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?