In Which Our heroine takes a big leap of faith

Hello Dear Readers,

I hope you are all well, and those who celebrated had a wonderful Christmas.  While I don't celebrate (the whole Jewish thing,right?)  I love the lights with which people decorate.  It's like a fairyland!  I may wax eloquent later.

For now, though, a small post about a large leap of faith.  I bought Baby Girl Surname a plane ticket home from California.  Jews, especially Ashkenazi Jews, especially Ashkenazi Jews who are baby-loss infertility fake pregnants, don't buy ANYTHING before the baby's born.  But we can't very well get stuck without a plan ticket.  So with great trepidation, we went ahead and purchased a seat.

That's the update for today.  Vacation is almost over, so I'm off to go enjoy it!

Shabbat Shalom -- there may be a later update on a new challah recipe, and whether it's as good as my current one.

So, what else is new?

Enough (more than enough) about the difficulties converting a baby who isn't even born yet.  What else is new in the life of Mim?

Because I know you were all staying up nights wondering.

I hope not.  You might be disappointed.

So I will bring my vacation to you in brief scenes:

Scene one, Thursday afternoon: my beloved grandmother comes over for lunch.  Mainly she drinks coffee (teaspoon of Nestle instant and a heaping spoon of powdered creamer), reheated at regular intervals in the microwave.  I don't believe she's ever actually finished a cup in one sitting.  She tastes and proclaims good my coconut-milk based soup.  (I threw together onion, carrot, celery, cooked in fake chicken broth with cumin, cinnamon, ginger, etc, then added coconut milk and chopped spinach and red lentils.)  My attempt at imitating the Cheesecake Factory avocado egg rolls was slightly less successful.  Maybe next time.  Anyone have a good recipe?  And then we are in the library, moving Husband's double-sized desk into the alcove once a closet in the houses's former incarnation.  Except we're short about an inch on either side thanks to moldings.  So I find myself in the basement hunting for a hammer, and then my grandmother is attacking the moldings.  Score: grandmother 2, moldings 0.  Abridged is a description of the tumult once tucked neatly in the alcove, now spread over the entire floor of the library, including but not limited to every letter I've received since I was twelve and a milk crate full of photographs.  Finally, however, we have everything rearranged, electronics plugged in, and the room looks fantastic.  We take a step back and imagine how perfect it'll look with the armchair moved out and a sofa bed for our guests instead.

Scene two, last Monday afternoon: three siblings at the movies, watching Disney's Frozen.  My brother has the extra-large popcorn which passes between us over the course of the movie.  My sister's seeing the film for the second time, except she missed several bits the first time around.  I try to resist analyzing the plot and the animation, but -- English major.  We do that sort of thing for fun.

Scene three, repeated several times over: my basement treadmill (about the only article not in our basement for storage), Hopkins Internal Medicine modules (power-walk your way through hypertension and dermatology for the internist), and some great music.  The satisfactory post-workout sweat at the end of 5.75 miles is impossible to imitate. 

Anyway, just a few scene from my vacation.  Looking forward to another work-free week!

To everyone celebrating next week, I wish you a Merry Christmas (or a Happy Christmas if you're British) and to all, a happy and healthy 2014!

34 weeks: Update, and asking for advice PLEASE IF YOU HAVE!

Hello everyone,

Hope you are all doing well.  Things are looking pretty good for us.  Surrogate just had a 34-week appointment (technically today is 34wks2days) and Little One has chubby cheeks, is vertex position (i.e. head down just like it should be), has plenty of amniotic fluid, and is practicing breathing!  I just hope things continue to go well.  I still worry every single day.

But now I have a new worry, for which I ask your advice, dear readers.   (If you aren't, Jewish, apologies for a rather long question below using terms you might not know.)

As Judaism is matrilineal, this Little One will need to be converted to Judaism.  And without getting into a very complicated discussion on religious politics, suffice it to say she needs an Orthodox conversion to be fully accepted as Jewish in all circles.  This may seem unimportant.  But try getting married in Israel without being Jewish by Orthodox standards.  And here in the States, too -- depending who she might one day want to marry, this could be a Big Deal.

One might think it then becomes simple: just get an Orthodox conversion and drop her in a mikveh (ritual bath).  Except the vaad harabbonim (council of rabbis) will not perform an Orthodox conversion unless the parents promise to raise the child in an Orthodox home.  And I am masorti, meaning Conservative.  I don't cover my hair, and while I dress relatively modestly, I do wear (appropriate length) shorts and I do wear pants.  And I use electricity on Shabbat although I won't shop and I don't intend to work once I finish fellowship.  And I keep kosher but I put things in the dishwasher (different sides) together.  And I plan to send my daughter to a Solomon Shechter Day School, not Akiva (the Orthodox school).  Actually, if you really want to know it's not keeping Shabbat or anything

What's a mother-to-be to do?  Dear readers, anyone out there with experience having a child converted to Judaism?   Anyone who wasn't frum succeed in arranging an Orthodox conversion?  And anyone reading from Israel (if there is someone), is it any easier through the giyur office?   We will visit, G-d willing, when the child is 6 months old for about two weeks.

And one last question: if I take the baby to the mikveh, I assume I cannot be nidah?  So I'd need to adjust my cycle?

It just stinks that this same child would be unquestionably Jewish if I bore her myself.  I love being Jewish.  But sometimes -- it REALLY gets frustrating.

Updates, and asking for advice

Thanks, K for the good wishes!  It was overall a wonderful Match Day with congratulations flowing between the residents.  Actually, even my kindergarten teacher sent me a congratulations on Facebook! I treated myself to my favorite artisan pizza (fresh basil and roasted garlic, and a mixture of sumptuous cheeses on a perfect thin crust).  Several of us in the third-year class met afterward at a local movie theater-bowling alley where I thoroughly embarrassed myself by bowling gutter ball after gutter ball.  But it was good fun.  Actually, we very much looked like a commercial for world peace: an observant Muslim girl wearing the traditional hijab, several Indians from various states (and probably castes too), and little Ashkenazi Jewish me.

So how will this fellowship work?  I will do seven months of consults (meaning, seeing patients in the hospital) followed by twelve months of research followed by another five months of consults.  Throughout, I will see patients in the Infectious Diseases clinic one half-day each week.  Mostly I will follow them for HIV, some for bone or joint  infections, and some for hepatitis C or confection with HCV and HIV.  I am so excited!  The program director is excited too.  And I have no regrets at all that I will be staying in my current location.

My enthusiasm is somewhat tempered, though, because a friend who applied for gastroenterology didn't match.  He is a hard worker, a great physician, and really should have gotten a position.  Worse, the GI program at our institution took another resident who isn't as strong.  It must feel like such an affront and I heard he is despondent.  I sent him a text message, letting him know I am thinking of him and his wife and that he is a wonderful physician and that I hope happier times are ahead and that I do believe things will eventually work out for him.  I didn't call because I thought he might not want to talk when so upset.  I might text him again in a few days.  But it sure feels unfair.  He really deserved a spot.  You can't be happy when you know other people are sad.

I have also had the challenging experience of leading "morning report" twice this week.  Morning report is a tradition in Internal Medicine.  Interns (i.e. first-year residents) or senior residents present a case from the hospital, while the rest of the residents (and sometimes students) are asked to discuss the case: differential diagnosis, workup, and sometimes treatment.  We have historically had an outstanding morning report.  The level of discussion, the faculty participation -- it's actually one of the reasons I chose Internal Medicine.  But a large part depends on the chief resident, who is the facilitator.  Those are people one year post-residency who dedicate that year to educational activities and administrative duties as well.  Our program added two junior chief positions this year, one for a second-year and one for a third year.  I was chosen.

I have always wanted to lead morning report.  It's been my dream since I was a third year student.  But teaching is NOT as easy as it seems!  And it is SO DIFFERENT teaching a large group from the teaching I do leading a small team on the wards.  I still haven't got the hang of it.  I learned a few things:  I summarize three key points from each case at the meeting's end.  I have a a question or two from an internal-medicine question bank at the end.  But I don't just want to be adequate.  I want to do as good a job as the fabled SH, former resident and now awesome attending.

How do I get there, dear readers?  Anyone in an educational field -- tips?  Because I could use them.

In baby news, things are, thank God, going okay.  We are thirty-two weeks and five days today.  Surrogate was diagnosed with gestational diabetes but her HbA1C (a measure of glycemic control over the last three months) was only 4.5, and her glucose readings have been very well-controlled with diet alone. She will soon start doing NSTs and more frequent monitoring, I guess because she is advanced maternal age now that she's thirty-six.  We will start looking at flights soon!  I still refuse to believe fully, but it feels nice to tell people.  And, I actually had a very fake-pregnant moment last weekend:  I was at a baby shower, and the mom-to-be received a copy of the book Love You Forever.  It's about a mother and baby, and the baby grows into a mom, who ages and becomes ill.  I have never been able to read it without crying.  My sister was at the shower too, and asked about the book.  I burst into tears.  Seriously!  Full-blown tears, over a book!  And I wasn't even reading it!  I thought you had to be hormonal for that sort of thing, but apparently not.

Anyway, we are off to a family friend's holiday party, so have a good rest of the weekend everyone.

ID? I do!

Yes, I have officially matched into an Infectious Disease fellowship at my top choice institution, which also conveniently happens to be my home institution.  I can't wait to get in the Gram stain game :o)

I'm not especially surprised, but I am still one hundred percent thrilled about this next step in my training.  The ID docs at my university are the best, and the current fellows are so smart that it will really make for a great training opportunity.  I do have small doubts about being "inbred" (i.e. doing all my training at the same institution) but I can't imagine a better program.   And yes, that includes what locals call "the U."

Otherwise, things are going well.  My loved one is doing well.  And so are Surrogate and Baby.  We're really getting close, now.  We still haven't found a name, though.  It's tougher than I thought!

I'm currently on Rheumatology.  It's very interesting and the pace is relaxed.  I will hopefully write more tomorrow,

Good night and shabbat shalom!

Not-so-happy birthday beginnings

According to the English calendar I have been thirty years old for one hour and eight minutes (well, technically I was born at 14:24 so I suppose there's still a bit of my twenties left), and by the Hebrew calendar, 9 Kislev passed a few days ago.  Thirty!  A new decade, hopefully filled with exciting changes.

Except I'm not excited, even by the thought of birthday cake.  And I have a sweet tooth that should be in a dental museum.

Someone I love very very much is suffering from a serious alcohol problem which has worsened dramatically in the past couple months.  This person is one of the most wonderful people in know: generous, loving, creative, and always putting other people first.  And this person has no insight into the problem alcohol is causing.  And the rest of the family is concerned enough that they are talking about organizing an intervention and inpatient rehabilitation.

I love this person so much!  He or she (I'm trying to respect this person's privacy) is not a bad person, but is suffering from an addiction which has led to lack of insight and poor decisions.   If anything happens to him or her, I don't know what I would do.  And as a physician, I'm scared to death because I have seen end-stage alcoholism, and I could not bear to see my loved one in that place.

I hope there is a chance for recovery.  This person is a strong individual and has been through a lot but always come out resilient, and this person wants to be healthy to be there for our Little One.  That's a pretty strong bit of motivation.  I wish somebody could give me a hug and make me a glass of tea with sugar and lemon and tell me everything will be okay.  But I know it doesn't work like that, and even if someone is motivated to quit, it's a lifelong uphill battle.

So I have spent the first hour of my thirties trying not to cry too much, because it makes it hard to read about dizziness and Meniere's diease -- oh, yes, I also have the pleasure of starting my birthday working overnight at the local VA hospital -- and trying to self-sooth with Chopin.

At least there will be Shabbat dinner tomorrow night (today now, I guess) and my brother has ordered a delicious lemon-white chocolate cheesecake torte in which to drown my sorrows. (The meal will be dairy.)

..And yes, things are going ok, thank God.

Surrogate is twenty-nine weeks today.  She and Little One are doing well, thank God.  But I won't truly  exhale until the proverbial fat lady sings.

A stand up routine that does NOT make me laugh.

A college acquaintance recently shared to Facebook a stand-up routine entitled "People with no kids don't know." I consider myself possessing a reasonable, if somewhat dry, sense of humor. But this particular routine did not tickle my funny bone.

 The premise of the routine was that couples without children don't have a clue how much more difficult everything is with children, and how these couples are living a carefree life of ease because they haven't any responsibilities outside themselves.

I nearly vomited.

 Many people come from large families and raise their younger siblings. I was changing diapers at ten, driving carpools and reading bedtime stories in high school, and was entrusted for an evening with a nine-day-old baby at eighteen. We may not be the true parents, but we witness the demands of parenting and we do our share of helping out.

Many people care for elderly parents or grandparents. And let me tell you, a fully-dependent adult is a lot more difficult. Have you changed a diaper on someone who weighs two hundred pounds? Or tried to dress him/her? I have only the minimal experience of caring for geriatric patients in the hospital, and even from that small bit of experience I see how difficult it is caring for ill adults.

Other people are not carefree because they take on tremendous work responsibilities, or volunteer, or fill their lives in other ways. I can understand the argument that it isn't the same of having children, but it doesn't mean one doesn't have true commitments.

But mostly -- what infuriated me was this: a good percentage of the people with children chose to have children. Did they know what they were getting themselves into? (Forgive my ending the sentence with a preposition; it just sounds so much better.) If so, then why complain? After all it was a choice made fully informed. And if they didn't, then why should they mock those who are in the SAME position the parents were prior to having children.

And honestly, here's the true hurt: WHAT ABOUT ALL OF US WHO WOULD GIVE EVERYTHING TO JOIN THEM?

You see, fertile people also don't know.

• They don't know what it's like to lie in bed wondering if a baby's cry will ever punctuate the night.
• They don't now what it's like to cry oneself to sleep after a third miscarriage and wonder if it's possible to be happy again.
• They don't know what it's like to face the embarrassment of providing a sample as a man, or of a transvaginal ultrasound as a woman, or the pain of a progesterone-in-oil injection.
• They don't know what it's like to hear "you're next" for the hundredth time.
• They don't know how painful it can be to answer the seemingly-innocent "Do you have kids?" question.
• They don't know what it's like to attend a baby shower just after you learn your road will be infinitely more complicated.
• They don't know what it's like to hear someone tell a new mother how much a baby looks like her, when you know yours never will because you have no viable eggs.
• They don't know what it's like to worry every minute that a pregnancy will end in disaster, no matter how far along into the "safety zone" one is (because there is no safety zone).
• They don't know what it's like to hate one's uncooperative body.
• They don't know what it's like to question what defines female because one's body can neither create nor sustain life in the way that is classically the epitome of womanhood.
• They don't know what it's like to sing someone else's baby to sleep and wonder if your turn will ever come. And I do mean "if" and not "when."
• They don't know what it's like to time intimacy until the romance is gone, or how tortuous a two-week-wait is.
• They don't know what it's like to feel out of synch with everyone else, who are now having their second child when you started beforehand and are still empty-armed.

I could go on, but I just want to leave it with this: They don't know how much it hurts when someone complains about that which you want most.

This same routine could have been far less hurtful. The comedian could have done it as "before kids vs after kids" and that would have made me chortle along with the rest of the audience. Because of course life changes, and gets more complicated. But go easy on those of us without children. It wasn't always a choice. And we aren't all "free."

Yes, it is 2:38am in my time zone.

And yes, I have to be at the hospital close to 5:30am.  And I will be giving a presentation on secondary syphilis in an HIV +ve patient at 11:00am.

I have yet to finish the presentation to my liking.

I am not sure I will even be awake enough to give this presentation.

On the plus side, thank God things are going well with dear Surrogate.  We are just over 24 weeks.  Continuing to hope and pray.

More to come...if I ever get a break from this rotation!

Happy and healthy and sweet 5774 שנה טובה ומתוקה לכולם! And it's a...but you'll have to read to find out.

Welcome to the year 5774.  Or, תשע"ד.  I'm still terrified, but I am a little excited that it might be a really wonderful new year.

Yes, thank God, things are going well.  We are about halfway there, and our Little One is doing well, as is her dear Surrogate Mama.  And yes, that was a "her" -- it is a GIRL!  Husband and I would of course been thrilled either way, but I have to admit I would have no clue how to raise a boy.  (And then of course there would have to be the conversion asap before the brit milah, meaning within eight days.  So a girl sounds like sugar and spice and everything nice.

Which brings us to the Name Game.  Welcome and prepare to play as often as you like, free of charge. We're looking for L names that sound good in both Hebrew and English, and preferably Biblical.  Husband doesn't like Leah, although I do.  And while the Internet has provided numerous options, none of them appeal.

And one other note -- while I wish I could grow this baby myself, it IS definitely amusing to tell people we are this far along and have them stare confusedly at my lack of bump.

When life gives you a fragile aorta, you gotta get a few laughs for it!

Question for all the Intended Parents out there

What have you done to make a surrogate pregnancy feel more real?  Our dear Surrogate lives on the other side of the country so physical contact isn't much of an option.

Thoughts?

Sort of...

We are, God-willing, fifteen weeks today.  Or rather, I am nothing, but our dear Surrogate is fifteen weeks and feeling well, thank God.

I am more grateful than I can possibly express that things have been going well.  This is a precious tiny hope.

But I am not excited.  I am terrified.  I am tense.  I wonder when the ticking time bomb will explode.  I wonder if I could withstand it.  I have friends and cousins who are pregnant, with similar due dates.  Where they are excited I am scared what the next day will bring.  Two years since losing Peanut I miss him just the same, and feel the same numb disbelief and longing and hurt I did on 19 August 2011 when they told me I had to terminate a pregnancy with a beating heart.

And then there is that feeling of being a fake mommy-to-be.  I know pregnancy doesn't make the mother, and I am grateful not to be part of the conversation about nausea and constipation and bloating and heartburn...But at the same time I feel like an outsider, or perhaps a junior member of the club who will never have a full-fledged card, or maybe someone peering in a window to somebody else's party.

But please don't think I am complaining when science is working a wonder.  I mean it when I say I am so very grateful.  I am however confused, and worried, and trying to sort out the feelings of being "sort of" pregnant.

Other people will announce their pregnancies.  There will be Facebook posts, and discussion at work.  But I am telling only my closest friends, and I weigh each one carefully.  I am telling about twenty people outside of my immediate family (and Mim's "immediate" family includes grandparents and aunts/uncles) and that's it.  And those twenty include my program coordinator and the scheduling coordinator, and the program director of my future fellowship, who obviously need to know.

Of course, keeping a big secret is easier without a big bump :o)

On an entertaining note, I ended up visiting the emergency dept. Saturday night after a needlestick injury where the patient on whom I drew the arterial blood gas was hepatitis C positive (but with a virla load of only 14,000, thankfully!).  Of course one of the nurses asked if I could be pregnant.  (She obviously didn't know about Turner's Syndrome.)  I told her I am pretty sure that requires functional ovarian tissue!

Of course, the fact that one of the ED docs who I know assessed me for the needlestick injury makes me feel all sorts of weird about her knowing I have TS.  I am not ashamed of it.  But it is sort of private health information and a bit of a bigger deal than the HTN and hypothyroidism which I readily disclose to anyone.

TS sisters, what's your disclosure policy?  Whom do you tell?  Or if you don't have TS, who would you tell if you did?

...and we have a decision. And some really cool cases at the hospital.

Thank you, Kim, for your encouragement.  Means a ton.  I told my father no again; we want to stay here and be close to family.  I think I'm happy with this decision.  Sure, the ego boost if I were accepted at a Big Name University would be fun.  But the fellowship match is a binding contract; you don't get to choose between multiple acceptances.  The computer algorithm matches your preferences and your program's preferences and that's where you go.

Today is beautiful.  It's about eighty degrees, and sunny, and I'm sitting in my backyard preparing a presentation on a patient with acute GI bleeding.  (Don't worry- I'll spare you all the details!)  The sky is clear blue and it is so peaceful.

I really wish I didn't have to work tomorrow.

Oh, well.  Surrogate is doing well, thank goodness.  She had a course of nitrofurantoin for UTI (or was is asymptomatic?  Either way, she's pregnant, and the guidelines suggest treating.  We are waiting on the AFP triple screen and the nuchal scan.  I'm so incredibly nervous that something will go horribly wrong.  One of my friends who's pregnant the usual way was so excited for me when I just told her (without intending to disclose, but ended up stuck).  I think people who haven't experienced infertility or loss don't understand what a ticking time bomb this seems.

In other news, I may have some fabulous cases at the hospital about which I can't disclose much due to HIPAA.  What I can say is one might involve pneumococcal endocarditis presenting with subdeltoid septic bursitis, and another might involve Klebsiella endocarditis.  (Endocarditis is a heart valve infection.)  it's a future Infectious Disease doc's dream!

Little Miracles

Also, I heard my little one's heartbeat courtesy of a recording from yesterday's ultrasound.  It brought tears to my eyes.

Dear Readers: your advice, please! Or, whether or not to unleash the not-so-secret weapon

With kind thanks in advance.

Dear readers, I have a quandary.

I am applying for a fellowship in Infectious Diseases; that is, two years of additional training beyond my residency.

I have been called reasonably intelligent, occasionally even bright, and have decent evaluations.  I have (I think?) good letters of recommendation.  I have strong board scores.

I stand a decent chance of being accepted to stay on at my current institution, and life is wonderful here.  Husband and I live within a brief walk of my parents, grandparents, aunts, uncles, etc.  Our neighborhood is charming and we own our home.  And I was always taught that family is the most important thing.  Plus, we may perhaps? have a little one on the way, though I still hesitate to believe it.

Here, then, is the debate: I have a not-so-secret weapon at my disposal.  His name is _____, Division Chief of Infectious Diseases and internationally-renowned expert in the field.  If ____ makes a call, I could go Elsewhere and train and Big Name Universities.  At least, I am told so.  If he tells you to take a candidate, you take the candidate.

Thing is, if you unleash The Division Chief, it is binding.  You rank the Big Name Universities first on your match list.  You can't have someone make a call and then change your mind.

Now, training at a Big Name University might be a life-changing opportunity.  It has been known to Open Doors.  But what if the doors I wish to open are those of a home down the street from my loved ones?  And how would I effect child care if we do have a baby and we live far away from my family?  My family is what is dearest to me in life.

Thoughts?

1 July: a day of terror in hospitals across the nation.

That's right -- it's the day yesterday's medical students become today's doctors, still unable to form the word "Doctor" without hesitating.  "Me -- a doctor?" they think.  It's a word that embodies knowledge and confidence, neither of which most interns have or really should have.  Med school can never prepare you enough.

And then there are those of us who suddenly find ourselves the most senior members of the team.  We're third-year residents, meant to know Lots of Stuff and Take Excellent Care of Patients, while Teaching Said Stuff to the eager young minds waiting to lap up our every word.  This would work out so well if we actually knew something worth teaching.

I sure hope that when graduation hits, I'm ready.

My very long day will be chronicled in more detail after I finish my Infectious Disease Fellowship application, due today but not likely to be done until hopefully, maybe, tomorrow.  But it was an interesting one, I promise.

In other news, none of the three hundred students have yet to mention anything about our little hope, so I will keep quiet as well.  I just applied for Surrogate's maternity insurance which was scary as it requires acknowledging this little hope and pretending I am hopeful enough to purchase insurance.  There are still a long 29 6/7 weeks to go.  But all I can do is pray and hope and try to protect myself from attachment, right?

But for now?  Sleep, blessed, beautiful sleep.  I do miss you, dear Bed.

Just between close family, friends, and THREE HUNDRED MED STUDENTS!

Dear readers,

I always knew my mother (while able to keep a secret -- I thought) had no filter.  She gets it from my grandfather.  But I thought she had a reasonable amount of common sense.

What, then, prompted her to tell three hundred incoming third-year medical students that her daughter (yes, the one at the SAME MEDICAL SCHOOL/RESIDENCY) is expecting via surrogate and is nine weeks along?  And that she requires a surrogate because her aorta is a delicate flower waiting to dissect?

No, gentle readers, she did not first ask my permission.  Nor did she tell me she had told them.  I found out from a friend who is in the third year class.

Oh, and she also told them about how we had and lost Sweetpea.

I realize you all know this story.  But I post anonymously, and there is only one person in my real life who knows of this blog's existence (who I doubt reads my posts and who knows me better than I know myself).

So there goes my grand plan of keeping all a secret until, G-d willing there is a baby.  And what if this puts an Evil Eye on everything?

So here we are.  Now what?  Do I just hope people don't bring it up?  Do I now have to start telling people?  I don't want to tell people.  I want to keep this secret because I am still terrified something could go wrong at any minute, and I don't want people asking how the baby is when the baby isn't.

Thoughts?

Pictures from Israel!

Once upon a time, a little girl went hiking in the Upper Galilee followed by an exploration of Rosh Pina.  And was very impressed by her iPhone photo quality!

In Which Our Heroine wonders if she has perhaps gone too far

Below is the email I sent my incoming team of interns and medical students with my expectations for the following Medicine Wards rotation.

Have I gone too far?

Hello to everyone, and welcome to (name of hospital) Floors Block One!

You will be working with me for the next month.  It's going to be a busy month and we will all need to work hard, but we will learn a lot and (I promise) have fun.

YOU CAN CALL ME ANY TIME, DAY OR NIGHT, FOR ANYTHING!!! (phone number here)

I have a some expectations that I want to set out.  I set a high bar but we have patients' lives in our hands and I take that responsibility seriously.  It is a privilege and an honor that should humble us.

1. If you have questions, just ask!  I almost never bite :o)  Don't ever be afraid a question is too foolish because I promise I probably asked or will ask the same thing.

2. I do NOT expect perfection, but I do expect a COMMITMENT TO PATIENT CARE.  That's what we're here for.  You don't have to get it right but you need to do your best and know your patients.

3. Your history should focus on the chronology.  Be complete.  Do not copy others' histories but take your own because you can't trust other people's histories.  You might need to call a nursing home or family member.  Medical students, this is often a good way you can contribute to the team!

4. You will do proper physical exams.  That means undress your patients!  Examining through clothes is unacceptable.  I expect a funduscopic exam on new patients and a basic neurologic exam (CN, DTRs, strength).  Bandages are to be uncovered unless they are post-surgical and the surgical team hasn't yet changed the dressing.  LOOK AT EVERY LINE/TUBE ON EVERY PATIENT EVERY DAY!

5. Patients' PCPs are to be contacted upon admission and discharge.  Medical students, this is again a key responsibility for you.

6. Our team reviews primary data.  This means: we do our own Gram's stains, review our own peripheral smears, examine our own urine sediments, and go to Radiology to review cases with the radiologist.  I will help you find all of these places so don't worry :o)

7. We will pre-round in the morning, probably a half-hour prior to rounds but this may change depending what the team's needs are.  On pre-rounds you will give me a brief update on the patient including the vitals from the last 24hrs, new test results, etc.

8. Update your nurses, and get updates from them!  They are valuable resources particularly for patients who can't speak for themselves.

9. Eyeball all your patients at the end of the day.  I promise it makes for much easier mornings.

10. Address code status.  Obviously you don't need to have a lengthy discussion with the twenty-five year old admitted w cellulitis.  But if somebody should be DNR, or should be hospice, address it!  We can go over some techniques.

11. Read something every day.  It doesn't have to be long.  But otherwise you won't grow.

12. Interns, I expect you to TEACH YOUR STUDENTS!

13. Students, ASK QUESTIONS!

14. PLEASE LET ME KNOW if there is ANYTHING I can do to enhance your experience, teach you better, etc.  I hope to go into academic medicine so I want to learn as much as I can about teaching.

Well, dear readers, what do you think?  I am still learning this Senior Resident thing.

In other news...still terrified something will go wrong with intermittent moments of relief.  Don't want to go to bed late so will elaborate later.

:o)

Thank you again everyone for your encouragement.

Surrogate had a repeat ultrasound today...and there is a little embryo measuring 7w1d with a heart rate of 145!

We still have thirty-three very nerve-wracking weeks to go, but thank you to Hashem for granting me at least this.  Maybe G-d really does hear my prayers.  I guess being at the Kotel (Western Wall) doesn't hurt.

Husband and I continue to have a wonderful time, and I may have eaten WAY too much popcorn while watching a wonderful new Israeli movie tonight called פלאות (Wonders) starring Adir Miller.  I highly recommend it, by the way.  (The movie -- not the popcorn binge).

I will also soon post pictures of a wonderful hike we did in the Ayun Wadi, aka נחל עיון or נחל תמנון.  Absolutely beautiful!  But it's late, and we have a fairly long drive tomorrow to Beer Sheva.  Will update soon.

Have a wonderful weekend everyone and Shabbat Shalom if it applies :o)

Hello everyone -- or should I say "Shalom," or perhaps the more frequently used "allo," or even ma nishma?

I want to thank you for your support.  We are still waiting for news, which will be late this week.  Right now Surrogate is still having some symptoms which I hope is a good thing.  And I think also no news is good news, right?

Meanwhile, we are keeping very busy and trying to enjoy ourselves.  We had a hot and sweaty but very fun time in Tel Aviv, are now in the Krayot, and will be visiting Jerusalem next.  I will put a note in the Kotel (the Western Wall) according to Jewish tradition -- essentially a written prayer to G-d.  I am happy to include anyone else's hopes/prayers too if you want; just leave me a comment.  Today Husband's parents had a bunch of friends/family over for lunch (very yummy and way tooo much food -- and killer cake!) and in the afternoon Husband and I met friends at the beach (and I even tried my hand for the first time at "matkot" (a sort of beach ping-pong game), followed by the new Star Trek movie.  I will post more details but it's after 0100 and I want to get some rest.

In the meanwhile, check out the beautiful "Yerushalayim Shel Zahav" with Shuli Natan as the singer, song written by Naomi Shemer.  I'm sure there are many Youtube links and let me tell you, it truly does describe the city especially in the late afternoon.

Layla tov!

In Which Infertility wins...again...but the score isn't final for a week.

Riddle of the day:  What is more fun than four failed IVFs with three lost babies?  Why, five failed IVFs with four lost babies, of course!  And for extra fun, how about having that loss occur when you're in Israel, far from your support network, and every SINGLE one of your couple-friends has at least one baby and some have two.

I have been quiet, dear readers, because I was afraid to put an Evil Eye on this last cycle.  We transferred two embryos on 9 May and got a beta-hCG of 64 on 20 May.  Our repeat beta-hCG on 22 May was 166.  Our dear surrogate started having symptoms - mild ones, so I was glad she wasn't suffering -- but enough that I thought things might be working out.  But I didn't want to announce anything even to the blogosphere.

But on 3 June, which was the 6-week scan, our little one measured on 5w1d and there wasn't a heartbeat.  Of course it's very early but to measure so behind is concerning.

Surrogate is scheduled for a repeat ultrasound next Thursday.  Nobody is very hopeful, though.  Dear readers, do any of you know of a similar case which ended in success?  I am already assuming this is a lost baby but am trapped in limbo.

I'm not sure what our next step will be.  We have six frozen embryos but I don't want to proceed without first having a WTF conversation with the doctor.  I also need to figure out how many more cycles, losses, I can take.  Husband remains stupidly, steadfastly opposed to adoption.

So meanwhile, we have another week and a half of "fun" in the very hot Israeli sun.  We actually have had a pretty nice time thus far.  We're at a lovely boutique hotel in Tel Aviv and have been to the beach, walked Sheinkin, and eaten hummus at Abu Hassan.  (Those in the know, know.  And those who don't -- get your tush to Jaffa and order a plate!)  We have also of course spent time with Husband's family and friends, and tonight we are meeting his friends at a fancy steak restaurant.  Husband's niece and nephew are absolutely adorable.  They're both school aged and I helped his niece with her homework the other night.  She is a bit impish but I like that about her.  Nephew is a little energizer bunny -- he doesn't stop moving :o)

Anyway, I have to catch up on some emails, so this is it for now.

Brief interlude while at the hospital, in which Our Heroine lies through her teeth

Is it ten at night, or morning?  Night float has me properly confused.

Of course it is actually night, and I sit in the resident conference room.  I'm not thinking a bit about this current cycle, or hormone levels, or endometrium thicknesses.  I'm not calculating when and on what day we will get our beta-hCG results.  I'm not wondering how I will take the news, be it good or bad, and where I might be when we get The Call.

I am perfectly captivated by Harrison's Principles of Internal Medicine.

PS If you believe that, there's a bridge to Brooklyn I'd like to sell you.

I've actually been doing well thus far.  I have been reading Salman Rushdie's Midnight's Children.  It's quite interesting, and the style is unique.  This is the first of his books which I've read.  I don't yet understand why it led to the ramifications to which it did, but my Indian history is practically non-existant, so perhaps that's why.  I've watched some episodes of the "Lizzie Bennet Diaries" which are a wonderful modernization of Pride and Prejudice.  I still recommend the book beacuse Jane Austen is AWESOME and HILARIOUS, but these are a nice adaptation.  It's spring and the air is heady with lilacs, and Husband and I have started taking walks outside again.  Modern life keeps us so cooped up inside, and with the constant pull of technology, it's too easy to forget that there is, indeed, a Real World out there.  (And yes, I did indeed spend a fair amount of time studying the Romantic Period.)  It's also so difficult to disconnect from technology.  At least when we walk, we might look up the answer to a question on our smartphones, but we're actually talking to each other.  No television or computer in the background.  Although, we are fans of Doctor Who, and of the Big Bang Theory, and have been watching both.  I also very much enjoyed Verdi's Aida last night, but Husband was non-plussed.  I suppose this is not surprising as his patience is equal to a two-year-old's.  (But a lovable two-year-old's.)  I love the music, and the spectacle, and the story, and the singing was quite good.  The set was also very well done -- not extravangant, but appropriate, and with a very interesting color scheme involving ltos of green.

Anyway, back to learning.  See you all tomorrow!

Of kidneys and conferences and textbooks

So once again it has been a while...

I suppose that's what another busy rotation does to you!  I just finished the Nephrology consult services.  In other words, I am (was) your friendly neighborhood kidney doctor.  It was a relatively busy month, covering two to three connected hospitals with at least one and not uncommonly two new consults prior to 0900 attending rounds.  But Nephrology is an interesting field.  I enjoy working through acid-base problems.  I like using the primary data to inform my clinical decision making.  Yes, that means I looked at a lot of urine.  Well, okay, to be precise I centrifuged samples of urine and examined the sediment under a microscope.  It's actually fun.  I promise.

And should any of you be struggling with acid-base, I will pass on the NFR approach to acid-base.  Fun for the whole family.  If your family are physicians.  Otherwise they might switch topics.

1. What is the pH?  Acidemic, alkalemic, or noremic?  (REMEMBER: -emia is the status, -osis is a process).  This gives a clue as to the primary problem, because you can NEVER compensate past normal.

2. Look either at the bicarb or the pCO2 next, based on what your results are and what the pH is.  Does there seem to be an acidosis, or an alkalosis?

3. Check for appropriate compensation by applying the requisite formula.  No compensation?  You've got a double disorder!

4. Calculate your anion gap, remembering to correct for albumin.

5. Calculate your delta gap (observed gap minus expected gap) and if you have an anion-gap metabolic acidosis, calculate your  delta-delta gap (change in AG over the change in bicarb, or just add the delta gap to the bicarb and see what it comes out to be.)  If the delta-delta is greater than about two, or adding to the bicarb makes it over about 29, you've got a concommittant metabolic alkalosis.  If it is still low, you have a concommittant non-gap acidosis.

6.  You should have thought of most of these, though because you took a good...HISTORY!

Like I said, fun for the whole family.

We had some great attendings and I learned a lot; each had a different style.  I prefer to have one rounder for at least two weeks but ideally a full month, but I guess there is something to be said for experiencing different approaches.  The overarching message seemed to be to think critically, and never rush dialysis.  And of course avoid nephrotoxins and measure those ins and outs and electrolytes.

Now I'll be moving on to night float.  We work from 8:00pm to 10:30am maximum, three nights on and two nights off.  It's not a terrible schedule as night float goes.  But I don't think well in the middle of the night.  I'm tired and my brain shuts down.  So, I'm a bit worried about being the senior resident and being responsible for proper workup of my patients.  I'll just have to do my best.

In other news, we are quickly approaching oocyte retrieval and then of course transfer day.  I honestly just want this to be over.  Surrogate told me her endometrium is the thickest it's been in any of the cycles thus far, which I guess is a good thing; and there are several follicles developing in my Donor.  I don't want to get my hopes up, though.  I just want this cycle over with.

Meanwhile, of course it's almost M-day (and I'm NOT talking about my name!)  Last year this time I was fresh from losing Sweetpea before he/she even made it to six weeks.  It was a hard day.  This year it will be my fourth married un-mother day.  But I decided to buy myself something:



I didn't want something angry because I don't want to make a scene at Mother's Day, and I want to focus on my own wonderful Mother and Mama Phyll.  But I want people to know that it's a hard day for me, and that I wish I too was a mother.  (I found the shirt at Cafe Press, by the way.)  For the newer infertiles, I have no good advice on surviving the day.  Sorry :o(  At least there are usually sweets.

Hmmm...what else?  I came back from a major medical conference at which I had a wonderful time.  We were in a city I'd never visited before and it is lovely, very walkable and with two key features: a fabulous bookstore and a Cheesecake Factory :o)  I partook of both, of course!  I presented a poster about a patient of mine with Turner's Syndrome and Coronary Artery Disease.  It was a bit nerve-wracking but it turned out there was no on-site judging (had all been in the submission phase) so I didn't have to present formally, and if I do say so myself, I looked pretty good in my brand new suit and my sparkly eye makeup with my killer mascara.  I also attended a great update on chronic kidney disease and some wonderful workshops, one on narrative medicine and one on patient-centered interviewing.

Since then?  Well, it's become spring overnight here in my home town.  The trees are all blossoming: cherry trees, magnolias, dogwoods (I think?) and others I can't name.  The air is pure perfume and the sun is finally shining.  It does wonders for my mood.

Anyway, I think it's time to finish this VERY long post.  But wait -- I wanted to tell you, dear readers, of my "marathon" goal, in the style of K who is working from couch to 5K right now.  Training for a marathon isn't feasible now, although I try to powerwalk my way through lectures as much as possible. But my personal marathon is more career based.  The Internal Medicine "bible" is a text called Harrison's Principles of Internal Medicine.  (If you read Cecil, sorry.  It's not the same.)  I intend to complete all of it.  Yes, I mean ALL.  There's plenty of time.  My first goal is the section on cardinal manifestations and presentations of common illnesses.  I will do one topic a week at least.  I also want to finish Nephro since I'm close.  And otherwise, read according to my patients, at least twice a week.

Can I do it?  Let's find out?  And if you're a doctor, you're welcome to join me :o)  Otherwise, see you on my powerwalks outside.  Can we get four a week?

I am lying in bed after an abbreviated Shabbos dinner. (Husband was tired and wanted to come home early.)  It was one of those days when I spent a LOT of time thinking about infertility.  I recognize now that these things ebb and flow.  A year or so ago the depression was really getting to me.  Now I realize it's just what is, and it waxes and wanes, and I have to try to enjoy the good moments and remember that the horrible moments won't last forever.  I don't stop myself from being sad, I just let it happen.  Fighting takes too much energy.  With the sun I am usually better, and I am hoping we can finally shed the ski jackets sometime soon because seriously, April, it is too darn COLD.

We got the draft of our egg donor contract back.  Husband already looked it over and said she is asking for a lot of revisions and he wonders if some are unreasonable.  I still have to take a look.  But I worry, too -- I'm rather a captive audience, aren't I?  I just hope things work out.

I have been thinking too, what I would do if this cycle and the next cycle fail.  Husband is still against adoption and I don't know how much more IVF I can do.  I have my doubts even about this but am not giving up yet.  I try to think about what I can do and what could bring me joy if (G-d forbid) I don't have a baby.  It will never add up and it will never replace.  And I would rather die than live childless. But life is a gift from G-d so that's not really an option.

 - I can (theoretically) be a kickbutt physician, the one other doctors see when they need medical attention.
 - I can finish writing my novel and be an author, dividing my time between clinical and educational duties and my writing.  It works for Abraham Verghese.
 - I can still make kickbutt challah, cake, and matza-ball soup.  (Yes, I will provide the recipes one of these days)
 - there will still be chocolate soufflé and cake-batter flavored ice cream to eat
 - there will still be tea with sweetener and lemon
 - there will be opera and theater and ballet
 - there will be falafel and pita and jachnun in Israel
 - the Mediterranean
 - nachal zaki נחל זאכי, my favorite hike -- or it is a swim?
 - I can still inspire students at the bedside
 - I can still read a good book in bed until I can't keep my eyes open anymore
 - music: Beethoven and Mozart and Bach and Chopin and Tchaikovsky and more
 - frosting :o)  by the spoonful, straight from the container
 - the smell of new books at a bookstore

I think that's enough for a sleepy night with eight patients to see before rounds tomorrow morning.  Nephrology is fascinating but I want sleep!  And we are going to see Aida tomorrow night.  Viva Verdi!  (or is that Vittorio Emannuel Regnum d'Italia for you history buffs)

And one last question, dear readers:  I have been thinking about the idea of Infertility Photos as a foil to the maternity photos my friends keep posting.  I want pictures too!  I don't know what exactly I would do, or how much it would cost (not wiling to spend much).  But I am on a journey too, and it's longer and more painful, and I don't ever want to forget this time.

Any creative people have ideas for Infertility Photos?  I don't actually intend to make them public, but I sort of want something for myself.

Anyway, that's all for tonight.  Shabbat Shalom, everyone!

I know, once again I have left you, dear readership.  It's just been a very low-energy period for me.  I managed to go on the treadmill once, and outside once (which did wonders for my mood as per the Romantic dictum of the child in Nature), but other than that, I have felt like a complete slug.  I suspect it's psychosomatic.  A year ago we lost the second pregnancy.  I remember so well -- we were eating at מקום של בשר in Tel Aviv, a fancy meat restaurant, with S and E who were two months from delivering their baby boy, and S created a wifi hotspot and I received a bad news email.  It was before our food even came so I had to maintain a public face for the rest of the night.  Then we went back to the hotel and go figure -- what was on television?  Father of the Bride Part Two (just at the part where the two women have babies).  We switched the channel.  Fate was against us: Tali from the Israeli show Ramzor (רמזור) was having her baby in the episode that was airing.

But I made it through.  I didn't think I could possibly lose another baby after Baby A and my sweet Peanut.  But after we lost my Sweatpea, I finished internship, and now I have almost finished my second year of residency.  I don't even have another call month.  My evaluations dropped slightly but you know what, I made it through.  And that has to be a victory of some kind.  And while I hope and pray that I never deal with another trans-Atlantic miscarriage, I guess that if I survived before, I could survive again.  (And this time, I would not be afraid to make an expensive phone call if it made me feel better!)

But maybe I'll just have a BFN.  And who knows?  Retrieval and transfer must happen first, of  course.    we do have tentative dates for those but I prefer not to share yet.  I do know we plan on a two-embryo transfer and that once again, I probably won't be able to make it to the transfer.  I guess there's nothing much I would do there anyway, but it does feel strange to be so removed.

Anyway, that's the IVFun (not) update.

In other aspects of life, we had our annual mimouna party, where Husband and I pretend we are Moroccan Jews and whip of a huge batch of mufletot and other sweets to celebrate the end of Passover.  This year we had forty-six guests!!!  It was a bit of work but a lot of fun, and my beloved Mama Phyll and her best friend helped a lot.  My semolina cake was a big hit; I'll try to remember to translate the recipe into English sometime soon.  I hope everyone enjoyed him or herself but I was so busy trying to entertain everyone that I don't even know!

We also booked our flight to Israel today (we're going in June) and it will cost us only 400 total because we used miles.  Whoohoo!!!  We are looking at a boutique hotel in TA to use as a vacation from our vacation.  Husband wants to try the Diaghilev -- has anyone been or heard about it?

And in professional development: I think I have finally decided on a career in Infectious Diseases.  I still hesitate, but I think the decision was pretty much made.  I hope Dr. C wasn't joking when he essentially guaranteed me a spot!

I think that covers most bases.  I am hoping to get a full night's rest so will be going to bed now.  Goodnight, gut Shabbos, Shabbat Shalom, etc.  Will try to keep up better if I can.

And to top it off: your daily dose of irony

This letter came for me in the mail this week.  I can't post the letter because of course it has my true name, but here is the transcription:

Dear _____:

Birth control is not one size fits all.  Long-acting reversible contraception is becoming increasingly popular among women seeking a reliable and highly effective method.  MOre women are opting for long-acting birth control such as intrauterine devices (IUDs) and progestin implants.

Both of these forms of contraception have proved more than 99 percent effective ant preventing unintended pregnancy for as long as you want -- from three to 10 years, depending on the type.  The insertion of these devices is a simple procedure that is provided in our office by our specially trained physician.

The family physicians of ________________ are dedicated to helping you fid the birth control method that is right for you.  Our experienced clinicians provide women with a variety of contraception choices, including:

• The copper and progestin IUD
• The progestin implant
• Birth control pill, patch or ring
• Injectable contraceptives
• Diaphragm fittings

No birth control option is right for everyone.  Call _________ today to make an appointment to discuss your contraception options and receive a free makeup bag.

My question: can I still get the makeup bag?

Maybe I should write them back:

Dear _____,

I appreciate your offer to assist me with my family planning.  I actually decided none of your methods was effective enough, so I chose to be born with an even more certain birth-control method: the have-only-one-fatty-streak-ovary method.  It works so well I can't even get a gestational carrier using a donor-egg embryo to produce a live baby!  So I just can't rely on your leave-it-to-chance medical interventions.  I do appreciate the offer and your reminder of my infertility, though.  Until I opened your letter I hadn't thought about infertility for HOURS!  It was quite kind of you.

Oh, and one tip: if diaphragms worked well, I wouldn't exist.  Ask my mother.

The long-promised update

So yes, life has been busy.  Mostly I have been working.  My four-week rotation in the CCU (cardiac care unit) seems to have taken a fair amount out of me.  I don't want to complain when I say we worked hard -- that's what you do as a resident.  There's no other way to learn.  But working almost eighty hours a week doesn't leave much time for anything else, including blogging.  Now I have a brief reprieve in the form of two weeks of Neurology.  We have weekends off!  That's right -- I didn't work yesterday, and I didn't work again today!  I could get used to this -- or rather, I wish I was able to get used to this, but it's just two weeks and then back to business.

I've had some self-pity moments, especially when I counted the pregnant women around me.  There are at least four nurses, one resident, one fellow, one of my best friends (but she lives out of town so I don't see her often), another fellow from last month (though I don't see her often), and then a speech pathologist.  Then there are more peripheral people as well.  I think my current total is twelve.  Seriously!?!?  But I guess that's (the fertile) life.  I don't know anyone in real life who is infertile.  Thank goodness for the blogosphere for reminding me none of us is alone!  I'm not sure I could keep going otherwise.

It does seem to help when I find other ways to fill my time.  When I get to teach medical students that helps.  Yesterday I had a great time with two of my closest friends.  I went to the local art museum and then a tea shop with one.  (Our city's cultural attractions are vastly underestimated.)  Then another friend and I went to dinner and a high school musical, which was actually surprisingly good.  She came over afterward and Husband, E, and I watched "Brave," which was very cute.  Pixar is pretty dependable.  Today Husband and I went to a buffet lunch at a wonderful Syrian restaurant and had all the delicacies I miss from Israel and my aunt's family: bamya, mujadra, cauliflower with tehina zaatar pie...all sorts of goodies!  And then I made plans for us for next weekend with an Iraeli ex-pat couple, and luckily it works out best without their kids, so I won't feel sad.  We need more couple-friends and it would be especially nice to have some Israeli ones.  Who else understands why American pita is a poor copy of the real deal?  Who else understands why queues are silly and punctuality is even sillier?  Or why planning ahead is just dumb when you can invite people last minute?

Anyway...

I have precious little to report on the non-baby scene.  Our Donor and Surrogate have had some recent checkups that went well, and it looks like the IVFailure #5 transfer will be in early May.  I expect nothing and am worried because the dates will coincide almost exactly with the cycle two years ago that almost resulted in a son.  Let's hope this is a חוויה מתקנת (correcting experience).  We have to make sure the contracts are all in order, and then it's just wait and pray.  I also worry because G-d willing we will be going to Israel for the first two weeks of June, which is prime miscarriage time if the cycle takes.  Having been there and done that, coping with such sadness thousands of miles away from my support network is not my idea of fun.  Add to that the fact that our Israeli friends are mostly on baby #2 and all have at least one, and we will be stuck seeing some brand new babies too, and you get the picture.  So I just really hope we don't have another distance miscarriage.  And a live baby/babies would be a nice bonus.

So that is my current state.  A week from Monday is Erev Pesach, so I will be busy this week shopping and cleaning and preparing.  It'll be busy but I do love the seder, although I will miss my aunt and uncle and their little ones who will be in Afula.  (No fair!  I want to go too!)

What else?  It's still snowy, but I hope the weather turns by the seder.  After all, Pesach is supposed to be a spring holiday.  What kind of spring is it when the weather is barely above freezing?

Have a restful rest of the weekend, everyone!  I will try to be more timely.  I may also post about the passing of one of my continuity clinic patients.  She was young, and chronically ill, but her passing was most unexpected.  I don't think I can reveal more particulars but it was the most shocking phone call I got this morning, and I still can't believe the woman who called me last night is now dead. Baruch dayan emet and condolences to her family.

Apologies for my long absence -- will post more tomorrow

Sorry for my very long absence from the blog world.  Life in the CCU (cardiac care unit) was a full-time operation and then some!  But I am rotating on Neurology right now and should be able to update tomorrow.  And I will try to stay on top of things!

Take care everyone!  And here's the public service announcement of the day:

IF YOU OR A LOVED ONE IS HAVING A STROKE, SEEK MEDICAL CARE IMMEDIATELY!  Clot-busting treatment is key in certain strokes, but can only be given within the first 4.5 hours starting from when the stroke victim was last seen normal.  SO GET HELP QUICKLY!

Sweet dreams,

Mim

In brief -- signed agency agreement

I guess it's getting more real.  We signed the agency agreement for our new donor, and I contacted our lawyers (who are a good group; I can give the name if anyone needs) for the needed amendment to our surrogacy contract and to draft the new donor contract.

Here we go again...we even chose the donor payment plan which costs more but which is refunded if pregnancy is not achieved.  I wish we had done this last time.  But no, we naively believed that a new donor and a new surrogate were the ticket to parenthood.  We could have saved a few thousand dollars -- although in the scheme of things, that is such a miniscule amount.

They may have been referring to us when they said "million dollar baby."

I just hope my parents really do know how incredibly grateful I am for their help with this.  Dear Husband and I would not be able to afford even a portion of this on our own.  And I am one of the lucky few without student loans!  I try to tell Mama and Daddy periodically how thankful I am, but I hope they know I truly mean it.  I don't want them to think I take this for granted.

Although I do hope we are eventually granted children.

But for now...a presentation on cryptococcal meningitis (it's C. gatti, and there's a cyrptococcoma...totally sweet!!!) is stubbornly refusing to write itself.

And the public service announcement du jour: if you have HIV, PLEASE take your medication!  You can stay so healthy!  My poor patient nearly lost his life, all because of the aforementioned infection which could easily have been prevented.

Interesting article from Ha'aretz מאמר מעניין מעיתון "הארץ"

קראתי את המאמר הזה וחשבתי שאולי גם אתן תרצו לקרא.  ניסיתי להעתיק את כולו אך לא הצלחתי, אז היה יש את הגישה לאתר.  בקיצור, זה לא הכי אופטימי, אבל צריכים לקחת בחששבון שמשפיעה גם כמות הנשים שעוברות עשרות מחזורי טיפול.  מה שכן, אהבתי ללמוד שנשים בארץ (לפחות אלה שמבותחות) זוכות לטיפולים מכוסות, ואפילו הרפייה חוץ גופנית, ואפילו עד ילד שני!  חבל שלא עליתי ארצה, הה?  (זאת אומרת -- עדיין לא עליתי...תמיד יש תקווה, נכון?)

http://www.haaretz.co.il/news/health/research/1.1917264

For the English - speaking among you, the above article is likely translated if you are interested.  Briefly, it discusses the dropping success rates of fertility treatments in parts of Israel, but acknowledges that this may be due partly to the women who undergo as many as twenty cycles of treatments, and thus affect the averages.  The cool thing to learn was that many women in Israel have even IVF covered by insurance, even up to the second child!

Anyway, have a good night, dear readers!

Sign on the dotted line...

Our donor has agreed to proceed, so we just need to prepare the paperwork.  The nurse coordinator says we should expect a May transfer, give or take.  (It's far too early to know exactly when people will cycle.)  I am too tired to write more now, but will try to update later this week.

Good night everyone!

Update du jour...

...is that's I'm waiting for an update.  Husband and I chose an anonymous donor.  (Thanks to you, you-know-who, for your thoughtful discussion of the risks and benefits of known vs anonymous donors!)  Our reasoning eventually came to the fact that S, my best friend, has too crazy a schedule because of her residency and too high a stress level for it to be fair to ask her right now; also, she doesn't have proven fertility, which is the one thing the REI specialist suggested we could change.  So we found a lovely young woman with two children and we're waiting to hear back.

I'm trying to occupy my time as best I can.   I've gotten back to exercising, though to solidify it as a habit will take several more weeks.  I'm reading (Charles Dickens and Chitra Banerjee Divakaruni) and studying Infectious Diseases.  (When your Daddy is the attending, you especially want to look smart!)  I still get sad but it is a little better this month, perhaps because of ID being a fun field and my fellows being fun girls.  Sometimes, though, it's hard.  I called one of my good friends from high school.  She's pregnant, and I have a hard time figuring out about what to talk.  I don't want her to think that she's nothing more than her uterus, but I don't want her to think I'm avoiding the (growing) elephant in the room.  I will say I did a very good job of being excited for her for a solid hour and a half on the phone when she called to tell me her good news.  It's also hard when someone gets excited for me to proceed forward.  I ended up telling the ID fellow about needing a surrogate.  She's asked some questions, which is really sweet.  But she doesn't realize that when it's round 5, there is nothing exciting about it anymore.  You sigh, and steel yourself for disappointment, and try to force yourself not to be excited.  The two-week wait actually becomes easier each time, because you know it'll be a negative beta-hCG so why rush and why be anxious?

The scary part is, I find myself becoming hopeful.  That, dear readers, is not good.  Hope hurts when it's betrayed.  I worry that this cycle -- which isn't even a go yet since we still need to hear from the donor -- will fail and I will fall apart.

Yet this hope isn't like the anxiety and hope I felt with cycle #1.  It's more...prophetic in nature.  Of course in the Torah Miriam was a prophetess even from the young age where (according to midrash) she told her father Amram that he should not divorce her mother Yocheved.  But honestly, sometimes I have intuitions which are surprisingly accurate.  (Don't worry, psychiatrists -- I will provide an address to which you may send the antipsychotics at the end.)  With the first cycle, I didn't expect to lose baby B, but once we did, I had numerous visions of losing baby A.  I saw myself telling my internist/mentor and telling my batch-mates in residency.  With our second cycle, I looked at names for the brief moment of happiness, yes, but I never truly latched on to the idea that the transfer took.  Even before we knew there was no heartbeat, I felt the sadness and emptiness and had no expectation of a baby.  With our fourth and fifth transfer, I expected failure.  And now?  I don't have quite that same expectation of failure.  I had such clear visions of losing baby A.  It wasn't that I exactly thought it would happen.  It's more that I kept seeing these stories in my head where we lost the baby, me telling those close to me that we had lost the baby...and with the second cycle I had a dream too that we lost the baby before we even had the fatal fetal (haha) ultrasound.  Now I have had many pictures in my head of telling my attending that I might not finish out the rotation because (surprise) we are thirty-four weeks.  In these visions I haven't told anyone except close family and my best friends because I don't want to tell anyone until I hold a healthy baby or babies in my arms.  But I am not righteous like Miriam and certainly I don't merit prophecy, and anyway, if I did, I would hope Hashem gave my insight into something more helpful to other people that just knowing the outcome of my IVF attempts.

At any rate, I do wish that this next cycle might succeed, but I don't want to hope.  I am so afraid of hope.

I've Gotta Crow

In a rare turn of events, Mama, Daddy, and I are all caring for the same patient.  I can't provide details out of respect for my patient's privacy.  But I can say that I out-diagnosed and out-historied my Mama.  (rib fracture and pulmonary history)  I'm sure it was just a stroke of luck.  But I'm still going to brag.

PS: In Which our heroine hosts the lamest party ever

I invited all the girls from my residency class over for dessert Saturday afternoon.  There are eight or ten of us.

One girl came.

Plus side:  My Infectious Disease team enjoyed a whole lotta sweets today!

Now boarding: emotional roller-coaster #5

That's right, dear readers, Husband has agreed to try again.  We have to decide whether to accept my best friend's offer to be our egg donor or to choose another anonymous donor, and we have no cycle dates in place yet.  It will likely be a few months.  Surrogate N is thrilled.

I'm on the other hand, am worried and lonely.  Will I have the strength to bear another failed cycle?  I'm so close to breaking.  If we run out of eggs again, if Husband still refuses to adopt, I don't know what I would do.  Childless is an option for some people.  It's not for me.  I would die.  Except suicide is a sin, and so in all truth I would just live a very very sad life.  Perhaps it hurts less with time?

The loneliness hurts too.  Mama thinks I am ridiculously preoccupied, and Mama Phyll doesn't understand how one can pour one's entire heart into a cycle and be so devastated when it fails.  When your mother and grandmother don't understand, who will?  Even my other go-to person has been trying to convince me not to make this my entire reason for existence and instead to focus on other things.  She means well, but sometimes I wonder if even she doesn't understand.  After all, this isn't as if I want a new toy or a new book.  I want a child.  I need a child.  What else could possibly be as important for a girl who wanted to be a mama from the time she was three years old?

The other aspect of isolation is how my circle of non-pregnant or parent friends dwindles.  Every time someone makes an announcement, it's another person whose life is about to change forever in a direction where I can't follow.  I am left watching from the sidelines.  And while I have -- for the most part -- accepted that I will never be pregnant, when someone starts talking about her pregnancy all I can think about is how I will never experience that.  And yes, I understand it's not nine months of bliss.  But it's an experience most women share, the quintessential female experience, and I won't know what it's like.  I hate missing out.

But for now, this sad puppy is going to bed.  Busy day of Infectious Disease consults tomorrow with my very brilliant Daddy as the attending!

Liebster Blog Challenge, part two

I never posted the eleven random things about me.  Here they are:

1. When I was little, I thought the Troll Bridge at family camp really did have a troll living underneath it, and only Art Man could save you.  Even in college I felt a twinge of apprehension crossing it.

2.  I love thin-crust pizza.

3. I memorized the first 100 digits of pi in sixth grade because math class was boring.  Yes, I still know them.

4. I have never been drunk, or even had more than one glass of alcohol in a sitting.

5. I still feel like I am playing house even though Husband and I are married over three years.

6. I have dreamt in Hebrew, but only on very rare occasions, and usually there is a bomb and I wake up just before exploding into bits.  I have never dreamed in Yiddish.

7. When I was a child I had terrible nightmares on a regular basis, and it reached the point where I was terrified of falling asleep.  That part was solved by chronic sleep deprivation.

8. I don't like ice in my water.  It's too cold and it also makes my hands Reyanad  (ie they vasospasm)

9. I also don't like pop or soda or whatever you care to call it.  Rarely I drink diet ginger ale.

10. I love all desserts, but in general, the sweeter, the better.  Knafe from Shafiq makes my mouth water.  I also go head-over-heals for ooey-gooey underdone brownies.

11. My favorite ice cream flavor is Cake Batter from Coldstone.

January is named after Janus, the two-faced god of classical mythology.  The idea, obviously, is that the start of a new year entails looking both forward and reflecting on the year which passed.  I can't say 2012 was happy.  A miscarriage, two failed cycles, and not only are we out of embryos but Husband wants to take a break -- for who knows how long?

It isn't that 2012 was without anything positive.  And all I have to do is enter the hospital each day to feel fortunate.

But I felt so very sad on New Year's.  I love New Year's Eve.  It's when we all gather for a huge party at Mama Phyll's and it's freilach and fun and not fancy but just a nice evening with tons of family and friends.  Part of it was probably the strain of hosting my in-laws for the previous week, the fatigue of working a full day of Infectious Disease consults, and not even having time to shower before heading over to the party.  Whatever the cause, I just wandered through the party feeling lost.  I don't fit in with my sister or my little cousins.  My sister is a college freshman, and my cousins are young adults but single and not settling down right now.  I don't fit in with my parents' generation or my grandparents'.  I love my family more than life itself, but at the metaphorical dinner party, I have outgrown the kids' table and haven't quite made it to the grown-up table.  The only place I don't feel lost is with my baby cousins.  With little children you don't have to be anybody.  You just have to be honest and silly and imaginative.  And so the best moments of New Year's Eve were with my little cousin, S.  She is five years old and was wearing a white party dress with silver beading and white earrings.  I stole precious moments tossing her up in the air while her laughter melted my heart, and then, one precious glowing ember, at about 11:00pm when I found her sitting on the stairs watching "Brave" on the iPad because she was tired, and she snuggled against me and nearly fell asleep with her head on my shoulder and I could pretend.  I am lucky.  My little cousin is a warm child with a cuddly personality, and loves me to throw her in the air, or make her into a package to deliver to Mama Phyll or Auntie Diane.  But I have read James Barrie.  All children, except one, grow up.  How long before she's too heavy to play these games?  I am probably lifting at least a third of my weight already and though she helps, it strains my back.  How long before she loses interest?  She fills a void.

So now, after a vacation which was anything but restful (thank you, Mother-in-Law!) I am back at work, on the Infectious Disease service.  I am already exhausted and behind on my reading, but at least it's ID.  I know my ID.  I can Gram stain with my eyes shut.  I love detailed histories and physicals.  I like treatable illnesses and I like the cerebral aspect.  I read Mandell.  I like the meticulous attention to detail, or as Ghosh would say in Cutting for Stone, "constant vigilance!"  The fellows think I am on their level.  I am good at so few things.  It helps to have something I can claim.

Okay, so I want to brag for a moment.  Every internal medicine resident in the US took an in-training exam in mid-October.  It's a full-day multiple-choice exam testing all aspects of internal medicine.

I scored in the 97th percentile nationally.

That, dear readers, is something infertility can never take away!

So why is it Mama has decided I should do Rheumatology for the lifestyle?  I hate the musculoskeletal exam.  I hate the side effects Prednisone gives my patients.  And I don't want to spend my life taking care of fibromyalgia.  I actually like general medicine and infectious diseases.  And if God doesn't see fit to bless me with children, the only choice I see for me is to let work consume me.  Why do I need a lifestyle if I don't have children to enjoy?  So I can sit home and mourn that which never was?  So I can get a manicure and go shopping and do yoga?  Sometimes I just want to be numb.  And at least when I work twelve hours a day, I come home too tired to think much about the only thing I really want in life.