Bitterly sarcastic and enjoying it

I feel like being bitter and sarcastic. Deal with it. Herein find my solution to June, when all my friends will be talking about their new babies.

Husband and I just filled out the most adorable retainer form for the lawyers.

We just got the cutest little message about how some new obstacle came up.

You wouldn't believe how darling our embryos were as they failed to survive the thaw.



Who needs to talk about babies when you can coo over infertility?

Dear Someone: Our heroine wishes she had someone who would listen

Mama keeps saying I am depressed but I disagree.  I just need someone to listen.  But how could she understand, really?  She had four children, effortlessly, without even one month of disappointment.  She had me while trying NOT to have children!  So what could she possibly understand?  Yet I so wish she understood.  Other people realize this hurts.  Why doesn't she?  And Mama's failure to understand hurts almost as much as this whole process.

I just want someone to listen and to give me a hug.  My internist/mentor is so wonderful and caring, but by now must be exasperated with my whining; moreover, she's got her leadership roles at the medical school and her family for which to care.  I shouldn't keep burdening her.

I should learn to comfort myself without imposing on others.  Perhaps this writing will help -- if nothing else, at least I can complain without anybody else being forced to read this.

Chag Chanukah Sameach, update, and not going to lie -- sometimes I am just plain jealous.

Happy Chanukah everyone!  While actually a minor holiday, it is definitely top of the "fun" list.  No crazy rules/regulations other than playing with fire for eight nights :o) and eating fried food.  Specifically, potato latkes and sufganiyot (aka jelly doughnuts -- or if you're like me, dolce de leche filled :o)  As my baby cousin says, "delicious!"  I agree.

Still, first on my mind is Operation Baby.  We met with the new potential surrogate, "N."  She's lovely and we had a great time getting to know her.  Chicago would actually have been a lot of fun too, except Husband was tired and cross and stressed about everything so he started telling me he hated me and that I make his life miserable.  That part was not lovely.  I held my tongue and let him vent because I know he gets like this every time we travel to do something Operation Baby-related.  But I wish he didn't take out his frustration on me.  It hurts.  At least I don't *think* he means it.  But what if he does?  What if I really am a horrible wife and he would be better off without me?  At least without me he could find somebody who would give him children.

We should find out within a week whether or not N's bloodwork came back okay.  Even if it did, I still don't expect to end up with a baby.  I don't even want to hope.  Hope is a painful, stabbing hurt and I refuse to get snared in that mousetrap again.

And in other lovely news, my new pt admitted by night float is a G8P4 who doesn't even want the baby who took up residence in her uterus 5wks6days ago.  And who may be skin-popping.  And who has hydromorphone-dependence issues.  I know I should be counting my blessings, but sometimes I struggle.

At least I was able to wish my friend C congratulations on the birth of her (second!) baby boy.

Through the Looking Glass: What it's Like to be Infertile

If you want to understand what it's like to be infertile, try this simple exercise tomorrow:

1. Count the strollers, toddlers, pregnant women, and babies.  A newborn or a nursing mother counts double.   Extra-adorable babies also count double.  (And all babies are extra-adorable.)

2. Count how often raising children comes up in conversation, especially raising small children.  Yes, even the little things like "I have to pick my daughter up from day care again!"  Notice particularly what turn the conversation takes when a pregnant woman is around.

3.  Count the TV commercials related to babies/parenthood.  Aren't there a lot of them?

4. Pretend you must answer the question of "Do you have any kids?" when you would cut off your right arm in order to answer yes.  But you have just miscarried.  Again.

Do this while imagining your family telling you this painful struggle is "no big deal," your pain is complete overreacting, and more friends are getting pregnant each week.

Why am I so sad? Is this too sad?

Why am I so sad lately?  I cry after a disagreement with Husband, on my way home from the hospital, at morning report yesterday -- and I wasn't even the one presenting or being questioned!  And morning report is usually the highlight of my day!  I cried at Thanksgiving.  I even cried on the way to meet a friend for shoe shopping.  This week alone I have cried at least four separate times.  But what really bothers me is that I can't focus.  I go to work but my heart is elsewhere.

Mama says I should "get over it" by now and that if not I need an antidepressant.  My grandmother says it's "just" a miscarriage and that it is nothing because she lost a toddler which is much worse.  They both make me feel so alone.  I just want someone to listen and understand.  At least I got a little bit of that today -- thank you from the bottom of my heart if by some strange chance you are reading this.

It's been 3 months 19 days.  Oddly, the blanket of sadness is heavier now than it was right after losing the babies.  Its weight suffocates and paralyzes.  I can't focus at work.  I don't call my friends and I don't feel like hanging out with people, although I have dragged myself out a few times.

Is this clinical?  I don't know.  I get dressed every day, go to work, even apply makeup.  I can joke and laugh with my fellow house-staff and with the medical students.  All of which argues against a diagnosis of MDD.  Except then the sadness returns and I want to cry into my childhood security blanket.

My mentor told me I had the strength to get through this but maybe she overestimated me.  I am a self-centered, narcissistic emotional wimp who can't appreciate the countless blessings she has right in front of her.

What Not to Say to someone who can't have children

This is what I wish my family wouldn't say to me:

1. "You haven't been trying for that long."  So that makes it better?  And is that what you told the medical student who miscarried?  Probably not.  Oh, but it was different because she was carrying the baby, right?  I was less of a mother to be.

2. "I wish you would adopt."  We have our reasons for choosing to pursue surrogacy first.
 - Judaism is matrilineal and I don't want my children to have trouble proving their religion when they want to get married.  (Assuming we have children.  Which is, of course, unlikely if not impossible.)
 - Husband has this (foolish and mistaken, but I'm stuck) idea that it's important to pass on his genetics and he "doesn't feel ready" to adopt.  I can't do this alone, so I have to try surrogacy for now
 - It's our decision, so please stop nudging us.
 - If you get to have biological children, can't we at least try?
 - it takes less time, is easier to arrange, and you can actually get a newborn.  It's virtually impossible to get a newborn through adoption these days.

3. It's just a miscarriage.
 - No, it is NOT just a miscarriage -- and a double-miscarriage at that!  There is no such thing as "just" a miscarriage.  Miscarriage hurts deep inside and never stops hurting.  Ever.
 - Unlike most women who miscarry, I can't just try to get pregnant again.
 - I am looking at the very real possibility of NEVER having children.  Most of these other women aren't.

4. "Of course everyone you know is getting pregnant.  It's the age."  If it's the age, why don't I deserve to have a baby too?  Just because I can't have a baby, does that mean I should have to be perpetually on the outside peering in through the window into a family life I don't get to have?

5. "You have to tell yourself, 'I'm next.'"  That would be nice, but I know I won't be next.  There is too much time and too much fertility out there for me to be next.  And so far my track record, even with a successful implantation, is 0/2.

6. "Be glad you didn't have to deal with the physical miscarriage."  That's right, I am just thrilled that I'm not allowed to carry a baby and that we have to go through the complexities of surrogacy.  When I was a little girl I used to say, "I wish I could struggle for years trying to make a baby!"  And do you really think the pain is less?  Because that's what you imply.  Baby B and Baby A may not have grown inside me but I loved those little ones and I was NO LESS of a mother-to-be just because I wasn't physically pregnant...or was I?  Because that's what your subtext is.  And I was an English major.  I know subtext.

7. "Be happy for your friends who are getting pregnant."  I wish I could, but it's a struggle.  I am envious and guilty about my envy and it doesn't help when you tell me to be happy for my friends.



Here is what I wish you would say:

1. It must be frustrating dealing with this,  especially since you want it that badly.
2. We will support however you decide to (try -- probably unsuccessfully) to build your family because whatever you choose was what's right for you.  And if/when you decide it has been too painful to continue unsuccessfully, we will support that decision too.
3.Miscarriage is hell, especially since there is no tangible loss, and especially since you worked hard for those babies.
4. It must be hard watching all your friends do so easily what you struggle to achieve, and to realize that your relationships will change so drastically when the babies come.
5. It stinks counting the fertile friends and knowing that even if by some strange miracle things go okay, there will certainly be more pain before there is happiness.  And since your success is unlikely, we understand that you think bitter thoughts each time someone says she's pregnant.
6. I know how much you wanted those babies and I know how much you loved those babies.  You are entitled to grieve.  You were just as much a mother-to-be as every other women who loses a pregnancy.
7. Of course you cry and mope and can't get out of bed when your friends keep telling you they are pregnant.  It is a natural reaction.  We are here to hug you.

If you are reading this and you know someone struggling with infertility, please take this into account.  Your barren buddies will thank you.

Struggling with envy

I don't get it.  I have so many wonderful blessings, and my life is filled with such wonderful family and friends.  So why can't I be happy with my portion?  Instead I envy my fertile friends.  When they tell me they're expecting I wish them an easy pregnancy and a quick delivery and a healthy baby.

But inside -- I have a five year old kicking and screaming and throwing a temper tantrum  "Not fair!"

How come I can't learn to appreciate what I've got?

And also I wonder what will happen to my friendships.  All of my married friends but S and D will become parents over the next six months.  Their lives will change completely and what will we have in common?  Everyone will be focused on his or her baby.

I will be watching from the window.

Update

Seems our surrogate has an appointment for her initial consultation next month.  But I refuse to get excited because I will only get hurt again unless I assume the worst.

What could be more fun for an infertile than four pregnancy announcements in one week and a birth?

FIVE pregnancy announcements of course!  I extend a hearty mazal tov to S and E.  At least, I would like to.  But with all the pregnancy announcements going around, couldn't I have just one of my own?

When will it stop hurting so much?

Just sad

I know there will be good and bad days.  I know there is so much in my life for which I must be thankful.  So why do I still feel like crying every day, and why is the only think I think about when I'm not at the hospital (and sometimes there too!) babies and my lack thereof?

Infertile answer to pregnancy announcements

My dear Husband and I are pleased (not) to announce that we are expecting...Nothing!  A lovely bundle of emptiness will be delivered to our arms in several months' time.  It was impressively easy to conceive this infinitesimally small package, and we hardly had to wait for little Nothing to make its upcoming presence known.  Apologies that we can't show a picture -- after all Nothing is difficult to characterize.

Poem to the son I almost had

To my almost-son

I loved you in black and white,

counted your fingers, traced the contour of your face

as it changed each week.

You would’ve had your Abbas’s nose. 

...and it just keeps getting better

Clinic conflicts ended up landing me on a different team than I originally thought.  I'm on the team with geriatricians rounding on general medicine, and...Dr. C is our attending for two weeks!  I get to learn from a true master clinician.  Yes, feel free to be jealous :o)

Dreams really do come true

My co-intern wants to switch rotations with me.  I'll get to round at my favorite hospital on my favorite service (Infectious Disease attendings rounding on general medicine).   Bring it on, endocarditis -- preferably with Roth spots, Janeway lesions, Osler nodes, splinter hemorrhages (although they aren't part of the Duke criteria).

Hmm..birthday quandaries

To buy a fancy Proctor Harvey stethoscope, a Sapira textbook, or a copy of my mentor's textbook (can't remember its name)?  Cast your votes -- only three days to go!

My good Sir William Osler: Eat your heart out.

That's right, Osler.  Guess what physical findings I saw today:

1. aortic insufficiency: pulsus bisferiens, bounding radial pulses (not quite water-hammer), diastolic murmur
2. tricuspid regurg: giant V waves, head bobbing side to side, pulsatile liver
3. sinus venosus ASD: fixed split S2
4 hyperthyroidism: goiter w bruit, agitation, hyperdynamic state, tachycardia, fine resting tremor
5. TR again: REALLY giant waves, beautiful murmur again
6. summation gallop
7. HOCM murmur (see yesterday)
8. status epilepticus: rhythmic flickerig eyelids

I continue to be indebted to the wonderful patients who share their bodies with me and who are so willing to be my teachers.  You are truly generous and I must endeavor to "pay it forward."

It's that time again...time for another wonderful day in the world of Physical Exam

Dear Abraham Verghese,

Today I examined a patient with HOCM.  I then examined a patient with tricuspid regurgitation and atrial flutter w 2:1 conduction.

The first patient had the most beautiful murmur and it changed just as expected with standing and squatting.  (I tried Valsalva but she couldn't hold it for long enough.

The second patient had:
1. regular tachycardia
2. funny thick blood vessel w shiny middle on R funduscopic exam
3. JVD to the earlobe with giant V waves
4. diagonal earlobe crease consistent w atherosclerosis
5. loud P2
6. there must have been a murmur, although I couldn't hear it (but then my hearing sometimes seems to be going and I know Turner's is associated w sensorineural hearing loss)
7. abdominal distension w +ve fluid thrill
8. pulsatile liver
9. b/l pitting edema to the knees, worse on the L

Beat that in just two new patients!

Sincerely,

Mim.

On a daughter-of-an-infectious-disease-specialist-note

When did ceftriaxone/doxycycline become the treatment of choice for congestive heart failure exacerbations?  And did I mention that I HATE CLONIDINE!  Oh, and when someone's blood pressure is 240/130 it may be wise to ask if she missed her midday dose of said clonidine and spare yourself the nitroglycerin drip.

Or in other words: TAKE A HISTORY, and (pretty please) stop misdiagnosing CHF as pneumonia!

Sound advice on coping with Infertility from a website I came across

If only I actually followed this advice.  But in the words of Alice in Wonderland, "I give myself good advice, but I very seldom follow it."  Lewis Carroll was a wise man

Anyway, for anyone out there struggling with the same feelings I battle, the excerpt below might be helpful.

The Short Course on What NOT to Do to Cope with Infertility

Put yourself down for being infertile. The trap-buster he suggests is that you get a paper and pen , and make a list of the negative or self-critical things you've said or thought in the last 24 hours. Next, pretend that a close friend is also infertile, and has said those things you've written down. Now, for each item, ask yourself what you might say to him or her to cheer her up. What advice would you give your friend when she begins to feel so low, and so self-critical ? Be your own good friend, and say these things to yourself !

Lose control over your treatment and your life. Retaining a sense of control is one of the essential ingredients of emotional well being. The more control you are able to exercise in your lives ( even if it is for something as simple as to what clothes to wear) the happier and emotionally healthier you'll become.

Don't feel grateful to anyone for anything. Gratitude improves emotional and physical health. Saying "thanks" keeps us human, and helps keep us happy and healthy.

Don't have a sense of humor. A sense of humor and an appreciation for the absurdities of are valuable resources to use to help you cope. Check out our infertility cartoons for a quick chuckle !

Don't take time for yourself. Many women are so used to putting others first, that they often end up neglecting themselves. However, if you don't take care of yourself, you'll never be able to take care of anyone else ! And you don't score any brownie points for being a martyr either ! DO ONE SMALL THING A DAY TO MAKE YOURSELF FEEL BETTER - you are worth it !

Don't take responsibility for your medical care. Obviously if you don't get good medical care you're reducing your chance of starting your family even further ! Unfortunately, many patients still hold their doctors in awe, with the result that they often settle for poor quality treatment and even worse service in the clinic . Don't fall into this trap - there are lots of good specialist around - find the one who is right for you.

Dwell on your infertility day and night. This is one of the easiest ways to get seduced into misery. Remember that there is more to life than having a baby - don't underestimate your contribution to making others happier; or minimize your success in the other areas of your life.

Isolate yourself. Isolating yourself makes it much easier to forget that no matter how serious your problem is, there are always people who have it much worse. While knowing that won't make your infertility better, it will help put it in perspective. Join a support group - supporting others can help you support yourself !

Brief note to my long-lost friend Sleep

Dear Sleep,

I miss you.  Hope you are well.  Would love to spend more time with you.

Love,

Mim

The meeting went well, and both Surrogate and her husband and my Husband and I agreed to proceed forward.  The difficult thing now will be preparing mentally and -- more, really -- emotionally.  I am so afraid to open myself up to another disappointment.  I try to be pessimistic just to shield myself -- if I expect the worst I can't be disappointed, right?  But oh, if it were to work out -- no, must NOT entertain that possibility.  Not unless I actually embrace a live baby.

I wonder if it's normal to be so unfocused and still sad two and a half months after losing Baby A.  I definitely don't have the motivation or the mental energy I wish I did.  I know I'm not caring for my patients the way I should.  I can barely remember physical findings and keep confusing which patients have which findings.  It's completely unacceptable, and yet it continues.  My program director thinks I am doing well and am one of the top interns, well ahead of at least my July senior resident.  But I know she's wrong.  I am nowhere near the level at which I need to practice medicine.  And my mentor reassures me I will be okay.  But what if she's wrong too?  I'm really terribly average at best.  And one day there won't be anyone overseeing me and preventing me from killing patients, and then God help us all.

In other medical news -- no more ramipril.  This cough got way out of hand.  It's on to a more distal part of the RAA pathway, and hello to losartan.  Hope the ARB keeps my BP down and doesn't cause a cough.

Quick Update

This will be brief as I am exhausted despite sleeping eleven hours last night.  (Okay -- I'll admit those hours were punctuated by numerous coughing spells.)  We had a lovely lunch at the Indian buffet joined by Mama and Mama Phyll.  All I can say is, no dinner necessary after that brunch -- it would only be a downhill move.  

But now the update for which you (probably have not) been waiting.  The telephone meeting seemed to go well -- we're agreeable to proceed and hope Potential Surrogate and her husband are too.  Of course I can't post details about them.  We'll hear tomorrow if they want to proceed.

The remainder of the day was spent reading Dale Dubin's Rapid Interpretation of EKGs, but also a conversation with my best friend who is doing her surgical internship in another state.  S, I miss you!  Come home!

Debating whether or not to celebrate my birthday.  The idea of making a party sounds like too much energy.  Maybe if I don't have to cook/bake...Coldstone cake-batter ice cream cake anyone?  Or my favorite lemon-raspberry torte?

But now, shower and bed.  Five CCU patients tomorrow -- yikes!

Well, here we go again...

Different agency, different surrogate, same process.  Tomorrow we're scheduled to have a conference-call "meeting" in order to get to know a potential new surrogate since she lives in a very far-away state.   

For anyone curious about what these meetings entail, they are usually moderated by somebody from the surrogacy agency or by a psychologist.  The questions usually are  

  o   General Background (hobbies, employment, family, residence)

  
  o   Fertility Story (physician, reason for using a gestational carrier, fertility treatment history and future plans)
  
  o   Surrogacy Expectations (communication, presence during prenatal visits, delivery)
  
  o   Thoughts regarding multiples (including how many embryos will be transferred, views on selective reduction)
  
  o   Views on genetic testing as well as termination of an abnormal fetus. 

Right now I'm dreading another go-round.  Honestly, I'm terrified to do this again.  It just seems like it's only a matter of time until the next disappointment.  And the cruel thing is, the disappointment usually hits just when my hopes are highest.

So meanwhile I'm trying to protect myself.  When nothing works I'll devote myself to my patients and spoil my littlest cousin and pretend she is my own.  I will get used to it.  You can get used to anything, right?  And I'll cling to the promise of those six babies I will (hopefully not until I have lived a long and full life) have in Heaven.

On that strange note, those of us setting alarms of 0530 tomorrow had better go to sleep.  Goodnight all!

Irony of the week awards, and PLEASE -- SOME ADIVCE!!!

I am utterly exhausted, and so frustrated with being such a bad physician and intern, and just wish I knew how to improve.  ANY ADVICE WELCOME!

But at least we have irony.  Here's for the irony of the week awards:
1. My patient asked me if I have any children.  "No," I replied.  "Why?"  His answer:  "You're very maternal."  If only he knew.  Maybe caring for patients will have to be my maternal outlet.  I've come to expect only the absolute worst.  I keep myself going by reminding myself that my Heaven will have six babies eating for me, and my great-grandmother too.

2. I keep getting email from some breastfeeding organization.  Seriously!?  I couldn't do that even if I were ever going to have babies.

3. I also get invited to the Family Planning Conference on a School-of-Medicine-wide email.  Again, seriously!?  My single streak ovary and I only wish I had to worry about family planning.  Instead I must plan a life with no family and learn to accept it with grace.

4. Several people this week asked me "How's the baby?" or "You must be getting excited."  I don't think this one needs an explanation.

Bad Mim!

Honestly, I'm not sure I deserve to be a resident.  I admitted a patient with pneumonia complicated by pleural effusion.  I performed a thoracentesis (drained fluid in the space between the two linings of the lung) and since the fluid was purulent, foul-smelling, and turbid, I labeled it as empyema.  (Which it was -- see the beautiful Gram's stain below!)

As is protocol when performing a thoracentesis, I ordered a STAT chest roentgenogram to evaluate for iatrogenic pneumothorax.

But did I check the roentgenogram?  No!  I am pretty sure I didn't or perhaps I glanced at it far too quickly.  I assumed my senior was following it.  (Shame on me!)  I also shouldn't have assumed Surgery was reviewing it.  (We consulted their service for chest tube placement to drain empyema.)  While I tried to push for a chest tube overnight to drain the empyema, I didn't realize that I had caused a pneumothorax.  If I had, I would have gotten that chest tube in immediately.  Instead, my poor patient didn't get his chest tube placed until the morning after admission, a good sixteen hours after I created a pneumothorax.  He's lucky he did okay.  He was never symptomatic from his pneumothorax but his pneumonia was so bad that he was already requiring supplemental oxygen at that time.

There must be a special guardian angel looking after my poor patients.  And from now on I will make ABSOLUTELY sure I review post-procedural studies on my patients.

Thank you, God, for getting my patient through a serious medical mistake!  Let's hope he and all the other patients have a speedy recovery.

I don't want to hope

I don't want to hope because it hurts too much.  But we did find a second surrogacy agency, and they have a surrogate available in Florida.  I'm sure there will still be plenty of fun and exciting roadblocks and we will get our hopes dashed.  But for now, at least it isn't bad news yet.  And maybe the pomegranates we eat tomorrow night will bring luck.

Aren't I sweet and Pollyana-ish?

Details to follow once we have more.

It's self-centered to document the silly little chronicles of my life, but then nobody is required to read, so I suppose it's okay.

I'm writing this from my brand-new laptop, bought with the sweat of two floor months and one night float. A lot of H&Ps went into me being able to afford a computer.  It is a good feeling to be able to say, "I earned this computer.  I worked hard and saved up and then I walked out of the Apple store with a 15-inch MacBook Pro."  I am grateful to my parents for all their support, but I feel bad asking them for money when I am married and supposed to be an adult, so it felt nice to purchase this computer myself.  We would still need major assistance if a surrogate or two would ever walk into our lives, but then who knows -- maybe by then we will have saved up the money ourselves.

Okay, focus on the positive -- so many people wish they had been expected to medical school, and (kinehora) I have a wonderful family and husband.  And I should remind myself that I get six children in Heaven.  But I wish I could have some soon too.

A visit from one of my best friends is just what I needed!

But I am on call tomorrow, so details later.  Love you, S!  You are a second sister and I will miss you SOOO much until I come visit you in April!

In response to my last post

I have the BEST program director in the world of Internal Medicine!!!  One little email and everything is set.  Passover 5772 (2012) in Israel, here we come!

The Joys of Residency: Maternity Leave for a Lost Baby

Aren't I lucky?  I don't get to have a baby, but I do get to have four weeks' maternity leave for a baby who's never coming.  In late January, when Husband can't even take vacation. 

It's not that I can't switch.  But who'd be willing?  I sent a mass email and nobody came forward.  I'm sure they'd help if they could, but it's tricky to find someone with the appropriate schedule since every schedule change affects everyone.

I'm okay with having an extra floor month.  I can handle having only one elective month.   But must they rub salt in my wound by making me take "maternity" leave?  Or is it, taking leave of any hope of maternity?  Or maternity leaving me behind?

But these word games don't make me smile at all.

Musings

First of all, I should correct my previous post entitled "Heaven."  Actually my Heaven will have six children.  How can I forget Baby B, and my almost-son Baby A.  And of course my beloved great-grandmother will help me take care of them, because she is already keeping watch over them until I (hopefully not for a long time) join them.

I'm super sleepy right now.  This rotation started out light but somehow the "VA spa" Red team grew to fourteen patients and didn't diurese, and we have some very ill patients.  I don't mind -- challenge is good -- and in fact my day was less bad today because I got to Gram stain :o)  I have missed one Gram stain, third year, of course when my mentor was rounding and I wanted to make a good impression.  I have not missed one since.  I also spin my own urine, examine my own peripheral blood smears (and now know how to make them),  review images with radiologists.  Oh, and I EXAMINE my patients.  Should it worry me that I might be the only intern doing so?  And that I try but still don't do all these things on all my patients each time I should?  I really worry about the future of medicine.

Magical thinking

...because if being realistic doesn't help, why not have fun believing in fairy tails?

Maybe if we wish on the first star the Blue Fairy will come and turn our kitty into a real girl? It worked in Pinnochio.

Heaven

If I can't have babies now at least maybe when I die my Heaven will have babies. I will have four babies or as many as I want. I won't have to wait for them and worry that they won't survive gestation beacause in Heaven every baby is born healthy and happy. They will be sweet, good, beautiful children. The eldest I will call Nessa, from the word for miracle. My second I will name Gila, from the word for joy. My third will call Rina, from another word for joy. And the youngest? She shall be Liora, my light. With each child we will have joyous celebrations welcoming their arrival: all sorts of sweets -- knafe, different ladoos, seven-layer cake, home-baked Tzvia cake, name cakes (of course!) and brownies, and special date cookies, and komish cookies, and strudel, and there will be klezmer music in the background, and everyone will given the new baby a blessing -- not in a religious way but in a fairy-tale way. And the children will be endowed with all those blessings because after all, this is Heaven we're discussing. And because it's Heaven I will be able to control time. I can mother newborns if I want, or take them by the hand to their first day of school, or go back and watch them take first steps, or fast forward and watch them graduate medical school. I will be able to enjoy first words over and over, and the heartache will end.

Maybe this way I can tell myself motherhood WILL happen -- only later. And Heaven lasts a lot longer than life, so really I should consider myself lucky.

Right?

Glum

Today I don't feel better. I feel sad sad horribly sad and bad and a little bit mad. I guess it comes in waves. We went to my favorite restaurant this weekend but lo! Ther was half the residency celebrating R____'s baby boy, who is to be delivered by c-section in less than two weeks. And of course I ended up sitting beside her in clinic today, and she asked me when Husband and I are planning on children. I told her what had happened. I changed the subject but it was a hard day. And yesterday I felt sad too. When my grandmother asks me if there's any news I tell her it will take months -- if we're lucky. And then I get sad thinking about it. I don't feel like doing anything all day but curling up crying. I haven't even an interest in reading about my patients. I try to force myself to care about them and at least to focus when I'm at work but it's such a struggle...even today I am afraid I should have appreciated that my patient had osteomyelitis and not just soft-tissue infection. Actually I don't know yet that he does have osteomyelitis because I tried to probe to bone with a metal probe but wasn't sure what I felt (having never tried before), and the imaging is pending. But what if I wasn't treating him with appropriate antibiotics? What if I narrowed the spectrum too soon? What if I's my fault he ends up with a BKA? That is completely unacceptable. I should never had been given an MD.

But mostly I just spend most of the day thinking about the baby I had and didn't have and won't have, and the babies I am afraid I won't have, and being sad. Even when I'm interviewing a patient, or examining a urine slide and Dr. J________ is teaching me about tubular cell casts, I've got babies on the brain. I feel tired all the time and nothing really seems like fun. I don't even feel like taking a walk. I feel only like curling up with my childhood security blanket and crying.

At least it will soon be September. September means ACP State Chapter meeting with the amazing, awesome, Thieves' Market (David Scrase rules!) and my best friend is visiting and then it's Rosh Hashanah. I love the new year, the family all gathered together, the start of fall, and of course the feast. And again I will pray that God finds me meritous this year and grants me children. But I'm pessimistic. And I'm angry. I prayed so hard and it brought me only heartache. Another new year without a baby. How many more?

In Which our heroine learns to bury heartache deep inside in order to care for a patient, then learns flexibility in scheduling

It is possible. Even when the heartache is so great that you spend a part of each day curled up with your childhood security blanket staring sideways out your bedroom window at the trees, too sad even to cry (there is such a thing), you can compress the heartache into something small, bury it deep, and do what must be done.

I wasn't sure I could do that until today.

But I can. I did. My first patient of the day was a pregnant woman, 30 weeks along, with three other children at home. She may be induced early for polyhydramnios but still has a good shot at a healthy baby. And it's a boy. I was tempted to ask that someone else take the patient but I didn't let myself. I saw her, took her history and examined her, felt that baby's head and saw hr excitement. I presented the patient to Dr. B_____ without showing a hint of my inner feelings. I didn't even cry afterward although I was definitely in a funny emotional state all day.

Okay, no crying may be because there was no time -- I was pulled from my carefully-requested Hematology Consults elective to fill an open intern spot at the VA on general medicine floors. To be accurate, Mama requested that I be the intern pulled because the senior on the team with an open spot is supposed to be wonderful. I was not geared up for a floor month and I've never been good with change, but I know I'll learn a lot and a good senior can make ALL the difference. And a front-loaded schedule is a blessing.

One piece of advice if you know someone who just miscarried. Especially if it's your daughter, and she can't have children, and she can't even carry them. Don't say to her "It's just a miscarriage." That hurts.

Anyway, I just you to know, dear reader, that you can be horribly sad and still find a way to function. Time moves on. When you are about to lose it, take a deep breath and tell yourself you have full permission to lose it as soon as you get home. You get to have your emotional outburst, it just needs to wait. You can make it through many a day like that.

PS

And regarding my chest roentgenogram: interval resolution of hilar lymphadenopathy, known pectus carinatum, but -- increased ap diameter and hyper expansion? I'm pretty sure I don't smoke or have significant passive exposure. What gives? And what does this mean?

I guess I'm doing better than on Friday and Saturday, but I'm still so sad and bitter and hopeless. I don't think I really knew what psychomotor retardation was until every step became a physical struggle, and lifting my feet? Forget it.

Isn't this ridiculous? I have such a wonderful family and so many wonderful friends, and I have a wonderful career just starting out, and I have a roof over my head and food on my plate. Why do I feel like curling up in a ball with my childhood security blanket and crying?

We did find out the baby would have been a boy. I haven't heard about the genetic testing yet.

I also spoke with the surrogacy agency and they don't have anyone available currently. I must learn to be patient. Considering I am NOT a patient person, this is a challenge.

People keep telling me I will get my happy ending, but I just don't believe it right now. I will go ahead whenever they find a new surrogate (or even two!) but I honestly don't want to get my hopes up ever again. It hurts to much.

But, dear reader, you probably have no interest in my self-centered sob story. After all, there was just an earthquake on the East Coast and I just heard something about a hurricane on CNN, and there are people going hungry and without a home every day.

So why can't I put this in perspective???

It's done.  We met Surrogate at the Maternal-Fetal-Medicine specialist Friday and Dr. K_________ said it was hopeless and also risky to Surrogate to do anything but terminate.  I know that technically this was just completing what had already started.  I know the baby couldn't have survived and I would never want to endanger Surrogate.  But that little one had a heartbeat and now it doesn't.  And it won't.  I know I had no choice but I feel like I killed this tiny 17week2day creature.

Mama and my grandmother tell me this loss is not a big deal, that it's not like losing a live child, that I should move forward and try again and I will eventually have a baby.  My grandmoher had a miscarriage and even lost an eighteen-month-old.  But she knew she could have children and in fact already had children.  Even though we have four embryos left I feel as if I am one step closer to ending up childless.  That's what this means to me.  I know my family loves me and cares and supports me but I feel like they don't understand.  But I also know that I should listen to my grandmother.  She has been through a lot and speaks from wisdom.  And if my dear, wonderful, amazing great-grandmother were here, she would also say to me "Tochter (daughter), life is for the living."

So I quite literally force myself to put one foot in front of the other and keep going.  I'm trying not to break down and cry.  I desperately want to but people keep telling me I shouldn't be so sad, and honestly I'm working or sleeping so I haven't had time to cry anyway.  When I feel I need to I just tell myself I will put it off until I can, and thus I carry on.  Last night was easier than the night before, and tonight is a little easier yet.  I still feel hollow inside and distracted but I guess it will improve with time.  Tomorrow the surrogacy agency is supposed to contact me regarding new surrogates.  I hope they find someone quickly.  I'm open to two surrogates simultaneously as well -- anything to increase the chances of getting a baby/babies.  I hope Surrogate doesn't feel guilty or bad that I'm not using her again. It's nothing she did, and this was NOT her fault.  It's just that I think mabye at her age and multiparity she might be done.  I really hope she understands.

Anyway, I'm sleepy and writing this makes me sad again, so I think I will be done.  Stay tuned for updates from x-ray land; I'm supposed to repeat a chest roentgenogram this week to see what's happened to my "hilar lymphadenopathy."

Sadness, Anger, and Bitterness are poor company but can't be shaken

I want to do nothing, because nothing matters except the little one I am so close to losing.  It's after eleven and I am still in pajamas.  The bed isn't made.  The dishes aren't done.  I haven't watered my orchid.  I don't care.  What's the point of getting dressed and doing all those thing?  Will it get me a baby?  I feel like wallowing in self-pity.

This is what I started writing last night.

Wished-for Child

I have a wished-for child of pen and ink.
In writing I create what I cannot in real life.
And so I have my my darling doll, figments of imagination lighter than air but solid on paper:
Her laugh
Her squeals when we play peek-a-boo
Her big brown eyes that beam when I lift her from the crib.
But the paper never hugs me back.



Wondering

Is this a punishment?
Do I not deserve children?
Am I unworthy?
(When) will my turn come?



I try telling myself we can try again.  But I wish it didn't mean so many months of a setback.  We'll need to find two more surrogates, meet them, arrange contracts...and of course we are limited because they have to come from Illinois so that everything is legal.

If that doesn't work -- I honestly don't know what to do if I can't convince Husband to adopt.  Life without children seems sad and bitter and pointless and endless torture watching everyone else bring little ones into the world.  If not a mother, what am I?  What fills that great black void?  The bottle of oversize potassium chloride tablets left over from when I became hypokalemic?  NO WAY.  I couldn't do that to the people who love me, and suicide is wrong.  Fortunately I'm not impulsive enough to do something horribly stupid.

I want so badly not to be angry and just to accept this all with grace.  But I am burning up with anger, boiling over, want to break things and pound walls and kick and scream like a two-year-old having a temper tantrum.  I don't know what to do with these feelings.  My best friend suggested going to Teavana and buying some really fancy teas and then curling up with Harrisons.  But the only thing that would really make this better is a baby.  And I begin to think that's an impossibility.  At least here's a comforting quote from David Ben-Gurion:  "Nothing is impossible.  The impossible just takes longer."  But how long, God?  And then there's good old Theodore Herzl loosely translated.  "If you want it, it isn't a legend."  If those quotes could build a state from nothing, can they get me a baby?  Because the quote that's foremost in my head right now is "Give me children or else I die."

ה נתן, ה לקח, יהי שם ה מבורך God giveth, God taketh away, blessed be God's name

My exuberance was premature.  So was the rupture of Surrogate's membrances.  Not just premature.  Preterm premature rupture of membrances resulting in oligohydramnios.  They are referring Surrogate to a maternal-fetal-medicine specialist but it looks bad.  I am trying to accept it.  Job said "God giveth, God taketh, blessed be God's name."  I should learn from that.  And I hope one day I can look back and this will be a small grief compared to a life of motherhood.  We do have four frozen kidsicles, and maybe we will find two surrogates and go for broke -- if I can open myself up to heartbreak again.  But then, motherhood is a lifetime of opening oneself to heartbreak, isn't it?  I'm told.  Not a member of that club.

I must learn to bear this with grace.  I'm so fortunate in every other aspect of life.  It'd be wrong to get angry and bitter, and it's ungrateful.  And I know I shouldn't cry when I have additional opportunities.  I should list my blessings again.

A weighty matter

My first post covered most of my past medical history: Turner's Syndrome (xi variant), hypothyroidism, hypertension, osteopoenia.  I may not have mentioned the eye muscle corrective surgery I had in infancy (familial cranial neuropathy), the five (incidentally very painful) corneal abrasions I had, my bilateral tubal myringotomies, or my giant-cell tumor of the tendon sheath.

And then there's something I know I didn't mention: my weight.  I've never been considered overweight by anyone other than me.  I've always been significantly under my so-called Ideal Body Weight of 122 pounds.  But I can't remember a time I didn't feel fat  I remember being a little girl, not yet weighing 50 pounds, and hoping I wouldn't ever weigh that unimaginable amount.  I remember ballet class as early as fifth or sixth grade, feeling so ugly compared to the other girls.  There was seventh grade when I would wipe the grease off fries or pizza at bar/bat mitzvah parties.  I remember in eighth grade reaching one hundred pounds and feeling so frustrated with myself that I had let myself weigh that much.  And let's not even get started on the ballet classes I took in undergrad where half my classmates were prepubescent or barely pubescent and stick-thin.

Basically, you can see how this is the setup for constantly trying to lose weight through a combination of diet and exercise since age twelve or thirteen.  And through a combination of iatrogenic hyperthyroidism, vigorous exercise, and willpower I finally did in the first two years of med school.  I made it back down to one hundred pounds and then held steady at 103-104  after discontinuing the diuretic that made me hypokalemic.  I gained a few more pounds over third year but got back down to 104.

I know it makes no sense.  A medical student - I guess doctor now -- should theoretically realize that a BMI below 18.5 is associated with increased morbidity and mortality.  But I have the ability to hold two completely contradictory ideas in my head.  And so I continue to exercise and restrict my diet.  And it upsets everyone around me: my parents, my grandmother, my husband, my doctor/mentor...

They keep telling me it will make me unhealthy.  But it's not as if I intend to go really low.  I don't want to weigh less than one hundred.  I just want to get down to one hundred pounds and stay there.  And I felt fine when I weighed one hundred pounds!  I could jog six miles a day!

It's not that I am complacent.  Causing grief and frustration to people who care about me, worrying my amazing wonderful grandmother and my sweet caring husband and my mother who does so much for me, is wrong.   Even my doctor/mentor tolerates my melodrama without complaint or showing how sick of me she must be, and gently urges me to build up my reserve so that I can better handle infections and -- most importantly -- so that I am prepared for the wonderful stress of motherhood.

But instead of listening to anyone, I keep at it.  I don't understand.  And I'm not asking for sympathy or pity.  I'm simply telling the story and thinking aloud, metaphorically speaking.  A simple URI last week completely knocked me out and you'd think that would be a clear message.

Why is it my appearance is so important to me?  Why can't I listen to medically sound advice?  Will I ever change?  People always say children change everything; maybe that will do it.  What if I never change?

I'm not even sure exactly why I decided to post this chronicle.  I don't want to change right now and I don't want to think about changing in the future, but I feel tortured about what I'm doing to people who care about me because I know it's wrong.  And my dilemma is completely of my own design and I have all the power to end it if I were to choose to do so.   

Incidentally, there are only ten or eleven case reports of girls with Turners Syndrome and Anorexia Nervosa.  so if I would actually accept the diagnosis somebody could maybe get a publication out of me.  Has anyone ever written a case report where he or she is the patient?  I am curious

A good book and a good cake

So our heroine has again contracted bronchitis.  Fortunately, she is not scheduled to work again until Wednesday night.  Instead there will be much tea and Kleenex.  Also there will be sending of parentage forms to our lawyer in Illinois.  These are supposed to be done by around week twelve, but I'm superstitious....anyway, they are going out today.

Theoretically, it wouldn't hurt if I did a little academic reading as well.  But fiction is so much more fun!  I'm reading the House of God by Samuel Shem.  It's engrossing  I can identify with parts of each character.  It's also fun sort-of reading about medicine without feeling as if I must commit to memory every factoid.  The feelings of incompetence, elation when something goes right, inability of outsiders to understand, frustration when being forced to deliver futile care...all so real!  I was so wiped out from this URI that it took me an hour to muster the strength to get up from the sofa and shower, but I kept reading until Husband came to bed because the book has me hooked.  I didn't realize how much I miss that feeling of being totally engrossed in a book.  Sometimes I will say I wonder if I shouldn't have been a literature professor.  I feel so much more competent when I am in the literary arena than the hospital.  But I love patients and hopefully (please?) the competence will come with time?

Otherwise, how about a delicious cake recipe?  this one is named the Tzvia cake, because a lady named Tzvia taught us to make it.

3 eggs
1 cup oil
1/2 cup orang juice
almost 2 cups sugar
2 tsp baking powder
2 cups flour
fruit - can be frozen berries, cut plums, almost anything works -- but if you are using apples then I recommend sauteing them in some butter and brown sugar and vanilla

Directions:
Preheat oven to 355 and grease a loaf pan
Mix everything except the fruit together -- you don't even need an electric mixer.
Pour cake batter, then fruit, then cake batter, then fruit...
Bake for one hour -- may even need a little longer.  The crust will be crispy and brown but shouldn't really be burnt.

Enjoy!  Especially delicious served hot from the oven with a scoop of vanilla ice cream on top!

Birthday wishes

Today is JK Rowling, Harry Potter, and my aunt's birthday.  I wish them all a happy birthday and many happy returns of the day.

It's also the birthday of the most wonderful, amazing, generous, just all-around awesome person ever: my grandmother.  Only she's not really my grandmother.  I don't call her grandmother.  I call her Mama because that's what she really is.  From the day my mother went back to work at six weeks postpartum, my second mother took care of me.  She is my guardian angel here on Earth and my role model and I wish her a mazel tov and biz hundert tzentzik and that she should have health, long life, happiness, and many many many great-grandchildren and just all good things.  (kinenhora.)

I know she isn't reading this but I have to put it out there, even though I already called her.  Because she's the best!!!

I also just spoke with Surrogate, who is doing (also kinenhora) well, thank God, and even starting to show a little!  Yay!

The gender jury is still out.  Surrogate is getting girl vibes, but her husband is getting boy vibes, and I had a dream that we have a beautiful healthy baby girl, but Idan is thinking boy.  Guess we'll have to wait and see!

Already I feel like a bad mother?!

Our little Peanut isn't even born, and already I feel like a bad mother!  I feel guilty about that fact that I probably won't be able to nurse my baby.  I can tell countless moms-to-be about the benefits of colostrum and secretory IgA in helping Baby build its immune system, but I will be stuck giving my baby formula.  Yes, I know moms the world over use formula.  And babies the world over do fine.  But the American Academy of Pediatrics has made it very clear that breastfeeding is optimal.  And yet, for me to produce even a drop of milk, I would need to do relatively extensive preparation and probably adjunctive hormonal therapy with not just our old friends estrogen and progesterone, but also the dopamine antagonist metoclopramide.  (Dopamine inhibits prolactin.)

Then again, it's not as if everything up to this point has been "natural."  From an endocrinologic standpoint I'm a miracle of modern medicine, as artificial as they come.  Levothroxine for my thyroid.  Growth hormone (don't miss that one!) from fifth through eighth grade.  Estrogen and progesterone.  It's amazing and wonderful that we have these medications, and I am glad to have benefitted  But I certainly can't say I ought to breastfeed because it's more "natural," or that I shouldn't breastfeed because it's not natural.  I'll admit the idea of nursing when I didn't have a baby weirds me out.

So I don't know where I stand.  I have plenty of time to figure this out, though.  My best friend is urging me to breast feed but I don't know if all the hormones make sense when induced lactation doesn't usually produce enough milk to feed a baby.  But maybe I should do it for the bonding?

Any experience either way, do let me know!

In Which our heroine is once again convinced that this country needs universal, public, single-payer health care!!! Oh, and feels really guilty for milking all her parents' savings for Operation Baby

Honestly!  I do NOT understand private insurance.  Shouldn't health care be something everyone gets?  Why is it I can't get my patients the medicine they need, or the subacute rehab they need, because of insurance?  I have a young lady who would really benefit from intensive therapy after her proLONGed hospitalization, and should go to SAR rather than a nursing home.  But no, her insurance won't cover a SAR.  So she will go to a nursing home and not get the PT and OT she needs.  And she's young.  And at the other end of the spectrum I have an elderly lady who really needs a Bi-PAP or at least a CPAP machine, but we had to fight to get one covered.  It's just her breathing, after all.  Oh, and my young man who spent four extra days in the hospital (at 1200 a day, mind you!) because insurance took their sweet time approving his outpatient IV antibiotics.  For the life-threatening infection which would take weeks to treat.

And those are just a few examples.

I won't stay on the soapbox too long; I need to nap before I start night float tonight and work from 8:30pm-10:30am tomorrow morning.  But if anyone doesn't understand why we need universal, public, single-payer health care -- he or she is welcome to join me on rounds.  Or better yet, join the Care Management Specialist or the Social Worker.

Back to happy things.  Or, - phone call; gotta go.

In Which our heroine is very sleepy but still has a few more notes to write

...except the electronic medical record freezes when I go back more than a month or two!  So while I wait, I thought I would write.  I haven't anything important to write about.  We're 13 weeks, 5 days today, thank God.  I really can't wait to find out if it's a boy or a girl.  I am delighted either way, but I am not a very patient person, so I would like to know.  Peanut does at least look relatively human, so that's a good sign.

One more note to go!  And I am delighted to make it a discharge summary...Mr ___________ was dying to leave the hospital already and it was a matter of arranging his outpt IV antibiotics.  Finally, daptomycin and ceftaroline are on their way to a non-hospital near you!

...and that's a wrap.  Bedtime, then back to the hospital in five hours to round on seven patients.  In the evening we meet with the lawyer to make a will for our Peanut and name a guardian.  (That's part of the contract.)

In Which our heroine is impressed, stressed, and goes to see Harry Potter and the Deathly Hallows Part 2.

First of all, I am SO incredibly grateful to everyone for their support in this Adventure in Baby-making.  It's impressive how understanding and accepting people are of our rather unconventional path to parenthood.  Nobody has even pressed my explanation of "some cardiac thing" and most are just excited, the same as they would be for anyone else who announced she was expecting.

So if you are worried about announcing that you are sort-of pregnant, don't be!  People are far more accepting than you might think.

On another note: I must be an incompetent intern.  I'm stressing out about carrying nine patients and potentially admitting three new patients tomorrow.  SERIOUSLY!  When my parents and my mentor were interns nine and three would have been a cakewalk. And I still feel that I haven't a clue how to actually take care of anyone.

Am I going to end up like Potts from the House of God?  I'm slightly less than halfway through, but I don't see myself becoming any better than he.

Okay, enough whining.  I need to read at least one article before bed.  Is that breaking my day-off promise?  But I was "good" all day.  I even saw the new Harry Potter movie!  Which, by the way, is absolutely wonderful and a nice capstone to the series.  The books, however, are still better.  God bless JK Rowling -- and could she PLEASE come out with a new book?  (Jhumpa Lahiri, this goes for you too!)

Besha'ah tova, b'ezrat Hashem... (aka in a good hour, with God's help...)

...we are expecting a little one in late January!!!  Husband and I are absolutely thrilled, delighted, and very nervous!  Apologies for the suspense along the way, but I didn't want to put an Evil Eye on things by telling before the end of the first trimester.   But here we are, thanks God.  We feel so very blessed, and we hope and pray that everything continues to go well.  Thank you to everyone who has supported us along the way!

Pictures to come, but not when I have to be at work early tomorrow...

...and mazel tov to my wonderful, amazing, grandparents on their anniversary today!  They should only live to have many more happy years together with all of us.

But like I said, the alarm is set for Early tomorrow -- so Good Shabbos and Good night!

Infectious Disease Pearl of the Day

Here it is, folks: the Infectious Disease Pearl of the Day.

There are NO biting spiders in my home state.  Not one.  There is, however, CA-MRSA.

Thus my first-ever continuity clinic patient went home with a script for TMP-SMX.

That's all for tonight.  I have to round on the entire service minus one patient tomorrow morning.  Mim vs. eight patients' worth of notes.  Can she do it?  YES!  (We hope!)

In preparation, much ice cream and cake were consumed this evening, followed by a feeling of being ten pounds above my goal weight.

I never said stress eating was a good thing.

Any advice? How does one announce that she is pregnant...sort of?

Hopefully we will eventually be blessed enough to announce that we're expecting a little one (or ones).  While I can't wait for that day, I wonder how one announces such a pregnancy -- especially since I hang around doctors all day, and consiously or subconsciously they will start diagnosing me based on the explanation I provide.  I'm not ashamed of having Turner's Syndrome -- in some ways I'm proud -- but I don't necessarily want everyone knowing, though.  Yet a surrogate pregnancy requires explanation.

So if you have suggestions or if you have personal experience, I welcome your advice!

Goodness, being post-call on the weekend certainly makes it easier to keep up with posting!  Not that I have such a treasure-trove of information to share...my patient with MRSA endocarditis is still bacteremic despite the addition of ceftaroline to his daptomycin, but I doubt anybody wants to read about that.  Despite the fact that endocarditis may be my favorite infection.  Also I have a very frustrating ethical issue right now as a gentleman we admitted last night who at basline is not alert or responsive and is unlikely to improve is being pumped full of antibiotics and getting a new PEG tube.  I understand that he is young, and that this must be incredibly hard for his son.  But I don't see aggressive treatment benefitting either the patient or his family.  Fortunately, we have a wonderful palliative care team, and everyone will meet tomorrow to determine the goals of care.  (Except me -- I have day off #3!)

Meanwhile, I struggle to keep up with my friends.  One of my best friends is on night float in another city, so we struggle to find a suitable time for conversations.  Another is a teacher and I have so little to talk about these days except residency that I don't know how to talk to normal people.  Even Husband -- I try to spare him my recitation by calling Mama on the way home and processing my day before I get home.  I've never had such a need to talk about my day at the hospital before residency.  True, I sometimes carpooled with my parents during my rotations, and obviously we discussed our day on the way home; but now I just feel like I need to get it out and to process it.  I did feel like this back in February when I was working in the ICU.  I will be there again in two months, and I'm dreading it.  I nearly cried every day.  Yes, death is part of the cycle of life, but sometimes it takes people so young and it's so sad!

Okay, I though I was NOT going to discuss residency!

I do have a life outside the hospital, don't I?

Actually, I do.  My aunt is hosting a Spanish Night party next weekend, and we have a wedding the folllowing weekend.  I've never been to a full Catholic wedding, and I've never been to a Romanian wedding, so I get to see both at once!  It should also be wonderful to see my college girlfriends.  We had a nicest group, but it's such a struggle now to keep in touch.   I'm really looking forward to celebrating with them.  Of course, it might help if I hadn't lost the RSVP card...

Anyway, I should straighten the house but first, the Cool Physical Finding of the Day: increased tone, and 3+ reflexes -- yes, with extension!  (not as in the opposite of flexion)

Have a good week!

Cool Physical Finding of the Day

...that's right, ladies and gentleman -- courtesy of a very nice young lady the Physical Finding of the Day is smooth, non-tender, non-nodular thyromegaly with audible bruit!

In Which our heroine fails to recognize early shock liver, is once again glad she d/c'd antibiotics, and has a hard time bringing herself to discharge elderly patients. Oh, and anticipates tomorrow's DAY OFF!!!

I know as intern's we're not expected to get it right every time.  Especially not as July interns.  But really, couldn't I have recognized that Ms. _________ wasn't having a panic attack?  I should've listened to my gut that something wasn't right.  I should also have realized her bicarb was 16 (non-medical translation: she had some metabolic process making her blood to acidic) and she was hyperventilating to blow off CO2.  Two days later she was in the intensive care unit, and shortly thereafter she was transferred to another hospital for a liver transplant.  Her metabolic acidosis was due to the lactate her cells were producing due to hypoperfusion.

SO INTERNS READING THIS, IF THERE ARE ANY: remember that agitation doesn't just mean panic attack!  You don't want your patient -- or cross-cover patient, as in this case -- to become the subject of a morbidity and mortality report.

At least I seem to have made the right decision regarding a patient admitted with a supposed urinary tract infection, who didn't have one and who always gets antibiotic-associated C. difficile colitis when treated.  I didn't give any antibiotics, but unfortunately she returned today with C. difficile colitis.  I guess probably from the antibiotics she received before I admitted her?

But maybe she already was infected when I admitted her earlier in the month?  Perhaps I failed to recognize it.  She originally complained of constipation last admit, and Dr. _______ did teach us that C. diff can occasionally present with constipation.   I didn't check then.  If I had, maybe I could have started treatment and she wouldn't have gotten as sick.

Couldn't I have just ordered a PCR before discharging her last time?

So I missed the boat, again.

Is part of this the pressure to discharge patients?  We get so much pressure to push people out.  Of course nobody should stay in the hospital unnecessarily, and other sick people may need that bed, but haste makes waste, too.

I almost cried today over a discharge for an elderly lady who couldn't even walk.  She had strong social support, and good support, but still...how will she go to the bathroom?  Fortunately we delayed that discharge until the appropriate assistive devices can be delivered to her home.  And nobody wants to read my soapbox about discharges.

So how about something happy?  I get a day off tomorrow!!!  I almost bought tickets to the premier of Harry Potter tonight, but then I'd sleep my entire day off away.  No fun.  So I will be very lame and go to bed instead of seeing the last-ever midnight premier.  Oh, well.  I'm hoping to spend time with my grandmother, my aunt and my baby cousins tomorrow, and then of course there's my favorite Shabbat Dinner!  Yes, there will be challah.  Homemade, fresh from the oven.  Mmmmm....And I don't have to write a single progress note or discharge summary tomorrow :o)  I love seeing patients but I loathe documentation.  I know it's SOOO important, but it takes a long time!

Here's something sweet: my patient with the C. diff and her family remembered me!  I hope that means I made a difference.  Because that's what it's about.

And here I am, thinking again about work.  I wonder how other people separate?   But I don't know if I would want to.

At the moment, though , I want to curl up on the sofa next to my husband with the latest issue of my favorite cooking magazine, so enough silly rambling for now.

In which our heroine tries to keep her patients alive, and free of infectious diarrhea

So I almost gave my patient C. difficile colitis today -- ordered ciprofloxacin po as directed by my Sanford Guide to treat her UTI.  Then I reevaluated my thought process, determined she did NOT have a UTI, and found an old note from the time she got C. diff from a course of cipro.  I discontinued the antibiotic I never gave.

I guess that's a win?

If you don't count my breakdown this morning over her continued refusal to let me take a history or examine her, and then my blankout at how to manage her hyponatremia.

But we got her sodium up and her confusion resolved.  And I found a cool physical finding that will unfortuantely remain nameless because I don't want to take a chance that she become identifiable.

All in a day's work.

Oh, and I'm supposed to teach a medical student?  Thank goodness she's enthusiastic, smart, and talented!  I think maybe she'll teach me!

Sleepy intern say hi

...and that's about all I have energy for today, folks.  Three days into my internship I could barely drag myself out of bed on my day off.  Inronic that my senior resident commented on how much energy I seem to have!  I'll try to elaborate on what it's like to play doctor later, but it's a beautiful day outside, so I am making a cup of tea and relaxing on a lawn chair.  If I can keep my eyes open.

Welcome to Internship!

Apologies for the long break in posting.  It's been a busy several days.  We started orientation to residency, and I've been trying to take care of as many errands and get the house as organized as possible before residency -- especially since my first rotation is general medicine wards, and I am on call the first night!  Clearly when he created the schedule, the chief resident confused me with somebody who actually knows what she's doing.  The program director promised us that we will not kill anyone, and my mentor told me I am "more than competent," but I am afraid I will prove both of them wrong.  I guess I'll just do my best, and pray that my patients do okay.  On the plus side, my co-interns are really nice, and I enjoyed meeting many of them at orientation and at the welcome picnic.  We're a melting pot of American, Indian, Persian, Arab, and more.  I wish there were more women interns, but I guess that just means we are so good, we're worth twice as many men :o)  Several interns have families, and the little ones (I met them at the welcome picnic) are so adorable!  One intern brought his seven-year-old little girl, who is adorable and has such a cute, exact way of speaking, and his four-month old infant, who made me want to pick her up and hug her.  But the Vice Chair of Education beat me to the punch and wouldn't let go of the baby for almost an hour, so I didn't get a chance.  I think somebody is dreaming of grandmotherhood!  Another intern brought his three-year-old and eighteen-month-old boys, who ran around and were also adorable.  They look almost like twins -- the elder has Down's Syndrome and so is small -- and had a great time playing with the hammock.

We had some sadness Friday night, which I would write more about, but it'll have to wait a few more weeks for reasons that will later become clear.  I will simply say that Husband and I are trying hard to stay positive, count our blessings, and remind ourselves that any heartache we experienced along the way will be altogether insignificant if -- no, WHEN -- we hold a baby in our arms.  At least I hope and pray it's "when...."

In Which our heroine uses her physical exam skills, walks many miles, and enjoys beautiful summer weather

Oh, glorious summer!  This vacation is passing far too fast!  I am not at all prepared to start internship.  Couldn't they give us another month, or two, or three...but I guess not.  I spent the majority of yesterday enjoying the outdoors and walked a total of ten miles!  Not at once -- I walked four miles in the morning listening to a Medical Knowledge Self Assessment Program (MKSAP) lecture about diabetes while basking in the bright sunny day.  I originally planned to stop at the library and fill in the gap in my Russian Literature with Anna Karenina, but I forgot my library card.  So after a very nice lunch with my grandmother, sister, and cousin at Mongolian Barbecue, I set out again, because aside from trying to exercise I am trying to "be green" and driving to the library -- a mile away -- is NOT green and also a sin when the sky is blue and the sun is shining and the birds are chirping and the temperature is just perfect.  So I walked to the library, but it was so nice out that I ended up extending the walk, so it turns out that three miles later I was back at home with Tolstoy as the literary guest du jour.  I started making dinner, finished with help from Husband, and then he wanted to take a walk.  As he definitely needs the exercise, I agreed to another walk, so three miles and a lovely visit to my grandmother later, we returned home.  Total: ten miles!  I really enjoy walking with Husband not only because we get our exercise, but also it gives us a chance to talk without a television or other distraction.  We had a nice conversation last night about raising children and I learned some interesting history about his step-siblings.

Today I finished the lectures on diabetes while enjoying another perfect summer morning.  I ended up by my grandparents, and got roped into going to the office with my grandfather for his afternoon orthopedics clinic.  We saw seventeen patients with interesting findings.  I caught an Anterior Cruciate Ligament (ACL) tear.  Both Drawer and Lachman tests were positive, although my grandfather elicited the forward movement of the leg much more easily than I.  I suppose it's a matter of mass and experience.  I also injected a knee with a cortisol/lidocaine combination and correctly identified a ganglion cyst (which felt surprisingly indurated).  This was reassuring, since feel most uncomfortable with my musculoskeletal exam.  ***Note to medical students, residents, and physicians: the NEJM has a wonderful Video in Clinical Medicine about examination of the knee.  Watch it.***  My shoulder exam is still lacking, though.  I haven't properly reviewed it since January and have forgotten too much.  But some I could still remember.  Oh, and we did a nice incision and drainage on a boil which was likely MRSA.  Ebe pus, ebe vacuo.

Aren't I a fun person about whom to read?  It gets worse -- I have also been reading Harrison's the last few days.  Seriously, though, I do have fun.  Tomorrow my sister and I leave for a day and a half vacation in Chicago.  I have one destination in mind, and it is the Cheesecake Factory.  I am mildly obsessed.  Just mildly.  Not as if I already know exactly what I'm ordering or something...dulce de leche cheesecake...We will also see the Willis nee Sears Tower and walk the Magnificent Mile.  Perhaps a museum or two as well?  Fireworks over Navy Pier?  Who knows?  I would never live in a big city, but I love visiting.  Let's just hope the weather cooperates.  I have yet to enjoy good weather in Chicago.  I've done sweltering, humid August, freezing December and January, and June which would have been nice but I dressed for the eighties and it was in the sixties.  This time I am checking the forecast.

Not too much else.  Husband will be working hard through the weekend but promised me a date night Saturday night.  Yay!

Summer Recipe!

Hello all!

While Husband works, studies, and does his project, Dr. Mim continues to work on her culinary skills.  Today the score is Mim: 1, kitchen:0.  (We'll call yesterday's Tuscan Vegetable Pie a tie and Friday's challah a definite win, but pasta a major FLOP.)  Anyway, if you like tabouleh, you will LOVE this:

Tabouleh Chicken Salad

From the recipe book of EWC

Ingredients:

1½ cups bulgur

3 cups warm chicken broth

¼ cup olive oil (haven't tried skipping the oil but I'll bet you can if you're counting calories)

juice of 2 lemons (I go much lighter on the lemon -- half a lemon to maybe a whole)

700g chicken breasts

4 tbsp swet chili

2 tbsp fancy mustard (honey Dijon works well)

1½ cups chopped parsely (I measure before chopping -- estimate, really) 

½ cup chopped mint (I measure before chopping -- estimate, really)

6 green onions, chopped

2 cucumbers with the peels on, chopped (I don't like cucumbers so I add another half tomato instead)

3 garlic cloves, chopped

2 tomatoes

50g pine nuts, toasted

salt and pepper to taste

Directions:

To make the bulgur –

In a large bowl combine bulgur, 1½ cups chicken broth, and lemon juice.  Cover with Saran wrap for at least one hour (until it absorbs all the liquid).

To make the chicken –

Cook the chicken in a pan with the other 1½ cups chicken broth.  Salt and pepper to taste.

When the chicken is ready, remove from the pan and cut into strips or cubes.

Pour out the broth from the pan.  Return the chicken to the pan and combine with the chili and mustard.

And finally –

Combine the chicken, bulgur, and all the chopped vegetables.  Enjoy!

Makes 6-8 portions.  Does not reheat well -- you want warm chicken and room-temp salad -- so if you plan to eat leftovers, either eat at room temperature or keep chicken separate and mix only each time you eat, so that you can warm the chicken separately.

Next up: chicken meatballs, either from EWC or my favorite cooking magazine (על השולחן).

Happy cooking!

Advice for consumers of the healthcare system, or In Which our heroine again battles the hospital billing department, and emerges victorious

If you too are embarking on an infertility adventure, I cannot emphasize enough -- keep careful records of bills paid and what each payment covers!  I received a bill from Northwestern for $3200.00 last week.  This seemed odd, considering that we have already paid the hospital $15,300 and that was supposed to cover the IVF and implantation.  I called the number listed on the bill for enquiries, and -- surprise!  The REI department has its own number.  The operator transferred my call but as nobody answered, she was supposed to forward a message and my phone number.  Either that didn't happen or the REI department was out of the office, because they didn't return my call.  Today I called them and...the bill was a complete error!  The only thing left to pay is $875.00 for embryo cryopreservation.  (We haven't gotten that bill yet, despite it being a month since the event.)

So, the moral of the story is: If you think you received a bill in error, DON'T pay it until you are certain you actually owe them money!  I can only imagine how difficult it is to get the money back once it's theirs. This message applies to any dealing with the health-care system, I suppose.

Moral number two: Big-name, fancy universities have billing departments no better than our own little UPG billing department.  Gives me a sort of pride in my home school.

And in case you were curious: the running total for a ride on the Amazing Infertility Adventure, aka Operation Baby(Babies) has just about reached $100,000 after-tax dollars.  Mazel tov I'm sure.  Mostly, thank you Mama and Daddy and my wonderful, amazing grandparents and everyone in the family who has helped  us out.  I only pray we can pay this generosity forward.

Happy Shavuot! חג שבועות שמח!

apparently I was quite sleepy when I wrote the following, since I accidentally posted it to a blog which I never  meant to use!  But here is my intended post from last night.

...and it's Jewish holiday time again!  From yesterday sundown until tomorrow night sundown we celebrate God giving us the Torah (see previous post), as well as the first fruits of the season.  We read from the Book of Ruth and it's customary to eat dairy and wear white.  Mmmm...cheesecake...I did not actually consume cheesecake today.  But I made a spur-of-the-moment decision to invite the family over for the holiday.  I prepared six homemade pizzas, (okay, not the sauce -- but everything else, including the dough) sauteed spinach, eggplant with tehina, and an Israeli salad of tomatoes and cucumbers tossed in olive oil, lemon juice, and salt, all while listening to lectures on Neurology.  Yes, I was busy in the kitchen!  The pizzas unfortunately looked far more gourmet before baking.  I rolled the dough out very thin because we're a thin-crust bunch, and I roasted garlic and tomatoes and sauteed onions and fancy mushrooms for toppings.  I also bought fresh basil and mozzarella. Oh, how lovely those pizzas looked!  I should have photographed them.  But I didn't put enough flour underneath, and we had a very difficult time getting them onto and off of our pizza stone.  Husband may have had a few (or more) harsh words with me.  But it's behind us, and everyone seemed to eat it, so I guess at least it was tolerable.  A good time was (hopefully) had by all.  After everyone left we hung new posters above the dining-room table and also hung our ketubah (marriage contract).

It's been quite hot today; over ninety degrees!  But tomorrow is supposed to cool off a bit.  I hope so!

Also, I owe a big thank-you to my mama and grandmother for helping with the cleaning -- or rather, doing nearly all of it and not letting me work!  I hate to see them work when I made the party, but I guess I will pay it forward one day, hopefully.

I'm realizing I used the word "hopefully" quite a lot in this post.  I'd say it describes my current state pretty accurately.  Another good word would be "sleepy," so that's it for tonight.

Curious: anybody raising bilingual (or multilingual) babies? Advice?

At some point in the future, God-willing, Husband and I hope to raise bilingual children.  If anyone reading this has experience, what challenges did you face and how did you overcome them?  Any advice?  Obviously this is still very far in the future, but I got to thinking about it after returning from my aunt and uncle's early Shavuot party a few minutes ago.  My aunt is bilingual but her children really only speak English.  It happened unintentionally -- their oldest is autistic and a second language became problematic -- but I think the three children missed out.  Husband and I want our children to read, write, and speak both languages equally well.

So if you've been there and done that, any tips are appreciated.

Thanks!

No earth-shattering news...except my previous :o) should be perhaps :o) :o)...turn the Evil Eye, hamsa hamsa hamsa, tfu tfu tfu.

Firstly, I have learned more about what happens if a couple is lucky and Operation Baby succeeds.  There is a six-week ultrasound to confirm pregnancy.  That's when they count gestational sacs and know how many babies.  Assuming that goes okay, the insurance companies then get a letter confirming pregnancy from the doctor and send you information about depositing the deductible.  That amount depends on how many babies and on the surrogate's age.  The surrogate also starts getting funds from the escrow account.  That's the responsibility of the escrow agent, so you needn't worry.  Your next date to mark is an eight-week ultrasound.  They do a heartbeat scan then and if all is well, then you graduate to an obstetrician.  If you aren't doing CVS or amniocentesis, the next appointment is at twelve weeks and the pregnancy is treated like a typical singleton or twin pregnancy.

So for the mundane news:  Friday I visited the first-grade where my best friend teaches.  I spoke about becoming a doctor and about hospitals, and I taught them to use a stethoscope and also to find their pulses.  Then we learned what happened if we ran really fast for sixty seconds.  Our pulses sure picked up!  I was impressed that the kids were able to identify the increase in heart rate.  They are a very bright group and good readers, too.  They all gave me hugs and it was such a nice feeling.  Afterward I did some errands and then came home and made the Best Challah Ever.  (Excuse the bragging, but I have two things I do well, and that's challah and matzah-ball soup, so I gotta cling to what I've got.  Light, fluffy, and delicious if I do say so myself.  I then let my sister cut seventeen inches (fifty centimeters) off my hair and it now falls to just below my chin.  It's so short!  I don't remember the last time my hair was this short, or if ever.  The new 'do is getting rave reviews from everyone but me; I'm just not sure I like my hair this short.  But it's light and bouncy, and it grows, to quote my sister, "freakishly fast."  It's gotten hot and humid in my hometown, too, so a short cut is fitting.

Yesterday was a Party Day.  My first first-cousin had an open house to mark her high-school graduation.  It was over-the-top but a lot of fun.  From there I went to a friends bridal shower.  That, too, was a blast.  I saw my two best friends from undergrad, one of whom is twelve weeks pregnant with baby number two -- and baby number one is not even a year old!  The bride is a PGY-1 in surgery  and her intended is in the Army.  She looked radiant in her pink dress and wedding hairdo.  She's Romanian, and the Romanian community in her area is like extended family, so it was a wonderful, warm party with everyone speaking different languages and lots of food and fancy desserts made by friends and family but looking as if a chef had done the work.  Needless to say, I was VERY well fed.  (And yes, I did eat.)  Then Husband and I finished off the evening with "Dr. Who" and Ramzor (רמזור), a hilarious Israeli television show that just started it's new season.  I think they just keep improving.  We couldn't stop laughing for an hour straight.

Today we relax and study.  Everything is green and blossoming and it's beautiful outside!  Husband and I took a nice long walk and enjoyed the sun.  With sunscreen, of course.  Then we had a delicious lunch of spaghetti and meatballs and now I am trying to convince myself to read Harrisons.  Or at least JGIM.  Wish me luck!

In which our heroine says cooks, says goodbye to her best friends, and celebrates her new degree

Here's to a beautiful, sunshine-y day!  It's been raining most every day since we returned home, so as I sit in the family room now I have our house's double-doors thrown wide open to let in as much light as possible.

It's been a fun but emotional few days.  We sent our best friends from medical school stayed with us for two days and we had a wonderful time hanging out, eating or trying to find someplace that sells frozen yogurt, and cooking.  I taught her how to make my matzah-ball soup of bicontinental fame (the secret is that the longer you cook it, the better it tastes, and baby carrots just don't cut it) and my challah -- really a good friend from Israel's recipe.  She taught me how to make what we call "the Rachel Ray thing," a scruptious pasta dish that involves roasting grape tomatoes and garlic cloves in lots of olive oil and salt, tossing the tomatoes with angel-hair pasta, and using some pasta water to make a paste out of the garlic, which you then also toss in with the pasta.  Then you add mozzarella.  Mmmmm.....I meant to add fresh basil but it was too late.  That's for next time.  We even got manicures and pedicures.  Not something I would ordinarily do -- in fact have never done of my own volition - but I will say it is fun to look at pretty nails and not my typical amateur filing job with no polish because I haven't the patience to let it dry.  Meanwhile, the husband half of our best friends was supervising their movers and running errands.  I like this division of labor.  (We did feed him the fruits of our culinary labor, so I guess we're not too terrible.  And she did help with the cleaning of the apartment.)

Sadly, we then sent the two of them off the Washington, DC where they will be doing their respective residencies.  I know they're only a phone call away, and we will visit each other, but we won't be able to meet up spontaneously at least once a week, and we'll be busy interns.  I miss them already.  At least I do have another good friend who will be doing her residency at the same hospital as I will.  I have a feeling we'll need to support each other.

Yesterday my parents threw me a beautiful open house in honor of graduation.  I originally intended to have something simple at my house, but it ended up being a fairly large party at my parents' house.  No complaints, though. We almost ran into trouble since we called the restaurant at the last minute to arrange to pick up food, but fortunately our second choice came through and the weather held out just long enough.  I tried to visit with everyone but it was hard; I hope I didn't leave anyone out and nobody felt neglected.  It's challenging to make everyone feel welcome!  I am really grateful to everyone for sharing in this simcha (happy occasion) with my family and me.

Today's agenda consists of a walk, thank-you notes, and turning bananas into banana bread.  Tomorrow is going to be great!  We are invited to a barbecue and then...I get to meet Faith Fitzgerald!!!!!!  She is the internal medicine equivalent of a rock star, and a colleague of my parents is bringing her in and inviting my parents and me to dinner.  And...said colleague is apparently a gourmet cook.  I met Dr. Fitzgerald at Internal Medicine 2009, when she did a Professors in Action case about bromium (I think.) But then I was one of many audience members.  Now I will actually get to bask in her brilliance.  The unfortunate corollary is that she will realize that medical schools are producing incompetent interns-to-be, but oh well.  I'm still super-excited.

And now everyone is super bored of reading this update, I'm sure.  So have a wonderful day and that's it!