Isn't She Lovely!

Well, two days after my last post I was in the hospital being induced! We went in on the evening of J's birthday to get things going. I didn't have enough amniotic fluid anymore and my blood pressure was starting to creep up so we scheduled the induction at 38 weeks. The next morning contractions were really intense but the little one's heart rate was not tolerating the stress. She was having what's called late decelerations. In most cases this is due to "uteroplacental insufficiency". It's a dangerous situation if it is allowed to continue, and if the baby doesn't come out it can cause a serious loss of oxygen. So 18 hours after we checked into the hospital we made the decision to get her out via c-section. The little one was born on July 29th at 2:45pm.



Here's the very tired momma after the c-section when I finally got to hold my baby. Somehow the epidural traveled up to my arm and face so for a while I was numb really high and couldn't hold her.



Day before we went home from the hospital in mom's favorite piggy pjs.



On the way home!



She's now three weeks old! Being a mom changed everything, from the very first minute. It scares me all the time, but I've never smiled so much. I have four more months home with her and I plan to enjoy them as much as possible. It's hard work, keeping a baby alive, more than I ever could have expected. The days fly by so fast I can't even believe it. I'm sure the challenges will just keep coming, but I'm already starting to know her better. One of these days I'll possibly even feel comfortable taking her out of the house on my own! I'm getting there, slowly.

I will be starting to keep a password protected blog to post all the updates about the baby. If you would like to be added, just send me your email address, either as a comment or on facebook or to my email address. I just wanted to let everyone know that mom and baby are doing great. And dad couldn't be more proud (or more helpful, he's the best!)

What I'll miss...

About being pregnant? This is a question I read online all the time, and I always laugh. Miss about being pregnant....hahahahahahaha! But there are a couple of things I might miss. I'll miss her moving and grooving in there, when she's not bruising my ribs. And I'll miss blaming all my food desires on her ("the baby wanted the ice cream. I had to have it")

But seriously. Am I done yet?

I see the finish line....

Inching so much closer! As of now the kiddo is full term. She can come at any time and be ok. I prefer sooner, so we'll see. She's already over 6 and a half pounds. Which is plenty if you ask me. So hopefully soon. We got her room ready and I even took some pictures!



That's pretty much my favorite seat in the house. Gotta love the glider. The dresser was a partially finished mess we got for $5 but was made of good wood so J refinished it to match the crib. I think it looks great! What you can't see is how completely packed with clothes it is! She has more clothing than I do!



Here's her cute crib and bedding. I suppose once she's in it, and leaking all over it, it won't look as cute, but I like it lots right now!



We also got the bathroom fixed up. Not that she'll be using it anytime soon, but we seem to like the monkey theme so we're going with it.



Yes, I know she won't have teeth to brush for some time, but come on, how can you not get the see-no-evil-hear-no-evil-speak-no-evil monkey toothbrush holder?



And, last but not least, J's very favorite outfit for her. Even though it probably won't fit her until long after the regular season!

Speaking of finish lines, J crossed his first half marathon finish line at the end of June! He ran the Slacker half marathon in Georgetown. He even kept his time under 2 hours! Not too bad for not training!



Well, I think that's enough for today. I have today and tomorrow off from the clinic, so I'm just trying to keep myself busy until either the baby comes or it's Friday. I hope everyone is having a great week!

I'm still here!

And still pregnant. And still studying. But the good news is the end is in sight on all counts. I'm taking my boards on Sunday, and after that I will post pictures of the baby's room and our little herb plants we're growing this year. J has had the whole week off, which has been awesome, and we've cleared a lot of clutter so that it actually looks like a 3rd person might fit into this house in the near future. My practice scores are creeping closer to where I won't be calling J in tears when I get the scores back. I'm spending this month doing some elective work with my OB, so I'm sure I will be constantly thinking about the day that I go in to the office and don't come home without a baby in tow. But, that will come after boards on Sunday.

Boards, boards, bored

I have officially moved my test back to July 11th, and it's truly as late as I feel I can take it without going into labor during one of the blocks. Though it might make for a great story, probably won't make for a great score... I took a practice test on the weekend and I'm still not quite where I want to be for this test. The problem is, I have other rather pressing things on my mind that make studying more than a little difficult. Why would I want to stare at practice questions when I could be refinishing the baby dresser, buying those last minute things that I haven't gotten around to yet, putting shelves into the closet, packing the hospital bag, reading the mounds of books I've accumulated on labor and infant care, making frozen dinners that can be easily reheated after we have her, etc.

I would be less freaked out if I felt like this kid was going to term. But somehow I just know that is not the case. I've been having some seriously painful contractions, disturbingly often recently, and not only does it make it hard to concentrate (or sleep or anything productive..) but it makes me worry about getting this test done before we have a kiddo. Yikes.

Not to mention that she's definitely "dropped" and now I truly understand the uncomfortable pregnant woman. Blah. I'm just a little stress ball right now, and hopefully I'll get it together this week so I can relax a little. Anyone have any tips?

PS. The application for residency opens this week. Not that it's stressful or anything....

33 weeks

I don't talk about my pregnancy too terribly often on public forums. It's just kind of a private thing, and frankly, not my favorite experience ever. But I thought I would update folks about the little peanut. She's doing great! Had an appointment this morning and she's wiggling around as usual. As of right now she's about 4.2 pounds (seems shockingly big to me!). My doc thinks she'll probably get to about 7-7.5 pounds by the time we have her. He also thinks we won't make it all the way to the due date, but of course doesn't have a crystal ball and can't really predict when she'll make the grand entrance! I'm ready to start a pool soon, so let me know if your interested! J thinks she'll come on July 26th since that's the date I was assigned to for my meeting with the dean to go over my dean's letter for residency. I think my doc thought there was some dramatic irony in that, would be about par for the course in the past 7 months! I'm just hoping for the end of July so I have all of August to spend at home with her. But, she'll come when she wants to. One can dream though!

As for me, I'm getting to the point where I can't really sleep. I fall asleep no problem but I'm uncomfortable and wake up often. She's super low now and it makes my hips pull apart which is not super comfy. I feel bad for J since I wake him up as well. But I have lots of time to rest today. So it's good. I'm really more rested than I have been in the past year, and a lot less stressed out. Overall, things are good. Now I just need someone to walk one of the pups so I can just handle one of them. It's so beautiful outside and I want to enjoy it. I feel really lucky that as of now, I really feel happy in the heat. Everyone has been telling me how miserable summer will be, but I've always been the type of person who is more comfortable in the heat than in the cold, so I'm just happy I can wear nice loose clothes and enjoy the Colorado sunshine. So far so good!

Happy

Things that make me happy this June:

-I actually took a bubble bath in the middle of the day yesterday, just because I could!
-It poured down rain yesterday with the sun shining. Summer is wonderful!
-Studying for this set of boards is infinitely better than the last time around, and I feel good about learning a lot in the past year
-My dogs are great company! They love me even when I waddle.
-I am already finding time to meet up with old friends. So great! One of these days I will get my big belly to Golden and revisit my favorite places. Then it will really be a perfect June!
-The house is starting to look like a 3rd person is at least on the way. Scary, but exciting!
-I baked cookies on Monday, and they didn't turn out like big puffy pillows for a change!
-I have made and eaten my weight in pasta salad in the past week. I do not feel bad about this. It is delicious.
-It's farmers market season, and the big guy is great company. He's such a ham when we go to all the stalls, everyone has to pet him. He's great, and never pulls me around. I don't think I could so much stop him anymore so at least he's good on the leash!

June makes me happy. It's gonna be a great month!

Heart failure....and summer!

I think I promised a while back to have some less depressing stories from my 3rd year of medical school. I've been saving this one. Now, don't judge. Although I find this absolutely hilarious on some level, it's still sad that there are people who really let things get this bad.



Last week of my medicine rotation we get a consult on a patient who is in kidney failure (yes, I know the title is heart failure). She has no history of previous kidney failure. She has pitting edema in both her legs. Pitting edema is just what it sounds like, you push your fingers into her legs and the imprint of your fingers stays there like a pit. Hers was particularly bad. I was sent in to get her history. You know it's bad when...

"Well, I last went to the doctor about 3 months ago and I was so surprised because I had lost about 20 pounds, and all I had been eating was cheesy puffs. So I figured, if I could lose 20 pounds eating cheesy puffs, it must be because of the cheesy puffs. So that's all I've eaten for the past 3 months."

Me: "When you say that's all you've eaten, do you mean that's mostly what you've eaten?"

"Nope. I am on the cheesy puffs diet. Sometimes I have water, because they make me thirsty."

Far as we can tell, she was on such a low protein, high salt diet that several things happened. The decrease in protein in her circulation allowed her blood vessels to get really leaky and her blood volume got squished out into her interstitium (area in tissues that is not in blood vessels). This made her functionally dehydrated, even though she was full of fluid weight that was making her all puffy (the pitting edema). Her heart was trying hard to keep up with the decreased fluid by pumping faster than it was used to. Over time, this put her into heart failure causing fluid to back up further and contribute even more to her edema. This also made less blood available to the kidneys, which are very sensitive to changes in blood flow. The kidneys were also seeing all this extra salt that made them think the body was very dehydrated, holding on to as much fluid as possible and making her more fluid overloaded, which also ended up in her interstitium. Also over time, this led to renal failure, which was then picked up on routine labs and ended her up in the hospital.

Lesson: though cheetos are delicious and a fun bright orange snack, they are in no way enough to maintain a human being for any sustained length of time. Sorry Cartman.

The good thing, for this woman it's a reversible condition treated readily by protein replacement and fluids. And likely lots and lots of nutrition counseling.

More good news: she'll likely lose even more weight after all the fluid is diuresed from her legs.

The best news: this was actually the day before I was done at this particular hospital, so I didn't have to be responsible for the care of this misguided patient.

Ah memories.

I'm happy to say that my subinternship ended well and that I had a wonderful time. I learned so much and I feel like there's no doubt in my mind that this is what I want to do and that I found "my calling." I find that folks in medicine are always on about where their passion lies and what they are called to do. Considering all the training that goes into medicine, it doesn't completely surprise me that people want to end up doing something that really speaks to them and will make all that work worth it. I'm glad that I've decided to bite the bullet and do that. When I started med school I was pretty focused on "lifestyle" specialties which could afford me a lot of free time and good pay. But, ultimately what I do for a living will have to make me happy while I do it, since so much of my time will be spent working, regardless of the field I enter.

And for now, I'm even happier to say that summer is here and I'm home to enjoy it! Today starts the first time off I've had in some time and I am looking forward to it. So are my feet. They get tired standing for 14 hours at a time. I am taking my Step 2 board exams this month, so it's not a complete vacation, but I think it will probably seem like it! And the way fresh air feels in the morning in the summer is something I'm excited to experience again! I love summer!!!! Shoot me an email or text or let me know when you all have some free time! I'm looking forward to catching up again!

Time Flies

I'm still crazy about my subinternship. It really does make the time fly when you're having a great time. I love what I'm doing at work every day. I might not alwaays love getting up at 4:30, don't always love the beautiful way my ankles swell when I am on my feet for 14 hours, and don't live for the bad outcomes that seem inevitable on this service, but I know now more than ever that I want to do this. And that counts for a lot!

So what have I been up to? I've gotten to do a lot! A couple of weeks ago I got to do an amniocentesis, the procedure where a needle is inserted into a pregnant woman's uterus and amniotic fluid is removed for evaluation. An amnio! Me! I was excited. I've been in surgery, and happily have retained my knot tying skills. I've seen lots of forceps deliveries, and now have a new greatest fear for my own delivery.

And now I feel like I'm on cruise control. I had the whole weekend off, which after the 24 hour call last weekend was greatly appreciated! And since tomorrow is technically a holiday, there are no scheduled procedures or anything of that sort. My resident is having me come in at 7am instead of the usual 5 and told me that if there's nothing interesting for me to see I can go home. This is my last week on this service, and though I'll miss it, particularly the patients I've been taking care of for the last month, I'm also happy to have some rest.

We get to see the kiddo this Friday and we're looking forward to it. If my growing gut is any indication, she's definitely a lot bigger. J has the week off to get the house ready for her, and I'm pumped to be able to set things up in her room instead of continuing to make many, many piles. One of these days I'll post an ultrasound picture of the little bug.

But it'll be sweeter to have a picture once she's here!

Fourth Year Rocks!

I have to start out by saying sorry, sorry, sorry to everyone who has been trying to get ahold of me, or expecting a call or email that just isn't getting to them. I am exhaused. Currently I'm taking my sub-internship, which is a fourth year medical school elective that focuses on students learning to act as an intern and be more autonomous with their patients in their chosen field. It also kind of acts as an audition at the residency program where you are doing the rotation. I am doing mine in Maternal Fetal Medicine (high risk obstetrics) at a major referral center. I have never been this busy at work in my life. And I love it!

The hours are crazy. I get in at about 5am and leave after 7 most days. This isn't the most I've ever worked since I don't have every fourth day (or q4 in medspeak) call on this rotation, but being over 6 months preggo and on my feet for every one of those hours gets exhausting to say the least. I originally specifically chose this rotation because weekends are free. I need this time to recover right now. And it's a luxury I won't have as an intern. I was worried when I registered that I would have nothing but bad outcomes for my patients and that I would feel sad and overwhelmed for the whole month. This has, thankfully, not been the case.

My patients are almost exclusively women who are pregnant but not yet at term (defined as 37 weeks pregnant), so their babies are premies. They usually have either an obstetric or medical condition that causes them to have a difficult pregnancy or to have the expectation of a difficult labor (or no labor at all). This week I scrubbed on a c-section for a 28 week baby(due dates are at 40 weeks of pregnancy). I have never seen a kiddo that tiny. At this center we have an amazing NICU (neonatal intensive care unit) and this little one has been very well taken care of and is doing quite well. I know they won't all go well over the next weeks, but I love that I can really get to know these women and give them some sort of comfort when they are so uncomfortable most of the time.

And I'm learning SOOO much! It's been a year since I got to spend any time on labor and delivery. It is a place I really like to be. I think the medical issues are challenging and there's surgical issues too. It's definitely the field for me, and even though I'm tired and my feet hurt, I am happy.

I also really love this residency program. I love the residents, and yes, they are exhausted. But I've never really seen residents who aren't tired. Residency is hard. Every one of them. But I think these residents are so well trained. They really know what they're doing and they come out exceptionally well trained. My favorite part is the awesome OB training they get. I think other programs get great surgical experience, maybe better than here, but OB is such a big part of practice and the OBs from here really know what they're doing. I would feel confident after finishing a residency here that I would not panic regardless of what walks through the door. It makes me excited!

I'm not gonna lie, though. Sitting here in my chair with my feet up on a Saturday morning feels pretty great, and after June 4th, when I can do this all the time, I will be a happy camper!!!

Patient story of the week:

A woman was being induced (unsuccessfully) for labor. Her cervix was not dilating much and we were inserting what's called a Foley bulb. It's when you take a Foley catheter (the kind that goes in your bladder), thread it into the cervix, and blow up the baloon. This acts like the baby's head and makes the cervix start to dilate. We were explaining the procedure to the patient and her mother. Her mother had this horrified look on her face and said "they're gonna pop you like a champagne bottle!"

Third Year Memories

Now that 3rd year is over, I'm starting to prepare my personal statement for residency and filling out questionnaires for the dean's office to make sure my dean's letter is the best it could be. It makes me remember a lot of the memorable patients and situations that I've been presented with in the past year. All of these things have shaped who I've become and what kind of doctor I will be. I feel humbled to have been a part of their lives.

The most vivid memory I have of my entire clinical experience to this point was from my OB rotation on labor and delivery. I did my rotation at the University Hospital, which does a lot of high risk OB care. I think I wrote about my experience with the fetal hydrops baby at the time, and it's an experience I've thought about often throughout the year. As the year went on I felt I needed to write the experience down. It was just published in the arts in medicine journal for my school. I'm copying it here. It's a sad story, but it was a life changing experience for me. I promise to write happier stories in the days to come!

Can We Name Her

The induction of labor had carried on for 48 hours when I sat at board rounds. My intern was nowhere in sight, and someone let me know that the lengthy labor was at an end and Mrs. T was ready to push. I remember running down the hall, feeling strongly this was where I was supposed to be. My first vaginal delivery.

But it wasn’t to be a normal delivery. Mrs. T had come in two days ago to triage at 32 weeks. Her ultrasound showed a baby with severe hydrops, edema so bad that waiting much longer to deliver would only make the delivery more difficult. The baby had little chance of survival regardless of how long the pregnancy was allowed to continue. The parents, who spoke only Vietnamese, spoke with the fellow for hours before the understanding started to show. Their child would not live; mom’s health was at risk if delivery was postponed. They would induce. And so for two days they would walk the halls, without pain relief, to deliver their first child, a daughter.

When I reached their room my intern calmly asked if I really wanted to be there. I agreed that I did. I had been taking care of this family since they came in, and I wouldn’t feel right if I left them now. I gowned and gloved, and for some time only myself and the intern were there. Slowly, as rounds were finished and the baby was imminent, the room filled to capacity. Every OB resident, attending, student, pediatric fellow, attending, resident, student found their way into the room. Fetal hydrops is not common; quite a learning experience.

The delivery was nothing like what I had expected. When she was born there was no crying; not from the baby. She was hurried to the pediatricians. I saw her only briefly, but for weeks to come I saw her again and I again whenever I closed my eyes. My first baby. The saddest thing I’d ever seen.

I couldn’t keep the tears out of my eyes as the pediatricians intubated and compressed; trying desperately to keep fluid out of her lungs. They tried to make a miracle.

Twenty minutes later, though, it was clear that there wouldn’t be a miracle today. She hadn’t made it. She was swaddled and wrapped as any other infant headed for the nursery. She was brought to mom and dad, who waited to hold her just once.

Quietly, everyone wept. The pediatricians quietly left the room, holding each other for support. I stayed with my intern as the placenta delivered and the lacerations were repaired. We stayed as the family cried together, trying to stay quiet and small, to give them their moment together, as alone as they could have it.

Out of their quiet moment, as the instruments were being put away and the drapes taken down, came a question. The English was broken, but the question was clear – “Can we name her?”

“Of course,” my intern said, “I think that you should.”

I felt like a voyeur watching this tender moment. My mask still covered my face and it was as if I was watching from behind a two way mirror. Such a small comfort, but one the family needed so desperately. I couldn’t imagine a time when a physician could have made more of a difference than she did for that family. In such a terrible moment, so much compassion.

In the week to come, so many happy deliveries came through that floor. And every happy delivery confirmed just how great this career could be. But I’ll never forget that day when I learned what it was to be truly needed. From surviving the lowest low I could imagine, I found new meaning in my future work, and I’ll be forever grateful for the lesson.

I never found out her name. But, somehow, knowing she has one makes me feel better. I know this moment changed me forever. At that moment I knew what I would do with my life.

Rant

So, I avoid politics on this blog. I find it's a topic that is unpleasant whenever discussed unless you are certain that the other person shares your exact view. And hence, I'm not going to rant to anyone about health care reform or anything else along those lines.

However.

Some things are too ridiculous to watch them roll past without comment. In my post third year reading (for fun!) I came across the story of Sue Lowden, the woman running for Senate from Nevada. Ms. Lowden has an interesting idea of how to move forward health care reform in this country. The barter system.

She states, in nearly so many words, that doctors should, in fact, be paid by barter, specifically citing the fact that in the past docs have accepted chickens and paint jobs for their houses as reimbursement.

I wish I were kidding.

My questions are these, Ms. Lowden:

1)Should I pay my tuition this semester with eggs? I am actually fairly skilled at making paper airplanes, I could potentially pay for tuition with those instead...

2)When I have my future practice and I need to order new equipment or lab supplies, do you think I'll be able to, in turn, pay for things with the barter system as well? Or will I actually have to make money by taking on a second job at the grocery store (likely the only thing I could be qualified to do outside of medicine) so that I can cover the costs of my patients' care?

3)Will the electric company, landlord, heat, internet, etc also work on the barter system, or shall I rely on my husband to pay for that for the rest of my life?

4)Do you really think that doctor reimbursement is what drives the cost of healthcare up? Do you think so many docs are jumping ship to take on jobs in the corporate sector because they are just rolling in dough? Do you think that bartering, to some extent, does not already go on for the good of the patient?

Ms. Lowden believes that doctors are an altruistic bunch and I agree. However, they are human and they are citizens of this country too. They are people with families of their own and they undergo a difficult training which leaves them sidled with debt. How can we possibly in all seriousness afford to take care of ourselves and our families. Why should the (way over 40) hours we work a week be worth nothing because what we do helps people? I fully intend to provide pro bono care as a regular part of my career and I truly believe that everyone deserves health care. I don't aspire to be a rich woman from practicing medicine. I also don't pretend to know the answer to how to fix health care. I just know that this ain't it.

And just like that...

It's over. I take an exam this morning and this year that I have been counting down since before it began comes to an end.

I learned more than I could have imagined, truly. When you study for boards you think you have learned a lot, but it pales in comparison. I've seen wonderful stories and terrible stories, met wonderful people and horrible people. It's a lot when I think about it and I plan to write about some of the stories when this test is over.

For now though, it should be a fun day! A short exam, then a short presentation. I'm meeting a friend from high school for some coffee and we get to go to the doc to see the baby. Should be a great day!

Snow Day!!!!

Hurrah! Snow day! We got a bunch of snow in one of those CO freak spring storms and classes were cancelled this am. Me and the dogs are enjoying some quality R&R, which is extra nice since I haven't been able to sleep properly for about the last week. In fact, I've been so miserably tired I've started writing a blog post about 3 times entitled "Not glowing" referring to the difficulties of being preggo.

But, everytime I've started it, I've deleted it. Even though there are days (many) when I totally want to fast forward to August, I don't want anyone to believe for a minute that I'm not thrilled about this baby. Baby yes. Being pregnant...less so. It makes it even less tolerable when you're so excited to meet this little person who's coming to change your life forever! She's kicking the crap out of me even as I write this. Letting me know she's on the way and to get ready!

Days like today make me think about it even more since, seriously have you seen what's on TV during the day? Wow. And really, who studies on a snow day?! I can't wait till I have a little 1 1/2 year old to run around in the snow with on a day like today!

The big bright side right now...half done!!! Wahoo! On Friday we go for our anatomy scan, which means a lot less when you've had as many ultrasounds as we have! Since the big 16 week ultrasound where we learned she is in fact a she, my doc's checked two more times and there's no doubt in my mind, it's definitely a girl! Also on Friday I'm doing my oral glucose tolerance test. Basically I drink a high sugar syrupy drink and one hour later they check my blood sugar to make sure I am able to use it appropriately. Women become more insulin resistant during pregnancy so that a larger amount of glucose stays in the blood to be taken up by the baby. This becomes a problem when blood sugar gets too high and can lead to birth defects if it is uncontrolled early in pregnancy (we're past that point) and very large babies in women with poor control. Then after birth, the baby does not get as much sugar as it is used to, but it's pancreas is still kicking out a ton of insulin, so these big huge babies get hypoglycemic after birth and can have seizures from that. I have a strong family history of diabetes and so we are doing this test a little early. I'm hopeful that it will be ok, but this has been my biggest anxiety about pregnancy for years. Those women who have gestational diabetes are 66% more likely to develop type II diabetes later in life, so it's a big deal. Hopefully it will go alright; should find out by Monday or Tuesday next week. I'll feel better when that's done with!

I hope everyone enjoys their day, even if you're all not lucky enough to have a snow day!!

Light Reading

I don't think any one will really appreciate how pumped I am to have stumbled over a copy of The San Francisco Ferry Plaza Farmers' Market Cookbook! I love that farmers' market so much that it inevitably leaves me disappointed when I visit any market around here even in the bounty of summer. Maybe J, but maybe not, could understand how much I think about thsi place. I get cravings to go there. Many cravings. And not just because I'm pregnant. At least once a week I think about being there on a Saturday morning, seeing all the delicious produce and looking at the beautiful city, bay, bridges. I probably tell J about these once a month or less, so really I control myself better than I get any credit for. Anyway, I'm pumped to read the recipes and look at the great pix. It's like an early birthday present! (I love my birthday, and my birthday is tomorrow...woohooo!)

On a sadder note, I actually heard someone running for office on the platform that as a state legislator she "defunded Planned Parenthood." Whaaaaaa? Regardless of your feelings on abortion, I think we can all agree that birth control, affordable birth control, is one of the most important services health care can provide. In this country 50% of pregnancies are unplanned. The emotional, physical, and financial toll this takes is enormous, not just for the individuals involved but for society at large. I feel very passionate about pregnancy prevention, it is a major part of my desire to be an OB/Gyn. I'm not asking everyone to feel like I do, but seriously, I was taken aback by that commercial.

One more reason to read my awesome cookbook and turn off the boob tube!

Hard

Today I spent the day in a hospice setting. It was a difficult day. I really only saw one patient throughout the course of my day, she is dying from cervical cancer (don't get me started on getting paps in a timely fashion, that's for another post). Advanced cancer is painful, and this woman is in pain. Her family does not want her to receive pain meds because they've "seen other hospice patients and they are all out of it." They want her to only receive pain medications when she asks for them, or in med lingo, prn.

Here's the difficulty with end of life pain meds. Pain is difficult to control, particularly in patients who have a lot of it for a long time. And once the patient is feeling the pain and asking for meds, it is harder to keep it at bay than it is if we "stay ahead of the pain". By staying ahead of the pain this does not mean snowing people so they are completely incoherent. It means giving a monitored dose of long acting pain medication in a scheduled fashion so that people are less likely to need the short acting, heavy hitting "breakthrough" meds. In addition to the benefit of less pain, the patients are often less agitated and better able to handle their surroundings and are less likely to become delirious secondary to pain and anxiety.

It's also important for patients and families to understand that addiction to pain medications in this setting is almost never an issue. Addiction implies an illness defined by the patient actively seeking out a drug. Pain medications for chronic pain almost never fit this category. Dependence on the pain meds often does happen. The patient will grow to require higher doses, but often this stems from advancing disease processes rather than the patient getting used to a certain dose of meds. The patients may withdraw if they are removed from the pain meds, and this is also not a sign of addiction. In fact, withdrawal can occur even from antidepressants, a class of drugs which is not addictive in nature.

It's important to me that patients become informed about what palliative care and hospice really mean. It is not simply a place to die. In fact, hospice is not a place at all, but a philosophy of care. Hospice often happens at home. Currently the average patient is in hospice care for a median of 15 days. 15 days until they pass away. This is most often because both physicians and patients are not informed about when a patient may receive hospice and what kinds of services they may be eligible for when they do. If you feel a loved one may need Hospice care, or would like to find out more about what Hospice entails, please visit www.hospicenet.org.

The people who work with Hospice are about as caring and giving as it gets. I truly believe if more people understood hospice and what they do, more people would take advantage of this amazing benefit at the end of life. Check them out.

And as one last note from my soapbox - talk with your loved ones about your wishes long before you reach an end of life situation. It can make all the difference in the world.

I learned sumthin...

Everyone all year has told me how much they learned on the internal medicine rotation (re: rotation I just finished with). I didn't really believe them as I went through the rotation and pretty much just struggled to hang on for the ride. But now as I go through my family medicine rotation, I know that it's true. I know what meds to give people with specific conditions. I know when a symptom is very serious and can't be ignored, and when "it's just a virus." And I'm finally starting to understand treatment of diabetes. Starting. Diabetics who can alter their insulin levels to their carb intake are still much more proficient than I am. I'm starting to feel like a doctor. Or at least like I could someday be a doctor. Which trust me, at the beginning of third year, was not the case. And more importantly, I like it and know it was the right decision. Every now and again when the hours are long I haven't been able to shake the feeling that maybe I should have just finished the PhD and moved on. It would be done by now, there would be no residency to follow. But there would be no catching babies. No teasing out a history of potential endometrial cancer that may have gone overlooked. No pulling off ascites fluid to make someone's quality of life better in their end stage liver disease. It would be a different life. In some ways better (more time with the coming kiddo) and in some ways so much worse. I know residency will seem impossibly hard at times, but in the long run, I don't want to do anything else.

It does make it easier to feel this way when you get off work at 3 every day.....

Drumroll please....

For those who knew, this is not what we were expecting going into the ultrasound on Friday! He was pretty sure it was a boy! He sounded so sure we had even picked up some cute baby sheets that were on a crazy sale. Luckily, returnable. Those who know me well, know that I'm not a huge fan of the little girls covered in head to toe pink. Never has been my thing. I'm a little nervous.

When we went in, my sister came with us, but waited in the waiting room so me and J could find out the sex alone, then J went to get her. As soon as he left the room I said "oh god, here comes the pink nightmare." Please keep this in mind when looking at those "oh so cute" pink lacy...things. I do, however, love purple. And really, yellow is not as gender neutral as people think it is...how often do you see boys wearing yellow...

It will be great to have a girl. Almost all my girlfriends have girls, and it makes me excited for them to someday meet. Knowing what wonderful women are in my life, I know their daughters will have such great role models, and become such wonderful women in their own right. I just hope I don't screw mine up so she can fit in with all those beautiful ladies!

I am not, however, excited about how tight my pants are getting. It's a weird feeling to feel like you'll fit into your clothes one day, then the next there's no way that button is getting to that hole, no matter how hard you try. Tough stuff for any woman, any person really. But I'm trying to stay positive and today I finally feel like I am well enough and have enough time to get back to the gym. I got the red light on running/jogging and that makes me sad, so I guess I will become one of those power walker types. The big guy should appreciate that. Not that any of this will help the expanding waistline (clearly) but I'll be better ready for delivery (too scary to think about really right now) and hopefully I can stave off the dreaded ankle swelling. Blah.

Well, I do plan to keep updating this site on the baby, but I won't forget about medicine stuff too. I will be starting family medicine today, and I'm really looking forward to it. I'm even more excited for it since I got an email from my attending saying she works from 7:30am to 3pm. Nice!

Tests and tea.

For the first time in what seems like months I feel well rested and really excited. I was granted the last day of clinicals off to study for my exam, and my dog actually let me sleep until almost 9! I do plan on studying a lot today but I also plan to stop my whole foods for some delicious grub for dinner to celebrate the end of a very tough clerkship. And no one's more surprised than me that I liked it. My patients were very interesting and I couldn't have gotten luckier for my team. My residents and interns were super helpful and let me have just the right amount of autonomy. My attending was a really great teacher both on rounds and in these didactic lectures he prepared for us. When I saw the last group of students leave the U at the midpoint of this block, I was sure I would hate it. They looked exhausted and so UNHAPPY! But, though I am exhausted (or was last night), I am not unhappy with my experience. And the best news of all, one of my patients is getting written up for a journal and I'm going to be published! If I got nothing else out of this rotation, which I did, that would be worth enough.

Even better is knowing what the weekend brings. Yes, I have a crazy hard test on Friday morning, and a less hard but still irritating test on Thursday morning, but then the fun begins! My sister is coming in while I'm taking said crazy hard test and will be at my house when I'm done! That's the day we'll find out the sex of the baby, so that's pretty exciting too! We're doing 5280 week for dinner and I'm super excited about it. Then Saturday we're going to the Celestial Seasonings Tea Factory for their tour. I haven't been there since I've been a little kid and it just seems like a good thing to do when you're pregnant and can't go to the beer tours :-(. It feels good to have lots to look forward to and some time to rest before it all goes down.

But a question, anything up in Boulder that we absolutely shouldn't miss while we're up there? I really would love to go to Redstone meadery, but I don't really think my sister would like it, and as previously mentioned, alcohol and pregnancy etc. But any place to eat or see on a February day you can think of? Comments appreciated.

Getting there

Well, I'm over half done with my time at the U. I am exhausted. This week I have Friday off since I am on call next weekend. Two more call days. I don't sleep so well at night these days, and I pay for it during the afternoon when the work slows down but I'm still stuck in the hospital. Since today is pre-call I am hoping we'll get out a little early, but we picked up a ton of patients on Friday call and haven't discharged very many. Which means we'll probably be pretty busy trying to get that accomplished today before we are on call again tomorrow. It makes me feel a bit less optimistic about the finish line when I'm so tired and I'm starting to get sick (I am never sick, is it kosher to blame the unborn?).

But there really is a bright side. I have 9 work days left of internal medicine. And on the really bright side, I do not hate it as much as I thought I would. I've been lucky to have a good team that is interested in making sure I learn lots and make me feel like I'm helpful,and when there's nothing to do, they make sure I get out of there. And at the end of the tunnel my little sister is coming out for a visit! And at that point I will have only one more rotation in my third year. Today or tomorrow I should get my fourth year schedule, and I'm really, really hoping to get the sub-internship (aka acting like an intern, not getting paid) I hoped for in May. It'll give me some peace of mind to know I'll get through the 4th year requirements and that I'll graduate on time even with the baby.

If I can just make it through 9 more days of squeezing like a sardine into my normal clothes I will be a happy camper. Four of those days are call or post-call, so those are scrubs days. And I have to thank my dear friend D who hooked me up with some more options for when my normal clothes are no longer an option. You are the best!

Hopefully I'll write about some of my weird stories in the days to come. But if not, I'll catch you all on the other side of medicine.

Kind of a Big Deal!

So, I've been about bursting with the news, and now it's official. Rocky and the little guy are going to have a baby to protect, starting in August. By ultrasound our due date is August 5th. My sis's bday and our anniversary. By dates, I am due on August 12th, so you know, somewhere in between would be a-ok.

It's a pretty great story, how we found out. We knew having a baby 4th year would be pretty perfect for us. Lenient schedule, lots of flexibility. So it was in the works. As lots of you know, though, I have endometriosis. Not a huge deal, but can get a bit painful when I'm off birth control for long lengths of time. It was reaching that time. So my preceptor, who I'm thrilled to say is now my OB, was planning a surgery in the beginning of Dec to clean me up. An added bonus of the surgery is the increase in fertility following so it would be perfect. J and I showed up that morning all set to go, got the IV going, left some pee in a cup, and we were wheeling back to the OR. The anesthesiologist gave me some Versed, wicked stuff that cuts the anxiety, and I was pretty out of it. I scooted over to the OR bed and that's when things started to get a bit hazy. I remember Dr. B saying we couldn't do the surgery because I was pregnant. And I remember bawling my head off when the pre-op nurse handed me the positive tests in a ziplock baggie for me to keep. I remember crying and asking if I would remember this (because Versed has amnestic properties-can't shut off the med student in me), and I remember coming out of my haze and seeing the pictures J took on his phone of me clutching positive pee tests to my chest and crying like a little girl. It was a pretty great day.

I'm really excited, but I know I'll be even more excited when I'm done with internal medicine and have more time to think about getting the house ready. But being in medicine when you're pregnant has it's benefits! It is really great to have immediate access to ultrasound whenever I want. And Dr. B is always excited to see the baby. I've had 6 ultrasounds already, and he's pretty sure of the sex...but I won't post that 'till he will commit to it for sure!

Anyway, we're excited. Very excited. And even more excited to be out of the first trimester. Zofran was my best friend. I am starting to feel like a new person, but really tired. Could be partly due to internal medicine. So in four weeks, bliss.

Skool is hrd

So, let me start out by saying that internal medicine is not for me. I had guessed this before I even started by 3rd year. I didn't really have a reason for it at that point though. I knew I didn't like to round for hours on end, and that was as far as I ever got. Well, I've learned a lot about myself, internal medicine, aging, all sorts of stuff really, in the last 2 and a half weeks.

I ended up getting extremely lucky (again!) with my assignment for a rotation. I am spending this first 4 weeks at St. Joe's. I'm in love with the place. Internal medicine here would be wonderful, if you're into that kind of thing. They work on a night float system which means no overnight call unless your on Friday or Saturday. This makes for happy residents from what I can tell. Call on the week days involves admitting until 7, then finishing up what you've started, and leaving by 9. The day usually starts around 7 am. These are great hours for internal medicine. Truly. During the day the teaching is exceptional. Every day there is morning report where different teams on the wards and the unit present interesting cases and we all sit around and generate a differential diagnosis a la "House". It's a great way to learn. Then at noon there is a conference every day where an attending presents an important topic to help with patient care. Oh, and they provide lunch at that conference every day (M-F). Then there is a teaching attending assigned to each ward team who meets with the team for at least 3 hours a week. For us, we present a patient and go through the House-esque routine again. Then we see the patient and all assign each other a topic to look up to help us better understand the case. It's great experience. Once a week we do the same with the head of the department. It's busy, very little down time, and I am pressed to get my progress notes done in a timely fashion, but so worth it.

So, no, it's not the rounding or hours that deters me from internal medicine. It's just the type of patients internal medicine sees. They are so complicated!!! Me, I like to look at a single problem at a time: i.e. baby's coming, I better catch it! Somewhere along those lines. Internal medicine is complex, with each patient having 10 medical issues that are all intertwined and all of which need addressing. These docs are the thinkers. They have to look at it all. It's easy to miss stuff. I told my resident today I don't think I'm smart enough to do what she does. And that's not necessarily what I think, but it's close. I am just at my best when I can know a whole lot about a smaller area. It gives me confidence that I won't miss something huge because I'm so bogged down with the details. I give those docs credit. They are amazing. And I am lucky to have a great team that really is invested in my learning. My resident even told me she thinks it's her job to make sure when I go to the U next month that I look like a rock star. I'm learning so much, but it's taxing and I'm tired - even with this great schedule. The patients can be very sad, lots of end of life issues.

But there's a lot of hope in this field too, so I see why people like it. I actually had a patient who was 98, and when I walked into the room for the first time and saw him lying there, I turned around and walked out because I was sure that was a 60 year old! Nope, 98. "I climbed a lot of mountains in my day." That's his secret. Guess J was right about that afterall.

I only have a week and a half left at St. Joe's. Then I'm back to academic medicine. I'm pretty sure that type of medicine, any field - not just internal - is not for me. I like private practice. I like how nice people are, and I like how they still respect you as a person while acknowledging the fact that there so much more to learn. My experience at the U has been one of a very strict heirarchy. A place where you never forget your "station." It's only 4 weeks. It's only 4 weeks. It's only 4 weeks...