Vacation log blog

I've been on vacation now since 7:15am Monday morning. I have a total of 3 weeks of vacation time left to take (because I haven't taken any vacation (ok, I've taken 3 of 21 days of vacation, so now I'm taking 15, and I think I'll probably loose 3 days), and all of my vacation goes *poof* and resets in July, it doesn't accumulate between academic years). I've completed the list of tangible things I was supposed to do while on the vacation (although I probably need to mow the lawn one more time before I go back to work).

My goals:

Hang out with the family

Reconnect with some old friends from residency

Sleep... sleep and more sleep. I've added my 4th alarm clock to the rotation (thinking that the reason I can't get up in the am is that I'm too used to my alarm clock), and someone suggested that perhaps the reason I can't get up is because I'm possibly just tired... hm... that may have a little truth to it

Figure out what I want to do with the rest of my life.... do I sell out and go private practice and have a nice life? Do I slave away in academics despite the fact that I don't really like research all that much (it's not that it's not interesting, it's just that what motivates me to get up in the morning is taking care of patients)

Figure out how to tell my attendings that I think I'm going to get a private practice job when I finish.
On Monday:

Gone to a lecture at work (um... yeah... I agree, that was an odd choice)

Got my travel shots for Ecuador. Yellow Fever, typhoid, hepatitis A, Diptheria/Tetanus

Ate a pizza bagel

Napped for 4 hours

Had 2 hours of Tae Kwon Do

Came home and slept poorly (lingering postnasal drip from the cold. I would fall to sleep and wake up drowning in my own phlegm, but the combo of sudafed and benedryl eventually helped)

On Tuesday

Slept until noon

Ran errands to prepare for trip to the Pacific Northwest

Cleaned my house

Met with kitty sitter

Ate pizza bagel (I do love pizza bagels... an odd addiction)

Went to 1 hour of tae kwon do

Did laundry for trip

Went to bed at midnight (the laundry took too long, the loads were a little too big and the clothes took longer than I was expecting them to dry).

On Wednesday:

Got up at 6:30 am to go to work to meet with residents (what can I say, I'm not terribly good at vacationing)

Picked up laundry

Mowed lawn

Payed bills

Fixed old financial aid hold at medical school (a loan I've actually paid off, but they hadn't removed the hold)

Fed cats

Cleaned catbox

Flew 2000 miles across the country to the land of salmon and cedar and $4 coffee. ;)

tomorrow? Sleeping, reading.... maybe some time in the pool. :) Maybe the new Narnia movie. Friends from residency. What more do you need?

(image credit)

Pushmower

I mow my lawn with a push mower. Kind of similar to the one pictured here.

I don't believe it's all that much more difficult than a gas powered lawn mower, and definitely has a smaller carbon footprint. It's also good exercise. It also causes people to talk to me, and since I tend too be a little bit less social than might be good for me (although it's a step up from my previous social rating of painfully shy), that's also a good thing.

I had a conversation with my next door neighbor, with his working-man hands, and his Afghan poppy plants, and the almond tree he's trying to grow. He said, "you're too heroic", and told me a story about how everybody in the neighborhood had tried the push mower and eventually got tired of it, and about how they all switched to power mowers.

The little farmers market/street market that's down the street was playing some fun music, and the birds are out. And, when you mow with a push mower, you can hear them all, too!

A push mower might not be for you if:

You refer to your lawn as "the back 40"

You are a perfectionist with respect to your lawn (it doesn't do as good a job as a powered mower, and the "self mulching" "feature" means that the grass grows in a little less dense, unless you rake the lawn after you mow it)

You have a lot of sticks in your lawn! (even if you think you can get over a stick without it stopping the mower, you're probably wrong!).

You have a lot of hills in your lawn


Hm.. I guess that's it. I have a medium sized lawn, and mowed it in about an hour. My heart rate was in the aerobic range for almost that whole time. Good exercise, minimal pollution (unless you count grass clippings), sun, and neighbors.

Overall, I give the push mower experience a "B+"

(image credit)

Drowning in Phlegm

Why is it that nuisance ailments such as a cold are so annoying? I mean, if the cold virus was planning its attack strategy, it's done a good job. I'm literally a fountain of infectious mucous, mostly originating in my sinuses and then running down my throat and nose.

Yet, I'm not sick enough to stay out of work (although it's Saturday, and I think I'm going to go in to work if mowing the lawn doesn't kill me, but nobody else will be there, and I didn't get a whole lot done this week), so I can go and (theoretically... in the days before hand washing and anti-viral tissues) infect more people.

It is a perfect evolutionary strategy for a virus. After all, if it made people sick enough to stay home, that would limit it's infectiousness to household contacts. As it is, people can wander about as they please and infect unsuspecting bystanders (like me!).

The rhinovirus is a magnificent feat of evolution.

However, I still don't like that choking sensation as the phlegm drips down the back of my throat. Sudafed... Claritin.... Benedryl (at night), they all help, but there's still no cure for the common cold (except maybe rest and fluids, but I'm not into rest!)

(image credit)

Could I Be Any Less Productive?

Yesterday was a gorgeous day in America's 3rd world country. The sun was shining, it was not cold outside, the birds were singing, so after 2 attendings told me that I should take some time to enjoy it, I left. I wasn't getting much done anyway.

Then, today, I've been trying to do some data analysis. One is from some genetic stuff, and it involves more than 2 million data points, and I did some of it by hand before and now the analysis is automated, and I'm trying to make sure I got different results because I made a mistake with the manual analysis (not a big stretch there).

But mostly, I've spent the day reading blogs and pondering my coming night on call tonight. I've been chatting with the other people in the lab. I walked over to the hospital cookout. I've been thinking about how I only have 50 call nights left as a fellow (assuming I do the analysis and finish my thesis!). And trying to decide what I really want to do when I grow up. But mostly... wasting time.

There are some days that I just can't do data analysis on 2 million data points.....

Somehow I can always get my act together to see and take care of patients.

What do people do on days like this in the real world where their productivity matters more than mine does?

(image credit)

What I'm Going to Do on My Summer Vacations

That's right. Summer vacations. Our "vacation year" (is that a real term?) runs from July through June (like the academic year). I haven't taken real vacation in over a year, and I don't believe in letting vacation time go unused. So, I'm taking 3 weeks off, starting in 8 days. During that time, I will clean my house and go to visit my family. I'm hoping it will be relaxing, although there's always that family stuff. The fact that my mom always resents my visiting other people other than her (although, really, that shouldn't be my problem. I've taken to telling her my plans and expecting her to deal with it, which isn't a perfect solution, but.... really.... she's a grown-up, she has to learn to act like it).

Then, in July, I'm going to Ecuador to provide medical care for a week (as it turns out, there's not a lot of docs in Ecuador). The hilarious part of this is that I'm helping to staff a general medical clinic. I have done no general medicine in 6+ years, and I speak no Spanish. I'm told that this won't be a problem. If anybody has any good medical Spanish references, please feel free to let me know! I want to go see the Galapagos, but I'm not sure if that will work out with my time and money restrictions. Having said that, I'm about 14 months away from becoming an attending, and so, I may just do the Galapagos as a separate trip then.

Then, later in July, I'm going to Bar Harbor, Maine for 2 weeks for a course on clinical genetics. I think of this as "summer camp for grown-up science geeks". Seriously, it should be fun. And since it involves the Hyatt Regency, I don't think we'll really be roughing it all that much.

Then, in August, I have a couple of job interviews I'm working on lining up (more later, one of the opportunities sounds perfect, but I have to decide if I still like the geography). I'm also giving an oral presentation at the International Society for Ultrasound in Obstetrics and Gynecology.

All in all, a busy summer. Too bad I can't plan on hibernating next winter!

(image credit)

Self Indulgance and Exercise

I have many posts I've been meaning to do.... home births, non-compliance, the rising c-section rate, teaching residents, the fact that nobody ever listens to me (heh!), but instead of blogging about something important, today I'm blogging about me...

So, I've been on prednisone for the colitis for most of the past year, with doses averaging at about 20mg, but on 10 mg for the past couple of months (ever since I saw New GI Doc). I'm not symptom-free on 10mg, but my symptoms are manageable and tolerable on that dose. It's not a very high dose, but there's still a difference (for me) in side effects in being on 10mg vs 0 mg of prednisone. Most of the side effects have to do with appetite; and since my weight's always been a bit of a struggle, well, being on prednisone at any dose isn't terribly helpful with that. Also diabetes, vascular disease, and osteoporosis (my mom had an osteoporotic hip fracture a couple of years ago and has some vertebral compression fractures... pretty severe osteoporosis) are concerns on prednisone. Exercise actually reduces the risk of all of those things, helps with weight control (although whether or not it helps with actual weight loss is debatable, I think it does), and it makes me feel good.

So, I started jogging, which I liked more than I thought I would, and still do, especially since the sun is coming up earlier in the morning now, and soon it will be dawn when I'm out jogging at 6am. I like jogging at dawn. But the problem with jogging is that it's lonely.

And I get lonely here sometimes. I mean, I work with plenty of nice people, and I have plenty of friendly acquaintances, but no real true friends here (although I do have friends from other places I talk to on the phone at times). It's part of the price of living a nomadic existence during medical training, sometimes.

And I needed a hobby. I liked pottery, but didn't have much in common with the other people who took pottery. So, then I tried tae kwon do, and it's been a lot of fun. 2 hours every night I can make it of kicking, punching, throwing, and self defense. And the people who go tend to be people who I have something in common with, in general. Even though I haven't found my BFF there, we chat and laugh, and it's a good time. In fact, I got my yellow belt (which means I'm not a newbie any more) on Friday, and I will be sticking with the tae kwon do for a while. I think I want to get a black belt.

But I also still like jogging, and that's a good 45 minutes of time in the morning. You add that to the tae kwon do in the evening, and maybe throw in some strength training (so I can keep improving my upper body and core strength, which could use some help), and that's like 3 hours of exercise a day.

I know that my program directors (we have 2 for the fellowship) would think that spending 3 hours on exercise, plus the time I need for ADLs (15-30 min a day), plus the 8 hours (and when I'm exercising this much I really need 8 hours) of sleep would think that it's all self indulgent, because when you do the math, I can only spend 10 hours a day on work and do all of this exercise.

24-8=16-3(exercise)=13-1(driving)=12-1 (eating)=11 -1 (ADLs, blogging, tv, etc)=10 (work).

If they knew, their argument would be (and I've heard it before, but not directed at me) that I should spend all available time while I'm a fellow on my fellowship, and that this sacrifice will pay off later. Or that I should sacrifice sleep for my exercise (although like I said, all this exercise makes me need more sleep... and makes me sleep like a rock) or for work.

I've come to the point where my tolerance for this level of sacrifice just isn't there any more. So, I continue my self-indulgent level of exercise, mostly in secret, so that the powers that be at work don't find out.

Having said this, it used to be that doctors (both in training and after training) gave up everything: exercise, family, sleep, activities of daily living, absolutely everything, in order to be doctors. And all of my current attendings trained during that era, so to them, my 3 hours of exercise, 8 hours of sleep, and an hour of adl's really probably does seem self-indulgent, and it isn't their fault, entirely, that they view medicine and life like that.

And maybe this is a temporary phase in my life. Perhaps, I'll return to working harder on work soon. Figuring out where a good work-life balance actually is is really quite difficult, and I expect that that balance will shift for me quite a bit as the years go on.

(image credit)

Six Word Meme

A long time ago, I was tagged by TBTAM for the six word memior meme. The instructions? Write a 6 word memior and tag 6 others.

Catch a baby, watch the floor.

I'll tag all three shrinks at shrink rap, someonetc, RLBates, and Mark's Tails.

Still Alive

Hey everybody, thanks for the inquiries. I'm still alive, just working a lot. I'm on clinical service right now, and working at least 12 hours/day, plus prepaying my call so I can take all of my vacation (I have 3 weeks left) in May/June.

So, if you haven't given up on me, thanks for not giving up on me. If you have, well, then, that's your fault.

More soon. I understand I get my life back at the end of the month. ;)

Bruce is Still the Boss

I am finally back up to ~35 minutes of jogging (approx 3 miles for me. I'm slow, but stubborn). Anyway, as I was jogging this morning, I was listening to the new Bruce Springsteen album (Magic) on my ipod, and I have one thing to say: Bruce, you still rock!

I especially like "I'll work for your love" and "Radio Nowhere"... in fact almost popped into spontaneous dancing while jogging.

"I'll work for your love" is a fantastic little rocking love song. "What others may want for free, I'll work for your love. The dust of civilization and love's sweet remains... slip off of your fingers and come dripping down like rain." :)

And "Radio Nowhere" just plain rocks! "I want a thousand guitars, I want to pound them drums, I want a million different voices speaking in tounges.... This is Radio Nowhere, is there anybody alive out there?" Great song about connections or the lack thereof.

Other songs on the album, including "Last to Die" (about how can we ask our soldiers to be the last to die for a war [in Iraq] that is clearly a mistake).

(image credit)

It's not your fault, except when it is.

So, departing from the world of my gut for a (hopefully long) while....(Although if anybody has any suggestions on getting rid of erythema nodosum, let me know. They're not a big deal, but they're kind of annoying).

I was on call last night. And like most nights, we had a woman on labor and delivery who was loosing or who had lost her baby. And it seems to me that it almost doesn't matter if the loss is at 22 weeks (prior to viability) or 40 weeks, if it occurs after quickening (the time when the mom first feels fetal movements), the grief is always severe.

When women (and their families) are caught up in this terrible grief for this terrible loss, their first assumption is that the baby's death is somehow their fault. In ~90% of circumstances, this is not true. And those women, I always tell, every time I see them, "Remember that this is not your fault. This is a terrible thing, but you did not deserve this." I'm not sure that they believe me, but I think that telling them that is part of doing no harm, as it were. The loss of a child is such a terrible thing for most women, and sometimes heralds the onset of another disease (some women, for example, are diagnosed with lupus only after having a lupus related stillbirth), families have so much potential for self doubt and guilt, that if I can limit the amount that they torture themselves with guilt, then maybe even though I can't save their baby, I've still helped them.

But what about that 10%? The 10% of stillbirths that are preventable. The 10% of stillbirths that are due to uncontrolled diabetics, or patients who did not comply with our recommendation for fetal monitoring once or twice a week? What do I tell those patients?

I think that the diabetics make the best example. Diabetes is the reason Maternal-Fetal medicine came into existence. Way back in the dark ages (pre-insulin), diabetes used to be a death sentence for pregnant women and their fetuses. Then, insulin arrived, and not long after insulin (just a couple of decades, really) fetal monitoring became routinely available. These inventions changed the whole game for pregnant diabetics. With diabetics surviving their pregnancies, we (ok, not me, I wasn't even born then, this is ancient history) noticed that a large portion of their babies died as they got closer to term. We tightened their glucose control, and then we were able to monitor their babies for problems. (The mechanism of diabetic stillbirth is still somewhat subject to debate, but the prevention of it is not) Now, we work towards tight glucose control through pregnancy and twice weekly fetal monitoring after ~32 weeks in all pregnant diabetics. This has resulted in a fairly dramatic decrease in diabetic stillbirths, to the point where diabetic stillbirths, once expected, are now rare. This improvement in pregnancy outcomes for diabetics is the first real success of Maternal-Fetal Medicine.

Most diabetic stillbirths, in fact, occur in patients who are non-compliant with their blood sugars, insulin, and their fetal monitoring regimens. During pregnancy, I give them my "You need to do these things, otherwise your baby could be seriously damaged or die" talk (dead baby talk for short). And despite the dead baby talk, a subset of our patients will not follow our recommendations. Now, I know most of our patients are very poor, but they all get free care through us. We have a baby van that tracks them down and brings them to their appointments. We make sure that they have the appropriate emergency Medicaid so that they can get their insulin. And in fact, few of them have jobs, which makes it easier for them to make their appointments. And we never ask them not to bring their 12 screaming children into the waiting room. We just want them to come however they can, with or without screaming children. Without hospitalizing them for their entire pregnancy and administering their insulin to them (and sometimes we do that, but it's not practical to keep people hospitalized for 9 months of pregnancy because they're non-compliant), we could not do more to make them able to comply. And, rather than telling us they're not taking their insulin, etc. they bring in fake blood sugars. I think it is a case of denial...they don't believe it will happen to them. That combined with the fact that many diabetics don't feel bad until they're really really sick.

So, these noncompliant patients get dead baby talk after dead baby talk. And they have a much higher rate of fetal death than the compliant patients (whose rate of stillbirth is still higher than the general population, but not by a lot). So, when these women come in with their stillbirths, although part of me wants to say (just to be compassionate), "This is not your fault", the other part of me keeps me from saying those words, because they're not true.

I don't know that it really helps the patient to hear "This is not your fault" when it is kind of is their fault. In some ways, these women are suffering a consequence of their lack of personal responsibility (I know it sounds pretty harsh to put it like that). If these women choose to get pregnant again, they deserve to know that they increased their risk of having a stillborn child by their bad behavior. Because if they behave the same with the next pregnancy, they may very well get the same result. And the only thing that's worse for a mom than a single stillborn baby is recurrent stillbirths.

In fact, when women come in for their postpartum visit, and I get to the part of the visit where we talk about the pathology/autopsy results and talk about what caused the stillbirth, I will tell women, "We know that diabetics are at a high risk for stillbirth. And we know that taking your insulin regularly and showing up to have your ultrasounds and have your baby monitored decreases that risk. I see here that your blood sugars weren't well controlled and that you didn't come in for your monitoring visits. My recommendation to you, so that you don't have to go through this again, would be that you avoid pregnancy until you're able to do the things we recommend you do to decrease the risk of stillbirth. If you want to have a safe pregnancy as a diabetic, you have to do these things." At which point I launch into my contraceptive spiel and make sure they have an internist who takes care of their diabetes between pregnancies. We can never get diabetic stillbirths down to 0, but we could get them pretty low, if we had the assistance of the patients.

The thing is, this feels very much like telling the patients that their dead baby is their fault. And in many ways, it is. Telling them that seems unkind. Not telling them that seems unkind. I just worry that laying it out like that does more damage than it prevents. At the same time, I worry that not laying it out like that will do more damage. For now, I'll continue to tell them that they may have been able to prevent the stillbirth, simply because it seems like maybe the best thing for me to do is to empower them to avoid having a repeat stillbirth.

(image credit)

Random Update

I will get back to medicine once of these days. Heck, if things stay as good as they are, I might never have anything interesting (even to me) to say about my gut ever again.

The UC/Crohn's disease diet is not one I would have considered "colon friendly". It's mostly about limiting insoluble fiber (lettuce, raw veggies, skins, etc) and things that could irritate your gut (pineapple, alcohol, fried food). I'm not sure where watermelon, berries, and nuts fit into these catagories (they don't seem terribly high fiber, or irritating), but they're out too. In fact, it's not a diet I would have ever thought to recommend to a patient. Limit fruits and veggies to 4-5 servings/day. 8 servings of bread (and friends) (none of which should be whole wheat). 6oz of meat or more a day (except sausage which is out). Deserts "as desired". Fats "in moderation".

And I don't know how I got so sick so fast, really. Ok, I do know, it's because my usual trigger of the otherwise innocent-appearing URI then got followed by my other usual trigger of working too darn much. The two in combination seem like a particularly powerful provoking stimulus to my dysfunctional immune system. So, then I got sick, and got sicker because I had to work even more and more to make up for the time I missed while I was sick. That apparently made my immune system angry. And you wouldn't like my immune system when it's angry. :)

This time, my extra-intestinal stuff (especially the annoying tendonitis/arthritis stuff) was actually more disabling than the intestinal manifestations. I still have a collection of erythema nodosum, but only about 4-5. They appear to be hanging around, but are really only minimally annoying.

The thing is, I am a bit angry. I'm angry that I spent almost a year feeling terrible or on 40 mg of prednisone. I'm pretty annoyed that old gi doc, instead of trying some different stuff (the UC/CD diet, which isn't magic, but may have taken me a long time to come up with on my own; or the Lialda, which is the same drug as the asacol/mesalamine but in a different formulation where it more reliably delivers the drug to my colon), just kept doing the same thing every time, despite the fact that it didn't seem to be working. I got exposed to a ton of prednisone, and had all sorts of annoying side effects from it. Now my only real side effects are insomnia (really only noticeable if I take it later in the day) and a small amount of edema (just a bit of ankle edema and a general feeling of puffiness). That's on 10mg a day. I even might be able to get away with less after I've been better for a while. Heck, with the Lialda, I might be able to get off of it and stay off of it for long periods of time. (I've spent 8 of the past 10 months on 20-40mg prednisone/day, and it sucks. I hate the mood changes, irritability, insomnia, apetite increase, puffyness, bitchyness that I get with it). And even 10mg/day minimizes side effects to a tolerable level, and reduces risk to something tolerable.

I'm angry that old gi doc never talked about what it might be reasonable to expect. I figured I might always feel at least a little sick. New gi doc says that I should expect to be able to find a way to feel well most of the time, and that I may have to put up with some stuff (the erythema nodosum can be hard to eradicate, I'll probably always have to be a little bit careful with the diet; I'm thinking I may end up making some career decisions based on allowing myself to get enough rest to feel well most of the time); but that there's no reason for me to feel so bad for so long.

And most of all, I'm angry with myself that I let old gi doc get away with it for so long! I feel like I lost 8 months of my life to Inflammatory Bowel Disease. I'm angry that I spent 10 months of my life listening to old gi doc say, "It's just UC, it's not that big of a deal, you'll be fine. Everybody goes through periods where they have more disease activity..." But it is a big deal, and I wasn't fine, and it didn't take that long to fix. But at some point, you just got to say, "Here's where I am, how do I go forward?" I guess. The other thing? I'm a doctor. They gave me all sorts of "special considerations" because of that, but I would give up all of those perqs just to have had good care.

But as much as I am angry, I'm also hopeful. Maybe the UC/IBD/Whatever it is that I have can be controlled well enough that it really won't be a big deal, most of the time.


Anyway, thanks for listening!

And PS, I have no intent to rush into a colectomy, it was just good, in a way, to hear it talked about as not the worst thing ever, anyway. Because there's almost a 50% chance I'll end up with one no matter what I do, eventually, so it had been scaring me.

New Gastroenterologist

I saw the new gastroenterologist today. He might not be my ideal gastroenterologist, but it's a step up. He was at least a little more aggressive than the previous gi. I had been worried about having to explain why I'd like to transfer my care, and he didn't even ask.

He also explained some things. He explained that one of the reasons gi fellow and friends might have been confused was because my path wasn't entirely consistent with ulcerative colitis. Apparently, the scattered granulomas hiding out in my colon are somewhat suspicious for Crohn's disease, as is the fact that I loose ~10lbs/week every time I'm sick. As is the fact that anything I eat seems to reappear virtually unchanged 4 hours later. (ok, tmi, I know. Sorry) Everything else is suggestive of UC, and that's probably what I have, but... apparently it's not entirely clear.

He also decided to start me on a couple of different drugs, Lialda, which appears more effective for UC (and costs my insurance company a tidy $1600/month minus my $15 copay), a short prednisone burst to get me back into shape to get to San Diego tomorrow, and after that 10mg prednisone/day. Which is liveable.

He also started the conversation about total colectomy with J-pouch vs biologics/Imuran. He also laid out a long term plan. Try this new regimen, plus the UC/Crohn's diet (which old gi doc hadn't even shown me... it's a funny diet. Limits fruits and veggies, but deserts are to be eaten "as desired" . Clearly the people who wrote this have no idea how much I desire desert! Made me laugh.), if it isn't working ok in a month, repeat the colonoscopy to shed more light on the diagnosis, and see if it can be made certain. He seemed awfully positive about a laparoscopic colectomy with j-pouch (in fact he said he usually recommends that over the biologics/immunomodulators, because it is curative for UC,), but his doubt about whether I have UC or Crohn's Disease makes me feel like it might not be such a good idea. Although I don't really want to go there (either to the colectomy or to the biologics/immunomodulators), I appreciated that he laid the plan out for me so clearly.

The diet seems somewhat restrictive, but I plan on cheating.. I mean experimenting... once I'm better. And actually, I'm already feeling better. I've been able to eat some stuff today (and now it's certified inflamed gut friendly). And actually drink. As much as I hate it, there's nothing like prednisone for turning stuff around.

Here's hopin...

14 Pounds (Or the scale lies)

That's how much weight I lost last week. Same scale, same clothes, same time of day. I'm having another UC flare, and when I do, I just completely loose my appetite. In fact, I get a weird combination of feeling extremely hungry but having zero appetite. It's a very odd feeling. Although, I am eating, some. Midmorning seems to be my window of opportunity for food. And to sneak in a little caffeine to prevent caffeiene withdrawl.

But... I was thinking about the 14 lbs. Let's say I burn 2000 kcal just going about my day (you know working, etc. Basal metabolic type stuff. I haven't been exercising. Martial arts class isn't fun if you have to run to the bathroom several times during the class. Also, it doesn't seem wise to exercise when I'm not eating much. ) And, let's say that I'm eating 500 kcal/day (I actually am probably eating more than that, but stick with me here). So.. there's a 1500 kcal difference each day. 1500 x 7 is 10,500 kcal difference each week. Each 3300 kcal you burn more than you eat is a pound of weight lost. So, 10,500 would be ~3.2 lbs. So, 14 lbs would be a 46,200 kcal difference. Or, to look at it another way, even if I ate nothing all week long, I'd only be down 14,000 kcals, which is less than 5 lbs. If I really lost 14 lbs not eating at all (which, I have been eating, just not a lot), I would have to burn 6600 kcal/day. That's like marathon-running or climbing Everest levels of physical activity, or burn-patient levels of metabolic activity, which I'm just not doing. Admittedly, work's been particularly busy as of late, but not THAT busy.

The weird thing is, I'm not really dehydrated. I keep up with my fluids pretty well. I made myself eat more yesterday, and I must have replaced my liver glycogen (for you non-docs, your liver stores sugar so that you can use it between meals), because I'm up 2 lbs from yesterday. That's another weird thing.. forcing yourself to eat. It just feels bizarre. And the scale number seems to be pretty consistent. Although I actually feel kind of puffy, so I am wondering if maybe I had a barbel in my pocket or something when I weighed myself last week. If I'm feeling this puffy, that number can't possibly be true. Actually, with the laws of thermodynamics in place, that number can't possibly be true.

If true it would be good, in a way (almost half of my prednisone pudge would be in those 12 lbs). But bad, because I have a doctors' appt on March 12 (switching docs, at long last to a nice private GI, but between his busy schedule and my busy schedule, that's the soonest I could get in). And between now and March 12, I have a trip to Toronto for a conference, and I have a trip to San Diego on March 14, and I don't have a lot of energy right now for preparing presentations, etc. for those trips. And besides, it's never good to loose 12 lbs in a week.

Anyway, just some random ponderings.

Understanding (or how work has saved my life)

So, my mom was terribly ill a number of years ago. So ill that the doctors told us she wouldn't live. My mom is a tough lady and proved them wrong. My relationship with my mom has been a bit difficult. We both love each other, but she's an alcoholic, and like most alcoholics, drinking is usually very high up on her priority list.

So, anyway, mom hasn't been the same since that bout of illness. Since she was ill, she barely leaves her room. She says everything makes her too tired. Now, she doesn't work, she has no real obligations, and most days sleeps until noon (or later) gets up to her chair and watches tv. One of the reasons this frustrates me is that she's too old for her life to be that small.

So, anyway, since January, and I've noticed it more recently, I've had noticable muscle weakness, which I'm pretty certain is due to 6 months on prednisone. Steroid induced myopathy or something. Like... I have a hard time hauling my laptop around because it feels impossibly heavy. Like I dropped my laptop on the ground because my hands weren't strong enough to hold it. Like my legs get tired walking up a few stairs (before I actually get out of breath). It's actually quite annoying. It's also exhausting. I think that having reasonable muscle strength seves as a buffer against the fatigue that is part of my job. I think that having reasonable muscle strength is a buffer against a lot of fatigue. Mostly, all I want to do is rest. Not that I'm not interested in stuff. I'm enjoying the martial arts classes. Work has been interesting. I'm just exhausted all the time.

Well, I think that the combination of deconditioning and steroid myopathy is probably nothing compared to what people recovering from serious illness suffer. My mother, for example, I think never recovered from her deconditioning. Her illness occurred just after her separation from my dad, she was grieving and depressed, and couldn't find the energy to make the extra effort it takes to build muscles back. So, her body only reconditioned itself to her daily activities (sitting in a chair), and because of that, she's never had the energy to do more. And since then, her health has been worse.

One of the things that will save me is my job. My body will recondition to at least my daily activities, which include running up and down stairs (or trudging as I am today), carrying things, exercising, etc. I worry that I may not have the strength to pull a baby out, but there are chief residents and attendings (at least privates) in the hospital, so I could get help if I needed it.

But if I didn't have a job, I can see how it would be so easy just to do what I felt like doing, and that is, nothing. So, in that way, my job is a bit of a buffer against my illness. If I didn't have a job (especially if you were to throw in some depression at an inopportune time), I could easily end up like my mom, living between my chair and my bed, and having to plan a trip to the mall weeks in advance. It sort of has given me just a tiny glimpse (because I wasn't very sick) of what it is really like to recover from a serious illness with a long hospital stay, or even for our patients who need to recover from a really long time on bedrest during their pregnancies for various complications.

As it is, I'm doing ok. I'm tired, and I feel weak, but I can do what I need to do and a lot of what I want to do, although I am a little annoyed at being too tired to go to martial arts on Thursday. My internist tells me this should begin to get better once I'm off the steroids for 3-4 weeks, and to avoid a negative nitrogen (i.e. protein) balance (my carb-lust while on the prednisone may have contributed to this because I think that there were many times I didn't eat protein because I was eating carbs).

Midwife with a Fist?

All right. I did it. I started martial arts training last night. I'd always thought of it as being for little kids or for mystical Asian men. But as it turns out, the list of people taking martial arts lessons can also include curious perinatologists.

It was a ton of fun. The studio that I joined teaches Moo Sool Do, which, as I understand, is an eclectic Korean martial art that's kind of a combination of Tae Kwon Do (kicking and punching, mostly) and hapkido (involves locks, throws, falls, weapons).

Why did I do such a thing? Well, I've always been at least a bit overweight, and I gained a ton of weight on the prednisone. Also, after spending 6 of the last 8 months on 20-60 mg of prednisone a day I must have lost some muscle mass. I certainly feel like I've lost some. I'm used to feeling pretty strong, but for a while, even my notebook computer has felt impossibly heavy. Carrying my groceries into my apartment has become more difficult. Also, as it turns out, strength seems to be interlaced with endurance, I think, because my (admittedly grueling) schedule has just seemed almost impossible.

Although I do indulge in self pity on occasion, I really believe that the best way to approach most problems is to find solutions, so I decided I needed some real exercise. And since we've had below zero windchills for a while (I know, I'm a wuss, but I don't jog if the windchill is below zero), I decided I needed something indoors. I tried the whole gym thing for a while, but I just get bored in a gym.

So, wandering around my neighborhood one night, I saw this place, advertising lessons. I decided I'd give it a try. It seemed interesting. And, really, I'll try anything at least once if it looks like it might be a good time.

So, I tried it. And it was fun. Apparently I'm a good puncher and a fair kicker. The teacher seemed to think that it was an accomplishment that I didn't loose my balance and fall flat on my face while learning how to do a roundhouse kick. And my arms are sore from the punching. Which feels good, mostly. I'm imagining those myocytes (muscle cells) hypertrophying.

This particular studio does contact sparring, although I have to get some more experience before I can graduate from non-contact sparring, I'm not sure I'd be able to actually hit someone. I guess I'll find out.

(picture credit)

Brrrrr!

If my checkbook balance is negative, it means that I owe someone (generally, the bank) money. Since the temperarture outside is -1F (windchill is -30 F), does that mean that the weather owes me some degrees? Because it's pretty chilly, and I could really use them. It's funny, since it's that cold outside, even though my house is heated to a comfy 68F, it still feels terribly cold (the house was built in the 1910's) because of the draftyness. Even the kitties, covered in luxurious coats of fur won't get off the bed (I did leave the electric blanket on for them all day).


Brr!!

(photo credit)

Just a Reminder

I had an interesting reminder when I was on call the other day. The reminder that every obstetrician needs on occaision. A cesarean section isn't necessarily atraumatic for the baby. We (the chief resident and I) did a c-section on a midwife patient. She was laboring and then pushing for a long time. The baby's head was high up. The midwife (one of my favorites) asked me to do a little consult regarding mode of delivery. I checked her, she had a condition known as deep transverse arrest: Where the baby comes into the pelvis (which they do when looking to the side because their head fits best in the pelvic inlet that way); but can't come out, at least not vaginally. People used to do forceps (Keillands and Bartons forceps were invented for this very indication) to rotate the baby and then get the baby out in this situation. I didn't train in rotational forceps, because they're so seldom done (because there's a higher risk of fetal or maternal injury if the provider makes a mistake) any more. Besides, this woman's pelvis felt small, and the baby seemed large.

That leaves really one option. C-section. Which is fine. We went back to the OR, the anesthesiologist put in a spinal, and we delivered the baby. A somewhat difficult delivery, because the baby was really stuck in the pelvis. But we got the baby out. Healthy mom, healthy baby. That's the whole goal of obstetrics. Everybody was pleased.

Except, I went to look at the baby after scrubbing out to let the chief resident and the intern finish. The baby had a cephalohematoma and some bruising from the delivery. Now, the baby will be fine, had to get some light treatment for jaundice (a common complication of a cephalohematoma), but went home with mom. The baby also had quite a bit of bruising from the delivery. I went over things in my head quite a bit, and I don't think anybody did anything wrong. We never attempted an operative vaginal delivery, she didn't push for too long, we delivered the baby as gently as you can when you're pulling a baby that's wedged into the pelvis out through the abdomen.

I think it's just one of those things that happens. It's also a good reminder that the forces of labor are powerful, and that not all birth trauma happens because of vaginal deliveries.

photo credit

I'm Back!

I'm back from Dallas. I learned some interesting things. My posters were well received. I seem to have caught the plague (or maybe just a bad cold. ;) ). Rash, super sore throat, sore joints, extreme fatigue. You know... the kind of fatigue where you need a nap after taking a shower. So I emailed in sick today. I feel a little better today than I felt yesterday, so work probably won't be a problem tomorrow.

The cats were fine. Happy to see me. :) I was happy to see them.

More on the big D later. I need another nap.

Science Fair For Grown Ups!

Tomorrow, I am heading off to Dallas for a Science Fair for Doctors. AKA the annual meeting of the Society for Maternal-Fetal Medicine (SMFM for short). I have 2 posters of my own, 2 posters with another fellow, and 4 posters with residents. I have been really busy this week, at work until midnight every day except Friday.

But now, my house is clean (ok, kinda clean... well... cleaner), and my stuff is packed (mostly. I'm going to let the laptop and ipod charge up over night, and I'm planning on trying to jog tomorrow, so my running shoes and running watch are out). And soon I will be sleeping. I'm on a 12:50 flight to DFW, which puts me there around 2pm, which is perfect.

A week's worth of clothes is all tightly packed into one overstuffed garment bag. I'm a little concerned that it might be over the weight limit (55 lbs per bag), so I might throw an extra bag in my car. I also have no travel-size toiletries, and forgot to make my pre-travel pilgrimage to Target, so I'm going to try to get up and do it in the morning. Since I have nothing else to do tomorrow except run, shower, and get dressed, I should be able to leave in time to buy tiny toiletries to put into little ziplock bags and throw into my carry-on. I'd prefer to put them in my checked bag, but I honestly don't think they'll fit. As it is, I had to roll up a pair of slacks and throw them in my carry-on. I never learned to pack light, but now I've learned to pack tight. Almost as good, eh? P.S. if anybody has any packing light suggestions, I'm all ears.

I also have purchased my pre-flight tunes. For this trip, it's Pearl Jam. :)

My only worry is the kitties. Everybody I know will be at the conference, leaving me nobody to check on the kitties. They should be ok for a week with a really big mixing bowl full of food, the same of water, and the tap left running. I just hate leaving them alone for so long. They always puke on my bed when I do this, and I probably deserve it.

I Think Its Done

I'm heading off to a meeting in a week. I'm presenting 2 posters as the primary author, and helping a very motivated and good group of residents with their posters, for a total of 7. The posters all need to get to the printer by Wednesday. Not only that, but I'm trying to finish my thesis bench work. And call. I've been at work from 8am-midnight several days this week, and the others I've been there until 8pm. And last night I was on call. (Fun call, but sort of steady, business-wise).

And now I'm exhausted. So exausted that sitting up makes me a little nauseated and dizzy. And why does exhaustion give me insomnia? This I want to know! I have such weird sleep when I'm really tired, it takes me forever to get to sleep and I wake up a lot. I would think I'd sleep like the dead!

But it's all worth it, because everything's almost done for the meeting, my benchwork is making progress (although I kept messing stuff up today, so I went home). I'll take my posters to the printer on Wednesday, and pick them up on Thursday, just in time to fly down to Dallas, Texas. I even cleaned my house and did some laundry today.

All my exes live in Texas... ok, only one of them actually does, but I don't think I'll look her up. :)

(Image credit)

Decision Appears to be Made

I appreciate everybody's input about the PhD decision. At first, I was sure I was going to do it. I even put things into place to start figuring out the mechanics of doing it. I was offered a junior faculty position for the time it took me to complete it. I was all excited about it, and then I started to think.... a PhD usually takes 3-5 years even when the student does nothing but their PhD work, and although my medical school stuff would count for a lot of PhD work, I really feel like if I got one in a year, it would likely be sort of a rubber stamp PhD, and I'm not interested in that. I respect what real scientists do too much for that.

The other thing is, while I'm having fun doing my thesis work right now (the work is going well, and things are always more fun when you're successful), I do miss patient care. And medicine is what I love about medicine. I think I could be good at research, but I'd never really love it enough to make up for the time I didn't spend taking care of patients.

And then I got a job offer. From a very smart guy. Who seems to respect me. He asked me to be the dirctor of (something) in a different city, far far away. He said that I was the person and the doctor he wanted, and he was happy to wait a year and a half for me to finish my fellowship if it meant he could have me. Also, he was very non-pushy about it. He specifically told me I should look at other jobs, come and see the place in the different city. He said that he cared about my happiness, and if I thought I'd be happier in another place I should go there, but that again, I'm the doctor he wants to be the director of that thing in that city, so he'd appreciate it if I'd at least consider it, and make a trip out to see the place sometime in the summer or fall. I can't give details, but lets just say that for the first year out, getting to be director of that thing is very complementary. Also, he offered me a lab, sort of as a play-thing to get me to go there.

This made me realize a couple of things. First of all, I would love being that person that was the director of that thing in that city. Also, I don't want bench science to be my hobby, it's too important and way too expensive to just be a hobby. Thirdly, trying to give 100% to research and 100% to medicine is too many percents!

So, I probably won't go to PhD school. Now I just have to figure out how to explain that to the bigwigs at my program that although I told them I was interested, I've really decided it's probably not the right thing for me.

Anybody Care to Make My Life-Altering Decisions for Me?

I was recently offered the opportunity to spend an extra year in my current position and earn a PhD. It's very tempting. And a year really isn't that long.

Also, a PhD is quite handy on the CV.

But a year is kind of a long time at the same time because sometimes I hate it here and it is a long way from friends and family. I bet that a PhD doesn't involve a lot of naps, either.

Decisions, decisions. Maybe I'll just flip a coin.

Complementary and Alternative Medicine

I was watching an old edition of Frontline:World that I had on my DVR. The one about CIA rendition of terrorism suspects to other countries for torture... excuse me, I mean alternative means of interrogation.

Anyway, the next segment on this episode was about Ayurveda, a form of traditional Indian medicine. The reporter goes to an Indian Ayurvedic retreat with a frozen shoulder maybe, or maybe severe osteoarthritis of his shoulder. He'd been offered a shoulder replacement surgery by an orthopedic surgeon, but was trying to explore non-surgical remedies. His shoulder ailment was relatively severe, in that he didn't have enough movement in his shoulder to comb his hair.

So, anyway, he spends (I think) 2 weeks at this Ayurvedic spa/hospital getting his Doshes balanced with various noxious potions (judging by his descriptions), massages, anointings. Also he got daily shoulder exercises and daily shoulder massages.

Surprisingly (or not, really), his shoulder got better. At the end, he credits this to Ayurvedic medicine.

I'm not a believer in complementary and alternative medicine. At all.

Except, I am. Kind of. But not really.

Let me explain. I don't really believe in Doshes or in homeopathy and the memory of water, aligning chi, or any of that stuff. I'm not a big believer in the supernatural.

I think that Western medicine (hereafter known simply as medicine) is great at curing acute illnesses. Accupuncture/Ayurveda will never be widely promoted for curing tuberculosis or meningitis, or for healing traumatic injuries. What we don't learn in medical school is much about promoting and maintaining health. Western culture also doesn't promote a lifestyle conducive to health. Additionally, what used to be common sense with respect to health is no longer so common.

Many, many people don't have time to cook their own food on a regular basis due in part to work demands and also in part to long commutes. The average commute in the metropolitan area I live in is something like 45 minutes each way. That's 1.5 hours each day. So, if people could afford to live near where they worked, and had a 30 minute commute, that 60 minutes would be enough time to either cook dinner or to get the exercise they need that day. Or, if they lived a 20-30 minute walk away from work, they could just use that extra 45 minutes to cook dinner.

Additionally, most (almost all) of my patients live in the grocery desert known as the inner city (seriously, you can't buy produce within 6 miles of the hospital I work at!). So, they live on fast food. Church's chicken, McDonald's hamburgers, Wendy's, that sort of thing. And the hospital isn't helping much by having an expensive cafeteria with very limited hours, and making Wendy's the only food that's either available or affordable to most of their patients and employees. Is it any wonder we have so much hypertension, obesity, etc? I mean, a certain percentage of the population will always be hypertensive and/or obese and/or diabetic. It does seem though, that those with the genetic predisposition to those diseases who happen to live in the inner city and be poor don't really have a fighting chance.

So, back to the story. You take this reporter with a bad shoulder, feed him good food, let him rest, have him do daily exercises and get daily massages on this shoulder, and what do you get? It's basically intensive physical therapy, which we know works. Why don't we do this here? Because it takes a lot of time and money. The guy didn't continue with the exercises as he was told to do, and his shoulder got worse again. So, I don't think it was Ayurveda balancing his Doshes that fixed his shoulder. It was the rest and intensive physical therapy. What Ayurveda really offered him was wellness.

And what he failed to continue to do was maintain his wellness. So, although I don't think that people have Doshes that need balancing or chi that needs redirecting, I do think that some of these traditional systems of medicine may have a thing or two to say about maintaining wellness that we in western culture (particularly in the USA) seem to have forgotten along the way.

(Picture Credit)

Push Any Button To Rock!

I have to say that Guitar Hero III is definately a winner! It's a lot of fun. More fun with a crowd, but definately fun on your own.

My only complaint (and it's a small one) is that the difficulty increase between easy and medium is a bit steep. I can beat all the songs the first time on easy, but medium is a lot more difficult than easy, but the hard and expert settings, while being an increase in difficulty aren't THAT much harder. Oh, and the other criticism: Extra guitars are a bit expensive, and you have to buy an additional Wii-mote to use them.

It's got good songs, a funny plastic guitar, and amusing animated cut scenes.

The game is innovative, a bit different from the parade of platformers, first person shooters, etc (nothing against Mario and Halo, mind you, but they've been around for 10-20 years (I think Mario Brothers first came out in 1985) ). I'd highly recommend Guitar Hero.

And just remember, if the music's too loud, you're too old. ;)

A Note To Hospitals

Now that many of my friends are attendings (aka real doctors) while I'm still a fellow (aka a pretending), something is becoming clear to me. Hospitals need doctors at least as much (probably more) than doctors need hospitals. If a hospital makes its doctors' professional lives unbearable by implementing various gimmicks from the business world ("lean thinking", customer service, etc.), doctors can take their patients to another hospital. In general, patients are more attached to their doctors than to any particular hospital.

I can practice in any hospital that has operating rooms, anesthesiologists, and an ultrasound available for me. Therefore, any hospital that makes me do computerized learning modules about how "Customer service is our number 1 priority" can simply go away, once I graduate.

For the record, customer service is not my "number 1 priority". Providing excellent obstetric care is my number one priority. My patients mostly seem to want disability for life, unlimited vicodin and ativan (and then they'll want to sue me when their kid doesn't go to Harvard). If I were all about customer service, I would simply give them what they ask for. Giving the customer what they want is good customer service. It isn't always good medical care, though. I will prioritize good medical care over good customer service every time.

This Ends Now

After having spent 5 days sleeping 12-14 hours/day and eating buckets of chocolate (although still exercising), I have to say that this ends now. I will clean my apartment, I will get out and do some shopping, and I will start getting up at a reasonable hour. I am on call at 8am on 12/30, and I must be able to get out of bed that morning. I also must continue to fit into my clothes.

So.

THIS

ENDS

NOW.