Nescafe rabbit

Baby story.

Saw my twin baby on Monday. He was born at 35 weeks by c-section, which I helped do. Everything was going great until one day on Peds when the post-call resident says to me "I admitted your kid yesterday. both of them." I knew it had to be bad news. she tells us about his mother's feeling that something wasn't right, he was slow eating and red in the face. "And he's always been the pale one." Group call took too long getting back to her, so she bundled the twins into car seats and took them in to the ER. Good thing, too, since that meant that when he crashed and needed intubation, he was in the ER. So they did the echocardiogram because of his huge whopping murmur (which I'd never heard) and it was significant. Off he went to $childrens_hospital to get his chest opened up and his ductus-dependent Total Anomalous Pulmonary Venous Return fixed. One month later, he's in my clinic for a follow-up. Just got out three days ago. His brother is 12 pounds. He's pushing six. This is a mom who has nothing - she's 21 and alone because she gave abusive father of the babies the boot. Her only help is some friends and her dad. But despite everyone's dire predictions, she's making it work.

I love my job.
Nescafe rabbit

From the road...

So to speak.
LiveJournal just released a client for Windows Mobile, which means that potentially I can use some of my Sudoku time to compose journal entries, which rumor has it are sorely missed.
I'm currently in $rural_county where my mother in law works, reviewing the possibilities of coming down here in a year and a half after I do my OB fellowship (assuming that nothing goes horribly wrong). Today is my afternoon to visit the next county north, where I'll be delivering, if I come, since this county doesn't have a hospital with an OB wing. They have an obstetrical group up there, which is good, except that that means I'll be trying to convince the OB-Gyns that they want to share call with a family doc. I wonder if the fellowship will mean anything to them.

It's a different world down here, in rural Indiana. My mother in law had a patient in the hospital, first day I was here. She shows me the blood gas. pH low, pCO2 high, oxygen sats borderline. "What do you think?" I think she's going to need intubated. Did you try her on BiPap?; She smiles slightly. "Guess I'll call $major_hospital..." It's an hour away, to the big city. There was a long pause while I processed this. They don't have an ICU here. They can do BiPap, but the only ventilators in the place are the two in the ER, for short term stabilization. ICU patients get transferred. This hospital averages 5 inpatients at a time...not even enough to cap our Medicine service.

I'm spending the mornng with Dr. Y, who's in the hospital employed group. It's a nice office, all new and shiny, with electric tables and twisty otoscopes, and you couldn't offer me enough money to use their paper charts. As much as I hate our current EMR, I'm beginning to see its finer points. Things like our electronic prescribing and tracking. And labs. I miss being able to track labs on one page. At least the community health center here has electronic charts, even if they don't know how to use them effectively.

It's beginning to become real, O Best Beloved. Before long there won't be any supervising faculty...
From the road...

Modern Art

I check my baby every night...

Walked into the peds ICU this morning. My patient is a cute little 12-month-old who had a grand mal seizure with refractory status epilepticus about 8 hours after her year shots. Certain features (such as an abnormally small head) on clinical examination lead us to believe that it was not the shots that made her seize, though they may have contributed. She is doing well and being extubated today.

Next door to her in the bay lies L. Born at 34 weeks and home from the NICU 1 week ago, she's not even supposed to be out of the womb yet - and now probably will never see that milestone. Her parents fed her and put her down to sleep one night, and two hours later she was found limp, lifeless, and pulseless. Resuscitative efforts produced a heartbeat and clonic muscle activity and nothing else. She was transported here to die, really; the chance for survival - let alone meaningful survival - is essentially nil. We wait twenty-four to seventy-two hours, do an apnea test (if the brain doesn't have a drive to breathe, it doesn't have a drive to function) and a brain perfusion test or an EEG. And that's it...
I went into her room when her parents were out, and stood there, just looking at a perfect little baby under a brightly lit warmer and couldn't stop from crying. Morning rounds were subdued this morning, as A presented her case. Nobody asked many questions - we all just listened.
Her grandma wanted to know, he said, if there was something she could do to help someone else.

I don't understand this one, O Best Beloved, and I don't know how to begin to.
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    sad sad
Modern Art

A serious question...

Let's talk about two different early-twenties young men, O Best Beloved.

The first one, B, is the son of one of our most-loved faculty members. He was involved in the non-medicinal use of prescription narcotics. He went out partying with some friends, took some recreational prescription narcotics, crashed around 3 AM with everyone else and never woke up again.
I attended his funeral. Almost the entire residency did. His father is back at work and we are nervously awaiting the time when he gets called in in the middle of the night to do an ICU admission on a patient like S.

S is a staff medicine patient. He was involved in the non-medicinal use of prescription narcotics. He went out partying with some friends, took some recreational prescription narcotics, got dropped off at home, and was found twelve hours later barely breathing in a pool of his own vomit. He spent days in the ICU on a ventilator and now has anoxic encephalopathy. We didn't anticipate he would ever do anything; he now responds to simple commands and smiles when music is played to him on an iPod. He doesn't talk or do much else. He'll require 24 hour care, suctioning, turning, and therapy to keep him from getting bedsores. We don't know if anything is left of his frontal lobes and personality. His family lives at his bedside, announcing every tiny motion and change, agonizing over fevers and the days when he doesn't respond to anything.

I can't decide, O Best Beloved...if it were my child, which would I choose? Either is a future too painful to contemplate.
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    thoughtful thoughtful
Notre Dame des Dons

Never what you expect...

Walking into $ER this morning at one-to-midnight. The air was full of the bass diesel hum of a waiting ambulance, a chugchugchug that accompanies a busy night.

The waiting room was empty, and the chart rack was as well. I don't want to curse the rest of the night, but I've gotten Miri's photos reorganized (incidentally, drop me a line if you want a paper one, I have lots) and now I'm settling in to tell you about some of the things I've seen.

Psychiatry was fascinating. I saw K in the support group, who sat and explained to a roomful of recovering alcohol and drug addicts that it was her fault that her boyfriend had sent her to the emergency department. He was drunk - she told them that she'd said it was OK for him to have a beer or two. She had, apparently, walked on the wrong side of him, an indication that she was available - in an attempt to keep his drunk self from stumbling into the road. All of this led to him getting off a couple of good punches, and she reciprocated in self-defense. She's in support group. He's in jail. And it's her fault. She's quite certain of that.
It's a level of self-deception founded in self-disgust that amazed me. Where do you start?

A lot of child and adolescent psychiatry, a lot of ADHD evaluations and a lot of troubled children. Kids shouldn't have to worry about things like drugs and meals and gang violence.
I brought in Wandering Jew cuttings for the cognitive/behavioral therapy group, and they were flabbergasted that someone would bother.

Psychiatry made me sad.

I'm on Surgical Subspecialty now; the other day Dr. A the ENT surgeon let me hold the coblator and take out part of someone's tonsils. It was exhilarating. I spent a week in the opthalmologist's office and actually looked at a lot of retinas, which I could see clearly. I had the good sense to say so if I couldn't see something, and he appreciated that. My skills were improved and I got to watch the ultrasound probe break up and suction out a cataraceous lens before the slow unfolding of an IOL (intraocular lens) implant.

Opthalmologists get to play with lasers and microscopic sutures. There's a lot more to otorhinolaryngology than Ear-nose-throat, but nobody knows that. I've never seen someone remove so much wax in one day.

There's a drunk in the drunk tank at the end of the ER. He tried to tell me why he was drunk, but it didn't make any sense, and I think he only came in for a sandwich. He ordered the nurse to have it for him in less than ten minutes. A screening exam is a screening exam is a screening exam.

My mind and heart are not in my work tonight; when I left home Miri was getting her second dose of Ibuprofen for the 102 temperature she spiked this afternoon (I got out my otoscope and listened to her chest and couldn't find anything), and Monday morning the clinic is closed so that we can go to the funeral mass for the eldest son one of our favourite faculty members. Accidental overdose. I could just cry.

Patients are filtering in; I'll try to save something interesting for later. It feels good to post - I should do it more often, in the bustle of days. It feels good to reflect.
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    sleepy sleepy
White Coat


W is pregnant. Barely over twenty, fourth baby, and not on her psychiatric medications. We weighed very carefully the option of putting her in $psychiatric_hospital due to a tool-throwing incident a few weeks ago in which her soon-to-be ex-husband arrived at the ED with a fractured skull. He had lost his job, was sleeping in the car to feel safe (for some reason, this made me imagine my 130-lb patient prowling around the house like some kind of raptor), and was leaving this weekend to go back to $other_state. This would leave her homeless, without transportation (she doesn't drive), and with no way of getting anywhere except by ambulance.

Meanwhile, as I am trying to figure out what to do with W (they have no telephone and no reliable message drop), the OB floor is paging me frantically. J, who is now just over 30 weeks with a twin pregnancy, was admitted to Special Care with preterm labor - her first episode, a startlingly benign course as twin pregnancies go. She was hysterical and screaming and swearing and sobbing because she was on bed rest and couldn't go have a cigarette and could I please calm her down?

I told them to tell her to sit tight, and I would be there. This is the patient whom C described to me as "a bitch", but who seems to adore me. I was, after all, in clinic.

Once I got to the OB floor an hour or two later, finally - and still without a plan for what to do with W, except to make her husband promise to bring her back in three days and not to go to $other_state before the weekend - I was confronted with a hysterical girl (98 pounds of J, 60 pounds of two full-size 30-week babies) who couldn't catch her breath long enough to finish a sentence.
I'm not going to give you a cigarette. Or permission to smoke one.
She ranted at me. Most of it didn't make any sense.
You're still not getting a cigarette. But if you stop bugging me about it I'll get you a Coke.
Our OB floor, you see, has only 7-Up as a soda. I hate 7-Up. There's nothing with caffeine in it at all, and that's no good for my post-teenage junk-food junkie OB patient. She shut up. I got her a Coke. Other than nearly throwing a table at her brother, she was sweetness itself right up until I sent her home.

Yesterday, she paid me back a dollar for the Coke. I took it - I don't know what the rules are, but it was important to her.

I spent some time going over W's history with the OB proctor and ultimately established that ACOG has approved "social inductions" after 39 weeks. I called the proctor for the day after she was 39 weeks, and he said that it sounded like a very good reason to deliver a baby to him. Then came the fun part.
W and her husband have no telephone. There was no way to get hold of them. She was fourth on the induction schedule - a potential hold-off. I had to talk fast.

She made it in at eleven - hung out at McDonald's to use the pay phone to call in and check whether or not she was on the list. And now, baby is delivered, psychiatry consult called, and all seems well. J went home, no further dilation. But I'm three days behind on calling patients with lab results and discussing things like trichomonas on pap smears, and I'm tired of dealing with hysterical people, and I really wish people would stop complaining about being my box buddy because I'm my own box buddy all the time so I know what a pain my patients are...

At least, when you program, it follows its own logic. Computers don't come from dysfunctional families.
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    tired tired
Modern Art

It's been a while...

Autumn leaves tremble
     faintly in the dawn
  wind and winter play,
           here and gone.

Threads break, leaves fall,
     snow drifts down
                covers autumn leaves
       silent below

Wind wakes spring buds
             sun finds day
       rain falls gently
washes snow away

Day breaks, petals fall
           silent as the snow
     Earth takes the autumn leaves
        to the damp below

Summer leaves tremble
         faintly in the dawn
    sense the waiting autumn
             here and gone.

NsB 27-Jul-07
"Remembering winter"
Baby cat

Tonight, tonight...

Good thing I napped last night; this morning's ER shift has been hellacious. Ten patients seen in seven hours, five admitted. I spent half the night passing patient name stickers back and forth with the front desk to have physicians paged. I spent the other half trying to track down lab results.

Headaches and chest pain and children who were not really sick at all.

I'll be posting poetry, soon as I can complete the post, but I don't know that it's very good. I'm on a swing-down cycle and it's hard for me to think. Leaving for NCFMR Tuesday; I'll be presenting my inconclusive research project and I can't summon the energy to be nervous. That's how today is.

I have things to tell you about psychiatry. I think they'll have to wait a while, for patient privacy. But it amazes me how people can internalize hostility and make it into self-distaste...
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    sleepy sleepy