The worst (and best) phone calls

I dialed the number while sitting in my garage, because it was 5 PM, and that's the time of day when my house "kinda sounds like someone is being murdered over there." (in the words of one hilariously honest resident)

But the background chaos didn't matter.

Nobody answered.  I let it ring for an eternity, as I had been doing.  Nobody was going to answer.

Our patient had days, maybe hours - the list of what could happen to cause them to suddenly decompensate was a mile long, and included "Rupture of known varices in setting of multifactorial coagulopathy"

We knew this was coming, they knew it was coming - the only thing that was uncertain was when their family would arrive. 

A month ago, it was the 20th. A week ago, it was Thursday.  

The barely there, tarnished silver lining to this scenario is that we all had time.  The conversations had taken place - the ones held after hours when the commotion of the wards has quieted and there's that still quality that lends itself to answering hard questions.  The kind that leave you with drying sweat under your white coat once you walk out of the room, the physically palpable emotion still hanging in the air.

So once our patient had made peace with what their diagnosis meant, what things would come to pass despite all our best efforts, everyone planned for It - planned for the change-over to comfort care and DNR once papers were signed and affairs settled.  

But y'all know the one about best laid plans, right?

Wednesday, both the brother and Dad would answer the phone, to answer questions and give updates.  After the no-show on Thursday, the brother would still answer, but we couldn't reach the Dad - who our patient had been so desperate to see for the last month, going through increasingly painful days and treatments to buy them those last weeks.  After Saturday and still nobody arriving, the brother wouldn't answer either.

We as doctors have the opportunity to know someone more intimately than their own family - but in so many other ways, we don't know them at all - we have no clue about missed events, or broken promises - or why family may decide they can't make it to sit vigil over a deathbed.

And so Sunday night I gave the word.  Yes, they were full code.  We had promised not to change their status before family got there.  But the knowledge that it was futile care was spread amongst the night code team - I explained how they could try and do the least harm to the patient at the end.  If any one of the many complications set it, even heroic efforts would not bring them back.

As the sun was just starting to rise Monday morning. The Call Came.  I scrambled up from the couch cushions where sleep had finally come between notes, calls from the ER and refreshing vital signs.

The night intern, who is known for his wit and great big grin... "Uh, it's about, ah... 4502."

Medical Trivia: Sinus pause is a medical condition wherein the sinoatrial node of the heart transiently ceases to generate the electrical impulses that normally stimulate the myocardial tissues to contract and thus the heart to beat.

"I just wanted to make sure that you wanted them to be DNR and comfort measures only. Their Family is here, and they're ok with it."

Our last ditch efforts had worked.  They had even been awake enough to talk for awhile, cracked a few jokes before lapsing back into sleep. 

We could not beat splanchnic dilation in the setting of advanced liver failure.  But we got them time, enough to say goodbye.  

Third Time's the Charm.

He's a cute little goober!

Hokay, another inadvertent hiatus.  But I've been blogging since Geocities (oh, the glory of 90's internet), and I'm not about to let anything as simple as having a second child, moving our entire family cross-country after going through a hurricane, Nick going through Rookie School again, holding down temp jobs and moving twice before settling on my current job keep me down!

So again, with the blog.  And some new clinical context.

As much as I loved Hospitalist work, it was never my end-game.  I wanted to go and put in my years in the front lines of medicine, understand efficiency, disposition and clinical practice outside Academia before coming back to teach.  So when the opportunity came to return to Michigan, the natural inclination was to move to the next phase of my career.  

Actually taking the leap was.... exhilarating. (Terrifying, as the primary breadwinner.)  It seemed like Locums work would be my go-to while I searched for a full-time academic position.  I knew I wanted to teach residents, and hopefully students, and maybe even work at a community type program - something similar to where I trained, not too far out of my wheelhouse.  I had some concerns about my strengths as a clinical educator matching up with a heavily research or academic University based practice.  Oh, and it needed to be relatively close to Nick's job - and our extended families.

Just Kidding.  I was hired almost a year ago.

Of course, finding something that fit such laughably specific standards was going to take quite some time.  Academic positions are more scarce and have far less turnover than Hospitalist jobs, so I found a great Locums company with the plan to work with them for a year or two while I found my dream job....

It would be tough, working in a different city each week, but our family would manage - I was willing to wait.


Happily, I got in contact with the right recruiter and met my new family at St. Joseph Mercy Oakland.  So my days look a little different now.  The census is shorter, rounds are longer, and I even venture into the brave new world of outpatient clinic.  (Definitely more on that in a future post)

But I still hustle home for dinner, the kids occasionally get schlepped over to the hospital to finish up things while Nick is at the firehouse and there are definitely still bodily fluids flying around. 

The hobby changed too.  As much as Roller Derby Saved My Soul, there simply weren't the hours in the day to devote to a highly competitive team sport, with practices usually held right at bedtime.  So I get my bruises and the "You do what, now?" looks from a new source:

Because who doesn't want to run away and join the circus sometimes?

I got the duct tape. Now I can try out.

I am a deeply superstitious person.

It's ridiculous, I know.  Scientific training, educated reason, yada yada yada.

And yet I will continue to wear a piece of jewelry for an entire week if I deem it "lucky" in regards to work.  (Lucky being that the onslaught from the ER and consult services remains manageable instead of the full torrent)

D's Go-to-sleep ritual has become increasingly elaborate, in which you turn on a musical seahorse, hand her a stuffed tiger and cover the whole shebang with a polar bear blanket.

But there's reason to my madness.  The fall down, go boom practice was one of the very few I hadn't been wearing pearls.  We have days like today at work, where I end up with a daily rounding list of 27 patients.  And thankfully infrequent all night dance parties that Diana invites us to.

So I needed Duct Tape if I was going to go back.

Jeez, at one point my skates were immaculate.  They're not so pretty now.

At some point, I decided that black and white checks were going to be my "thing".  Raven had giant fuzzy leg warmers, Skates of Wrath had a truly B.A. helmet with fantastic decorations.  So I latched on to the duct tape, because you need something to keep your skates from getting too ripped up on cheese-grater sport court or concrete.

Of course, now that I've started skating again, I've been looking in every store for my elusive tape.   It was interesting to note that the patterns had expanded to include Mustaches and Jonas Brothers.  But no checkered tape in any display I looked at.   I started to take it as a sign that maybe I shouldn't skate anymore - without my "lucky" tape.

Amazon.  $6.07 (Prime Elegible)

So I'm ready.  (Of course, just getting TO tryouts involved a switch in my schedule call times, a favor from my partner, my babysitter willing to stay until 9:30 PM and not seeing Girlie until after she goes to sleep, since Nick is gone the entire Sunday they're being held on.)

Time Travel.

The "Timehop" phone app will, if you ask it to, show you a snapshot of what you were doing on this day in previous years.  It digs through your photos and social media, and has been an interesting reminder in just how significantly one's life can change in a relatively short period of time.

And for me, it's psychic.  It KNOWS stuff.   It knows when Girlie's response to everything is "NO! THAT THING (a nap, her shoes, toast) IS TRYING TO MURDER ME!"  (Adorable photo of sleeping 6 week old baby sleeping on my chest.)

It knows when I am absolutely fed up with work and need a laugh.  (The Kidnapping and Ransom of Dr. Armstrong's Elf of the Shelf.  Complete with dramatic rooftop return of the hostage in exchange for Christmas Cookies.)

It knew that I was waffling on whether or not to return to Derby.  I had gotten back on skates a few times, and each of them was a heart-pounding affair.  The idea of falling, which used to be no big deal, was now scary.  Honestly?  It felt like the first night of bootcamp, all over again.

So it reminded me just how much fun bootcamp was. (I am amused that even though I committed the sin of publicly picking out a Derby Name before i made the team, it all worked out in the end)

But there were still issues - I already feel like I'm stretched thin trying to get through an 84 hour work week and then pick up the pieces (and the groceries) after... while being a single parent every third day.  Why on earth would I add more?

Because it was even better to come back to boot camp as a veteran skater.   Because I see faces (or at least their trademark helmets) in this photo that I spent far too little time with in the last year, despite all our efforts.  

Because I take care of the sick and injured all the time.  And I tell every single one of them that they will get past this... that they will look back on this time in the hospital, when they felt broken and hopeless and it will be just a bad memory.  That their illness shouldn't define who they are, and they need to get back up and walking, to take care of their family and do what they love.

I have to take my own advice.  I refuse to be someone who's afraid.

Tryouts are the 25th.  

I fully expect to not make the team, because I am not Ellen Page and this isn't a movie.  However, wRECk league starts the next week - and I have coerced one of my Mom-buddies to come with me - that we will lay aside our guilt for one night a week and go hit bitches on the track.  (If you can believe it, her job requires an even greater tolerance of BS and shenanigans than mine).  

The one quote that convinced me to try out at the beginning of all this Derby stuff was "If it's important to you, you'll find a way to make it work."  So I'm deciding that it's still important to me.  Being a Mom and a Doc is great.  But neither of those are optional at this point... I need something in my life that I choose to do.   

Now, all I need is duct tape.  (But that's another post)

"I wanna be like her when I grow up." (Part 1 of 2)

The first rule of the residents lounge: Everyone Bitches about their Attendings.  It's the Goldilocks of patient management - this one is too Mean, this one has No Cojones, and that one never answers their phone so I guess I'll figure it out on my own.

Dr. D was the only person who was above lounge bitching.  She was fair, kind, capable and had an amazing bedside manner.  The kind of attending who didn't have to rip you a new one when you screwed up, because you were already berating yourself - "How could I have done something so stupid in front of Dr. D?"   Plus, she always looked professional and put together when I was still rocking Dansko clogs and dress pants that were always a little wrinkled.

In contrast to today - when I had a casual lunch with Dr. D, while we talked about balancing work and kids schedules (try and get as much as possible done before 9 AM), how the babysitter she helped me find was doing (fantastic) and the key item to making work outfits mesh with a White Coat (cardigans)

In truth, she and I were part of a rotating table of fantastic women in medicine, passing through during a special Holiday Lunch Service in the lounge - several were my colleagues, who freely exchange Tirades over weak admissions as well as hand-me-down baby clothes.  Others were subspecialists who I've worked with and looked up to for years and am now finding that their lives aren't so different from mine at this point.  (Heck, some might even be reading this - Hello!)  

The one thing we all agreed on, in between keeping small ones settled on our laps and checking the clock to make sure we were still on schedule is that paying full-price for any piece of Child's clothing is insane.  

Decades ago, the understanding was that a Doctors first and most important commitment was always to their patient.  They would come and see their families once the work is done, but if that was after dinner and bedtime, so be it.  (The scene in Scrubs where Dr. Cox bursts into his son's room, story in hand only to find him already asleep hits home for me)

These days, I have to figure out a way for my patients to get the best care I can give - but seriously, the Daycare closes at 7:30 and I have to be there.  And so I am relieved to see the physicians I respect and admire, who do provide excellent care day after day happen to also be mothers and active participants in their families day-to-day lives.  

I wasn't positive I could do it, to be completely honest.  I had to go back to work when small one was 5 weeks old - not even old enough for day care.  (Thank God for Grandparents and Dads who take extra vacation...)  

I dealt with this fact in a very mature fashion: spending one memorable morning holed up in the office crying and eating a box of leftover Christmas Cookies.  However, once the hormotions (hormonal emotions) passed, things did get easier.  I started to see the ways that Dr. D made things work - planning ahead, finding (and then trusting) people to help you, and always having a backup plan.

5 years later and my, how things have changed.  I have traded orthopedic footwear for stylish flats and paid a hip young person to tell me what clothes will make me look fun and professional (while camouflaging rogue booger wipings).

I still want to be her when I grow up, though.  

When we last left our heroine....

(Two freaking YEARS ago...)

I was a wee baby hospitalist.  I was finally "not a resident", but still too intimidated to actually EAT in the doctors lounge.  I had also just finished my first real season of derby, where I actually made rosters and scored points.

The not-blogged about fact what that my husband and I made the agreement to "stop not trying to have a baby... but y'know, after the holidays."

I was pregnant by February.  :)

So 2013 was the year of learning new skills: in the first half of the year, it was how to professionally exit a patients room in order to go vomit, and doing my level best to come up with reasons why I had to miss 6 weeks of derby practice.. "Oh, y, know... work..."  Later, it became how to scoop up Derby girls from the track and intubate patients even though I had... well, a person in the way.  

With our beloved Bone Collector temporarily relocated, I filled in at the team's medic for the season, still attending practice when I could and watching my fresh meat class grow.  :)

Happily, I birthed a healthy baby girl in November, enjoyed my holiday maternity leave and even got right back on the hospitalist horse 5 weeks later. (I may have cried and eaten leftover christmas cookies in the office for a few of the mornings... but I got back to it!)

  And of course, returning to derby!  The excitement was building.  After months of keeping all manner of hormonally boosted emotions bottled up - AND no booze, I was certainly ready to "hit a bish" as we say on the track.

My first practice back, I pulled myself out after an hour because I couldn't do one of the drills in what I felt was a safe manner - seems that gestating does take a bit out of your endurance and cardio status.

So imagine my surprise when at the next practice, I fall and break my ankle doing a totally routine, no impact, low speed, fresh meat drill.

FUN FACT:  You lose a significant percentage of bone density while post-partum and nursing.  Guess when I learned that fact?



Yeah, it sucked.  When I am old and sharing stories with all the other old demented ladies at the nursing home, I'm sure I will repeatedly tell the tale of how I broke my leg and was non-weight bearing for 6 weeks with an infant at home, in a two story house and a husband that worked 24 hour shifts.  (And still going to work!  And nursing!  For every woman who's weighed whether she can have a glass of wine between feeding sessions, I learned how to stretch out a Lortab like a champ...)

Thank God for my parents.  For serious.  Especially because my orthopod nixed my plan to just deposit Diana in the little basket in the front of my three wheeled push scooter.

So 2014 was unfortunately not my triumphant return to skating.  I did sell the shit out of some merchandise, thanks to an adorable little helper.  :)

And where does that leave us now?  Well, my good reader - now that I have finally come to grips with the guilt that defines almost every working mother (see future post "You HAVE to shower" for details).  I'm starting to train back up.

And I'll tell you about how I actually talk to other attending physicians now.  Sometimes I even call them by their first name.

Except for Dr. R.  Because I suspect God himself wouldn't call someone that badass simply "Jim."

Level up

If the fact that I have a blog on the internet hasn't already clued you in, I'm a bit of a geek.  And by "bit of" I mean "was raised on video games and Dungeons and Dragons in the way that most teens gossiped on the phone after school or threw balls at things for points"

So to this day, if you give me some sort of objective number to measure and strive for in order to do a job well, I AM ALL OVER THAT SHIT.  If you really want me to get revved up, there needs to be a level of complexity that I can analyze and figure out if option A or B is the way to make number X go up or down.

Hospitalist medicine thrives on these kind of metrics.  Length of Stay, Case Mix index, mortality rate, core measures, relative value units... you can make spreadsheets for days.

It's funny, back in the day "being a good doctor" meant that all your patients were happy, nobody died when you could help it and you kept your white coat clean.  Now, with pressures from patients, insurance companies, healthcare reform acts and your own hospital, it means:

"make the patient better as quickly and inexpensively as possible in a way that meets national standards and they stay healthy once they leave.... and while you're at it, document everything that you did in a way that will maximize the amount of money we get paid by insurance so we can keep the doors open and the lights on."

(For extra fun, try and say all of the above in one breath.)

But hey, I knew exactly what I signed up for when I got into this whole "medicine" thing.  Because I love it, and I do want to be a good doctor.  So we come up with better history & physical forms to make sure we've documented all our patients' multiple and colorful chronic ilnesses, so we can take better care of them and get more money at the same time.  And my numbers go up and I'm happy.

And then when I'm exhausted from all of the above, I put on my running shoes and flee from hordes of shambling zombies.

No, really.

As a blocker who is thinking maybe.... just maybe this jamming thing might be fun too, (Click here if you don't remember the difference) I've had to up my cardio and endurance training.   Given my crazy schedule, I needed something that could be done at almost any time with minimal equipment... which means running

I hate running.

But I love zombies.

Enter Zombies, Run!, a smartphone app that turns running into a pseudo role playing game - you run, and while you're pounding the pavement, the program breaks in with "radio broadcasts" as you listen to a playlist of songs.  Even better, it tracks how far you've gone and lets you pick up items to take back to your base to build up your defenses and open new missions.  So yeah, all of a sudden running is fun again.

Especially when you turn on the interval training mode and it forces you to sprint by playing sounds of zombie moans getting closer and closer... 

But it was the amount of data they collect on you that really got my motor running.  

Now I know which songs I run faster to, how steady my pace is over the run, calories burned and how I do on the sprints.

I should amend that the data in the first screen cap was on skates.  Turns out the only drawback to using this program while on 8 wheels is that you occasionally come to the end of a neighborhood cul-de-sac and even the fastest turnaround-stop means you get your brains eaten. (Hence why I only evaded 1 mob on that particular mission).

The best part, though?  It's kind of like having Eenie Meanie, the vet I always thought of as my derby mentor with me...or at least the zombie version of her.  (You thought doc-roller girl was a good combo? Try undead derby badass.)