W.G. Snuffy Walden

The first year we were married, Daryl and I both bought each other the complete series of The West Wing on DVD because love means living in a shared delusion where Jed Bartlet is the President and Bradley Whitford does not have a mustache. Keep in mind that this was in 2007. I can't remember who was President because I've purged that part of my memories.

Needless to say we've come a long way since then and Emmaline, in light of Josh Lyman's transformation into the boozing and womanizing  Dan Stark, is breathing a sigh of relief that she was not born a boy and named Whitford. She's also very likely relieved that she was not born twins and named Molly or Huck. She does have to live with being Emmaline Abigail, however, though I think Abbey Bartlet (fictional or not) is a fairly good role model for anyone.

So I returned Daryl's Christmas present reasoning that our blind devotion to Aaron Sorkin's vision of our country, while wholehearted, does have its limits. I spent the money on something else. In fact, I spent the money on a wine of the month club that a change in state law promptly made illegal, so I got a refund on that as well and, well, I guess Daryl is still waiting for his Christmas present.

Last night, in honor of Daryl's Easter present for Emmaline (a copy of Monsters, Inc.), we hooked up the DVD player. Well, Daryl hooked up the DVD player. I pulled the wires out the back of the media console when he pushed them through. Totally a team effort. And it only took 8 months. We are very slowly settling in here.

After teaching Emmaline to say Mike Wazowski (sort of) and tucking her into bed, Daryl realized that we now had the ability to watch Charlie help the President find his glasses in time for his live national address. We have since had a precipitous drop in our collective productivity.

This led my father to bemoan the fact that he might never get anything done again. That, in turn, led me to inquire what, exactly, he gets done as it is. He is not my biggest fan right now.

All in all, though, I think a little bit of optimism and a whole lot of nostalgia is something we should allow ourselves on occasion. Look for my next post in about six months, which is how long I calculate it will take us to turn Matthew Santos from a long shot into Commander in Chief.

Egg!

It was almost too hot to be outside yesterday morning. Scout ran about the yard as if possessed and then collapsed in a heap in the shade. Even with rapid cooling of the afternoon and the occasional sprinkle, the weather held through the grilling of the lamb and subsequent overeating and the guests (I hope) went home happy.

During the pagan festivities of spring, Emmaline displayed her skills as egg hunting. She was especially adept at finding those that were in plain site and being pointed directly to. Brilliant girl. Then, once Scout and her own guest Shula commenced their game of tag, Em chased after them both. The dogs nipped at each other's tails while Emmaline toddled with outstretched arms, barely avoiding being knocked down, yelling, "Hug!" Sadly, neither Scout nor Shula could slow down long enough to entertain such affection.

Emmaline also did her best to make peace with her long-time nemesis, Charlotte, who (though a lovely girl) has been slow to realize that when it comes to winning the affection of their mutual friend Jack, Emmaline will play dirty if she has to. Still, Em only put sand in Charlotte's hair on a few occasions during the course of the afternoon and was otherwise willing to keep a shaky truce.

Here's hoping the weather holds. Emmaline has a busy social calendar and a sand box and swing with Jack's name on them.

April Snow-showers

There are flowers in the window boxes. The planters are filled with daffodils. Miraculously, they seem to have survived the frosty weather of the last forty-eight hours. And finally, it almost feels like spring. Thank goodness. It is long overdue.

Epistaxis

If I may, a moment's reflection on bloody noses. They happen. They always appear to involve massive, life threatening volumes of blood but, unless prompted by having your face blown apart by alien invaders, generally do not deplete one's blood volume appreciably. Thus, a trip to the ER for a nose that has stopped bleeding is generally not worth your co-pay. I am, of course, always happy to provide saline nose spray for all comers, but I'm not sure this is notably impacting my karma.

One more thought. When you ask why children's noses bleed, I am going to mention nose picking. Dry air, superficial capillaries, yes, blah blah blah. But nose picking ranks right up there. I am not talking about you, parents, though undoubtedly your fingers as well have sneaked themselves up a nostril on one occasion or another.  Instead, I am talking about your five year old.

"Oh, he doesn't do that."

That's a quote. Not from one parent. From many parents. Word for word. Always the same. Verbatim. And they don't say it during an awkward pause. They interrupt me. They interject. It's as if it is too painful to let a moment longer pass with my thinking their child is a nose picker. They have to act. To clear his good name.

Why, oh why, the need to protest, to feign embarrassment? Do you really think that my perception of your parenting skills is greatly impacted by whether or not your child might pick their nose? Rest assured I am not going to call the PTA.

Furthermore, I'm not suggesting incessant, class disrupting booger flinging while at school, though that might be more interesting. I'm not intimating he makes a snack of snots in the playground with his friends. I'm saying, only, that his nails might have (at some point in time) damaged the mucosa of his nasal septum making him more vulnerable to bleeds.

He will still someday go to Harvard...or Yale...or whatever. Though Princeton definitely has a policy about gross stuff like that.

Carpentry 101

There is something invigorating and wholesome about building things with your own two hands. Creating something useful as if from thin air. Starting with nothing and finding yourself at the end of a few hours work with a, well, let's say a sandbox.

Now that Emmaline's favorite word is outside, the question arose as to what to actually do in said great outdoors. The backyard is not overly spacious and is bordered on one side by an eight foot drop, fence to be erected shortly but for now something of a death trap.

The front yard, though much larger, is bordered by a relatively busy street. When the snow was piled high around the drive and Em could not rush at breakneck speed toward oncoming traffic this was less of an issue. Recently, though, it has become somewhat of a thorn. It's not that we still can't head her off before she goes too far. She's speedy but she's not that fast. Unfortunately, any intervention is seen as harsh and cruel punishment on her part and is the catalyst for shrieking tears.

I love my daughter. Most of the time.

Now, since I have absolutely no practical skills, the act of building something did come to rely heavily on a kit of pre-cut pieces of wood and a booklet of directions. I'll admit it. I'm proud anyway. Oh, and my husband helped. Well, did most of the work. You get the idea.

It was everything I imagined it would be. The smell of cedar, the grass stains on my jeans. Right until the moment Daryl put the screw driver through my finger and the dog ate half the bolts, it was idyllic.

In the end, Emmaline got to enjoy the product of our ingenuity and then stuck a finger covered with sand right in my eye.

I love my daughter. All the time.

Let Maria Talk Already

MariaTalks.com is a website sponsored by the Massachusetts Department of Public Health aimed at providing information geared to and understandable by teens regarding safe sex, birth control, and (gasp) abortion.

From the website:

"Abortion is a pretty hot topic with some of the kids at my school.  Some believe that it is wrong while others believe that it can be a good and responsible choice.  While everyone is entitled to their opinion, it can sometimes be hard to get truthful information because some people may try to get you to think the same way they do."


First off, I want to say that I think it is reprehensible that the government would provide information to the general public about a completely legal procedure. Wait, did I say reprehensible? I meant commendable. See, words are confusing. Maybe the outcry by Massachusetts Citizens for Life's Linda Thayer against the site is just a misunderstanding. Maybe she doesn't understand words. That must be it. Or maybe she just skips the ones that don't jive with her message. Yes, I said jive. Because it has a 'j' in it and is groovy. Words can be fun as well as helpful. So just calm down.


Without wading through the waters of an ethical debate about when life begins and whether abortion is right, let me take a moment to focus on one aspect of the opposition to the website, specifically there being a dearth of information on the actual risks of abortion. Dearth. Look it up.


Now this would be inexcusable if the website itself were performing abortions. Sadly, the internet is not that powerful and you actually need to see a doctor to have most medical procedures done, at which point the risks would be discussed ad nauseum as a part of informed consent.


So, let's talk about risks for just a moment. In fact, let's make a list:

• hemorrhage
• hemolytic anemia
• thrombocytopenia
• seizures
• coma
• death

Scary stuff indeed. 


The thing is, these are the risks of pregnancy, of carrying a baby to term. The risk of death from childbirth is higher than from an abortion. Not just a little bit higher. A lot higher. In the United States in 2005 at least 11 in 100,000 pregnancies ended in death, whereas complications from abortions cause death in only 0.2-1.2 out of 100,000 women in the developed world. It would be lovely if either of those numbers was a zero, but the world isn't all rainbows and miracles. It's messier than that and to pretend otherwise is madness. 


Now multivariable calculus admitted kicked my butt at Princeton, but I do believe that there's a tenfold reduction in dying by having an abortion. Anyone claiming to want to protect life may need to have a think about that one. I said think. Another wonderful word. Try it out.


I'm all for fair and balanced information, so might I also point out that at no point during my prenatal visits did my OB mention to me that I was putting my life at risk by having this baby. Nope. Never mentioned. Now who out there thinks I should sue? Maybe the Massachusetts Citizens for Life will take up my cause, though I highly doubt it. They seem to be too busy being angry, which is a shame. Life is short. Move on.

Speculum Speculation

Online banking, greater connectivity, and youtube videos aside I'm going to say that the greatest advantage gleaned from the internet is my ability to attend fellows conference in my pajamas. Today, against a background of echoing pagers and familiar voices and while simultaneously trying to teach Emmaline the word rhabdomyolisis (not so much), I was able to learn a few things. All while comfortably wearing my polar bear pants. Outstanding.

Why the lecture on obstetric emergencies for this group of pediatric emergency room physicians? Well, contrary to popular GOP dogma, kids sometimes get pregnant. Good kids. Kids with nice parents who limit their screen time and monitor their facebook and who live in houses with picket fences and dogs named Rover. These kids have sex and they get pregnant and they come to the ER and you code the visit as abdominal pain because you don't want the word pregnancy to show up on their parents' health insurance statement. 

Let me rephrase that. You don't do it to be nice. You do it because a pregnant teen is an emancipated minor and legally entitled to medical confidentiality even from her parents if that is her choice.

So imagine a teenager who has had an abortion. Here, in this country, it would have been performed in a clinic using sterile instruments and she would have gone home that day with a careful follow up plan in place and numbers to call if anything doesn't seem right. But what if she, like the girl discussed in lecture today, was from another country? What if the abortion, which she only reluctantly disclosed after her family had been asked to leave the room, was done in a place where such procedures are illegal? They are dirty, not from an ethical standpoint but from a physical one, and now her abdomen is filling with pus.

In the developing world, 25-50% of maternal death is the result of illegal abortions.

Young girls. Healthy girls. Many of them growing up in cultures where to refuse sex is a patriarchal no no. That is a discussion for another time, but suffice it to say that their deaths are a tragedy. They are victims, not culprits.

So she's in your ER, having just gotten off a plane, and you can tell just by looking that she is in terrible shape. She goes straight to the OR where they try to clean out the pus filling her up inside. From there she goes to the ICU. She never wakes up. They never take out the breathing tube. And two weeks later she dies.

What do you tell the family?

The pregnancy and the unsterile abortion that killed her were her choice to conceal. In death, does that doctor patient confidentiality persist? How much does it add to a family's grief not to know, to feel that the doctors were concealing the truth? On the other hand, how does knowing change the way they remember their daughter, her laughter, her dreams?

I don't expect an easy answer. What I want is for people to realize it is hard, incredibly hard, for the family but also the doctors who care for girls such as these.

In the ER with my own pregnant patient, who is entirely well, who came to see me after scheduling an abortion with her own provider, I realize that the only reason for the visit is that she didn't know where else to go. I'm not magically empathic. She actually said as much out loud. She's a smart girl. Even as she was saying, "I didn't think I could get pregnant the one time we didn't use a condom," she stopped herself to shake her head ruefully and ask, "Does everybody say that?"

Yes. 

So what did she want from me? She wanted to be told it was all going to be okay. We live in a country where abortions are safe. We live in a state where they are actually performed close enough to her home that she can get there and if that is her choice then, yes, she will be okay. She will not die like the patient I heard of today. If she has the baby then, well, she will also probably be okay, though having a baby is one of the most dangerous things women in this country do.

She wanted to be told if it would hurt. Well, not as much as pushing a baby out of your vagina. I didn't say that. Well, not exactly. But what I did say is that I have friends who have had abortions. This thing that no one talks about, maybe we should. Maybe that would help teenagers to make better decisions, both about whether or not to terminate a pregnancy but also about how and when they choose to have sex.

"Are they okay?" she wanted to know, meaning my friends.

"Yes," I told her, with complete honesty. "They became doctors and then they became mothers when they were ready."

The decision will be hers. I can't make it for her. But she didn't need that. She really just needed someone to give her a hug.

Age Appropriate

The first time I took Emmaline out for lunch after she was born, my friend Merielle and I walked a few blocks from our condo to Panera pushing Em in the adorable sky blue bassinet pram that I loved and she hated.

She cried the whole way. Recently nursed, changed, and napped she was noisy but she was safe. She wanted to nurse again, which we did as soon as we got to the restaurant, but she did not need to nurse if the point of nursing is calories and not only comfort. It was, despite the decibel level of my fourteen day old, completely under control. Nevertheless, some batty toothless old woman we passed along the way felt compelled to comment even more loudly than Emmaline was wailing, "Well, someone obviously needs something."

Someone obviously did. Someone obviously needed to be told to shut up. The lady. Not Emmaline.

The reality is that babies cry. You deal with it. When they get older they yell. They do lots of things we'd rather they didn't, but that is all part of the process of learning. Well done to those parents who can endure the chaos of creativity and come out smiling on the other side.

On a flight Daryl, Em, and I were on when she was very young and still in the nurse/sleep cycle that kept her quiet from take off to landing, a woman was traveling alone with her three children. One was in a carseat and babbled adorably the entire ride. The two others, across the aisle from mom and the baby, played games and read stories to each other the whole way. They were noisy, but not unhappy. I was terribly impressed.

But when it came time to disembark there was of course a small delay as mom helped the kids gather all their things and negotiate the narrow aisle. I don't even think there was crying and yet the person in the row behind her, smirking to the others who were waiting, felt compelled to say, "That's why you shouldn't have so many children."

Later, at the baggage carousel, I told the mom how beautiful her children were and she promptly burst into tears.

So today, at lunch with Emmaline, she was completely out of control. We went out in hopes of scoring the discount kids meals Friendly's has on Wednesdays only to quickly be reminded by the gaggle of families waiting to be seated that it is school vacation week. So we ended up at our favorite burrito place across the road where Em proceeded to eat several bites of lunch only to then become intent on pitching herself out of her high chair. Luckily, I was with my mom so we took turns eating and wrangling the baby and eating again.

Here's where it's possible we went wrong. Em, you see, really likes that there is a glass entryway of this very informal family joint that she can walk around the corner of and still see back to our usual booth to wave. She's not in any danger of being hurt. I can still see her. No harm, no foul, right? True, she's a little bit underfoot at times when she wanders back to the table, but people generally smile, comment on her overwhelming adorableness, go along their way.

Today it happened that there was another child about Em's size who was at the table between us and Em's usual play corner. He was sitting quietly in his high chair and eating while his parents sat silently beside him, not talking to him, not talking to each other. Granted, he was behaving far better than Emmaline, but he also wasn't saying words like outside, applesauce, milk, glasses, up, walk, sit, or any of the other sundry vocabulary wins Em had during the outing. He wasn't saying anything at all. Even when Em went over to him and waved and said hello, he only smiled wordlessly. His parents didn't look at her or (seconds later) at me when I came to retrieve her and tell Emmaline how good the baby was being by sitting so still. The baby smiled, but said nothing. Even without giving me the look, I still felt it from these parents - the disapproval, the judgement, the condescension.

Well, there are a couple of possible scenarios here, none of which actually makes me feel bad about my own parenting. One, the child is a few months younger than Em, at which point she (too) was willing to sit still at lunch for more than ten minutes because she had not yet gotten really interested in things. If this is the case, hopefully these parents will have an out of control but interactive child on their hands shortly. Good luck to them. Alternately, the child is a few months older than Em, able to understand enough to sit still, and shy and silent around strangers. Fine. Well done. Or, he's the same age as Em. Kids have different temperments, different energy levels. Maybe this couple is just lucky enough to have a kid who will never pitch himself out of his high chair. If so, yippee for them.

But in none of these scenarios is Emmaline (or am I, for that matter) doing anything wrong. She's happy. She's learning. She's safe. When this stops working for us, I'll let you know. In the meantime, let me brag about the more than one hundred and fifty words she says. Yes, I counted. I didn't believe it could be that many, so I made a list. And if you don't understand what she's saying, I suggest you take the time to listen and maybe even talk back once in a while. It does wonders for the vocabulary, even if it sometimes makes them leave their seats.

I have to go now. My brilliant nineteen month old just said mango open please so it must be snack time.

An Ounce of Prevention

I spent all winter doggedly NOT ordering flu tests. According to the algorithm provided by Children's, low risk individuals (whether they have the flu or not), are not eligible for treatment. So where's the use in testing? Why should I spend the healthcare system's money if my recommendations for 'supportive care measures' - ie. tylenol and motrin - is going to be just the same as for any other virus?


This is easy enough to do at Children's, where everyone else is doing exactly the same thing. But at the community hospital where I also work, I occasionally pick up the child in a mother/father and child combo. The parent is also there to be seen for flu-like symptoms and the doctor who sees mom or dad orders a flu swab and it is positive. Sometimes that doctor even initiates treatment with Tamiflu for the parent and I am left looking like...what exactly? Like I don't care? Like I don't believe the child is worth the cost of the flu test or a prescription for Tamiflu?


No. Because more medicine is not always better medicine. Sometimes the right thing to do is nothing at all. Would you want to take a medicine you have more chance of having a bad reaction to than finding relief from? Probably not. Having a flu swab shoved up your nose, or your toddler's nose, is exceedingly unpleasant. Why put him or her through that if it doesn't actually help? Especially if you chose not to vaccinate (which would actually have helped) because, as one mom of a six-year-old put it, "she doesn't like needles". No kidding. Who does?


Friday's Washington Post had an opinion piece written by one of my favorite teachers from my residency years, Dr. Sean Palfrey. Read it here. I'll hazard a guess based on what Sean wrote about preventive care and limiting unnecessary testing in order to improve our healthcare system as a whole that he would be more in favor of flu shots than flu swabs, that he would rather see his patients protected against illness than diagnosed with it. When you put it that simply, who would argue?


That sounds like a rhetorical question, but it's not. I actually want to know. Who would argue? Who are you faceless commentators who use the anonymity of the internet to unleash the most vitriolic and caustic statements, no part of which are grounded in fact? I am not referring to those who engage in the discussion to further it, who find fault with the assumptions or wording in a given piece in order to encourage the readers to consider points the author may not have considered or had space for. 


The thing about writing a piece that goes to publication is that you cannot take it back. For better or worse, it is out there. All the nuance and the flip flopping that normal, intelligent people do in the process of grappling with truly tough issues, is reduced to a seven-hundred word essay. You do the best with the space you have. You welcome the dissenters because the point of writing (contrary to the Fox News ethos) is not to ram your bombastic opinions down the throats of others but to offer them up for consideration and debate. We are all the richer for such intercourse.


When cunn9305 remarked on Sean's article, it was not entirely laudatory: "Hey dude ... speak for yourself ... I am a surgeon..." I would venture to say that the "hey dude" already clued us in that he was a surgeon (and yes, I'll take a wild guess and say cunn9305 is a he), but aside from being redundant he raises the very valid point that the consumer/patient in medicine expects perfection and so not ordering available diagnostic testing puts the clinician in a vulnerable position in terms of possible malpractice. Granted. If the issue of to test/not to test were simple, then I doubt the Post would have bothered to publish the piece.


But then you come to the rantings of rscott1293. At the risk of giving more credence to a nut job than he or she deserves, I'll go ahead and cut and paste as is:


"God help the students you are teaching on a daily basis. Your concept of reasonable care and reasonable outcome simply is rationing of care. Preventative and thoughful medicine to an idealogue such as yourself means looking and listening without placing a stethescope on a kid, without doing bloodwork, no x-rays, scans , etc...... You are the physician that hospitals and other professionals speak of when commenting on the downfall of medicine in America. You are putting medicine in the bucket of minimalism. You are a bean counting bureaucrat, a pimple on the face of healthcare in America, a useful idiot of the leftist, socialist, one-size-fit"s all scum that resides on the shady side of medicine today. In all likelyhood you finished close to dead last in your class and totally failed at providing good bedside care and barely passed your clinicals. You should be relegated to providing 8 to 5 care in a primary care clinic a a mall hidden deep in America."


Now I've been encouraged in the past to accept that by putting yourself in the public eye, in however limited a manner, one must expect some degree of irrational dissent. Perhaps it is best, as my husband has suggested, to not even read the comments on any internet article as it only leads to a loss of faith in humanity.


Perhaps.


But aren't there also times when you just want to be able to ask, why? Why should someone choose to be so hurtful, choose not to engage in the issues but instead to fling metaphorical feces at an individual who just happens to be one of the finest doctors I know? Even were Dr. Palfrey not the epitome of a compassionate primary care pediatrician, even if he were just an average or adequate sort of doctor, that still does not excuse such a hateful collection of words, words that serve only to tear down and not to move forward the discussion of what to do with a healthcare system that is so obviously broken.


Starting tomorrow I'll try to take my husband's advice and skip the comments section. For today, however, let me take just a moment to say:  


Shame on you, rscott1293. From now on you should read your comments aloud on a street corner before you post them. Then, when strangers actually feel compelled to stop what they are doing to wash your mouth out with soap, take that as a sign that you have stepped unforgivably over the line.

Peter Rabbit

Two weekends from now, our very dear friend Natalie will take time from saving the world with the International Committee for the Red Cross in Congo to tie the knot here in the States. Since it is Natalie who brought Daryl and I together one fateful afternoon at the Crooked (Tea) House in Windsor, there was no question that we would attend. So it is a given that Emmaline will need something fabulous to wear.

Generally speaking, Daryl and I feel that if we take Em out in public and people do not make audible cooing noises as she walks by then we are doing something wrong. Therefore, even her shopping outfit needed to be fabulous if it was going to inspire people to stop and stare.

Fully kitted out, we proceeded on our way. Women and teenage girls especially were helpless to resist her charms and as Em strolled purposely through Macy's they giggled, pointed, and repeatedly assured me that she was the most beautiful child they had ever seen. But of course, I replied.

Then, to avert an impending tantrum, we rode the escalator up and down more than a dozen times, which was understandably very exhausting. Even though the stairs do all the work of going up and down there is still twirling and posing for the people moving in the opposing direction, all of which is incredibly demanding.

Luckily, we were able to find some lovely wedding togs on our great expedition. Then, as we were finishing, we came upon a magical creature. He was as tall as a person, but looked very much like a bunny rabbit, and there were children of all ages waiting in line to sit on his lap and then melting down and refusing to look at the camera when it was their turn. The sound of crying filled the air around us and Emmaline, overcome with the excitement, said very clearly, "Bunny...lap...sit!"

There was no way to say no. There were no smiles, of course, since sitting on an enormous rabbit's lap is serious stuff indeed. But at least there were no tears...at least until our turn ended it came time to say goodbye.

Harriet Lane, Again

Tired of flipping through charts with Em on glomerular filtration rates and daily sodium requirements, I hid the Harriet Lane Handbook, a reference manual for pediatric residents, on the top shelf of the bookcase. Em, as you may remember, is quite taken with the tome and especially enjoys the section on children's rashes, which she turns to immediately upon opening and says, "Oh no!" She is so taken with it, in fact, that she was able to spot the book today despite my best efforts to keep it well out of sight.

"Mama," she said. Then, "Baby...boo boo...read," all while pointing clearly to it's hot pink cover peaking out from behind a stuffed rabbit.

I must say, as strange as it may be, the girl knows what she wants. Who am I to deny her this one small happiness in life?

"The writer, when s/he is also an artist, is someone who admits what others don't dare reveal."

Elia Kazan 

Off and On

Recently the mother of a fifteen month old asked if her daughter would start using more words soon. The girl was certainly on target and had several signs that she used regularly as well as a handful of words, but her vocabulary had yet to reach that point where it begins to explode, where you can no longer tell when or how you child learned a certain moniker or phrase.

I have to admit to being stumped as to how Emmaline, walking into a baby shower for our good friend Ellen, knew without a moment's hesitation that the large red monster was named Elmo. After much consternation I realized that Elmo, albeit a one-inch-high version of the enormous plush creature before her, featured prominently on Miss Em's diapers. It is still amazing to me that she would make the connection but it is the only explanation that makes sense.

For more on Emma's continuing love affair with the red furry beast, who I can only assume she is on the phone with, a video illustration:

And for those of you without toddlers, or those of you with toddlers who abide by the AAP guidelines for no screen time, this is what she's singing:

So yes, she is learning more words and yes, I find it enormously adorable. And yes, it seemed to happen all at once, so I was able to tell this mom of my patient that she was soon to be amazed by her offspring instead of simply enamored with her.

Back to Emmaline, last night, holding a pen cap in her hand. I find the pen the cap is missing and hold it out to her to practice sliding the cap into place. She has some trouble but she does it, over and over again.

"On, off," I say.

She looks at me, tilts her head to one side, then drops to the floor, jumps to her feet, and drops down again.

"Up, down," Emmaline proclaims.

Daryl, surprised but not wanting to miss the moment, interjects, "Yes, Em, those are opposites."

And Emmaline agrees, as if it is no big deal, and says "Oh-poh-sits," very, very clearly.

Daryl and I look at each other in stunned silence. And then I start to panic that we need to reinforce the lesson but are moving too slowly.

"There's a book, an opposite book," I say urgently looking toward the bookshelf, but the book is nowhere to be seen.

"I don't know where it is," Daryl protests.

Emmaline walks to the other side of the coffee table, picks up the book, and holds it out to me.

"Opposite," she says again, helpfully. Then, "Read!"

Freaking amazing if I do say so myself.

Fell on Head

Working in an ER, it is impossible to plan out your day beforehand, to organize your thoughts on the drive to the hospital and to divide your shift's work into discreet plans of attack. You take what comes your way. You try to move quickly. You remain flexible and you hope, when you disappear into a room for the better part of an hour to repair a laceration requiring countless stitches, that your colleagues pick up the slack.

But there are sometimes hints about how the hours will go. There will not, for example, be many patients during the American Idol finale. Then, twenty minutes after it has ended, there will be a dozen or so children with sniffles tramping through the waiting room doors. It will be quiet during the Super Bowl, the Oscars, and countless other television events, only to explode with activity in the moments afterward. And when it is rainy and disgusting those ERs in the city, where people generally walk or take public transportation, oftentimes feel a lull until the downpour has ended.

This sort of variation in activity has prompted me to repeatedly ask, what will the day bring? What can I guess from the date or the weather about what children will be doing? On Halloween I spend the evening sewing up chins. While parents fretted about the dangers of their children talking to strangers or wandering into the street and being struck by a passing car, the far and away winner for the night in terms of most frequent diagnosis was "cut on chin". Children, it seems, cannot be snatched by predators or run into traffic if they are too busy tripping on their costumes and falling flat on their faces.

Similarly, last night had a majority winner, with the triage sheets and tracking board repeatedly reporting "fell on head" next to the name of the child. I spent the evening discussing the risks of intracranial bleeding in the setting of a fall from the monkey bars. I spent more than a few minutes picking mulch out of hair. I was asked on more than one occasion by parents to tell their child not to swing upside down, which I declined to do since being upside down in by and large a wonderful thing and who was a to stifle a future member of Cirque du Soleil? I was happy, however, to caution my young clients to try to remember to hold on.

Emerald Island Resort

As spring comes into full bloom, doubtless there will be more broken arms and scraped knees to keep me occupied. Likely there will be nights featuring clusters of "got sand in eye" and "burned tongue on marshmallow". Hopefully the injuries will be mild. In the meantime, might I remind you all that bike helmets, sunscreen, and swim lessons are all a fantastic idea. 

Thank goodness for spring.

Luxury Goods

When I was in medical school, the first weekend of orientation the Dean would have a cook out at his lovely home on his beautifully manicured lawn. Sitting there in the shade by the crystal pool waters was like a promise. Work hard, the trees whispered, and all this can be yours.

Now I didn't choose medicine with any idea of what sort of paycheck might someday be mine. My parents, both dedicated and underpaid, had struggled but in their sacrifice had still found a way to send me to Space Camp, to send my brother and I off to college, to keep the heat on and the roof (usually) from leaking. Doctors made more, I guessed, but I knew this only abstractly. After all, how much more could anyone need?

At a panel on work life balance in my second year of med school, one of the speakers said, "If you have to drive  to the hospital at 3am, you might as well have heated seats in your car." Granted, I don't really remember the context of the discussion at that point, but presumably what she was trying to say is that in a job where your time is not ever your own, when you might reasonably be expected to leave your family and your bed on a moments' notice, then a little bit of luxury helps things balance out in the end.

My car has heated seats, or it had them, back in the nineties when it came off the assembly line and was bought by a wholesome couple with 2.4 kids and a golden retriever. It also had little wipers for both the front lights, whereas now there is only one. And it had windshield wiper nozzles that would direct the flow of fluid onto the dirty glass. Now that one of these is missing, the wiper fluid on the right side of the car bubbles up ineffectually and runs off down the hood.

When I was young, my mother's car had one such nozzle that had become cockeyed and would spray sideways onto whatever vehicle was beside it. She would wait at a light and if the car that sidled up next to hers was playing their music too loudly or even if it was not, she might wait until the light was about to turn and then press the lever to let the spray go wild. If it was summer and windows were open, this was particularly amusing, but also a challenge since you had to pretend to not be looking, not to realize, and had to wait for the light to be green and the cars to move forward until you could laugh out loud.

So there is some amusement to be gained from things that are falling apart around you. Our downstairs bathroom, for instance, has its sink handles on backwards - lefty tighty, righty Lucy. The same bathroom has a hole through which you can see down to the basement. Our stove has one burner that doesn't work (or so I'm told...I'm also told we have a stove, but I don't know for sure, you'd have to ask my husband). The heat in the unused guest bedroom is always cranked up because the valve on the radiator leaks if you turn it down. The list goes on and on.

We'll have to chip away at it slowly. Though I do make more than my parents did, it's not by much and they were gainfully employed years younger than I managed to be. So, no, I do not need heated seats or anything quite so grand. But I am thinking of upgrading at some point to ones that aren't held together by duct tape. Or maybe I'll wait and try to fix that bathroom hole.

Toxic

As work on the yard continues outside the window, chains banging in each unsuccessful attempt to pull the old and stubborn yew stumps out of the front beds, I'm taking a moment to hide and catch up on emails. The following alert was waiting in my inbox, issuing a warning about the use of benzocaine topical gel (or Orajel) for teething given the small but dangerous possibility of the infant developing methemoglobinemia.

What's methemoglobinemia, you say? I'm glad you asked.

Methemoglobinemia is a disorder in which oxygen is not effectively delivered to the body's tissues. Read more about this here. The salient point is that it turns you blue - Titanic, frozen in the ocean blue. And makes your muscles feel like they are on fire.

Or, simply watch the music video inspired by one of my favorite patients, who totally is never going to get Orajel again.

Curb Appeal

The landscapers made the first pass of the front yard today. We have never had a landscaper before. We have never had a house before. But we live in a neighborhood where apparently landscapers not only tend the yards but also put up Christmas lights and mount wire frame reindeer on the tops of each perfect house. There should be a handbook on how to blend in out here in the suburbs. We were completely taken by surprise and have been playing catch up ever since.

The main problem is that our house is not perfect. Nor is the yard. Last summer when we moved in we thought, foolishly, that we would sweat and get callouses on our hands but we would take care of the yard ourselves. It would feel good, to accomplish something so concrete, to smell the earth as we crumbled it through our fingers. And we did sweat. I do have more than a few callouses. Yet the yard remained a mess, overgrown with poison ivy and bracken, littered with pine cones and piles of ground stumps from August's Project Dead Tree Removal otherwise known as Project Don't Have Trees Fall on the Neighbors otherwise known as Watch the Crane Lift the Trees Over the Freaking House.

We did what we could. It was never going to be enough. A decade spent as a rental property ensured that we were very, very far behind. I planted some bulbs, reasoning that I might not notice the chaos if there were some splashes of color to distract the eyes. They are not yet in their full glory, granted, but I strongly suspect it is not going to work.

A friend suggested that we forget the big picture and concentrate on reclaiming one tiny corner of the yard each year, making it into what we want. Unfortunately we don't have that kind of time. There are two houses newly for sale down the street. You can't get to them without driving right by our property, slowing down in front of the twenty yard span of chain link fence that mysteriously begins and ends without clear purpose. You are forced to fully take in the overgrowth and spindly ailing shrubbery cascading down the ledge and threatening the street. Maybe you don't even make the turn. Maybe you skip the open house entirely and move on to the next one.

That's not fair. We may not be the best neighbors, but we should at least try not to suck. Thus the newly launched Project Clean Sweep otherwise known as Project I Hope I Can Stop Lying About Where I Live When I Go Out to Walk the Dog.

What will be left when they are finished? Hopefully something beautiful here and there, even now valiantly simmering just under the surface. I honestly don't care, as long as it's green and warm and not buried beneath snow.

All Publicity Is...What?

When I had finished my first reading and signing for Between Expectations, I was approached by a woman who had just bought the book. She wanted to tell me how excited she was to read it. Then she said something I found rather bizarre. She said, "You are so brave."

I have to confess I thought she must be somewhat addled, or at the very least misinformed. I am not brave. And I did not understand, at the time of our discussion, that I would need to be. I had not done anything particularly heroic, nor had I done anything particularly controversial.

Or so I thought.

In the introduction to the book I write about how I came to be granted time off from residency to write. Sixteen weeks off to be exact. Over the course of three years. Time for which I was not paid. Time that did not interfere with any of my fellow residents' call schedules. Time that I made up after all my friends had gone on to bigger and better things (there are rules after all). But time that was mine entirely. I did what I could with it. I wrote a book. I tried to tell the stories of some of the patients I had known in a way I thought would help others understand how hard it is for families to go through the significant illness of a child.

What is so horrible about that?

But apparently it is horrible. It is horrible on many counts. You see the thing that was compelling, the thing that interviewers honed in on and that everyone all of a sudden wanted to discuss, was that in that introduction I admitted that I sometimes struggled. In an effort to give context to the narrative that would come after, to offer insight at the same time as reassurance to those embarking on medicine as a profession, I confessed that I found the long hours and the stress of residency difficult.

Is there anyone out there who doesn't? Not only in medicine but other professions as well.

What I actually wrote about in the introduction is that good data exists that says this is not the safest way to practice medicine or train new doctors. The reason I "complained" was to be able to highlight some of the problems that exist with how residency training is practiced. The continued changes to residency scheduling are evidence that these problems are real and pressing. The discussion should and will continue, within the ACGME and within individual programs.

But that is not where the discussion has gone. Instead there is palaver about my personal faults. These do exist, I assure you, but they are mundane and trite and not overly remarkable. Why is it that to say that medicine is difficult, to say that there are days when you wonder if it would not be easier to have chosen something else, why does that mean you are unfit as a human being to be a doctor?

Of course I know the anonymity of the internet invites the cruelest parts of ourselves to surface and I'm finding that I accept this. I can take it. But what worries me is that for every thoughtless, hurtful comment made about me and sometimes about doctors in general, there is a bright and gifted college student out there who is considering applying to medical school and ultimately decides not to. I have gotten emails from more than a few, asking for words of wisdom, begging to be told that in the end it all is worth it.

The young, idealistic eighteen year old does not and should not want to embark on a career in which it seems acceptable to accuse a colleague of being weak or stupid or lazy simply because she dared to introduce the question: How do we strive to find balance in our lives in a field that demands continued learning and constant improvement? These are not questions for medicine alone to answer. They are ones we should each struggle with throughout our lives, lest we lose the parts of ourselves that we hold most dear.

Financially speaking, medicine as a career is not worth it. You can find the numbers here. Emotionally speaking, well I hope it is. I hope that in the end the wonderful moments I experience with patients and their families outweigh the tedium of the paperwork and the dictations. I hope that my jobs fits itself around my family, not the other way around, because as much as medicine is a calling, being a mother is the most important job I can imagine. And I hope, as I continue to call for help when I need it, unapologetically, my work colleagues know how much I appreciate their input, as I know that they do mine.

The other negative responses to some press, borne out of frustration with a medical system that cannot always cure what ails you, I have no quick fix for. But might I suggest, if you need something that your doctor is not providing, a better explanation of a decision or even just emotional support, tell them. To their faces. You might be surprised at how eager they are to please. After all, helping people is what this business is all about.

Closer to Home

Not long ago I met a family in the ER who arrived by ambulance. Their daughter was clearly very ill. She was febrile and screaming. Ultimately, I would find that with some tylenol she would begin to look better and with a few other simple interventions she would look almost entirely well.

I didn't get that far. As I was leaning forward to listen with my stethoscope her parents demanded to be transferred to the Children's Hospital in town.

This is, I have found on more than one occasion, an interesting dilemma. When I ask my adult colleagues what they do in situations such as this they shrug. The consensus answer seems to be: "If a patient wants to go somewhere else, he wants to go somewhere else. Who am I to argue?"

Medicine is, it seems, not immune from the cliched motto the customer is always right. But in pediatrics who is the customer? Is it the child or is it the parents?

Obviously the parents are likely to be somewhat more verbal than a toddler or even, for that matter, a sullen fourteen-year-old. So it is tempting to assume that pacifying a mother or father, making them feel safe and well cared for, is just as important as doing the same for their offspring. But that is not always the case.

The child above, who would within a few short hours, be stable and ready for transfer up to the floor where she could eat popcicles and watch Dora the Explorer to her little heart's content did not need to be transferred downtown. She did not need to placed in another ambulance and made to wait in another ER to be seen by a doctor who would do the exact things we were doing for her already at the community hospital ten minutes from her house.

There has been a rash of news coverage of late questioning the ability of smaller hospitals to appropriately care for very sick children, perhaps in part spurred on by this case. Certainly moving children from one place to another, quickly and without delay, is one important part of my job. But mightn't it also be that not moving them, when they are already getting the care they need, is another important part? If every boy or girl with asthma or dehydration is transferred to a major Children's Hospital then there will be no beds left for those children who need renal biopsies and bronchoscopies and all of the other procedures that smaller hospitals don't have the appropriate staff to perform.

Because I now spend a good portion of my clinical hours forty minutes outside of the city, I have been forced (or maybe I've been privileged) to ask and try to answer the following question: What are those things that smaller community hospitals do better than their larger counterparts downtown. A few years ago, when I was enmeshed in my training and used to having cardiologists and endocrinologists and pulmonologists available to chat by phone even in the middle of the night, I would not have been able to answer this. I would not have seen the point. Why not have the best, the very best, for your child if ever they are in need?

Then I transferred a few families downtown for various reasons, children who needed a particular test from radiology or consult from a specialist that I could not get for them in the hospital where we were. And parents grumbled. I confess I was surprised. I assumed they would jump at the opportunity. But there I was, pulling out the stops and whistles, and I met resistance instead.

They wanted to stay put. Families had other children at home and needed to be able to pop out to drive a sister to soccer practice or pick another one up from ballet. They were used to having a private room, whereas downtown they would more than likely have to share. Moms loved being able to run home during the day to shower and grab fresh clothes, knowing the entire trip would take no more than forty minutes at most. Dads loved being able to come by the hospital after work. (Yes, moms tend to stay during the day and dads tend to go to work. I challenge dad out there to go ahead and prove me wrong.) It was easier for these families being close to home. It was less overwhelming. They felt safer and more in control.

So overall I have gotten in the habit of not being quick to transfer. Yes, I have called a helicopter for a child before even walking into her room, but only because the safest thing for her was to go. I knew this because the nurses told me so and nurses are always right. I learned that even before I learned the right dosing for ibuprofen.

But are parents always right? Usually, but not universally. They can't be because parents are often scared. How could they not be, seeing their child screaming and in pain? So the child, in that moment and until he or she is feeling better, has to be my patient first. I want parents to be happy. I want to treat the family as well as just the child. But first I have to treat the child. Then we can talk about whose gourmet italian ice she will get to enjoy from her hospital bed - ours or our mother ship downtown.

Head Shot

As Emmaline grows older, we are finding it increasingly difficult to take quality pictures of her. In part because she is having more and more frequent tantrums demanding to be allowed to go outside and, once outside, to run wantonly toward traffic. Also because she has an uncanny knack for turning away from the camera just at the moment a picture is shot.

We keep trying nonetheless.

We keep at it and we never loose hope.

See? You can almost see her face.

The truth is I could use a little hope right now. You see, when I woke up Friday morning the ground was covered with this strange white substance that unfortunately we ultimately identified as snow. It was April Fool's Day, so the freak The Day After Tomorrow 3-4 inches of accumulation was admittedly apt. Still, I was somewhat bereft by the precipitation. I was dismayed. I was - how to put this - very ANGRY with the universe.

So we dreamt of better things - sunshine, sand, the ability to survive without wearing a hat and scarf indoors. Daryl began perusing the world wide interwebs for tropical destinations, at which point we realized that Emmaline can't leave the country. She doesn't have a passport.

I thought about getting angry with the universe all over again, but I got distracted by the dog who seemed to be trying to eat the baby.

Plans foiled, though, what had been an idle curiosity somehow took on an entirely different air. We became convinced that were it not for the matter of the passport we would absolutely have picked a location, committed, and taken off for a carefree long weekend later this month. In reality that is the exact opposite of how we operate. We have made an art of procrastination such that, in the end, nothing ever manages to get done. Of all of us, Emmaline is by far the most industrious.

Then, while out shopping today, Daryl insisted we detour to Walgreen. Why?

"I thought you would be a nicer person if you got some Cadbury Creme Eggs."

The jury is still out on that one, but I agreed I was more than willing to try. Then we realized that Walgreens offers passport photos. Why not? So we waited the ten minutes it took the teenager working at the counter to find the digital camera. Then we sat Emmaline on the stool in front of the white backdrop. But her head (I was going to say little head, but that's just entirely inaccurate - she has an enormous noggin) was in front of the back of the stool. That's a no no in passport photo rules.

The next step was to stand her on the wobbly stool and try to simultaneously hold her legs securely enough to avoid an ER visit and head CT while at the same time keeping out of the picture. That was the first hurdle. But then there's the matter of Emmaline's willful determination to look anywhere but at the camera. Finally, though, they caught her and proved once and for all that she does indeed have her father's skull.

Are we going anywhere any time soon? Probably not. Feel free to take bets on whether we even fill out the passport application. But, well, there's nothing that says we can't.

On Tap

For the first ninety days of Emmaline’s life I was coated in Purrel. For those of you who have seen my house, you know that I am a person who believes that a little dirt is good for you (at least that is what I tell myself to excuse the disarray). But for newborns, in the first three months of life, fevers bring with them a certain set of tests that I was determined to avoid.

A six week old is brought into the ER looking entirely well. She is smiling. She is nursing enthusiastically. When I first see her, she is bundled in his car seat looking fairly adorable. She cries only when taken out and stripped down to her onesie and even then consoles easily in her mother’s arms. But she has a fever of 100.4, the magic number, and so there are certain things we have to do.

The approach to febrile infants varies slightly from institution to institution, but generally speaking babies with fevers need to have testing of their blood, their urine, and their CSF. The first is done under certain circumstances up until six months of age, when the routine six month shots provide protection against pneumococcus, a particularly nasty bug. The urine is tested for good old fashioned UTIs and the cerebrospinal fluid testing is done to rule out meningitis.

 It all sounds fairly straightforward. It involves needles and catheters and holding down a screaming infant, but really this is all just part of a normal ER shift.

Until it doesn’t work.

The IV blows or the lumbar puncture (LP) is bloody. The urine can’t be obtained. Catheterizing a baby girl may be routine, but it is also sometimes impossible. Babies, especially the healthy ones, are incredibly strong and will fight when you are trying to stick things where they would rather you didn’t. The kids I really worry about are the ones who don’t. So she screams. She pulls her chubby thighs together. There is no way to get in. Sometimes it happens.

In the olden days, doctors would tap the bladder to get the urine, by which I mean stick a needle in the baby’s abdomen. Generally this procedure has fallen out of favor, what with involving a needle in the baby’s belly and all.

As an intern I was covering a patient who had a urine culture that indicated a likely infection. I called radiology to order the testing of the kidneys that was the standard follow up of a febrile UTI in that age group. The radiologist called back to demand I obtain a catheterized urine specimen since the sample catalogued in the computer was reportedly done by clean catch. The nurses had trouble with the catheterization, I explained. Then, when they cleaned the infant’s diaper area with betadyne before trying again, the girl had peed in a perfect arc into the collection tube. It was as clean a sample as we were going to get.

“Did you tap the bladder?” he demanded.

I told him that we did not. I had not been taught to, had never seen such a procedure performed, and didn’t think I deserved to be getting yelled at for things so out of the scope of my control, but such is life. He begrudgingly agreed to perform the testing and I went on about my day.

Should we tap the bladder if there is no other way to get the urine? Perhaps. Imagine an infant at that in between age, when doing the lumbar puncture is not absolutely indicated. If a source, such as the urine, is found to explain the fever, there are times when this other test can be avoided. So I asked a mother of one of my patients, would you rather have a needle in your baby’s abdomen or in the back? Which do you find more horrific? Which would you do anything to avoid?

“Stick the needle in her belly,” she told me.

Now this is certainly not a large enough sample size to make any real inferences. But it was not what I expected her to say. Maybe this is because I feel more comfortable with the prospect of performing an LP than a bladder tap, having been trained to do one but not the other. Still, I found it interesting. Bladder taps have not necessarily been cast aside because parents do not like them. The procedure brings with it certain risks. But I feel uncomfortable with the notion of them at least in part because I assume parents would object. It seems instead I should give parents more credit for appreciating that there are times you simply have to do what you have to do, whether it freaks you out or not.