Luck sucks

How is it on my very last call as a fellow I get a blood/body fluid exposure? Ah, well, low risk patient, and a scalpel stab is a pretty low risk exposure, but still.. I went 3 years without one, and now I get stabbed?

What if I don't Want to Multitask?

Multitasking has been a serious fad (or perhaps gone beyond fad status...fadus?) for several years now. And I know I must be some sort of luddites (do luddites blog?), but I DONT WANT to multitask. Seriously.

I want to do one thing at a time, and finish that one thing and go on to the next. I don't want to talk to a nurse at the desk while I talk to the pharmacy on the phone and make a decision about the patient in the next room. I want to do the tasks in the appropriate prioritized order, because in my experience, multitasking leads to less good decision making.

And all of these little gadgets that let you talk on the phone while you drive or do laundry or watch dvds while driving? I actually don't like to talk on the phone while I drive. It's too distracting.

I was told during my internship that the key to being a good intern was multitasking. Well, I've come to disagree. I think the key is prioritizing.

Should I Join the Uninsured?

A little dilemma... my health insurance through my current program will be immediately cancelled on June 30/July 1 at midnight. My COBRA payment would be $450. Clearly, one (even relatively minor) medical problem could cost more than that. I'm sort of strapped for cash these days (moving expenses, and all). I'm unlikely to need anything other than prednisone and the Lialda for my UC (ok, and I take some propranolol for migraine prophylaxis, but that's dirt cheap... so is the prednisone). However, a sprained ankle with an ER visit could cost >$1000.




Seriously, I plan on continuing my insurance. I can, however, see how some people make other decisions. And, outside of employer provided insurance, the ulcerative colitis would make me practically uninsurable.

Just some food for thought....

Homebirths

Because I'm, you know, a high risk obstetrician, people even my friends, often assume that I'm against homebirths. Well, I'm not, exactly.

There certainly are a few disasters that can't be predicted, and may not be able to be treated in time to prevent maternal or fetal injury that we can deal with better in the hospital. But that list is pretty limited to catastrophic abruption, moderate to severe shoulder dystocia and umbilical cord prolapse. Sometimes, with these complications, there is no time to get to the hospital, and the baby and/or mom can die. And, to be honest, sometimes laboring in the room 10 feet from the operating room doesn't help with these either.

The other thing to remember is that these are rare events. Even in hospitals. Even in high risk populations they're uncommon. In fact, they're so uncommon that the statistics for perinatal death for homebirths are not any different (it's like if you have a 1/1000 perinatal mortality/morbidity rate and add to it a rare event, it doesn't increase the risk by very much. Even if you double the risk, that's not a big increase for rare events). And most of the complications of pregnancy and labor are things like arrest of labor or infection, and with those, as long as the midwife in question acts appropriately and gets patients to the hospital, there's time to treat. In fact, a recent Dutch study in BJOG was unable to find a significant increase in perinatal mortality in low risk women.

If you are a high risk woman, you should give birth in the hospital. Mostly because that's where the pediatricians are. Sure, fetal monitoring reduces the risk of neonatal seizures (but not cp) in high risk women, but mostly, infants of diabetic mothers, infants with growth restriction, preterm babies, etc. need to be in the hospital. If you've had a previous c/s, your likelyhood of a catastrophic complication of labor (uterine rupture) is high enough that you should give birth in a hospital, because timely recognition and emergency delivery can be lifesaving for infant and mother. And many, many other complications of pregnancy are best managed in the hospital.

But a normal uncomplicated pregnant woman wants to give birth at home? Sure, go for it! There may even be some (at least hypothetical) benefits to home birth: We have MRSA (that drug resistant staph you hear about on the news) running around our hospitals... if you can avoid exposing your baby to that, that's excellent. But please, if things start to deviate from the normal, please come to the hospital. We'll take good care of you and try to limit what we do to only necessary interventions, but interventions really are sometimes necessary (10% of women used to die in childbirth... and 30% of babies used to die before the age of 1).

As for me, well, if I ever have a baby, I'll do it in the hospital... for a few reasons. Number one, Having seen all of the bad stuff, I'd be too nervous to do it at home. Number two: um... having a baby is REALLY messy. If you deliver in the hospital, someone else cleans up. And number three? one word: EPIDURAL!!! ;)

But... just because I'm a wuss and want pain control and someone else to do the cleaning doesn't mean that everybody has to make the same choices I do. The only thing I worry about with home births is that there are a lot of lay midwives doing them. I've worked with some great CNMs, but lay midwives have no specific training requirements. So, check out your midwife carefully.

Transitions

I'm on call, waiting for a c-section to go. My thesis is written (actually halfway through draft 2), my paper (about the thesis work) is also written, mostly. My presentation for my defense is done. What else to do, but blog?

You know, it's kind of funny. With fellowship winding down (IF they will ever let me defend so I can graduate...), I've been reflecting on the past.

Transitions are always an odd time. I've had plenty of them... you'd think I'd be used to it by now. But I think you never really get used to packing up your life and moving it halfway across the country. One of the weird things about medical training is that you have ~3-4 times you pack up your life and move sort of built into the training.

Anyway, this has me feeling kind of introspective, thinking about this and other transitions. I moved a lot as a kid. By the time I was in 9th grade, I had been in 9 different schools in 7 different cities, spread up to 5000 miles in distance. Thanks, BP! So, again, I should be used to this by now.

So, in some ways, this is like almost any move: Rediculously expensive, stressful (it takes a lot to get things organized to move me+2 cats), etc. But mostly, it's not like my other moves. Just a month into the fellowship here (back in August, 2006), I decided that these people were not very nice (the MFM division, not the patients... there are a few nice attendings, but for the most part, I'm treated worse here than I was as a resident), and that I wouldn't be staying. I flirted with an ICU fellowship and a PhD, but decided not to do them primarily because I don't want to have to be here any more. So, unlike most of my other moves, there's a sense of relief. A sense of "Thank goodness I can drive away on June 28 and it will all be over, and I'll never be under the control of those people ever again."

Also, this time, I have movers who are going to show up on June 27th and pack up all of my crap. I'm looking forward to that being a lot easier than packing it up myself, throwing it in a UHaul and driving it 2600 miles across the country.

However, the rituals of moving, the sorting through my stuff, getting immunization records, tb records, licenses, credentialling is so reminiscent of other transisions, it's just hard not to feel like it's happening again.

It's weird, sort of. My ability to get settled in this fellowship was hampered by the fact that I was still suffering the effects of a terrible incident from residency. Something I've realized wasn't really my fault, even if I was one of the primary 'dramatis personae', as it were. And, so I find myself feeling anxious. Anxious, partly because just the fact that I'm at another turning point in my life is so reminiscent of how terrible I felt the last time in my life I was in this place. And a little anxious because I keep thinking of that... that.. thing. (Although a little known secret... trying to not think about bad stuff doesn't help... but in a weird way, just letting yourself think about it kind of does).

And I'm anxious for all the normal reasons... will my new job be nice? Will people like me there? Will I like the people there?

Having said that, I'm not abnormally anxious, and in general, I'm really looking forward to working wiht and for people who will not (I hope) do things like cancel my defense 4 hours prior to the event, after I've already had to make an emergency call switch because they rescheduled it 4 days prior to the date..and then reschedule it ("with a 95% certainty") for 2 weeks away.

Sorry, another non-medical post. I guess I'm in a more personal mood right now. I'll get over it. Maybe.

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Seriously??

They cancelled my defense so that they could entertain out of town guests. 4 hours prior. ARGH!!!

But thanks for all of the well-wishes everybody.

Whew and Wha????

I just finished the first draft of my thesis (and have a firm defense date, scheduled, May 26th). I realize that the first draft is not going to be the final, and I have a bit of work left to do. It is, however, such a relief to have a (relatively) complete version finished!

And, because I've been doing a lot of "last things" recently, I did my last teaching conference (which we get paid a small amount of money into our 'educational' fund for). So, I went to buy a new laptop with the money. It wasn't a very expensive laptop ($800), just something that's lighter that will get me through until I start my real job (soon!!! Licensing is done, credentialling is almost done). Anyway, BestBuy tried to sell me a $500 extended warrenty. On an $800 laptop! If I had $500 to spend on an extended warrenty, I would just buy a new computer when the new one breaks.

Blogs Need Dogs

Ok, maybe blogs do or do not need dogs, but I really really want a dog, starting with a puppy, and finishing with what the puppy grows up into. I think a Newfoundland would be the PERFECT dog for me.. intelligent, easy to please, sweat disposition... and to do water rescue training with one would be really cool.

I now find myself plotting on how to pick a place to live that will be dog appropriate and how to figure out what to do with the dog when I'm at work.....

If anybody knows any reputable Newf breeders in the pacific northwest, let me know!

Are You Reading My Blog?

(I realize lemurs have nothing to do with this post, but I took this picture and thought these lemurs were adorable!)

I'm in Scotland (most of you already figured that out) at the annual scientific meeting of the SGI (Society for Gynecologic Investigation). Apparently after seeing that maybe I should have been a psychiatrist (on the previous post), they decided to take me up on it.

Today's symposium was on stress and reproductive dysfunction. So, it probably won't surprise anybody to hear that just like people have a range of height, they have a range of susceptibility to stress (as measured by basal cortisol levels). It also turns out that those people who are more stress susceptible are more likely to develop hypothalamic amenorrhea (loosing your periods because your brain stops telling your ovaries to ovulate), which is one of the major causes of infertility. It turns out when you have women with infertilty from hypothalamic amenorrhea (people we used to tell to exercise less and eat more), they get pregnant from CBT (Cognitive Behavioural Therapy). Or.. Rather... they get pregnant from sex, but CBT increases the odds, and restores their menstrual cycles.

And if you have certain stress susceptible monkeys (as defined by biologic assays performed when they're not stressed... they actually have chronically higher levels of cortisol), and you stress them out just a little bit (nothing dangerous... just moving them to a new room, for example), and make them exercise or diet, or expose them to more mild-moderate type stress, they'll get hypothalamic pituitary dysfunction related amenorrhea. And, if you give the monkeys citalopram (hard to do CBT with monkeys, they keep throwing feces at the therapists! ;) ), their cortisol levels normalize and their menstrual periods come back.

And although bedrest for preterm labor doesn't work, we probably feel like it does, because activating the CRH pathways in the maternal brain can activate them in the placenta and fetus... and people who live under chronic psychosocial stress (or who are socioeconomically disadvantaged) are more likely to go into preterm labor. When you put them in the hospital on bedrest, you isolate them from a lot of their previous stress, but when you randomize them to bedrest in hospital vs normal activity in hospital or bedrest at home vs normal activity at home, you won't see a difference.

The question then is, how do you talk to people about the fact that they're "stress susceptible" without making it sound like you're telling them that they're wusses? In fact, every time my mom says, "I think your ulcerative colitis is from stress" (Although certain forms of stress (certain aspects of work politics, not sleeping, etc.) make it worse, it is an immunologic/genetic condition) I feel like she's calling me a wuss. It's hard to refer someone for psychotherapy to treat their infertility without the patient getting the perception that you think there's something wrong with her... which, you probably do (you know, the infertility she came seeking treatment for), but not like she thinks (you (probably) don't think she's crazy, unless she wants you to transfer 6 embryos, in which case she DEFINATELY is crazy). Which, I guess is more a social stigma issue than a medical issue... although social stigma IS a medical issue. Becaue medically, I think the best I can do is to say, "We know that people with this type of infertility respond well to psychotherapy/antidepressants/nap time/whatever, and that's definately less invasive than IVF/ovulation induction, so I think we should try that first." I think you also have to have a psychotherapist that sort of expects these patients to come to them from you.

If that makes any sense....

I should have been a psychiatrist?

OB/gyn is down there at #26 or so, and perinatologist isn't on the list (it may not be one of the specialties on the test).

#1-10 in order were:

psychiatry (I'm not sure I really like talking to people this much)
general surgery (almost did a gen surg residency at one point)
occupational med (no way!)
ortho (ok... it always looked fun)
GI (erm... ok..)
colorectal surgeon (kinda like gen surg, so ok..)
urology (ok.. I could see this procedure oriented patient care specialty)
preventative medicine (is this really a specialty?)
radiology (not that fond of dark rooms, actually)
neurology (Um... I like for my patients to get better, thanks. Not that good with diseases that don't go away.)

I'm not sure how I answered the questions wrong, but it seems like there isn't even a consistent theme in my results. Try it yourself at: http://www.med-ed.virginia.edu/specialties/

I remain convinced that the real way to choose a medical specialty is to try out different stuff until you find something you love. There really is something for everybody from radiologists to psychiatrists, from preventative med (still not sure if that's a real specialty) to perinatology. But I'm not convinced this quiz will help you find it.

Thank God Someone Speaks American Around Here!

So, I actually made it to the meeting today, kind of. Long story short, I thought today was the 19th, and I'd signed up for some of the courses on the 19th (I didn't pay for any of the postgraduate courses, you know, the kind that cost $200+ for a single day of class). Anyway, I've gotten back into jogging (was out of it for 2 months because of a bad ankle sprain), but maybe overdid it a tiny bit (Glasgow's hilly! The midwest is not!), and have been a bit sore (esp in the iliotibial band type area). Mostly I just tell myself to suck it up because pain builds character (or whatever), but found myself feeling grumpy, so I decided to buy some acetomenophen/tylenol.

Stopped into a pharmacy (apparently all drugs are behind the counter here), asked for acetomenophen and tylenol (trying to think... now what else is this stuff called?), and the lady behind the counter was looking confused (but wanted to help). Someone yelled from the back, "That's American for Paracetamol!"

Hah! I was afraid I was going to have to ask for "something for sore legs" and see what they offered....

Seriously?

A sunburn? In Scotland? In MARCH??

WTF. I usually wear sunscreen every day (because I burn pretty easily and have lost most of the skin on my face and back and back of my legs at one point or another to blistering sunburns. Always surprised they don't scar). I forgot to bring it with me, and figured... "eh... it's March, it'll be ok", and now after a day out in moderately sunny weather, I'm feeling that post outing mild-sunburn warmth and redness in my cheeks and across my nose.

Note to self: buy sunscreen!

Thank you, Trooper

I'm doing a lot of traveling right now. I was out on the west coast earlier this weekend, and now I'm here, in Amsterdam, headed to Scotland. Lots of work to do, too. On Friday night, it all caught up with me. I was driving back to my hotel (nearish to the airport) from my mom's house (150 miles from the airport). I had given 2 hours of lectures at a conference, and hopped into my car to go visit my mom, who lives... well... 150 miles north of the conference venue.

Add the cumulative exhaustion of 11 years of medical training to the traveling and the conference giving, and well, I was exhausted. But my mom has had a rough time, and she needs to feel like people care, I think. So, I went to see her. My plan was to go, get there and leave by 630-7pm. I got there, she and my aunt wanted to go for appetizers, but they really kidnapped me into a full dinner. (Remind me to get better at setting limits with and saying no to them.), so it was 9-10pm by the time I was leaving town. I started the trip out tired, and I remember at one point thinking about whether or not I was too tired to make it down to the hotel, or if I should pull off and get some coffee or something and rest for afew minutes. Well, that would have been good, but before I could make that decision, I saw the police lights in back. At first I thought it couldn't have been me, because I was driving well below the speed limit...

They were after me. The officer said that I was changing lanes and braking erratically (How embarassing is it to be pulled over for suspected drunk driving only to be sober?). I didn't really remember that. After talking to the state trooper, I must have been driving pretty badly. I think I fell asleep while driving. He didn't ticket me, and the adrenaline from the traffic stop pretty much woke me up to get the rest of the way to the hotel (~15 miles).

In retrospect, he may have saved my life (or more importantly, kept me from killing some poor innocent people). I really appreciate that. Next time, I need to have the guts to tell my mom that I'm too tired to drive 300 miles round-trip. And in the future, when I feel that tired and sleepy, I will pull over before putting anybody else at risk.

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A Submarine... With Donuts?

Greetings from Shiphol Airport, Amsterdam, where I am sitting, during a 4 hour layover, on my way to Scotland. It's a very circle-ey place. It reminds me a bit of a submarine... with donuts. :)

On Healthcare Reform

(My VBAC post is getting written, but I just have a few minutes, and this post only takes a few minutes).

To me, it seems very wrong that our office pays $260 for an interpreter for 45 minutes to see a patient. It's wrong because the visit which I just saw the patient for is probably non-reimbursable, and if it's reimbursable at all, the reimbursment will be <$100.

I actually don't think it's a bad idea for docs to see patients for free... but who can afford to donate their time plus $150-$260 for any real fraction of their patient population. These things aren't tax deductable, yet we're madated to meet the needs of people who can't speak and understand English. Why is it the docs are required to donate their time and money while the sign interpreter donates nothing?

I can see why private practice docs don't see patients like this. If I were in a real private practice, I too might be forced to tell these patients that they should go to the local university hospital because I would be unable to meet their needs (unable to meet their needs and still pay my staff, that is).

If people are serious about healthcare reform, this is a problem they should tackle.

On Service

I've been a bad bad blogger. You know, work, etc. Now, I'm awake at 3am because of night sweat/fever induced insomnia and I find myself actually hoping I'm catching a cold. Because the other likely alternative is that the colitis is back after months of pretty good control on 10mg of prednisone (which induces its own insomnia, but one that's treatable with sleep hygeine and Ambien (tm) and more or less mild at this dose). And I often will have a flare when I work a lot of hours, and I've been working from 6am-8pm most days of the week this month (except when I'm on call in which case it's usually like 6am-2pm the next day)

Anyway, in response to Bardiac's question, being on service means being the fellow in charge of the MFM inpatient service and outpatient clinics. Generally, we also work with a group of residents (my residents are awesome!) as well as a supervising attending. Most attendings will let me have the autonomy to manage the patients how I want (within the standard of care), however, I'm stuck with an extremely anxious attending for the inpatients who freaks out all the time and yells at the residents (which is at least better than her yelling at me?), and so I make a lot of effort to anticipate what she would want to do and plan to do things that way (a month-long game of "guess what I'm thinking") so that she doesn't feel threatened or nervous and freak out and yell at them (or me... but mostly she yells at them). I know, I don't have to do that, but I really HATE it when people yell.

The other attending is a brand new attending (so new that she will be taking her board exams with me in a few months) and she doesn't trust anything anybody does. Including me. So, every time someone presents a chart to her, she hunts through it to make sure that there's nothing else. Probably good patient care, but #1: She can trust me, and it doesn't feel good when she doesn't (and micromanagement is bad leadership) and #2: it's not good patient care to cause such long delays... patients walk out without being seen.

So, because we have to round early enough to get everything done before clinic, we start at 5:30am-6:30am, which makes for really long days, because the residents will then have stuff to finish up on the inpatient service after the clinics end at 6pm. I think this is not compliant with their work-hours, because they also take call on the weekend, so my guess is that they work ~100 hours a week with only a couple of days off. I worry that after being yelled at (by attending a) and not trusted (by attending b), they will not like MFM, and that would be a shame, because perinatology is fun. And because, ultimately, we need a steady supply of perinatologists to replace people who leave (retire, etc). And scaring otherwise good residents away is not a good strategy for the continuation of our medical species.

The residents, however, are troopers, and are taking the yelling from a and the micromanagement from b in good graces. And now we're all halfway done with the month. Hurray!

So, anyway, being "on service" means being responsible for the care and feeding of 2-4 residents (for me, 3) , a variable number of medical students (right now 0, because they don't want to do the month with these attendings... wise choice), and responsible for making plans for high-risk pregnant patients. It's usually a good month, but right now, it's complicated. And at least it's half-way done.

Just Passing Through

I've been in San Diego for a conference for a week (end of Jan), and I'm headed to Scotland next month for another conference.

I'm on service for the next 3 months (and last 3 months of service of my fellowship! Yay!).

More soon.... I can't decide if I should post about resident work hours, the care and feeding of interns, or some more obstetric topic (vbacs, etc.). I don't plan to talk much about the octuplets except to say that that woman's infertility doc should be beaten with a wet noodle.

I'm a Tool (or 5.5 Months Until Graduation)

So, the program that I'm at primarily regards its fellows as tools... Tools to get vaginal swabbing done. Tools to help with the call schedule. Tools to do the resident education for obstetrical topics, etc.

Our education is such a low priority that there has not been an MFM fellows' lecture series. It's such a low priority that when there are interesting grand rounds or speakers, the attendings will often expect us to cover their resident protected time or clinical activities so that they can go. I try to give them a little slack, because they only have 3 MFMs (for 5700 deliveries and an ultrasound unit).

Our education is such a low priority at this institution that I'm essentially a self-taught MFM.

It's kind of a malignant place, in a lot of ways. They've totally broken the educational social contract of graduate medical education. You know, the understood bit about us helping out the department and attendings at a very low rate of pay (~$46k if you want to know) in exchange for education? Our educational needs/wants are dismissed under the guise of "Learn to be an independant life-long learner!". We can get called in on no notice for a 10 minute meeting on a Saturday that has no identifiable purpose other than to prove that we had a meeting.

Having said this, the most recent event takes the cake. It is no surprise that we are required to defend our thesis prior to graduation. Ok... whatever.

But imagine my surprise when I get an email one night that says basically, 'Your defense is in a week' (apparently that was a convienient time for the attendings). So, I spend 24 hours in a near-panic, until I get an email that says "Oh, never mind, it's in May....".

Now, I just need to manage not to quit for long enough to graduate!

You know, the people here seem to think I'm a disappointment because I didn't choose to go into academic medicine. Had my experience here been better, I might have stayed in academics.

In all fairness, the department has deteriorated to this level likely as a result of the demoralization and burnout of the few remaining attendings. I don't feel that this is an excuse for creating an environment uncondusive to learning, but it is probably the main factor.

For all of you looking at training programs right now, my advice is this: STAY AWAY from programs that don't have enough attendings to do the work!!

More Later

Happy New Year and Happy Holidays everybody (whichever holidays they are, I hope they're happy!).

I just wanted to say I'm not gone, or rather... I'll be back. I have my fellowship thesis defense in a week, so I'm drowning right now.

Wish me luck?

BRRRR!

I'm trying to work up the energy/courage to go outside and jog, but the windchill out there is 2 F right now, so it's difficult! I would just skip, except it's Sunday, which is one of the easiest days for me to find the time to exercise!




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Obstetric Psychiatry and Ethics?

For the first time ever, today I had to seek legal appointment of a guardian for a patient who couldn't make decisions for herself. We commonly consult our psychiatry friends with a question that goes something like, "This lady seems really not right, she wants to [leave AMA, refuse surgery, whatever], could you come make sure she's competent to make that decision." when patients seem like they're impaired and making poor decisions (although oddly (or not) we don't tend to question when they make good decisions).

Generally, the psychiatrists' answers go something like, "Well, she does have a history of [insert garden variety mental illness here], but she isn't too impaired to make her own decisions. And everybody has the right to make bad decisions." Which is true. I had every right to leave the ambulance AMA a couple of years ago. I had a skull fracture, it was a bad decision. But it was my bad decision to make. And you could argue that someone with a recent (say 20 minutes old) head injury with loss of consciousness may not be competent to make their own decisions. And I'm still glad they didn't make me go to the hospital.

So, we had a patient today with a history of conversion disorder (diagnosed after diagnosis of her present pregnancy after a long hospitalization), who actually now is sick with severe preeclampsia/toxemia. She needs to have her baby, but having had 5 previous c-sections, she needs a c-section to deliver.

So, she tried to leave AMA, but stayed for a psych eval. The psychiatrist said that she's not competent, suggested some haldol, and wrote a diagnosis which I can't read (typical doctors' handwriting! ;) ), but I think said something about psychosis, which makes sense, because at times, this patient seems almost delusional (thinks we can read her mind and forcast the past (I know, doesn't make sense to me either).

So, a couple of thoughts. First of all, it's got to be totally scary if your brain doesn't work right, and you have a really dangerous complication of pregnancy and are facing delivery at 30 weeks.

Second, I'm going to go deliver her baby tomorrow. During this admission, but before she seemed delusional, she signed for a tubal ligation. My medical recommendation would be that as this is her 6th c-section, she should have her tubes tied. Should we tie her tubes?

Thirdly, do you tell her she's been deemed incompetent? When I was there, we were skirting around the issues, and managed to get her calmed down enough to give her treatment for a few things (her blood pressure, monitor her baby, treat her headache, and give her the haldol the psychiatrist suggested (and some ambien is planned tonight because she hasn't slept in the 5 days she's been at the hospital. That might cause some psychosis in even the non-mentally ill, I might think!).

(Ethics consult/court signature for her mother's role as guardian/etc. is all taking place nowish.)

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This Blog Has Been Temporarily Interrupted

Blogging has been temporarily interrupted by the purchase of Call of Duty: World at War. Blogging will resume when the Japanese surrender.....

I Wonder...

Would my gastroenterologist think I'm nuts if I tell him that prednisome makes me able to feel my heart beat (it's like feeling your pulse all over my body, even my toes)?

It's a nuisance, but only a nuisance. I'm not tachycardic and my heart beat is regular. And when I distract myself I don't notice it nearly as much. No chest pain or anything, so I'm pretty sure nothing dangerous is going on. It just all falls under the category of prednisone side effects that annoy me (along with migraines, "water retention", insomnia, irritability and increased apetite (I think I'm rejoining weight watchers next week)). And while he never didn't believe me me about the other prednisone side efects, this complaint seems a little crazier than the others. The other issue is that insomnia and migraines can be easily treated (so can water retention, but I don't want to spend more time in the bathroom). While there's no great medicine for irritability (well, there might be, but I'm not interested in anything that will make me sleepy), treating the insomnia helps a bit with it, and so does trying to arrange my life so it's less irritating. (see below)

Thinking of treating... because constantly feeling one's own heartbeat can be distracting and annoyin,. I've surruptitiously tried a little bit of a beta blocker for it (just 10mg of propranolol... really a baby dose), but I got symptomatic orthostatic hypotension (meaning I felt so faint when standing up that I couldn't really stand, likely from a sudden drop in blood pressure) (in retrospect, since my baseline blood pressure is 100/60 and my baseline heart rate is in the 60's, it makes sense that I might be a little sensitive to beta blockers). [Note to self: just because I CAN self-prescribe doesn't always mean that I SHOULD self-prescribe. My body is not a science experiment...]. My friend tells me I should get a hemoglobin checked, just in case, but first off, I don't think it's an anemia thing because I have no problem exercising (it's distracting enough that I don't feel the heart beat thing), and when my hemoglobin was 8 a few months ago, I wasn't able to exercise. Besides, I'm not going to let anybody transfuse me right now (I'm not sick enough to need it), and I already take iron, folate and B-12 supplements. Therefore, if my treatment plan isn't going to change, there's no point doing the lab test.

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What Is a Perinatologist

I am sitting here writing this post waiting for a c-section to go back. It's midnight. The c-section isn't anything emergent, it's just a woman who thought she wanted to have a vaginal birth after cesarean but changed her mind 10 hours into the induction (she's not even in labor!).

So, Xavier Emmanual asked what a perinatologist does in the community and if there's a possibility for a reasonable life.

According to Wikipedia (my source for all matters factual :) ), Maternal-fetal medicine (MFM) is the branch of obstetrics that focuses on the medical and surgical management of high-risk pregnancies. Management includes monitoring and treatment including comprehensive ultrasound, chorionic villus sampling, genetic amniocentesis, and fetal surgery or treatment. An obstetrician who practices maternal-fetal medicine sometimes is known as a perinatologist. This is a sub specialty to obstetrics and gynecology mainly used for patients with high risk pregnancies.

So, for example, we help to manage (either as the primary obstetrician or in consultation) pregnancies affected by things such as lupus, diabetes, higher-order multiple gestations and twin gestations, as well as diagnosing and assessing fetal anomalies.

In a community hospital, we still do all of those things, if there is a Level III NICU available (which there will be in the job I'm going to). My scope of practice would be more limited if I went to a hospital without a level III NICU, which is why I didn't consider any jobs like that.

In terms of schedule, most of what happens on labor and delivery can be cared for by most competent general obstetrician-gynecologists. I also believe that in this day and age, nobody should work for 30 hours continuously any more. My schedule will involve home call (where I have to be within 30 minutes of the hospital for consults or to assist on complicated surgeries), 3-4 days per week of clinic, and 2 days/month of administrative duties in maintaining the regional perinatal network and some educational duties. Perinatologists are in high demand, and hospitals have started realizing that perinatologists are also a little lazy, and don't want to work 120 hours/week, particularly after having worked that schedule for 11 years already.

So, the role of the perinatologist in the community (assuming it's at a tertiary care hospital) is the same (except no research, usually). The schedule is well... an obstetricians schedule, but since we're in high demand, one can decide what they're willing to do, and find a job that allows it.

I hope that helps! :)

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I'm Leaving (the Ivory Tower)

I've returned from a bit of an exile from blogland. I was busy finishing up my job interviews (it's amazing how exhausting that was), I was then busy at work (still am.. but it's eased off a bit), and then I did a few weeks of Q2 call (paying people back who covered for me while I was interviewing). I spent this weekend recovering. And whining about the UC flare triggered by the complete lack of adequate rest for the last 1-2 months to anybody who would listen.

And, interestingly enough, I kept coming back to accepting the first job I interviewed at. It's in a lovely part of the country and the people there are nice. My best friend is a doc at the hospital (not an ob-gyn type though).

So, here's the thing. It's a private practice type job. In a huge multispecialty group. In a delightful area of the country. And everybody at work tells me, "you're too good for private practice." What does that even mean, exactly? Academic medicine has a certain amount of prestige, it's true. And I really do respect those people who can be awesome clinicians and amazing scientists. However, to do both successfully takes a huge time commitment. Those who aren't willing to make the huge time commitment are (generally) either sub-par clinicians and great scientists or sub-par scientists and great clinicians. At this point in my life, I don't want to spend so much time to be a mediocre anything. I don't want to be writing grants in my spare time. I'm actually looking forward to having a 4-day/week work week. I'm looking forward to taking call from home and only coming in for patients with whom I have a relationship or for patients who are so sick that they need me then and there.

I'm just not willing to make the academic medicine time commitment right now. On one hand, it feels a little bit like a concession to the UC. Part of the reason I took a private practice job is the fact that I have to be in control of my hours, and I can't work for 30+ hours in a row on a regular basis and continue to feel good. I don't want to spend my weekends off writing papers and grant proposals. Most of the academic centers I've interviewed at are still operating in that model where you work all day, cover L&D all night, and then work through the next day. I have no interest in doing that any more.

Also, this is a great excuse for me to get a life (which I haven't had for years).

I'm looking forward to this job. It involves serving an underserved population and involves some public health activities, which I haven't ever known much about but I am interested in it. I'm actually fairly certain I made the right decision.

But I still feel a little guilty for leaving "the ivory tower".

Having said all of that, it's still good to be back.

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I'm OK!

Hi Everybody! I've got a few comments in the last few days from people hoping I was ok. I'm fine, I'm just super busy, but it warms my heart to know that y'all miss me when I'm not around.

More later/soon...

I'm a Lazy Slob!

My house is a mess, my life is a mess (too long since I've paid bills), I'm behind at work (too much time traveling and interviewing for jobs), I think even my cats are feeling neglected.

My plan for today was: Jog, get drug test for new job (starts in July), go to tae-kwon-do class, buy groceries, clean house, do laundry, go to work for 6-8 hours, write checks for bills.

What did I actually do? Well, I went to get the drug test, the place was inexplicably closed, despite their posted hours of 8am-12pm. I bought some groceries, I went back to see if drug test place had opened (still closed), and I went home and napped. Woke up, went to the bagel shop for a sandwich for lunch, came home, watched bad tv, took a nap while cuddling with the kitties, got up (intending to go for a jog), watched more tv, talked on the phone, perused blogs.

I could make plenty of excuses (like I had pneumonia! I pulled a muscle in my back (I think it's my lattisumus dorsi), but the truth is? I just didn't feel like doing anything. Just like I don't feel like turning my groceries into dinner (not really hungry), and right now, I almost wish it were 9pm so I could just go to bed.

I feel like such a lazy slob.

But I will try to do better tomorrow!

An Apology to the Medical Students

Dear Medical Students,

I'm very sorry for the lecture I gave today. It was supposed to be about prenatal diagnosis. Yes, I was vaguely aware that I was drifting off and talking about cars, and making bizarre references to cheese in my near sleep. I am aware that I was finishing my sentences in completely uninteligible ways, and all I can say is that I was too exhausted to be lecturing.

I was on call yesterday, and I got utterly destroyed, and the period of time I sat down to give the lecture was the first time I'd sat down in more than 24 hours.

I usually don't send out my powerpoint slides (people have stolen pictures from me in the past), but I'll send them out this time, because when I'm actually falling asleep while trying to give my own lecture, I feel like you need a little help. To your credit, none of you actually fell asleep during my lecture, but that may have been because it was a... unique.... experience.

Oh, and I may reevaluate my position on God and whether or not he takes a personal interest in my life, because despite a level of exhaustion that made me unable to give a lecture without falling asleep while speaking, I managed to drive home safely. That suggests a level of poor judgement on my part (maybe I should have taken a nap before driving home), and possibly some sort of divine intervention on my behalf.

Sincerely,
Me

Maybe I am a Bad Patient

I have been doing a ton of traveling (for job interviews), some trips with plane flights in the 7-10 hour range. A couple of nights ago, I was unable to sleep because I was really short of breath. I had some fevers, some pain over my right chest wall. I had had a cold, which was almost gone. Other than that, I'd been pretty healthy, recently. Continuing to wean the prednisone, feeling strong and tough.

And now this.

Always being one to avoid actual medical care, I dragged one of the residents into my evil plan. "Hey, resident," I said, "I've had a cold, and I just feel a little funny. I'm headed home to bed, but I wanted to check my O2 sat first, because I'm a hypochondriac and it'll make me feel better, do you know where the pulse oximeter is?". The helpful resident was well, helpful. However, we got busted by one of my attendings, who kicked the resident out and yelled at me. "What are you doing? Seriously, you're on chronic steroids, you've been on long plane flights, if you're short of breath you absolutely need a work up. You could have pneumonia. You could have a PE!"

My response was a rather weak, "Well, I'm just getting over a cold, I figured I was just being a little hypochondriacal, and imaginging the shortness of breath." So as it turns out, my O2 sat was 96% (not terrible), and my pulse was 118 (a bit fast). My attending listened to my lungs, decided something wasn't right (crackles and rhonchi on the right side) called my primary care doc and um... told on me. My PCP made me promise to go to the emergency room.

In the emergency room, I had a chest x-ray, an albuterol neb (which did almost nothing except make me tachycardic to the 150's and shakey), some blood work. They were quite nice to me, although I ran into a couple of the interns, and I was too short of breath to explain why I was there, so I'm sure there's all sorts of rumors going around.

The verdict? A right middle lobe pneumonia. I have no idea where I would have caught pneumonia. I haven't been doing much patient care, just a lot of traveling. Some doxycycline (which isn't something I generally think of for pneumonia, but it should be a good antibiotic for it), some codeine cough syrup (which also helps nicely with the pleuritic chest pain), and some rest. Actually, a lot of rest. Every 20 minutes awake seems to result in a 1 hour nap.

So, yes, it was wrong of me to involve the resident in my evil plan. And I did deserve the lecture from my attending. I continued to actually get sicker over the first ~20 hours after I got out of the emergency room. If I had waited much longer, I might have ultimately been sick enough to need admission, and I'm not into hospital admission.

In my own defense, I actually don't really know at what point I should worry about these things. And my assumption is usually that I'm actually fine, just a little hypochondriacal.

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Ecuador: Days 4-9: Clinic

I'm not dead, not yet, anyway. ;) Thanks for your concern, but I really have been just super busy, off interviewing for jobs and going to conferences and stuff. Over the last 2 months, I've spent less than 2 weeks at home. Traveling is getting tiring!

So, anyway, the real reason I was in Ecuador! I'll start off by saying that initially I thought that the reason I was going to Ecuador was to take care of the people. And I did some of that, but as it turns out, I was a little mistaken.

Our clinic was in a little town called San Martin, in the mountains above Quito. Having arrived from near sea-level at Banyos the night before, I spent my first day in clinic being somewhat useless and dizzy. I wouldn't say I had altitude sickness (or acute mountain sickness to be technical about it), it was more a matter of needing more than 8 hours to acclimatize to the 14,000 foot altitude.

Anyway, it was me, 2 other docs (family medicine people) and a whole cadre of Spanish-speaking med students. I have to say, initially, I felt completely useless. Most of the patients complaints were things I had treated only long ago (if ever). Kids with parasites, old women with rotator cuff injuries. Men with BPH. That kind of thing. Kids with other problems. A kid with Henoch-Schonlein purpura.

Then I realized it. The real reason I was in Ecuador was to teach the medical students how to take care of people. That realization (and maybe actually becoming acclimatized made a huge difference).

Some other observations: The reason docs like to go to the third world to help out is the fact that you can do a lot with very limited resources. All of our meds, all of our equipment were donated. It cost some money to ship the stuff (and the team) down, but basically, we helped people in ways we would not have been able to in the US, simply because the legal system (and JCHAO) have made things so expensive. Patient expectations also add to the cost. In Ecuador, people are willing to accept some ambiguity of diagnosis and try a treatment to see if it works. In the US, if you tell someone, "I think you have x, but there is a small possibility you could have y, so we're going to try to treat for x, and if it doesn't work, we'll need to rule out y", they really want the ct scan or blood work or whatever to rule out disease y.

Interestingly, Ecuadorians don't expect perfect health all of the time. They don't expect their babies to be perfect (they're aware of the risk that things happen, and they're grateful when their babies are normal). They don't expect to be pain-free all of the time.

Having said that, Ecuador does need more trial lawyers (the US has too many... maybe we could ship some down there?). People have horrible work-place injuries (like blindings) and get either no or minimal compensation, often not even enough to pay for medical bills.

Ecuador is a dangerous place. They don't seem to think about safety much in Ecuador. This is why they need more trial lawyers. People to sue the pants off of people when they're a bus driver and drive drunk and end up in an accident that paralyzes some poor kid.

You can practice good and rewarding medicine in a building with a dirt floor and without indoor plumming.

There are some illnesses that are really difficult to treat without any real way to follow the patient up (the clinic's only open for 2 months).

I guess that's most of it. I'll close with some pics.

The road outside our clinic

Our waiting room

The exam rooms, separated by sheets hung from string

Washing out a little girl's ear

History Taking

A happy patient!

Curious

Could someone please explain to me why prednisone makes me have more migraines?

And while you're at it, please tell me why mowing my lawn seems to consistently trigger them? I'm not suffering terribly, I mean, I'm not getting as much work as I'd like to done right now, but I have good drugs (Relpax (basically a long-acting form of Imitrex) works well and doesn't make me sleepy (although the headache sort of gives me the urge to rest in a cool dark room)). But it wasn't too hot outside (hm... maybe 80?), I did get a little sweaty, but not dehydrated.

I'm really not meaning to whine, I'm actually quite curious. My last internist (who was great!) used to tell me that when I had a migraine I should slow down and rest until it was over, but I've basically done nothing but rest (and mow my lawn) today.

Ecuador: Day 1-3 Banos

Even in small town Ecuador, they have Jehovas Witnesses

The chasm into which I bunjee jumped (closeup on the rocks... ;) )

A little house along the route of our biking

I have to appologize for some of my Ecuador posts at this point. Blogger has no tilda.

Anyway, so after collapsing into bed after 40 hours awake (and almost 20 hours of travel), I woke up the next morning.

After realizing that yes, I actually am in Ecuador, I went out for a jog around the park near our hosts house. (Neigborhood pictured below).

On returning, the host family had breakfast ready! And the Spanish lessons begin. Cafe o Te? Hevos reweltos o fritos? An egg, a bun, a banana covered in yogurt, a cup of coffee. With the students. Now, Banyos may not have been my first choice for the only road trip I'd have time for in Ecuador, but the group had been in the country for >1 month, and I kind of figured that I'd hang with them. It made sense.

The plan? Banyos, a little town in the Ecuador highlands about 5 hours by bus from Quito (and about 8000 feet lower in altitude) with tourist stuff and hotsprings (hence the name). Do I want to go? Heck, why wouldn't I?

So, off we go, in a group of taxis to the bus station, and off and away we go on a bus! The ride is, generally pretty. A funny thing about Ecuadorian busses is that their steps are higher off the ground. I didn't really realize this until I fell off the bus. No worries, no real harm done (other than a skinned knee). So, then we drag our stuff through the little town to a hostel called Blanco y Plantas (White and plants, I think). The hostel was indeed white with plants. For $8/day, it was a pretty good deal. The only problem was on the second day of the stay when our shower stopped working (or, perhaps, wouldn't start working). They fixed it (kind of), but when they cleaned up the mess, the mop they used was full of mouse droppings and they spread mouse droppings all around our room. It totally grossed me out, but I managed not to say anything to the other people who, I assume, didn't know that that's what those black things were.

So, after checking in to our hostel, we ate lunch for 3 hours at the Swiss Bistro (this will become a theme. As we learned, it is impossible to eat a meal out in Ecuador in under 3 hours.) Then we went mountain biking. Some of the bikes (like mine) were in tragic disrepair. My chain kept derailing every time I tried to switch gears. There was also an unfortunate straddling incident. Add to that the fact that I haven't biked in 14 years, cut my leg on the chain, etc. etc. made the biking not such a great idea after all for me. Oh, well.

We biked out to a bridge where I bunjee jumped into a gorge. Yeah, it was pretty scary. The scary part is the < 30 seconds that involve the actual jumping (as it turns out, there's some sort of instinct that keeps us from jumping off of high things) until the bunjee cord catches you. After that, it's pretty fun, kind of like flying.

We continued biking, then caught a truck home. There was this kid who hitched a ride with us, who we assumed belonged to the dude driving the truck, but the guy charged us for the kid's fare, so he must have been on his own. I hope his family knows where he is!

So, then we go to eat at this restaurant owned by a guy from Michigan! How odd, but cool. The food was good (sort of a little bit of everything), but the desert wasn't good. I think that Ecuador doesn't understand desert the way we do.

The next day? Shopping, hotsprings, graveyard tours, and then home. Long bus ride.

Sometimes You Need to Talk to A Human (or Lost Luggage)

I just got back from my course in Maine at 3am this morning (it's now 9pm). They lost my luggage (or perhaps, it would be more accurate to say lost track of, since I had 3 connecting flights and got rerouted around them due to some mechanical difficulties).

This is not an anti-airline rant. I'm actually quite pleased with 3 of the 4 airlines that have been involved in my travels. I will never fly US AIR again, but that's another story.

So, my ticket read as follows: Bangor to NY Laguardia (US Air); NY Laguardia (LGA) to Washington Dulles (IAD) (United) and Dulles to Home (United). I usually fly Northwest (who happens to have a direct flight from Maine to home) but booked my tickets too late to get that flight.

Anyway, due to mechanical problems on the LGA to IAD flight, I got rerouted on a direct flight to Home. Yay! Airline error in my favor! Except the flight left 2 hours late (due to air traffic overload... this happens every time I fly through LGA and so, in the future, I will be avoiding that airport like the plauge. No flight ever leaves on time (except possibly the first flight in the morning) from that airport.) The direct flight to home was on American Airlines. So, I was directed to claim my bags and recheck them with American.

So, while I was waiting for my bags, I was informed that the (delayed due to mechanical failure) flight's already taken off, and that my bags will be joining me at home, or if it's convienient, I can pick them up at the airport. So, I'm thinking, ok, whatever..

As it turns out, the flight combo actually beats me home (mostlly due to air traffic problems at LGA), but my bags aren't on it. The problem here is that I leave for a job interview tomorrow night. It would be good if I had clothes to interview in. I suspect they won't be happy if I show up in capri cargos (2 sizes too big) and a stained t-shirt (which are all the clean clothes I've got left!).

AA has a website you can check your bag's status. However, it always says "your luggage has not been found". You get the same response when you call their automated hotline. However, if you manage to make it far enough through the phone tree to talk to an actual agent, they will transfer you to an actual human being in the baggage department. That human being must have supernatural powers, because she can tell you where your luggage is. She was able to figure out that my bags have actually made it to my Home City and will be joining me at my home tomorrow morning!

Overall, I give United and American kudos for actually trying to make me happy. US AIR now charges $2 for a glass of water on its flights, and they hire the rudest weirdest ticket agents and flight attendants, so they're off my list. I try to avoid American, too, because the checked bag fee annoys me. But in this instance, they were helpful.

The moral of this story? Sometimes you need to talk to a human being.

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Ecuador: Day 0 (or Sometimes Getting There is Half the Fun!)

OK, so the title is slightly facetious. Because I put off buying my tickets for so long, my only flight option to Ecuador involved a 4 hour layover in Miami. So, I waited, and waited. On initial impression, there's nothing in the Miami Airport. The key is to leave the security area and go to the ticketing/check in area. There you will find a nice variety of shops and restaurants. All of which are overpriced and mediocre, but can be used as sourced of nutrition and amusement.

I'm not sure what it is about the Miami Airport, but they're all about Toblerone there. Every shop sold a lot of Toblerone (but none sold Tide-sticks). Also, the laptop and DVD (and Civ4) combo can be key to surviving a long layover. I'm not sure how I ever survived long layovers without that kind of entertainment capability.

The flight from Miami to Ecuador was nice. I was put in a bulkhead seat, which isn't my favorite (because of the fact that I can't keep my carryon with me.) One woman sitting on the other side of me was making a big deal about it, and eventually, the poor flight attendant had nothing to say but "Would you like to change your seat?". Somehow this lady refused both to follow the rules of the bulkhead seat and refused to change seats. This scene delayed the flight a bit, but was quite entertaining!

I arrived in Quito at approximately 6:30pm. The Ecuadorians have a long and rich culture, but they do not have a Culture of Efficiency. Somehow, it never occurs to them that people are in a hurry! It took >2 hours to get through immigration and customs (and they didn't search anything). They just took their time. Ah, well. Oh, and at this point, because I was on call the day before the day I left, and then spent all day the next day getting ready, I had been awake for > 36 hours, and things were starting to seem a little surreal).

So, the arranged car had actually been arranged for the wrong day, unfortunately, and when the guy failed to show up, I figured I'd just take a taxi. Seemed easy enough. I'm not going to call the house and ask my host to send someone to pick me up when a taxi should be easy enough.

Remember, I haven't slept, and my Spanish is non-existent at this point! So, I showed a cabbie the address, he seemed to ask someone else where it was, and then he started driving.....

and driving....

and driving....

and asking random people on the street....

So, 2 hours later (11pm, ~40 hours without sleep), we finally happen on to the right house. I'm greeted at the door, and manage to figure out that the cabbie is demanding $25 (that's a lot for what should have been a 15 minute cab ride in Quito). The medical student who met me bartered the cabbie down to $15 (the fare is, apparently usually around $10).

I'm shown to my room (pictured), which is simple, but adequate for my needs. 2 beds, a shelf, a few hangers. What more do I need? And on my way to bed, I agree to go on a road trip (next Ecuador post!).