ability to eat to sustain myself.

So for me, making changes to my diet & fitness routines is a process that is fraught and stressful. How can I change my habits and improve my health without launching back into disordered eating and illness? This post won't have that answer tied up neatly in a bow, because I don’t have it yet. I’m still working on it. 

Recently I realized that I need to change my behavior in order to get quality of life back. By the end of my holiday schedule, I was sick, literally and figuratively, from my diet. I was out of shape, over-sugared and tired of eating crap. I decided that I would have a “dry” January. No booze, no desserts. I started when I got home from vacation on Jan 3rd. I needed a reset. I was very deliberate in my rules, or lack thereof: I’m not cutting out hidden sugars, restricting carbs or fat or even portions and not overthinking it: just no desserts and no booze. No booze felt necessary to help me meet the no desserts goal. Alcohol lowers inhibitions and diminishes decision making. I need my A game for this effort. 

Since then, I have pretty effectively detoxed from the sugar. I’ve started to add back treats, one small item every once in a while. That I feel better and have better fitting clothes is not surprising. That I have been able to refuse quite a lot of temptation has been more so. I get free food in the hospital cafeteria and there are candy bars, baked goods, a milkshake machine and one of those fountain drink machines that has a million flavor options. I suck at saying no to sugar and temptation abounds in my daily life! 

It is helping me is thinking of a dessert or a temptation as if it were a bottle of vodka and I were a drunk. If I were a drunk, it wouldn’t be okay for me to dip into a bottle of vodka. Even if other people can do it, I cannot. Accepting that fact has made it a bit easier to resist junk food at work. 

When I think about desserts like an addict, it feels more honest. It keeps me from slipping into temptation and escape. I acknowledge the harm food has done to me. While I recognize that I can’t stay away from all food (if only there were a pill you could take instead of eating!), I can stay away from desserts. I can regain control over my hunger & satiety, I can FEEL instead of get a sugar buzz. I can eat fruit or drink water or get seconds. Again, the goal of this is not to lose weight, it’s to feel better, without spiraling into self-destruction. 

This is a new approach and so far it is working for me. In a week I am starting a new rotation that will have me adding more stress and sleep deprivation back into my life. I know that these things make brains crave fat and sugar. I’m hopeful I will be able to continue to resist harmful substances. Wish me luck!

Everybody’s gotta eat - especially teenage boys

One of the things I have to do 100% of the time now is manage meals. I didn’t cook much while I was in med school - in part bc I dislike cooking (I really dislike everything to do with food, but that’s another story). But now the buck stops here. So how do I manage to make meals and manage our schedules? Planning, routine and a LOT of shortcuts!

1. Frozen chicken tenderloins: I get mine at Trader Joe’s. The tenderloins are smaller than breasts so they cook faster, but they do cost a little bit more (worth it!). Many things I used to do with fresh chicken in a skillet, I now do with frozen chicken in the oven. I use pasta sauce, curry or masala sauces (also from TJs) over frozen chicken in the oven for 15-25 minutes (depending on whether I want to wait for it to be fully cooked or just thawed enough to cut and saute in a skillet with veggies).
2. Shredded carrots: This may sound like a silly thing but not having to cut vegetables has improved my quality of life significantly. I use shredded carrots in several dishes, they cook quickly and are easy to manage. And hard for the fussy one who says she dislikes cooked carrots to pick out!
3. Menu planning: We have a weekly whiteboard on the fridge that I populate with at least 7 ideas for meals for the week, then I pick from the list in any order as the week goes on. Right now I’m on an easier rotation so I’m making some more intricate and time consuming meals so that I can save the real time savers for when the Onc rotation starts in 10 days. 
4. Cooked chicken: also from TJs (I don’t get much there, but what I get is essential). This is a pound of cooked sliced chicken breast, only very mildly seasoned. I save sandwich bags of it in the freezer to use for quick meals: quesadillas, pasta, etc. Today I used it to make a pot pie
5. Frozen pizzas: my kids like the DiGiorno brand and I usually have 2 in the freezer at the beginning of any given week. When I’m doing something in the evening, I will leave the kids to their own devices and 10 times out of 10, they make themselves pizza. 
6. Cereal, yogurt, turkey slices, fruit, instant breakfasts: Duncan eats at least 2 more meals than Ainsley & I most days. He has recently decided to care about nutrition, which thrills me, but does mean he doesn’t fill up on chips & pretzels so I need to have more food that he will make himself easily.
7. Muffin tin: I make a pretty good ground turkey meatloaf but it takes a long time for a whole loaf to cook. Instead I have taken to making them in a muffin tin instead for the simple reason that it cuts the cooking time in half. And the leftovers are really easy! 
8. When that onc rotation starts up again, I’m going to ask the kids to each cook dinner one night and we’ll plan to have pizza on Fridays. That will leave me with 2 meals to drum up during a time when my workday will be starting at 5am and I’ll be spending a lot of it on my feet in the OR. Low effort meals will be key!

Sorry for the hold up, I had more posts waiting than I realized!

My son is saving me from bitterness. Having a son keeps me from thinking and making broad statements about “men.” This is very useful as I am feeling quite burnt by one man and the human mind loves to generalize from individual experiences. This afternoon specifically, I was discussing video games and how an adult friend of mine has played video games with him and would like to do so again in the future. I wanted to make some sort of comment about the immaturity of men, both because of the video games but also because of the many similarities I have seen between the sense of humor of my 14yo son and those of young adult men I have had as classmates and co-workers in recent years. Instead of being negative about these aspects, I found a different explanation. I don’t have any idea if it is any more accurate than knee-jerk assessments of immaturity, but it was nice to be able to think of an interpretation that wouldn’t leave my son thinking I had a low opinion of his potential as a human and a man. 

My theory is this: part of the reason many men display interests in “juvenile” things - video games, potty humor, etc. - is in part because they have the luxury of not having to think of deadly serious things as often as women. We are concerned about safety, about assault, about sexual harassment, about being taken seriously. This sucks some joy out of the room. Men (just white men? I don’t know I’m still fleshing this out) don’t have the same burdens and they hold onto more of their innocence and their easy access to joy and laughter. When I posed this theory, I also said that the lesson in this notion for me is that I could remember some of that joy, re-embrace some of that innocence for myself and generally be more fun. It may be an indictment of patriarchy, but not of the character of men as a category of humans. And it flows with my goal of being a more joyful person. 

(there’s a whole thing coming up for me now about emotional labor and how primary responsibility for it contributes to the loss of joy & innocence but I’m just making that connection now as I’m writing, it wasn’t part of the original thought. Huh, I wonder about that too)

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Unfortunately I did not keep any records of the funny little things my kids said when they were smaller. I’m sure they were entertaining. Fortunately, it isn’t too late to be entertained by conversations with my kids! Here are a few gems from the last few nights: 

• We spent at least a half an hour debating about whether or not we were going to do 3 minutes & 10 seconds of mindfulness meditation as a family for 5 days this coming week. Though I have stated before that this is a beneficial activity, there was still mighty skepticism that I wasn’t just making up “studies” to get them to do what I wanted. So this time, there were medline searches, discussions of scientific jargon (“It says *may* help! Not a guarantee!”), some threats that requiring this to be done would cause permanent psychological scarring and negative associations that would damage any future efforts at meditation, a lot of stubbornness. Eventually they agreed to four days and reserved the right to complain about the bell I had chosen for the exercise. The fact that we spent 10 times the amount of time arguing as we would have spent meditating was lost on no one. And the monumental amount of STUBBORN that resides in this house is off the charts.  (As I'm publishing this, I'll add that I *completely* failed in my effort. I did not remember meditation practice ONCE in the last week at a practical moment in time that would have allowed us to continue the habit! So much for a hard fought battle!)
• On the car ride to and from soccer practice, topics of discussion included: what if I bought a motorcycle, emancipation, legal adulthood while still living with your parents as a legal adult and the impact it would have on freedom and life choices (like if I could own a motorcycle), that there is very little that would cause me to kick you out of my house (Okay, not if I got a motorcycle, but like if I were making crack in the basement?), crack vs meth, the basic premise of Breaking Bad, how awesome it would be to be a chemist, how such a show would have no traction if there were universal health care, having a teenager and an infant siblings in a family, cerebral palsy, the mechanics of delivering a baby, the difference between a roast and an insult, and a whole lot of groan-inducing rhymes
• Tonight I spent a half an hour playing soccer & basketball with Duncan. He is significantly improving his ball handling skills in soccer and I got him an indoor mini hoop that fits over a door for Yule. It was fun, though it mostly involved me trying unsuccessfully to get the ball away from him! 

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I know that modern medicine has a reputation for running too many diagnostic tests, and probably that is the case. However, we are trained to be thoughtful about the tests we run. The key question is: will it change your management? When a patient presents with signs & symptoms and you are initiating an assessment or a treatment plan, would the results of a given test change the plan you are implementing? If it wouldn’t, then don’t do the test. 

In that spirit, I did not watch the State of the Union address. Our president is a racist, a sexual predator, and fascist and I despise him and the parties in our government that are colluding to keep him in power and I want to work actively against them. Watching the SOTU will not change my management. It is an unnecessary test of my sanity & coping during an already difficult time. I wouldn’t subject a fragile patient to a cardiac stress test. I’m not going to subject myself to that horrible human being. 

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This evening I was running a stupid errand and spent most of it talking to my mom. She’s not entirely comfortable with me talking on the phone while I drive but there are really so few moments that I can have conversations, I think she’s made her peace with it. As a mother, I appreciate the trepidation. I’m fairly certain my kids are off dead in a ditch somewhere several times a month and they don’t even drive yet. 

So anyway, was running this errand and chatting and my mom came up with the best word to describe my mental state right now. I’m squarely in an IDGAF sort of mood about things, but not in an angry or stressed out way, just in a way where I can’t really bring myself to get activated by most things anymore. She observed that I am “saturated” and that is excellent. I’m not going to be running short of stressors any time soon, but for now, I have a hard time soaking in and responding to anything more. From professional feedback to adolescent backtalk, I’m just saturated. It has brought me to an interesting place of detachment. It feels a bit liberating, not to have the emotional reactions I often have to personal interactions. Happily, I don’t think the change is a sign of impending breakdown, I think it is more a sign of resiliency and healing. 

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A few of things happened today that gave me a sense of mastery & accomplishment: 

• I got the leg drape on correctly. These things are insane pieces of plastic & paper that drape over the legs of prepped, sleeping patients for pelvic surgery. They are folded in a way to make medical students & baby interns cry. 
• I did 2 hysteroscopies, which are procedures where you dilate the cervix and stick a camera in the uterus. They are pretty straightforward but still, I did them! 
• A medical student gave up a chair for me. “Pecking order” he replied when I told him I didn’t mind standing. He was right, I gave up my chair for years, looking forward to the time I could sit. Now I get to! 
• I think the second half of this year and next are going to be nice. The feeling that I know what I’m doing, I’m learning a lot and can demonstrate that learning in the OR and in clinic. Of course, the first half of the year will be a lot of starting over, not knowing much, as my scope of practice expands every year, starting in July. 

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Both my kids have the crud: one lost his voice, the other has stuffed up sinuses, both are dragging and playing the “who is sicker?” game. Fortunately, I’m on a brief outpatient rotation so I have later starts in the AM. Unfortunately, 2 sickies means there’s no one else to do chores around the house (I do NOT want them touching clean dishes!) and I am trying to sneak a day’s worth of parenting sick-care into the few minutes I have in the AM. Yesterday I assessed throats, made tea, gave out meds, set a kid up on the couch and walked the dog when I hadn’t even planned on having anyone else in the house with me while I was getting ready. Somehow I managed to show up to clinic on time! And I had “admin time” in the afternoon so I was able to go home and make the sickie some lunch and do my work on the couch, keeping him company while he laid there, staring into space. He’s lethargic enough and feeling worse this AM that I was inspired to bring him to his doctor for a flu swab (they did a strep too for good measure, both negative!). Today both kids are home though I suspect one of them will be back at school tomorrow (whether she likes it or not). I hope that if they infect me they will remember all the TLC they are getting and return the favor if I’m down for the count!

Really important things like, what I smell like

It is not in my nature to stay down for long. If I can, I like to process, get help, resolve. If I can’t do that, I can compartmentalize like a BOSS. Also I have amazing, loving friends and family who are helping me with love, hugs, emotional and material support.

I wasn’t kidding the other day, with my post title that my mantras are efficient. These are a few that I’ve been collecting the last few months. I write them down when I think of them or hear about them. 

Here is my latest compilation:

• No Matter What
• Be here now
• My life is mine
• This too shall pass
• Comparison kills
• The next right thing
• Context
• “True joy is a serious matter” 
• Ebbs and flows

I decided that tonight the kids & I needed a little active fun. Not just a movie, which has been our standard entertainment in various forms, but something active and engaging. After celebrating National Popcorn Day, we discussed our options. We considered laser tag, mini golf, bowling, and other ideas. Ultimately we settled on ALL the things! There’s a place in town called the Fun Depot that has it all, along with bumper cars, go carts, arcade games, a rock wall and more. We had been planning a trip to Fun Depot since their birthdays in September (my mom gave them money to go, it had been sitting in an envelope on my bookshelf). We played games, we fed the fish in the koi pond, we played free for all laser tag in a pretty big arena with the three of us! Ainsley bought us pizza and we played until they closed the place down!

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I had a patient recently who had a rough course after a surgery and because I had the time and she was inclined to ask about it, we talked a lot about why certain things were done at certain points and why they were not repeated later and what different things were done later in her course. It was interesting to have such an engaged patient asking specific questions and wanting to understand more in depth what had happened and why we had decided to do the different things we had done.

As a part of these conversations, it came out that she disliked some of the people who had taken care of her over her >1 week stay. Actually it was more that she disliked what they were telling her (like that she was stable for discharge when she didn’t feel stable). And she asked me why when some of those people came in the room, I never said anything. It was interesting for her to learn some of the power dynamics and roles of a resident care team. I thought I’d share some of the insights with you.

When you have a resident taking care of you, she is absolutely going to be part of a multi-resident team that is led by an attending physician. “Attending” is anyone who is out of residency to whom residents report, usually it is a faculty member. (Physicians who are out of residency but don’t have a regular teaching role in a residency program are called “privates”)

In the morning, one of the residents will “round on” you. That means they will be familiar with your history, your overnight course and the general trajectory of your hospital stay. They will do a brief physical exam, maybe check out your incision if you had surgery and talk to you about how things went overnight and what might happen during the day. Then they will leave your room. They’ll have a note to write to document the encounter and they will present your case to the other residents and the attending where a final decision will be made on the plan for the day. Then the attending will come into the room (ideally, sometimes we can’t get to everyone before the first surgery of the day then we have to come back later in the morning). The attending will say hi, share the gist of the conversation that was had amongst the team and finalize the plan. And yes, when the attending talks, the resident is listening. Not talking.

When you have a resident care team, there may be multiple plans formulated in the morning before the final plan is communicated to you. And unfortunately different attendings make different plans so your plans might change from one day to the next. This can make the care of a resident team seem confusing. But it is also a case where lots of people are thinking about your care, attendings are trying to teach residents how to manage cases like yours and they are careful to be making thoughtful plans that are backed by as much research and experience as possible. There are downsides to being on a teaching service but there are also upsides. It is absolutely your right to understand the care you are getting, who the members of the team are and what their roles are in your care. If you don’t understand what is happening, always, always ask!

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What if I wanted to be a sillier, more joyful person? How does one go about making that sort of change? I spent some time yesterday with a friend who is silly and I was reminded how much I enjoy that sort of interaction and wishing that I could manifest that more in my life proactively instead of waiting for someone silly to come along. I am going to have to think about this.

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It turns out that one of the best things to do to be a more joyful person is to decide you want to be a more joyful person! And embrace the process of re-defining your daily experiences - sure teens can make me crazy but am I going to gnash my teeth or am I going to find the poignant humor available to me now that I’m not the one experiencing adolescence in all its power. And choose who you call when you are having a crazy time - call the friends who have easy laughs and can find the humor even when it is gallows humor.

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I want my house to smell good. Vanilla, tea tree, cinnamon, lavender, amber (not all mixed together!). I want to come home and be able to smell that I’m home. But I hate chemically smells and air fresheners. That’s not what I want. And I can’t do lots of incense, in the dry air it irritates my respiratory tract. I need to make a smells plan!