30 July 2011

No Guinea for Ghana

Congratulations to Ghana and the CDC, WHO, UNICEF, and Carter Center on the success of their efforts to eradicate Guinea Worm!!

What's Guinea Worm, you ask? Here's the CDC's diagram of the worm's life cycle:

Informative, but hardly explanatory of just how painful infections are, how completely they can destroy a community's ability to function since walking is often impossible when the worms are crawling out of your foot and most people in the developing world don't exactly have desk jobs. There's a certain grossness factor as well, one we Americans generally get to avoid thinking about.

But let's take a deep breath and try. Clean water, check. Freezer stocked with Breyers ice cream, check. A single moment of appreciation for how good we have it, bad economy or not? Yes.

I think that's the least we can do. And if you'd like to do more, Guinea Worm is still endemic in Southern Sudan. Read more here and consider fishing your spare change out of the sofa and sending it their way. A world without wormy feet would make a world of difference.

29 July 2011

The Pox

When I was an intern, a family from Ireland who had given birth prematurely and were readying themselves to go home with their now fat and happy new baby, asked why we give the Hepatitis B shot at birth. It's a good question, since if a mother is not infected with the virus there is no harm in waiting to vaccinate the infant during the routine 2 month shots. But some women will catch Hepatitis B during pregnancy and after their screening labs were done. For these infants, the chance of chronic liver disease from the infection is 90%, which brings with it the danger of liver cancer and death, a horrible future for an infant who could have been entirely healthy. So the default in the U.S is to immunize.

In Ireland, they wait until 2 months of age for the first Hepatitis B vaccine, but at birth infants receive immunization against tuberculosis in the form of the BCG vaccine. This vaccine isn't used at all in the U.S., since the rates of tuberculosis are currently so low that the monetary costs of universal vaccination are not thought to be worth while.

There are several other differences as well. Infants in Ireland are routinely immunized (or immunised) against bacterial meningitis during infancy, a measure currently being debated here in the U.S. Hopefully we will follow suit since, having seen pus drain directly from a spinal needle placed in an infant's back, I can tell you that bacterial meningitis is absolutely not something you want your brand new babe to get.

But what about chickenpox? We vaccinate here against varicella but they don't necessarily do so in Ireland. Years ago my husband found himself embroiled in an online debate on the benefits of vaccines. Routine vaccination against chickenpox was only just beginning and there was, of course, objection to the addition of one more jab to the early childhood immunization schedule. Those opposed to vaccination protested that only about a hundred people die from chickenpox every year of the 4 million who contract the disease in the U.S.

My husband was agast. Surely, he protested, if two school buses filled with children were driven off the edge of a ravine and one hundred young and healthy kids losts their lives needlessly, you would think this was a tragedy. How is it different if they instead die horribly painful deaths in the hospital after their organs shut down from infection? And isn't it, in fact, worse to have a tool that could have saved them and decide not to use it?

But we are using it. Children are getting the vaccine and, as a result, the number of chickenpox cases ws down to 400,000 in 2005. More importantly, deaths in children and adolescents from chickenpox are down 97% here in the U.S. Canada and Australia have begun to adopt the vaccine. Perhaps soon Ireland will follow.

In the meantime, for those parents trying to avoid vaccination and considering the "chickenpox party" as a way to get your kids exposed early, good luck. I'll keep my fingers crossed that none of the kids at your party end up driving into the ravine.

28 July 2011

Annie Get Your Gun

When the ER is quiet I don't feel guilty for not being more productive. I get to be relieved that children are not sick and are not getting hurt. If it is busy, if a particularly noxious virus seems to be making its way through the ranks of the young, I still try to take the time to encourage good hand washing. Breaking the cycle of infection is essential to keeping others in the household and a child's group of friends healthy and well.

So what if my patient has instead come to be seen for a head injury after a car accident in which he was not wearing a seat belt, a broken arm after a fall from a trampoline, a bad laceration after being allowed to play unsupervised with a knife? It would be remiss of me to not address appropriate safety measures, but it is also (by this time) almost beside the point. The accident has happened and the pain that it caused is a better warning than any I could ever give to be careful next time around.

Other pediatricians, those who work in offices and see patients before they have accidents, have a better chance of preventing such injuries before they occur. Keep in mind that the most likely thing to kill a child over the age of 1 is an accident. Is a pediatrician really doing his or her job by doling out shots and prescriptions for antibiotics but ignoring this fact?


So regular well child visits at the pediatrician's office routinely involve discussion of age appropriate dangers. Mothers and fathers of infants are encouraged to be vigilant about not leaving children unattended on beds or changing tables, since falls in this age group can result in a skull fracture. When children get older, discussion turns to child proofing electrical outlets, use of bike helmets, rules about crossing the street. In 49 of 50 states discussions also include inquiries about whether anyone in the household owns a gun.

If a family answers in the affirmative then the pediatrician takes the time to cover the importance of gun locks, storing firearms and ammunition in separate places, and keeping guns locked up and in a place where children can not get them.

But in Florida, asking about exposure to guns is illegal. Under the auspices of protecting the privacy of households, pediatricians could now face jail time for this line of questioning. Theoretically the discussion of gun safety could still go forward in the hypothetical, but it's not likely to.

Pediatricians are already under extreme time pressures to discuss all of the necessary facets of development, injury and disease prevention, school readiness, and countless other topics of a typical well child visit within the time allotted by insurance companies. In Florida, not being able to ask which children are at risk of gun death will mean that counseling on safety is simply not done.

Had the parents of Seth Lasater not kept a loaded rifle in their home, the eleven year old would still be alive. Instead he died earlier this month. Would a frank discussion with his pediatrician have saved his life? Maybe, maybe not. We'll never know. But we'll unfortunately find out how many more children become statistics as the effects of this idiotic law play out over time.

27 July 2011

Deep Impact

Since I've taken care of more than one child who has been creamed by a car recently, let me take this opportunity to remind all of you drivers out there that the brake is the one on the left.

Yes, children do stupid things. Ideally they would do those stupid things in places cars were not. But as the mother of a twenty-two month old who thinks parking lots are the ideal place to stage tantrums, I can sympathize that there are times when (despite everything we do to protect them) our children may do things that are out of our control. When that happens, we can only hope that we are not the only ones looking out for them.

A Little Child Will Lead Them

Earlier this week the cat attacked Emmaline. At the risk of sprouting warts on my chin and talons in place of my not-so-manicured nails, I'm glad she got hurt. The two shallow scrapes on her arm were a lesson that was long overdue.

Let me qualify this by saying that Crake did not object when she chased him in circles around her bedroom. He did not hiss or spit when she tried to pick him up like a stuffed animal. He did not raise his hackles at her attempts to use him in place of a pillow. But when he was done with all this and had retreated for quiet under her crib, she crawled in after him and he thwamped her a good one.

I saw it happen and she totally deserved it.

The truth is we have been lucky with the patience of our feline family members. Even Scout, despite her inability to refrain from chewing every baby toy in sight, has been willing to put up with quite a lot.

The result, unfortunately, is that Emmaline has failed to learn what all children must.

"Crake bite you!" she proclaimed with no small amount of surprise, brandishing her arm to prove she had been hurt.

"Crake scratched you," I agreed, hugging her for the approximately thirty seconds it took for her tears to stop. Then, "Why did he scratch you?"

Emmaline whimpered and took a deep breath, "No chasing cat!"

Then she brightened.

"Band-aid?" Em suggested.

The trauma, it seemed was over but the lesson itself was learned. The following night Scout made an ominous rumble when Emma threatened to interrupt the meal she was making of some rawhide. Emmaline immediately looked up questioningly.

"Scout bite you?"

"She could bite you," I warned. "Step back. She wants to be left alone."

Emmaline did. This alone was groundbreaking since she usually has quite a different approach.

26 July 2011

Rubber Necking

Yesterday I read this article at Salon.com about a girl who was mistakenly given one vaccine in place of another. It was hard to pass up. With the subtitle "it changed her life in an instant" it promised the sort of tragedy we all have trouble resisting. But while medical errors are serious matters and the steps hospitals and doctor's offices take to minimize them are important, the story that followed that headline was unfortunately more about a mother's overreaction and her daughter's subsequent terror than it was about the system of checks and balances in medicine that we use to keep our patients safe.

While the mistake was unfortunate, it is one most people would hopefully see as easily forgivable. No one was hurt. The girl received a vaccine she should have gotten anyway. No harm, no foul. The doctor apologized. The world should keep turning and no one should shed tears.

My reaction to the article was so filled with frustration that I almost missed the small kernel of excellent advice the author had buried beneath the sodden handkerchiefs and smelling salts. After coming to terms with the mistaken administration of the HPV vaccine (an immunization that protects against cervical cancer and should absolutely be given to every child in the country, sans drama), the author writes: "Meanwhile, she still needs to get that meningitis shot, and I'm going to make damn sure that's the shot she gets."

This is the most important sentence in the entire piece. The system of checks and balances we rely on to prevent medical errors does not only include doctors and nurses and pharmacists. It includes patients. It includes families. It includes parents. When the author speaks up in her daughter's doctor's office to double check the vaccines she is getting, she will not be doing someone else's job for them. She will be doing her own job.

Years ago, a friend had surgery on her knee. Having heard tales of surgeons operating on the left instead of the right and vice versa, she prepared by taking a marker and writing NO! in big letters on her good joint. This has now become standard practice. The surgeon marks the site intended for repair with purple marker while the patient is still awake. Memory is faulty. Sometimes even medical records can be incorrect. The surgeon performs this last review with the most important member of the checks and balances system, the patient. 

The era of paternalistic medicine has passed. But with it comes a new responsibility. Patients and their families have opportunities to be involved in health care decisions in ways that were previously not entertained. But to do this effectively, we must be informed about our health, the vaccines we receive, and the medications we are being given. We should promote safety in our medical system and, when mistakes are made, look at the underlying causes and address them. Anything else is just a distraction from the real issue at hand and a waste of Kleenex.

25 July 2011

An Aside

My husband once said that he did not support lying to children - specifically our own then theoretical children - about the existence of Santa Claus and his elves, preferring instead the colder, harsher reality of a world without magic but full of hard truth. And yet he just faked a phone call from the cat to convince Emmaline that her presence was needed upstairs for petting and, by extension, for bed. When that was somewhat less effective, he gave her money to "feed the pig". We are batting a thousand here.

My Liberal Agenda

Last week the Institute of Medicine made recommendations that eight preventive services be provided to women at no cost. Included on the list was birth control counseling and prescription. If these policies are adopted, it would mean no co-pays at the pharmacy for monthly refills of the pill. It would mean that women who previously had to forego such medications because of cost would now be free to join the 15.3 million Americans already utilizing hormonal birth control to prevent unintended pregnancies.

This should be welcome news, since three-quarters of Americans support government funded birth control. According to Fox News host Greg Gutfeld, however, the recommendations were akin to a left wing conspiracy aimed at "eradicating the poor." His reasoning, if that word can be applied here, is presumably that if poor women are those most likely to benefit from free birth control, fewer children will be born in poor households. This would subsequently result in a drop in the total number of poor people in the country and this (help me understand this here) is a bad thing?

So I find myself in a bizarre form of agreement with Greg Gutfelt. I am liberal. And I do want to eradicate the poor.

We have, in this country, more than enough to go around. Paris Hilton certainly has more than she needs. And while I certainly don't want to call for socialist reform that would take away her drive to bring us such valuable series as The Simple Life and The World According to Paris, both of which I am certain are lowering IQs wherever they are shown, I do think that an ultimate goal of having fewer people instead of more people living below the poverty line is both achievable and GOOD.

If women struggling to make ends meet use the pill to delay childbearing and finish school or to space their pregnancies to avoid having more than one baby in diapers at a time, they will be doing no different than the 15 million American women already lucky enough to be exercise this choice. If having a baby at 22 instead of 18 makes the difference in obtaining a high school diploma instead of dropping out, then she is likely to earn (on average) nearly $7,000 more annually than if she stopped school just short of graduation. If she manages to get through college, her salary would likely jump by 76%.

Money isn't everything, unless you don't have it. Greg Gutfeld is neither a woman, nor is he poor, and he does not know what he is talking about.

24 July 2011

Sacred Spaces

Driving home from the city a little bit after midnight last night, the moon was low in the sky and looked almost as if you could reach out and touch it. Had Emmaline been with me she would have asked to do just that, as the moon is a great favorite of hers. But her big city adventure had been taken with her father while I worked in the ER across town.

So I was alone as I drove and had the music turned up to help keep me awake. The only CD in the car was my old copy of the Indigo Girls Nomads Indians Saints, rescued from a box after the epic summer move of 2010. When I listened to it then, a decade had probably gone by since I last heard any of the songs, but I still knew each and every word.

It happens that way with things that you love when you are young. For me, the Indigo Girls are synonymous with a summer camp named Bement, a girl named Meg Williams with whom I am sadly no longer in touch, the smell of mildew emanating from old bunk bed mattresses, snickerdoodles, Bar, Alphabet Soup Night, and so many friends I am still lucky to have.

As a child my family did not move around much, but we did move around some. The house I came home to from the hospital was not the one I went to school from on my first day in Miss Foisy's kindergarten class. Ditto middle school and high school and college, different driveways, different yards. This is not to say I was uprooted. I always felt very safe and very at home. But home meant family and not necessarily the house we were living in. Home meant my stuffed lamb and bunny blanket (and yes, they came to college with me) and not the banister on the staircase you peeked through on Christmas mornings since the banister, over the years, had changed.

Camp was the only place I had that was a constant, the only physical location I continued to feel a connection to over such a wide span of years. One winter I had walked on the pond and found two dollar bills frozen to the surface. It was the first money that was my own. Other summers I fell in love or fell out of love or became a vegetarian to be more like the girl someone else seemed to love and I sailed and I swam and I sat for hours on boat duty and got splashed by campers in canoes and every once in a while I felt, for just one minute, almost like someone who was special just by being me.

When I needed a babysitter for Emmaline and I had no idea how I could let a stranger take care of my brand new baby girl, I posted an add on SitterCity and within an hour ended up hearing from a girl who had been my camper fifteen years before. And somehow it didn't seem extraordinary, it felt inevitable. Because camp is family and family is forever.

Except that camp is not forever. It stands empty and is on the market for anyone looking to build McMansions on the pond where I learned to swim, along the shores I lost my cat Kristopher in a woodpile and found him miraculously alive weeks later, on the spot where we gathered each morning to sing B-Bement Camp and so many others.

They will pave over the White Cross Trail and raze the trees along Mill Stream and the people who buy houses there will put their patio furniture on the Lakeside Sports Field and never know what a toot is or a clanger or a Dessert-O-Meter or how the sign from Bucksteep Manor came to be in the Rec Hall.

They will never know what a special place they are living in. But I hope they will be happy there. I was.

The places we love can be ruined in seconds. But that does not mean we stop loving them. Maybe it means that we love them even more.

23 July 2011

Hotter Than Helios

I was planning on a very timely, very well researched post on the dangers of heat exposure. Unfortunately, in light of the 109 degrees the thermometer was reading outside and the absence of air conditioning in my lovely old fixer upper, I went to the movies instead. It was my first movie in an acutal theater since August Rush came out a million years ago, so I was pretty excited for the cinematic experience itself in addition to the climate control.

As an aside, this Harry Potter is totally not appropriate for small children, but I enjoyed it.

So it's hot outside, and not just here as the weathermen and my friends on Facebook tell me. Heat related injuries in children range anywhere from heat rash or mild dehydration to the more severe heat stroke, which can be life threatening. Staying out of direct sunlight is certainly helpful, as is liberal application of sunscreen for those children who will find themselves exposed to the sun. Serious sunburns bring with them additional fluid losses through the skin, so if your child looks vaguely lobster-like please make sure they are drinking.

In fact, everyone should be drinking. They should be drinking lots, because often they won't feel much like eating. I would say this is not such a bad thing, since who wants to cook when it's this hot out? But if your child's appetite drops off a bit, be all the more vigilant about fluids.

What sort of fluids, you might ask? Why the messiest ones around are usually the best since, let's be honest, anyone who has not gone through puberty is probably running around naked right now and everyone else (myself included) is probably in a swimsuit and can be hosed down.

So embrace the sweets, at least until the weather cools. Then schedule an appointment with your dentist to apologize and brush and floss diligently to make up for your transgressions.

In the meantime, stay cool. In addition to the usual water activities, might I suggest the following as well:
  1. Stand in front of the open freezer door until someone yells at you to shut it
  2. Go to the nearest restaurant that offers free refills and stay there until they close
  3. Visit Costco (or equivalent) and hide several lawn chairs in the garden shed display then snack on their food samples all day long
  4. Make friends with someone who has air conditioning
  5. Acutally physically BE someone who has air conditioning, call me, and I will certainly be friends with you
And for my husband, one very specific suggestion: STOP TELLING ME ABOUT HOW COLD YOUR OFFICE IS OR I AM GOING TO HAVE TO HURT YOU!

22 July 2011

Less is Not Best

Yesterday I suggested that the medicalization of childbirth and the overwillingness of the medical profession to allow, or even promote, surgical deliveries might be a less than fabulous thing, not only in the States but worldwide. And then I happened to have a chance to listen to Radio Boston's account of the legislation now on Beacon Hill proposing state regulation of home births and nurse midwives.

Clearly these two stories cover opposite ends of the intervention spectrum and, as with all things, the right answer for most expectant moms probably lies somewhere in between - some medical supervision of their birth process but a hands off approach when things seem to be going well all on their own. But for those who want, sometimes desperately want, their birth to go a certain way, should it really be for the state to say what is allowed?

Yes. Sorry. And feel free to unleash your fury in my general direction.

The fact of the matter is that delivering a child is probably one of the most dangerous things women in the United States will ever do. Natural or not, the act of child bearing has been killing women for as long as women were women. Before that, childbirth probably killed females from the species Homo erectus, but you'd have to ask an anthropologist about that and despite the letters after my name I don't really fit that bill.

We live under the misguided impression in this country that pregnancies result in healthy, happy babies. We are lucky enough that this is for the most part true. But it is not luck and it certainly is not evolution that has brought us to this place. Just the opposite. Our enormous heads don't really help the situation much. So why are fewer women dying in childbirth than they did before? Medicine.

Has medicine overstepped the bounds on many different occasions? Yes. From the soaring rates of infection on maternity wards due to puerperal or Childbed fever in the absence of hand washing before Semmelweis instituted good hygeine practices in 1847 to the overabundance today of Cesarean births in the U.S. and abroad, there have been and continue to be missteps along the way.

But before you consider foregoing all that medicine has to offer, consider this. Group B Strep (GBS) is a bacteria that many women carry. Before the initiation of antibiotic prophylaxis for carriers, 7500 infants in the U.S. contracted GBS from exposure every year. Once an infant is sick, it has about a 50/50 chance of dying. Not in Africa. Not if you fail to bring your new son or daughter to the hospital. Even with treatment, these babies die, they hemorrhage into their brains and ooze blood from around their IVs. So fine. Hire a doula. Have a midwife attend your delivery, but get tested for GBS and if you're positive (as I was) get your freaking antibiotics.

And while we're on the subject, just a word about vitamin K. Yes, it gets injected into your baby's thigh and no, maybe that's not the kindest welcome into this world, but seriously, you think getting pushed out of a vagina didn't already ruin your baby's day? Without vitamin K supplementation, the incidence of stroke (again with the BLEEDING INTO THE BRAIN) is not 1 in a million. It's not 1 in 100,000. It is, in Vietnam anyway, 116 per 100,000 live births. Why are these numbers difficult to calculate in the U.S.? Because babies get vitamin K! So for these 116 infants (and keep in mind that more than 300,000 infants are born daily so that's 348 babies having strokes EVERY DAY), some die and about half suffer serious neurologic impairment.

If your baby didn't get vitamin K because you refused the injection and then he had a stroke and needed to be fed through a G-tube and never recognized you, would you still love him? I hope so. But I think you would find it hard to love yourself.

So pick out music and scented candles for your birth plan. Buy an enormous bouncy ball. Take control of your delivery. But then take a moment to think about what happens if your baby is in trouble and realize that it's not actually about you, is it? It's about getting your baby out safe. So have a back up plan that involves a hospital and an obstetrician. Do your research about these things, even if you want to try to avoid them, so that if your baby needs out now, at least you are not standing the in the way.

The difference for Emmaline was about a minute. She was fine and then she was not. And even though the one thing I wanted from my delivery was to NOT be cut open by a surgeon, when her heart rate was plummeting I was one hundred percent grateful to be going to the OR.

21 July 2011

C is for CYA

As I was driving into the hospital the other day, I heard a story on Public Radio International about the sky rocketing rates of Cesarean sections in the developing world. Now on the surface this might seem like a good thing. Mightn't it be that women who would have otherwise died in childbirth and infants who might have suffered birth trauma without intervention, are instead surviving the complicated process of delivery unscathed?

Except this doesn't seem to be the case. Instead, women are choosing surgical rather than vaginal deliveries because of the convenience of being able to schedule their child's birth. This in turn means that other women, those who need emergent sections, do not always have access to the limited OR space their countries' doctors have at their disposal.

Doctors in the U.S. seem to be similarly guilty of failing to balk this trend, with rates of C-section quoted at 34% of pregnancies in 2009.

Now there is a saying amongst my OB friends that the likelihood of C-section rises proportionately to the length of the expectant mother's birth plan. The message here being that the more things you try to control, the less likely you are to be able to control anything. So I kept my own birth plan short when it came time to evict Emmaline from her warm and watery first home. I printed an article from NeuroReport that suggested that profanity increases ones ability to tolerate pain and I scribbled BIRTH PLAN across the top of the first page. I thought it might be funny, but it turns out I was too busy swearing to show it to anyone.

Ultimately, though, Emmaline's heart rate dropped to 40 and they whisked me away to the OR. She emerged, screaming and vigorous, while I was in a fuzzy haze of fentanyl.

"At least you didn't actually have to have her," was the take of the childless chain smoker in the condo next to ours, as if having your abdomen cut open and put back together again is not major surgery.

But it is. It is surgery. You wouldn't have your kidney taken out or a biopsy done of your liver if you didn't really need it, would you? So why have a C-section if you are lucky enough to be able to deliver the way Darwin intended, with lots of pushing and a few F bombs thrown in for good measure?

"Whenever you have to take her, take her," I said to my OB, granting her permission to act on the dwindling heart rate we were both following on the fetal monitor. But I know that what she heard could very well have been "get her out safely or I will sue." That's the world we live in. But maybe it shouldn't be. Maybe we should all think a little longer about going under the scalpel.

And when it comes time to give Em a brother or sister, here's hoping I manage to remember that myself.

20 July 2011

I is for Impatient

Fashion Faux Pas

I never expected my friend Brian to find himself at the center of a media storm regarding his fashion sense. Now don't get me wrong, the fine Dr. Skotko has always been a snappy dresser. He somehow manages to make even scrubs look one step above the pajamas they actually are. Unlike most people in our generation, he brings to mind spats and walking sticks. He inspires the word dapper. But he also, and this is one of his more important qualities, is one of the kindest and sincerely sympathetic physicians I happen to know.

He is quick to smile, the first to welcome a stranger, and (when I was expecting Emmaline and still taking overnight call) was always willing to ask the cafeteria staff for a plateful of pickles for the crazy pregnant lady upstairs. In the five years we've known each other, I don't think I've ever seen Brian get angry. I honestly didn't think it was an emotion he could possess. But then GQ's John B Thompson suggested that the reason Boston topped their list of the worst-dressed cities in America was that “Boston suffers from a kind of Style Down Syndrome, where a little extra ends up ruining everything.”

Even if Brian's sister Kristin had not been born with the extra 21st chromosome that results in Down Syndrome, I think he still would have been miffed at the language. Like I said, he's just a really nice guy.

Brian's eloquent response to the GQ post can be found here.

But I don't think you have serve on the Board of Directors for the Massachusetts Down Syndrome Congress and the National Down Syndrome Society to recognize when language is simply in bad taste. You don't have to have written books on the subject to realize that marginalizing a segment of any population is potentially hurtful and that hurting others is, generally speaking, a not nice thing to do.

So well done Brian on raising your hackles. I didn't know that you had any. I have to say I was pleasantly surprised, but then you have always been the sort to put others to shame, especially when shame is what they deserve.

19 July 2011

Tinkle Tinkle My Little Star

I've been preparing to write a post about potty training, but we haven't been making much progress in that direction.

I had planned to do the whole run around naked outside until she finds herself magically compelled to pee pee in the potty, but after an hour she found herself standing in a puddle with no awareness of what had just happened.

"Did you pee?" I asked, to draw attention to the amber liquid at her feet.

Em looked at me and then at the ground and then at me again.

"Oh," she said innocently. "Sorry."

So I put a diaper on again. And while I still recognize that it's important not to rush it...well, I'd appreciate a sign of any sort that hope is on the way.

18 July 2011

The God Complex

Tony Youn, plastic surgeon and author of In Stitches - a memoir about his experiences with the good, the bad, and the ugly - was recently asked to write an article for CNN.com about being a new doctor in July. He did. And in recalling the distant details of his harrowing initiation into the field of medicine, he was honest enough to choose a story in which he is not a hero. On the contrary, he described being placed in a situation he is unprepared for, one in which the patient survives his attempts to do the right thing primarily because the nursing staff is there to literally guide his hands.

As with all things medical, the responses to the amusing and self effacing tale are at times harsh. What interviewers and editors want is for doctors to open up about the uncertainty that exists in the practice of medicine, the nuances of which are unfortunately difficult to capture in 750 words or less. What readers (and consumers of medicine, for lack of a better term) seem to want, on the other hand, are doctors who are well trained, yet humble. To deny the possibility of fault is to develop a God Complex, yet to admit fault - to admit that the practice of medicine is messy and fraught with potential missteps and that the only thing that keeps the system running successfully is the teamwork between all of the different people who work in a hospital - is somehow to inspire condescension.

So let’s just be clear about a few points.

Not all new doctors are scared, but they should be. The ones who are scared, who can recognize when they need help and ask for it, those are the doctors you want working in your hospital when you get sick.

No doctor knows everything. Yes, there was a time when physicians used blood letting and leaches to treat fevers, when the sum total of medical knowledge was finite and flawed and, yes, maybe then it was possible for doctors to know as much about medicine as existed in books. Today it is simply not so. I would, however (and this is a radical statement), venture to say that the general increase in medical knowledge beyond what can be stored in a single brain is by and large a very good thing for patients. Embrace it. The doctor who looks things up is the one that you want.

New doctors, as riddled as they are with faults, are like puppies. They are highly trainable and they respond well to treats. If you find yourself in the hospital in July (heaven forbid) take comfort in the fact that the new intern who treats you will remember you forever. If your intern takes the time to explain something to you, or admits they have to ask their supervisor the answer to one of your questions, or even just asks you if you have any questions and stays in the room long enough to find out your response, reward them. Tell them you appreciate it and you will be training a doctor to be not only a better physician but a better human being for a long career to come. And if they don’t do these things? Don’t be shy. Tell him or her what sort of care you expect. The comment will fester and hopefully make a difference down the line.

Do I have a story, like Dr. Youn’s, of bursting into a room as a terrified intern and running a code? I do not. I’m a pediatrician. I had to ask approval of Julie, my first patient’s nurse, for permission to touch him for my entire first month. Every code I attended was standing room only, with ICU fellows and critical care attendings running the show. Children are precious. No hospital is about to let an intern slap paddles onto a coding infant’s chest. Nor should they. But the flip side of this coin is that it takes far longer in pediatrics than in other branches of medicine to gain the confidence that I’m sure Dr. Youn had attained only a few months into his training. Doing is learning. It takes patience and humility and there is nothing particularly God-like about that.

17 July 2011

The July Effect

Many people, even those without a clear connection to the practice of medicine, are aware of the so-called July Effect, the worrisome time of year when new interns and residents swarm into hospitals and medical errors surge. Knowing that the transition from student to doctor is wrought with potential dangers, my residency program staggered the start of the intern year so that we incoming inept and fresh faced newcomers were paired with more experienced supervising residents. The result was that our “July Effect” probably actually happened in June and the honeymoon my husband and I had been planning for months was sadly and cruelly cut short.

As I have been enjoying the summer, though, I have begun to muse on another sort of July Effect, one that I will blessedly never have to suffer through again. While sitting at the beach with my daughter, I have had time to remember just how frightening, soul crushing, and depressing that transition into residency can be. The eighty hour work weeks, the phone calls from family and friends that go unreturned for months at a time, the layering on of guilt at all of the the things you are missing in order to do a job that you realize you are not doing very well, this is a July Effect of an entirely different kind.

On many occasions I have been asked by medical students and resident for words of wisdom on how to survive with hope or at least a modicum of dignity. It seems writing a book on the subject of how much residency can suck sometimes means I should have this all figured out. But truly there is nothing I can say that will make it easier except to remind these younger versions of myself that it is a finite period of time and it ultimately comes to an end.

At the beach yesterday with two friends from my residency class and their offspring, I was amazed by how long ago those sleepless nights at the hospital feel and how this new life we are living, as mothers and working parents, seems to be the only reality I know. Perhaps that’s because there have been so many sleepless nights since, only these were spent at home with Emmaline in the months before she was transformed into the sleep trained wunderkind she is today. Or perhaps it’s just another way of saying that residency, while an important job and one that we committed our lives to for those years, was still just a job. Life, our real lives, are what we are living now.

And it comes complete with sandcastles and sunscreen.

15 July 2011

Concrete Advice

New parents tend to be anxious. Sometimes it hurts to watch. In the same way it must hurt to send a child off to school, as excited as you are for them you are scared as well. That’s how I feel when I round in the nursery. I meet these strange and small infants and their terrified parents and while I want to tell them that everything is going to be okay, I also know that a healthy amount of watchfulness is precisely what makes everything okay.

Anyone who has had a child knows that there’s an incredible amount of work involved. Physical work, emotional work. In the first few weeks of life the feedings and changings and incessant bouncing up and down accompanied to the sound of a stove vent or vacuum cleaner or white noise machine are a huge undertaking. You do it in a sort of fog, completely taken with the extraordinary creature who has just come into your life.

But in addition to this there is the other enormous piece of work most new parents face – worrying that they are doing something wrong. For nursing moms this often centers on how often and for how long their infant is breastfeeding and whether or not he or she is getting enough milk. Many of the teenage moms I’ve cared for have actually opted to pump breast milk and feed their babies with bottles just to know how much milk they are giving. While I think it’s ridiculous to make the already gargantuan task for caring for an infant any more complicated than it already it, I do understand they find this reassuring. Alternately, though, might I suggest that a baby who is peeing ten diapers a day is probably getting plenty to eat. That’s just basic plumbing.

So this morning I told a mother whose infant’s weight was down a bit that she should follow up with her pediatrician in the next 2 days. It was not unusual advice. I know her milk will come in and the baby will gain weight and I also know that if for some reason this doesn’t happen – some strange and unlikely reason – her pediatrician will recognize this and tell her what to do.

“Until then,” I said, “don’t worry. It’s our job to worry, not yours. You’ve got more than enough on your plate.”

“The pediatrician said don’t worry,” dad said waving a finger in the air. “I’m going to remember that and I’m going to remind you later.”

And mom said, “Thank you. Thank you so much for saying that.”

The other thing I say a lot is, “You’ll figure it out” because by and large this is absolutely true. Specifically when it comes to nursing. Babies may be born knowing how to suck but moms are not born knowing how to nurse. It took me two weeks, many tears, some very helpful youtube videos and a 4 day hospital stay with mastitis to figure it out myself, but I did. And Em nursed for a year. For normal people who remember that it’s okay to ask for help, it takes even less time and typically doesn’t involve a hospitalization. So well done normal people. I’ll be calling you for advice instead of the other way around from now on.

In the meantime, program the number for your child’s pediatrician’s office into your cell phone and remember it’s their job to worry when something doesn’t seem right. All you have to do is call and let them know. And you’ll know. Of course you will. You’re a parent and parents know their children. And every pediatrician knows that.

14 July 2011

Literary License

When I was pregnant with Em I bought baby books like every other new mom-to-be. I got the Baby Center emails letting me know when she was the size of a kumquat. Then I googled kumquat since, well, I had no idea how big that was. I prepared for that surge of energy in the nesting phase the books promised and when that failed to come, trapped as I was in a air-condition-less apartment in the dead heat of summer, I learned the most important lesson of new parenthood: things do not always go the way the books say they will.

This is, I think, fundamentally a good thing. No individual, parent or child, should be reduced to the horrible task of being normal. Especially when normal is, as one of my pregnancy books suggested, to become distressed by violent or disturbing images. Out of context that doesn't make much sense, but what the book was actually suggesting is that I, in my highly fecund state of being, should not watch television shows with violence since I might find myself uncontrollably sobbing and powerless to look away.

Television. Fiction. Was the assumption that pregnancy had made me unable to tell the difference between SVU and the nightly news? I'll admit to being somewhat more scattered than usual during those forty weeks, but really, I was hardly addled. Perhaps the authors expected my corset to be cutting off the blood flow to my brain.

So fine, I remained essentially unchanged during my weeks of pregnancy. I grew larger, sure, but not more fragile. And then Emmaline was born. She ate, she slept, she pooped, she grew. And, because she sleeps through the night, I was recently lucky enough to pick up my old copy of Margaret Atwood's The Handmaid's Tale.

My mother HATES this book. It makes her viscerally and gut wrenchingly ill to discuss it. Growing up, having first read the novel in tenth grade on our battered orange (yes, orange) living room couch, I'll admit I thought her dislike was evidence of some inner weakness. I thought she couldn't handle the dystopian vision of an America ruled by the Tea Party...I mean a totalitarian theocracy.

But as steadfast and unchanged as I was by my pregnancy, it seems I was not unchanged by Emmaline. When reading about the narrator's separation from her daughter I nearly vomited. I fought the urge to cry. I turned into exactly the sort of hapless sap my pregnancy book said I would and I understood my mother in a way I never had before.

It's still one of my favorite books, but I don't think I'll pick it up again anytime soon. I'll stick to Atwood's other, less disturbing tomes. Like Oryx and Crake.

Oryx & Crake fighting over the box

Sure the world basically ends, but at least no one kidnaps a little girl. I can handle a theoretical apocalypse. I'm not a total wuss.

13 July 2011

The Unborn

Toward the end of my pregnancy with Emmaline I developed a serious addiction to Cheetos. 

“If she’s born orange,” Daryl threatened, “I’m totally blaming you.” 

“That’s called jaundice,” I informed him. “It happens, they fix it. Relax.”

The truth was, however, that despite what had been a very easy and healthy pregnancy for us both (apart from the propensity for post-call puking), I had probably not always made the best, most baby conscious decisions the whole way through. I had not entirely cut out caffeine, maintaining my habitual Diet Doctor Pepper as an early morning wake up on the short walk to the hospital. When chastised about this I would bristle. “At least I cut out the heroin,” I retorted on more than one occasion because, seriously, there are things that are important and then there are things that are not. And for clarity sake my never having done heroin I think should count for something in this race to make the perfect baby and win me a diet soda here and there.

Then a friend of mine who was also pregnant at the same time I was expecting Em delivered early, at thirty-one weeks. She was in the hospital doing a thirty hour shift when the contractions began. One of the nurses wheeled her across the street to neighboring hospital where her OB practiced and where they actually take care of adults. Her son, who ultimately did well in the NICU and went home several weeks later and who is now gorgeous and fat, had a thin bird like chest where every rib was standing out as he struggled for air until the breathing tube was slipped down his throat.

Apparently, and there are some studies to support this, just being a resident was potentially dangerous to our unborn. Are there good studies, recent studies that measure the increased likelihood of prenatal and birth complications? Nope. Because no one has checked since the nineties. But I would not be at all surprised to find that standing for thirty hours straight, not having time to drink, and having increased stress hormones is not an entirely good thing for your growing belly.

Does this matter? Should anyone care?

Well what if you miscarried, as another friend of mine did, at nineteen weeks during an especially stressful rotation in a cardiac ICU. What if you were convinced that the demanding schedule, nights on call, rules against drinking or eating in patient care areas ultimately contributed to losing that child? What if a jury was convinced as well and you were convicted of murder?

Thirty-eight states have laws on the books classifying violence against a fetus as a punishable crime. In most states the laws were passed under the auspices of protecting pregnancy women from domestic violence. But more often, the laws are used to punish women for actions taken during pregnancy that are interpreted as being harmful to their own fetus and that (maybe) resulted in miscarriage. Read more here and note that it's not an American news outlet:  http://www.guardian.co.uk/world/2011/jun/24/america-pregnant-women-murder-charges

The women discussed in the article, who have been charged with murder after a miscarriage or after an infant died shortly after birth, were accused of doing drugs during their pregnancies. Certainly I don’t mean to condone illicit drug use, which is known to have the potential to cause serious harm to a fetus, but neither do I think it is the equivalent of holding a gun to someone’s head. On a more practical note, the pregnancies that do involve drug use are those that are most in need of careful prenatal monitoring and counseling. But if women risk being charged with a felony by showing up for an OB appointment, then they are just not going to show up and when that starts to happen we (the collective we) should not really be able to blame them.

Furthermore, addiction is an illness. The woman in the article who ingested rat poison in a suicide attempt had an illness. Is she receiving treatment for her depression during the months of her incarceration? Is she being helped through the process of grieving the loss of her child by the kindly prison guards? Doubtful. I mourn for her as well as for her lost infant.

And I mourn for our country, where simply to be a woman seems to be a potential crime.

12 July 2011


My husband loves a healthy dose of controversy. In fact he seeks it out, something that will probably come in useful when he starts law school in the fall. Did I mention he’s going to be a lawyer? Apparently a terminal degree is not what it once was, or at least not when your employer offers to pay for your next terminal degree. As much as he likes to argue, he wasn’t going to argue with that.

What he likes even better than arguing, though, is watching other people do it…on the internet…in the way that people do when they are protected in a cloak of anonymity – specifically by making horrid, cruel and hurtful statement about someone who writes something they disagree with. Seriously, I think this is his favorite thing to do.

So he recently forwarded me this link to a pediatrician’s amusing take on “crying it out” or Ferberizing infants as well as the wounded response of the author after receiving a viscious internet-style lashing from parents who feel very strongly that it is important to practice “kindness” to your children, but not apparently to strangers with different viewpoints.

Now just to be clear, I don’t actually know Richard Ferber, but I did totally walk by him once in the hospital. And, if we’re keeping score, I had a meeting next door to T. Berry Brazelton’s office this one time and also shook hands with Buzz Aldrin. But that’s all I got.

So, sleep. Parents wish that children would do it and children are not always easy to comply. Books have been written on the subject, many books, some scholarly works of great integrity and others not so much Where to go from here? Obviously what works for one family will not work for all. Recognizing this is the first step toward happiness and a compassionate understanding that those who sleep train are not heartless uncaring parents and those who co-sleep and breastfeed on demand until age two are not hapless suckers doomed forever to bend to their child’s every wish. In fact, most of us live somewhere in between.

 Did we sleep train Emmaline? Yes. Did we do it at 2 months as Dr. Gonzalez’s post suggests is acceptable? No. She was still happily entrenched in the co-sleeping nurse every hour on the hour period of babydom at that point. Aren’t there risks to co-sleeping you ask? Yes. But that’s another topic entirely and remember what works for some doesn’t work for all and I’m telling you as my daughter’s mother and the person who tried to get her to sleep in the bassinet by the bed (which we spent good money on I’ll have you know) that it WAS NOT GOING TO HAPPEN. So yes, I think two months old it too soon.

At her four month visit her pediatrician asked if Em was sleeping through the night. The advice we had been given at her six-week visit was that until four months of age babies really need to suck to be happy and our job was to keep her happy. She didn’t like a pacifier so I let her suck on me. I kept her happy. So of course she was still feeding frequently overnight at four months. We were only doing what we had been told. And our pediatrician billed the visit as a well child check but also as a “sleep disorder”. This made me more than a little mad since the only disorder my child had was BEING FOUR MONTHS OLD and that was so entirely not her fault.

Before I found out about the billing code and totally unrelated to it, we Ferberized our sweet angel. Here’s how it went. She moved into a big girl crib and the cats moved back into our bed. On night one she cried for five minutes and the egg timer went off. Daryl went in and cuddled her. She cried for five more minutes and I went in. She cried for three minutes and fell asleep. On night two she cried for seven minutes and Daryl went in and then she cried for four more minutes and fell asleep. On night three she cried for three minutes and slept for eight hours.

That’s how it’s worked ever since, except every once in a while when she cries louder or for longer (five minutes!) than we can stand. Then we go into her room to comfort her and for the next few nights she cries harder than before. She’s smart. She thinks she can sleep train us and not the other way around. But she’s also only twenty-two months old, so she’s not the one in charge. When we find ourselves occasionally in the misguided delusion that sleeping in the same bed with her would be a precious and restful thing, Emmaline spends hours awake pulling the tiny hairs of our eyebrows and intermittently bursting into maniacal mad-scientists laughter. She just can't sleep when we're around because our very presence reminds her that she really likes attention. Little diva. 

Now clearly sleep training doesn’t work this easily for every child, but what gives it the best chance at success is consistency. Call it what you will but wimping out or giving in doesn’t teach your child anything but that they can get what they want if they cry long and loud enough. Which brings us to a friend of mine from college I recently had a chance to catch up with by phone who also happens to be a pediatrician. Her son, eighteen months old, still wakes up frequently overnight. She’s tired and frustrated, which means something has to change. Think she should go with the flow and embrace his natural rhythms? Imagine she's your child's doctor and she hasn't slept in more than a year and a half. Seriously, think about it, because she might be your child's doctor. You'd be lucky since she's so great, but you'd be even luckier if she was well rested. 

I can't possibly know what would have happened if she and her husband had tried to sleep train their son at four months old or at ten or twelve. But I do know that it’s only going to be harder now that they’ve tried a couple of different times and then gotten derailed. And I also know that in his eighteen months of life he has cried more overnight than Emmaline did in her three days of sleep training. So no, I don’t feel cruel. I feel lucky, very lucky to be sleeping through the night myself.

11 July 2011

The Sugar

When Emmaline was born she looked tiny, like a miniature version of the baby we had been expecting. Her clothes were all too big, partly because people told us she would grow out of newborn clothes so fast and so we hadn't really bought any but mostly because she was small.

Except she wasn't. She was dead center, 50th percentile, run of the mill average. She weighed what a baby should weigh. She was a little grumpy looking and her hands were blue, but that hardly seemed worth sending her back for a refund. No one gets an Apgar of 10 anyway and mostly we were happy that her heart rate, which had been 40 and entirely unacceptable, fixed itself quickly once she made it to the outside world.

Before she was born I got a bit of teasing from my mother-in-law about what I had in store. My husband was a big baby, so it stood to reason that he might produce big offspring. He was, in fact, such a big baby that in those pictures from his first weeks home where he is being gingerly held by his big brother, you often cannot really see his big brother all that well. That's because when a normal sized three-year-old holds a twelve pounder on his lap, there's not much lap left over.

But my husband was a lightweight compared with this baby, born recently and weighing sixteen pounds.

ABC News

And in light of the media coverage of the infant's birth, it's important to remember two things. First, JaMichael is not really a name. It's different, sure, maybe even unique what with being mom's and dad's names smooshed together, but there's a whole book about why this is just not a good idea. Second, a big baby is not always a healthy baby. Having extra sugar around from diabetes during a pregnancy makes the fetus think it's supposed to grow bigger because insulin-like growth factor is (as its name suggests) shaped sort of like insulin, but that's not ultimately a good thing.

So while we're reveling at how on earth it's possible to grow a sixteen pound baby in your belly, let's keep in mind some things that babies should be smaller than...just for perspective.

For instance, a newborn should be smaller than her uncle.

She should be smaller than a cat.

She should be smaller than stuffed lizards.

And smaller than her father's old textbooks.

She should be so small, in fact, that you can't help but want to protect her, despite the crying and frequent overnight feedings. You protect her until she becomes entirely grown up and insistent on wearing a certain pair of shoes that always make her trip and you can't protect her anymore.

Then you hide in the bathroom to cry on the pretense of looking for a Bandaid and remind yourself of when she was so small.