I have two daughters, ages 2 years and 2 months. Brooke and I live in moderate-to-serious chaos most of the time. When Zoë (2 years) was born, our social lives sort of disappeared, as did pursuit of things like exercise, backcountry travel, and consistent sleep. We got some of that back over two years, then it all went to hell again when charming Elliott appeared on the scene last December. Two years ago I would say to close friends, "I just want some tiny piece of my life back." This time around I don't entertain that same wild idea. No desire, no suffering.
And then yesterday, out of nowhere, this great experience came up. The four of us headed out on Saturday morning to the Galaxie café, a Beacon Hill coffee shop opened recently by our neighbors, Yen and Jeff. The place is great! It was quite lively, good coffee, pastries. The sandwich menu looked fantastic. But don't take my word for it, read the P-I review. There were also a bunch of kids there, and Zoë had a great time with the other kids and toys.
The interior walls are decorated in Beacon Hill murals, and the entire south wall is a building-by-building map of the neighborhood. Local customers can put a pin in their house--and there are quite a few pins. We called our friends, Sachi and Travis, to walk down and join us. They did, but I don't think they put a pin up. Next time, perhaps.
Best of all, it was a chance to do something social--in public--as a family. Brooke and I never really got to hang out in cafes much together before we had kids, which I kind of regretted. Now we can. And we'll be back there next weekend.
Sunday, February 25, 2007
Saturday, February 24, 2007
OB-RAMA part II: Noon - 5am
My last post got a little long on the details of fetal heart tones without actually saying much. This account of the rest of last Thursday (and Friday) will be mercifully thrifty...you hope. After delivering one vacuumed baby on Thursday, I found myself with a dilemma. I'm supposed to be on a General Surgery rotation this month, but my OB patient was a priority and I missed the morning. Missing the 5-7am portion of the GenSurg day is like missing most of anybody else's day--the rounding and planning all happens then so the surgeons can get to the OR and do what they do. I'd missed rounds and a considerable amount of loitering, but there was a noon morbidity & mortality conference beginning just as a wrapped up my post-delivery work. I like the way surgeons do M&M, and lunch was provided, so I went.
Maybe a mistake, looking back.
I discovered that I was to be "paired" with one of the interns who is also a medical school acquaintance of mine. Let's call her Tatum, which happens to be her name. I wasn't thrilled about being teamed up with Tatum, or with the idea of "shadowing" an intern at all. I've been an intern, completed my internship, and enjoy the rhythm and responsibility of my second year much more. Interns have crappy hours and few choices. Surgery interns have horrendous hours and buckets of scut packaged in an oppressive hierarchy. It's not my world. I'm okay visiting for a bit, but not so much with Tatum as my guide. But what can you do?
I got a brief explanation of the team structure from Tatum and an offer to go to the OR to scrub for a case. I declined, thinking I'd rather spend time learning about the patients on service. I'm also just not that interested in hanging out in the OR holding retractors. Instead, I familiarized myself with the in-house patients, returned to my postpartum mom & babe duo, and did some paperwork. Tatum and I had divided up her patients among us for the morning--I was to see half of them (about six) before 7am.
At about 4:30pm Brooke called to see if I could pick up Zoë from daycare on my way home. I said yes and made one last call to clinic to check in. Our nurse there told me that another of my pregnant patients was having contractions and was on her way in. It doesn't take long to assess whether a woman in active labor and needs to be admitted, so I walked up to OB Triage to wait for her. Annabella (not her name, but the surgery intern is definitely named Tatum for real) arrived a few minutes before 5pm. She was still shy of getting a room by my evaluation, but I thought she would be in active labor after a couple of hours of walking, so I sent her out and picked up Zoë as planned, knowing I'd be back shortly.
My colleague Sharon examined Annabella when she returned, determined she was "active" and got her a room. I was back before 8pm, and based on my exam, I calculated that she might deliver at about 2am. I'd be there until 3am, at least, and had clinic the following afternoon, which I don't like to cancel. Based on that, I figured I should do something about the morning (rounds and retractor holding), which might be my only chance to sleep, keeping in mind that at 7am I'd be over my duty hours for patient care, with at least ten hours of care still scheduled.
As an R2, I have a variety of responsibilities and frequently have to prioritize them in unfortunate ways. Occasionally clinic gets canceled due to a delivery. Everything can get canceled if I'm "goated" to fill in for a colleague who is unable to work. In this case, I was looking at three responsibilities, a duty hour conflict, and no sleep for nearly 40 hours. It didn't take long to figure out that if something was going to go, it would be "shadowing" a surgery intern for the morning and doing half her scut. Even if it were an intern I wanted to hang out with, I'd have made the same choice.
Here's what I did. I paged Tatum at home to let her know that I'd be up all night with a delivery and wasn't planning to see her patients in the morning--apologies. No skin off her nose, I figured: she'd be rounding on those patients if I weren't "shadowing." Shortly after I sent my text page, Tatum paged me back with a number. I called, and spent the next fifteen minutes listening to poor Tatum go on about my priorities and my work ethic, asking me what I intended to get out of my GenSurg rotation and grilling me on where I'd been all day.
Was she fucking kidding?
She wasn't. I'm not one to pull rank on anyone, it's not really what my people do (my people are family doctors, not surgeons). But holy shit! I couldn't believe this intern was giving me the third degree about my work ethic. I was at work. She was home eating pudding pops for all I know. After several minutes of actually indulging her line of questioning, I stopped and said, "Tatum, why are you giving me a hard time about this? Have I created some new work for you?" No! She's frickin' lazy and was pissed that she wouldn't have me around to do half her work for her. Argh.
That got me pretty riled, and I stayed that way for a while. I got it together for the delivery, though, which didn't happen until after 3am. Like the delivery the morning prior, it required a vacuum, but unlike that one, I figured out the vacuum myself. One pop-off and then a smooth delivery on vacuum attempt #2. Minimal tearing. Healthy mom and a healthy baby: that's pretty much my whole job.
I was done with the post-partum paperwork at 4am, and was on my way home when I decided that I would make one gesture to Tatum and anyone else on the surgery team that would call me weak and lazy for cutting out on a morning of doing someone else's busywork. I rounded on the damn patients from 4-5am, wrote notes, and sent Tatum a dawn page letting her know I'd done some of her work and that she should not ever put us through such an annoying conversation again.
That was 5am, which brings me to the end of the story, basically. The rest is pretty boring. I slept some, rounded on my moms and babes in the hospital, and spent the afternoon in clinic. It's now Saturday night and I'm off until Monday, when I'm back on the General Surgery team and will either face a hostile crowd (for being lazy & weak)...or no one will have noticed my absence.
Maybe a mistake, looking back.
I discovered that I was to be "paired" with one of the interns who is also a medical school acquaintance of mine. Let's call her Tatum, which happens to be her name. I wasn't thrilled about being teamed up with Tatum, or with the idea of "shadowing" an intern at all. I've been an intern, completed my internship, and enjoy the rhythm and responsibility of my second year much more. Interns have crappy hours and few choices. Surgery interns have horrendous hours and buckets of scut packaged in an oppressive hierarchy. It's not my world. I'm okay visiting for a bit, but not so much with Tatum as my guide. But what can you do?
I got a brief explanation of the team structure from Tatum and an offer to go to the OR to scrub for a case. I declined, thinking I'd rather spend time learning about the patients on service. I'm also just not that interested in hanging out in the OR holding retractors. Instead, I familiarized myself with the in-house patients, returned to my postpartum mom & babe duo, and did some paperwork. Tatum and I had divided up her patients among us for the morning--I was to see half of them (about six) before 7am.
At about 4:30pm Brooke called to see if I could pick up Zoë from daycare on my way home. I said yes and made one last call to clinic to check in. Our nurse there told me that another of my pregnant patients was having contractions and was on her way in. It doesn't take long to assess whether a woman in active labor and needs to be admitted, so I walked up to OB Triage to wait for her. Annabella (not her name, but the surgery intern is definitely named Tatum for real) arrived a few minutes before 5pm. She was still shy of getting a room by my evaluation, but I thought she would be in active labor after a couple of hours of walking, so I sent her out and picked up Zoë as planned, knowing I'd be back shortly.
My colleague Sharon examined Annabella when she returned, determined she was "active" and got her a room. I was back before 8pm, and based on my exam, I calculated that she might deliver at about 2am. I'd be there until 3am, at least, and had clinic the following afternoon, which I don't like to cancel. Based on that, I figured I should do something about the morning (rounds and retractor holding), which might be my only chance to sleep, keeping in mind that at 7am I'd be over my duty hours for patient care, with at least ten hours of care still scheduled.
As an R2, I have a variety of responsibilities and frequently have to prioritize them in unfortunate ways. Occasionally clinic gets canceled due to a delivery. Everything can get canceled if I'm "goated" to fill in for a colleague who is unable to work. In this case, I was looking at three responsibilities, a duty hour conflict, and no sleep for nearly 40 hours. It didn't take long to figure out that if something was going to go, it would be "shadowing" a surgery intern for the morning and doing half her scut. Even if it were an intern I wanted to hang out with, I'd have made the same choice.
Here's what I did. I paged Tatum at home to let her know that I'd be up all night with a delivery and wasn't planning to see her patients in the morning--apologies. No skin off her nose, I figured: she'd be rounding on those patients if I weren't "shadowing." Shortly after I sent my text page, Tatum paged me back with a number. I called, and spent the next fifteen minutes listening to poor Tatum go on about my priorities and my work ethic, asking me what I intended to get out of my GenSurg rotation and grilling me on where I'd been all day.
Was she fucking kidding?
She wasn't. I'm not one to pull rank on anyone, it's not really what my people do (my people are family doctors, not surgeons). But holy shit! I couldn't believe this intern was giving me the third degree about my work ethic. I was at work. She was home eating pudding pops for all I know. After several minutes of actually indulging her line of questioning, I stopped and said, "Tatum, why are you giving me a hard time about this? Have I created some new work for you?" No! She's frickin' lazy and was pissed that she wouldn't have me around to do half her work for her. Argh.
That got me pretty riled, and I stayed that way for a while. I got it together for the delivery, though, which didn't happen until after 3am. Like the delivery the morning prior, it required a vacuum, but unlike that one, I figured out the vacuum myself. One pop-off and then a smooth delivery on vacuum attempt #2. Minimal tearing. Healthy mom and a healthy baby: that's pretty much my whole job.
I was done with the post-partum paperwork at 4am, and was on my way home when I decided that I would make one gesture to Tatum and anyone else on the surgery team that would call me weak and lazy for cutting out on a morning of doing someone else's busywork. I rounded on the damn patients from 4-5am, wrote notes, and sent Tatum a dawn page letting her know I'd done some of her work and that she should not ever put us through such an annoying conversation again.
That was 5am, which brings me to the end of the story, basically. The rest is pretty boring. I slept some, rounded on my moms and babes in the hospital, and spent the afternoon in clinic. It's now Saturday night and I'm off until Monday, when I'm back on the General Surgery team and will either face a hostile crowd (for being lazy & weak)...or no one will have noticed my absence.
OB-RAMA: Thursday, 4:30am - Noon
Last summer I posted about a long day (or two) of continuity deliveries (meaning my own pregnant patients laboring & delivering, as opposed to someone else's patients). I had another extended day of moms-to-be becoming moms this past week.
I woke up, sort of, on Thursday morning to my pager doing the single-beep-and-vibrate thing at about 4:30am. It was my colleague, Jessica, holding down the inpatient service on nights (I was on the week before). She had one of my two post-dates patients in triage, in labor and in pain. She was moving over to a delivery room. I told her I was on my way, but that I'd be moving slowly. And I did. Move slowly. I think I fell back to sleep for a bit, then got in the shower, tossed on some green scrubs, and headed out. I felt a little bit guilty leaving Brooke to wrangle both Zoë and Elliott, but what could I do? It's my job.
My patient, let's call her Frances, was dilated to 8cm when I arrived at the hospital, but the baby was still high in her pelvis. She had an epidural block, so she was comfortable, but neither she nor her husband could really rest, for they were both nervous and excited about what was happening. I got a little nervous too when I saw the fetal heart tone strip, which showed some prolonged rate decelerations, indicating that the umbilical cord was being compressed with each contraction. Decels themselves aren't alarming, and the cord compression variety are fairly benign, but these things were going on for longer than I would like. I chatted with my attending, Jay, about my options for managing this situation. He reminded me that in general there aren't that many options for managing labor, which is both a blessing (fewer decision to make) and a curse (in medicine it's nice to have options). The basic choices here were to start an amnioinfusion (put some saline into the uterus to create a bigger pocket of fluid around the baby) or do nothing. Amnioinfusion is one of those interventions that the evidence says doesn't do a whole lot of good in most situations but is fairly harmless. If these were actually cord compressions, it should help. So why not try, right? I also took a moment to curbside an obstetrician, who helped me feel better about infusing.
It helped! She labored on with a happier strip and eventually got to full dilation (10cm) and the baby descended nicely. Time to push, which she did, with coaching, for about an hour before the decels came back. Again, not terribly alarming, but we thought we'd feel better if we could just deliver this baby into the world and free her from being compressed every two minutes--clearly she did not dig the squeeze. Jay and I talked about a vacuum assist and got the OB involved to help with placement, as the baby's head was still a little high. A novice with the vacuum, I got two attempts (or "pop-offs"), then, by previous agreement) handed the vacuum over to more experienced hands. Frances pushed and we pulled and out came a lovely baby, who immediately enjoyed the change in atmospheric pressure. With nearly all vacuum-assisted deliveries, there is some tearing of maternal tissues, and this was no exception. A few stitches and that was that.
Then of course, paperwork. A delivery note, post-partum orders for mom, a newborn exam, note, and orders and the odd surveys, code status declarations, and face-sheet (billing) stuff that litters the chart.
It was noon when I finished that, and this post is long enough, so the day will continue under another post.
I woke up, sort of, on Thursday morning to my pager doing the single-beep-and-vibrate thing at about 4:30am. It was my colleague, Jessica, holding down the inpatient service on nights (I was on the week before). She had one of my two post-dates patients in triage, in labor and in pain. She was moving over to a delivery room. I told her I was on my way, but that I'd be moving slowly. And I did. Move slowly. I think I fell back to sleep for a bit, then got in the shower, tossed on some green scrubs, and headed out. I felt a little bit guilty leaving Brooke to wrangle both Zoë and Elliott, but what could I do? It's my job.
My patient, let's call her Frances, was dilated to 8cm when I arrived at the hospital, but the baby was still high in her pelvis. She had an epidural block, so she was comfortable, but neither she nor her husband could really rest, for they were both nervous and excited about what was happening. I got a little nervous too when I saw the fetal heart tone strip, which showed some prolonged rate decelerations, indicating that the umbilical cord was being compressed with each contraction. Decels themselves aren't alarming, and the cord compression variety are fairly benign, but these things were going on for longer than I would like. I chatted with my attending, Jay, about my options for managing this situation. He reminded me that in general there aren't that many options for managing labor, which is both a blessing (fewer decision to make) and a curse (in medicine it's nice to have options). The basic choices here were to start an amnioinfusion (put some saline into the uterus to create a bigger pocket of fluid around the baby) or do nothing. Amnioinfusion is one of those interventions that the evidence says doesn't do a whole lot of good in most situations but is fairly harmless. If these were actually cord compressions, it should help. So why not try, right? I also took a moment to curbside an obstetrician, who helped me feel better about infusing.
It helped! She labored on with a happier strip and eventually got to full dilation (10cm) and the baby descended nicely. Time to push, which she did, with coaching, for about an hour before the decels came back. Again, not terribly alarming, but we thought we'd feel better if we could just deliver this baby into the world and free her from being compressed every two minutes--clearly she did not dig the squeeze. Jay and I talked about a vacuum assist and got the OB involved to help with placement, as the baby's head was still a little high. A novice with the vacuum, I got two attempts (or "pop-offs"), then, by previous agreement) handed the vacuum over to more experienced hands. Frances pushed and we pulled and out came a lovely baby, who immediately enjoyed the change in atmospheric pressure. With nearly all vacuum-assisted deliveries, there is some tearing of maternal tissues, and this was no exception. A few stitches and that was that.
Then of course, paperwork. A delivery note, post-partum orders for mom, a newborn exam, note, and orders and the odd surveys, code status declarations, and face-sheet (billing) stuff that litters the chart.
It was noon when I finished that, and this post is long enough, so the day will continue under another post.
Friday, February 16, 2007
Status-post
Well so much for 3am posts all week from the land of night float on the family medicine service: Swedish blocks blog access on it's servers. Booooo. I could have worked around it by writing a Google document and posting it, but I didn't. How did I spend my time? Well, there was plenty of patient care to be done, and once I switched from day-alert to night-manic, I was able to focus pretty well. But all work and no play...you know?
I took advantage of the hospital network's streaming video access and checked in nightly on both the Daily Show and Colbert Report. Last night I jumped from Comedy Central to ABC and watch the last two episodes of Lost, which look pretty good online, the non-skippable ads notwithstanding.
Every space needs ambiance, right? I dig the new lighting in the Gumby Lounge and each night killed the overhead fluorescents in favor of mellow area lights. Greg Parker clued me in to Soma FM a few nights ago, and the selections there became the background of the space for the duration of the week. Not so much an office but a working lounge. Many thanks to Anneliese and Sarah for the improvements!
I took advantage of the hospital network's streaming video access and checked in nightly on both the Daily Show and Colbert Report. Last night I jumped from Comedy Central to ABC and watch the last two episodes of Lost, which look pretty good online, the non-skippable ads notwithstanding.
Every space needs ambiance, right? I dig the new lighting in the Gumby Lounge and each night killed the overhead fluorescents in favor of mellow area lights. Greg Parker clued me in to Soma FM a few nights ago, and the selections there became the background of the space for the duration of the week. Not so much an office but a working lounge. Many thanks to Anneliese and Sarah for the improvements!
The theme of the week at SFM was viral syndrome. Especially among the interns. Seems like most of us were hit with fever, malaise, myalgias, diarrhea, URI symptoms--am I missing anything? I got lucky, or maybe it was a combination of luck, hygiene, and voodoo. I made sure to disinfect the lounge nightly (especially the phones and keyboards), wash and gel my hands, and took liberal doses of echinacea with zinc and vitamin C. Seems to have helped thus far: I figure I'm in the window for a couple more days before I can call my evasive maneuvers a success.
I did spend one night on my own due to Maria's illness. Far from being a burden, it was actually quite fun. I took advantage of my solo-status to (a) feel confident in my medical decision making and (b) look up everything. Many thanks to UpToDate and my trial of ePocrates expanded version for helping with differentials and treatment options.
Thanks to my colleagues on the service and around the hospital for making the week fun, too!
Now for the return to daytimes. This is the worst part--several days of sleepy, surly confusion. Fortunately, it's a long weekend, and being alert at night can actually help Brooke get some sleep--I'll cover some of the nighttime attention Elliott needs.
I did spend one night on my own due to Maria's illness. Far from being a burden, it was actually quite fun. I took advantage of my solo-status to (a) feel confident in my medical decision making and (b) look up everything. Many thanks to UpToDate and my trial of ePocrates expanded version for helping with differentials and treatment options.
Thanks to my colleagues on the service and around the hospital for making the week fun, too!
Now for the return to daytimes. This is the worst part--several days of sleepy, surly confusion. Fortunately, it's a long weekend, and being alert at night can actually help Brooke get some sleep--I'll cover some of the nighttime attention Elliott needs.
Friday, February 09, 2007
Bloomin' Seattle
Inspired by a recent post by Bus Chick, I snapped this (phone camera) shot a few minutes ago near my house in the Rainier Valley. I saw lots of tiny blooms on my walk to and from Dahlia Spa. Seeing new blooms in Seattle means that it must be February. The days are finally getting a little longer, and soon we'll all be making vitamin D again. It turns out to be just about the nicest day in recent memory here: thin cloud-cover and a mild 57-degrees as I write.Tonight I begin a week of night shifts on the SFM inpatient service. The transition into nights is always tough, but easier than returning to days. No one much enjoys my cross attitude during the days that follow night float. Fortunately for my family, it doesn't happen that often.
If I'm lucky, I'll get some good posts in over the next several nights. A hospital at night is a strange and wonderful place--so is the company one keeps. More from the other side.
Monday, February 05, 2007
Gellin'
Hand gel has been all over the news recently. Last week a study appeared discussing hand sanitizer technique--apparently it matters (I'm looking for that link). A bit appeared this weekend about the growing recreational use of alcohol-based gels in prisons (my search for Purell Appletini actually yielded something). And there's a new nicotine hand gel on the market (PubMed searches reveal no research on the stuff).
Makes me wonder what can't be delivered with a little gel?
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