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.