When It Doesn't Go As Expected: Guest Post

     Not long after I finished my rotation in women's health, my friend Mallorie posted to Facebook about some of the things she went through during and after the birth of her daughter, Quinn. I won't spoil the story now since you will read it below, but as I read her words I couldn't help but realize that she was shedding light on yet more aspects of pregnancy and womanhood that are rarely shared or discussed, and it was obvious how her words touched those who read them. My initial thought was to ask Mallorie if I could reprint her story on this blog as a guest post, an addendum to some of my thoughts from my women's health rotation. The more I thought about it though, the more I realized just how many women I know who could share their own tales of how pregnancies and entering motherhood didn't quite go as they'd planned. I started to ask myself, why stop with Mallorie's story? Why not share them all? The short answer to that question is that there are too many stories to share and not enough space or time, but I still wanted to do something. As I was pondering how I could bring my ideas to reality, October began, and I was reminded that it is not only Breast cancer Awareness Month, but also National Pregnancy and Infant Loss Month in the U.S. It seemed a fitting time for my idea, so I contacted a few friends, compiled their stories, and post is the result, even though taking the time to get everything together means that it's no longer October.

     Before I get into my friends' stories, I'd like to take a brief moment to spotlight miscarriage, the most common form of pregnancy and infant loss, as it does not come up in the stories below. I have many friends I could've asked to to talk about their own experiences with miscarriages, but instead I'm going to simply link the stories of two women who have already written about their own experiences. One is from Jessica, a doula and friend of my family. She shares the story of the stillbirth of her daughter, Daphne Grace, at 34 weeks in The Beginning of a Life Long Journey. In her post, Hello, Goodbye, Jessica provides summaries of all four of her pregnancies (only two of which ended in live births), and explains what October means to her in light of her miscarriages. The other story is from Laura Benanti, an actress, who wrote about her own miscarriage, and the lack of public discussion about them, in her article My Experience With the Voldemort of Women's Health Issues. In the article, Benanti mentions the song Beyonce wrote after experiencing her own miscarriage, which you can listen to here: 

     And now, finally, the three stories that are the focus of this post. Each of these dear friends tells a true story from their lives that deals with a different difficulty of pregnancy and/or becoming a mother. I apologize that this post is a bit long, but I think these stories are too important not to share. I am so proud of these women and so grateful for their willingness to share some rather personal, and painful, experiences from their lives. I know that I have many more friends and relatives whose stories could have been included in this post (in fact, I came up with 15-20 names in just a few minutes of thinking), so if anyone reading this would like to share their own experiences of pregnancy and/or motherhood, let me know. I would certainly be interested in turning this into a recurring series. 

Mallorie & Davide

Photograph by: Helen Carmina Photography

      When I saw this photo to the right I couldn’t help but get teary eyed. This is my story. This sweet mama in this photo had a birth plan and it played out a different way. I had a home-birth planned….we bought all the supplies and even had the birthing pool at our house, but I also had a breech baby. After going to two separate chiropractors a couple days a week, for a couple months and going through an ECV (External Cephalic Version WITHOUT an epidural—never again) the baby still would not flip. After much prayer and discussion, Davide and I decided a cesarean was the best route for us, and one that brought us the most peace in all of what was going on. It was SO HARD to come to that conclusion because it was the last thing I wanted. I wanted so badly to labor for my baby and even just feel what a contraction felt like (call me crazy, I know), but God had different plans. Without the support of my midwife, doula, doctor, midwives, friends, and family, I would not be able to look back on this day and see it as a blessing. They supported me and gave me the best experience possible even though it was not on my birth plan.

     The interesting thing in all of this and that I find God teaching me as well… is to LOVE my body. I was so self-conscious of having a scar and what would my husband think of me after the scar, stretch marks, and saggy boobs. Society feeds us ALL DAY long with messages that suggest we are not worthy if we do not fit a certain mold, and I tell you what….there is something so empowering in getting caught up in what our bodies can actually do, rather than getting caught up in what the world tells us about our bodies. My body created a human being and is now also sustaining that little human being. ARE YOU KIDDING ME??? That. Is. INSANE. So many women would take all the scars, stretch marks, and saggy boobs in the world just to be able to carry a baby, and here we get caught up in the saddest body image struggles because society tells us otherwise. The human body is incredible and God does not make junk. He makes powerful beings and enables us to adapt and overcome the hardest struggles even when our body is physically failing and doing things we don’t want it to. He gives us the strength to see the bigger picture and to push forward in hope even when things don’t plan out as we think they should.

Photo Credit: Abigail Andrus

     And to continue in my soap box….I just want to say choose LIFE. There are so so so so many families who would LOVE to build their family through adoption. It is an incredible, selfless, and priceless gift that a mother goes through in choosing life and adoption. I’m also sharing a second photo just to show off how badass of a team I had supporting me the day of Quinn’s birth. They did every measure possible to help me in accepting what was happening while doing what was necessary. This is them putting her straight on my chest and leaving her there while I was getting stitched up. Also, I understand everyone has their own opinion, which they are entitled to; all I ask is that comments are not rude or hurtful and are kept respectful. Thank you!!

Lynnea & Donovan

     My whole life, well more like since I was 12, I couldn't wait to be a mother. I have always loved kids. I started babysitting since I was 14, and kids became a huge part of my life. Later my career path has led me to be a full time nanny for the past 6+ years, I have become accustomed to potty training, swift meal making, tooth pulling, bedtime telling, boo-boo kissing, and many more uncontainable joys of helping to raise children. Experiencing kids learning how to write their name, after countless hours of singing our ABCs, have brought much happiness! And there is nothing more enchanting then post-nap snuggles. It's safe to say, I love kids. Always have and always will.
     So my husband and I decided Christmas last year, we would officially "try" for a baby.  Figuring it would take a couple months to actually get pregnant, I was happy, I was finally ready to be a mother, and I dreamt about taking care of my own baby very soon, where I could be the one to kiss them goodnight AND goodmorning. Not to mention, I've had The Box, ever since I was 16. The Box, is a collection of baby possessions I have saved, found or have been passed along from other mothers, that I'd hoped would one day be a part of my baby's life. I have always expected I would have a baby.
     But, life almost never goes as we expect does it? After several months of trying to conceive. I knew something was wrong. And after countless doctor visits, tests, hormone therapies, and other expensive and uncomfortable procedures, I received the news that at this time it appears as if body won't be able to conceive. And they are not sure why. I have seen over three doctors, all coming to the same conclusion. My body appears as if everything should work fine, but it doesn't.     

     Pretty big news. And I could go on for pages and pages of what Donovan and I have talked/argued/prayed/cried about for the past month since we got that news. And how many hours I have wrestled with this news and how it honestly has shaken me to my core. But I won't. I will only say, that despite everything, I have felt an overwhelming sense of Gods peace throughout this entire journey. He has helped me realize, that often what we expect for our lives, is not what He has planned for us. But He promises that what He does have in store for us will be good. And I believe that with my whole heart. That no matter what I have always expected for my life, what God has prepared, is grander than anything we can comprehend. That's not saying there wont be heartache, for I have shed many tears these past weeks, but trusting God and His will, is beautiful. I also fully believe that I will be a parent someday, maybe not in the way I have always expected, but Donovan and I have always wanted to adopt. So we decided to forgo any expensive procedures of attempting to make my body try and conceive, and put that money into a adoption fund. I also believe God is a God of healing and miracles, and that maybe down the road, He could heal my body, and allow Donovan and I to get pregnant. But, I'm ok if that doesn't happen. Because I know that whatever happens in my life, if I remain trusting in Him and resting in His peace, my life will be filled with contentment. Because the one thing I know I can always expect is God is good. And He has an exquisite plan for my life.

Summary: Life doesn’t always go as we expect, but we can learn to ride the waves that come our way when we trust in God and take on this crazy and exhilarating life.

Margaret & Cesar

     My husband, Cesar, and I were married in November 2010. It wasn’t too long before we were expecting our first child, and on August 3, 2012 Noah Alexander came into the world. I had wanted to have a natural birth, but that plan went out the window when his heart rate started dropping. After the third drop, our doctor warned us that they’d need to perform an emergency C-section if his heart rate dropped again. I opted to have an epidural so I could be conscious for the birth, if it came to that, and it did. Despite the scare with his heart rate, he seemed fine, at least for the first 24 hours. By the next evening, while trying to do skin to skin, we could see that he was struggling to breathe. He had also developed a fever, and his platelets had dropped, so he was admitted to the NICU that night. Your hormones go crazy after a C-section, so I felt so sensitive, and I just kept crying. I felt like I was an electrical cord that had been severed and everything was out of whack. In short: I was a hot mess. It didn’t help that I was lacking sleep.

Noah's last feeding before being
discharged home.

     Eventually I was discharged from the hospital, but Noah had to stay. On the way home from the hospital my milk came in, so I had to figure out how to pump. A nurse friend had told me to pump as much as I could, but I wasn’t sure how long to pump for, and I didn’t have a feeding baby telling me when they were done. I just kept pumping because I didn’t know when to stop. In return, my body kept making milk. During those first days though, while I was busy figuring out pumping, my husband was at the hospital with Noah, keeping a close eye on our son and worried that there too many babies for each nurse in the NICU. Finally, after 4 days, Noah came home. 

     Noah had been home for 11 days when he started to become yellow and lethargic, and we noticed bruising between his belly button and scrotum. When we brought him to the ER, the doctors thought the bruising was just from a bump that we hadn’t noticed, and we returned home. The next day though, he started crying more. That night we started co-sleeping, which was amazing, but we realized in the morning that Noah hadn’t woken up during the night to feed. The urine in his diaper seemed concentrated and unusual, so we returned to the ER. He was hooked up to IVs and placed in a radiant warmer, before eventually returning to the NICU. This time though, Noah was given his own room with his own nurse because he was so sick. Cesar and I were given a private room so we could stay with him. Noah spent 2 weeks there. During that time, Noah had to be NPO and he couldn’t drink any of the milk I pumped, so soon we had quite the collection. We had milk at home, milk at the hospital, and then we had to borrow a friend’s refrigerator space for even more milk. It made me feel like a cow. We ended up donating much of it to the Mother’s Milk Bank in Colorado because I pumped more than 300 oz.

The only family photo of Cesar, Noah, and Margie

     Initially Noah was diagnosed with an infection contracted in the hospital during his first days, but despite treatment he wasn’t getting better. One doctor finally raised the possibility of Neonatal Hemochromatosis (NH), and wanted to investigate the possibility, but warned me not to look it up, because “it was kind of a sad diagnosis.” They’d already looked at Noah’s belly with an ultrasound, but it hadn’t been enough, so they did an MRI. Noah couldn’t hold his breath like you’re supposed to for the MRI, but despite the blurry images, iron deposits were clear all throughout his liver and into his pancreas. It was NH, a very rare condition that is basically liver failure in the womb, which causes iron deposits throughout the liver and sometimes other organs. Most babies with this condition don’t make it to birth, and those that do rarely live long afterward. The only known successful treatment is a liver transplant.

     Cesar wasn’t there when we got the MRI results so I called him, explained that it didn’t look good, and said I needed him there asap. That was Thursday. On Saturday Noah was flight-lifted to Seattle. Cesar flew in the propel airplane with Noah, and I arrived on Sunday with my mother in-law. We had the option to stay at the Ronald McDonald house, but we weren’t approved at first, so we stayed with friends until we could move in on Tuesday. Being there allowed us to be closer to the hospital and surrounded us with other families who were going through similar, and even harder, things with their children. Being there made it all a better experience. It wasn’t as scary as it could’ve been, and we had something to come home to. The volunteers put so much time and effort into caring for everyone. We didn’t even have to pay because the house only asked for a suggested donation of $30/night and our insurance covered it all. Despite the house and other families, it was a crazy time. I’m glad I got rid of the pictures from this time in Seattle because one of the hardest things was seeing how much Noah was hooked up. I have never seen so many lines of support as all the lines going into my son. I wish I could forget that image. We had brought lots of luggage with us and prepared for a long stay because we’d been told that it could take months to get Noah better, but in the end he was only there for 5 days. Noah passed away on September 7, just five weeks after he was born. 

Cesar and Margie in 2013

     When you lose a child, it haunts you for the rest of your life. I thought that the way I carried myself after he passed was it. But it wasn’t. The grief comes in waves. It comes and goes. Cesar and I briefly moved from Oregon to Hawaii to grieve. Noah had been conceived in Hawaii when we visited after our first anniversary, and it was almost like we had the chance at a fresh start. During our three months there, I became pregnant with another son. This time I went through 22 IVIG treatments starting at the 18th week of pregnancy to prevent NH, and just one year and eight days after Noah’s birth, his brother Micah Leonel was born via VBAC, healthy and whole. There were a lot of triggers about Noah at that time, and more in the months to follow. I am so glad that my mother was with me when another wave came when I was 6 months post-partum from Micah. For anyone else who goes through grief, know that you need to surround yourself with those who love you. It’s a big part of your healing. Reach out to the people who know you and love you well. You should know too, that moments of “set backs” are not bad things. They’re a part of the grieving process.

Cesar, Micah, and Margie in 2013
A daughter will be joining them in January 2016

     If you ask what I learned from everything that happened with Noah, I’d say that it didn’t feel like a lesson; it was more an experience we have had to grow from and share with others. We saw how much God was with us in it all, good and bad. Looking back now I wonder too why on earth I worried about the little things. Those were the least of my worries! As a new mother I was so worried about the little things, like if I’d have enough diapers and wipes. Little did I expect for my son to go. Cesar and I ended up having so much left over, and we just gave everything away to other expectant mothers. There were more important things to be concerned about. With that I’d like to advise new parents out there to do what you feel inclined to do. If it’s not to write the baby showers thank yous in the first few weeks, don’t do it. If it’s to just enjoy nap times, do that rather than worry about getting everything clean. Let your baby sleep with you, enjoy everything, rather than get caught up in little details. 

     To close I’d like to say that Noah lives on. I see him in his brother Micah, and I continue to tell his story. I hope that through it others can find healing for their own tragedies, remember to treasure their own loved ones, and see God’s work in us, even in times of grieving. 

     
Further Resources
     If you'd like to support or learn more about some groups mentioned in this post or who seek to help women and families all over the world, here are some links to get you started: 

Ronald McDonald House
Mother's Milk Bank
Hope Through Healing Hands
For further discussion of some of the body issues Mallorie raised at the end of her section, I recommend this post on We Seek Joy: Babies Ruin Bodies. To learn more about neonatal hemochromatosis, this article by Medscape is a pretty good summary. To learn more about what childbirth used to look like in the 1950s in the UK, and to hear how the medical world finally started giving attention to maternal health, I recommend the book Call the Midwife by Jennifer Worth. To learn more about how women around the world experience pregnancy, and how much more work still needs to be done in the area of maternal health and prenatal care, I recommend Half the Sky by Nicholas D. Kristof and Sheryl WuDunn. Just know that you might need tissues while you read. 

Don't Believe What You See On TV (24/30)

     Last Tuesday was the last day of my rotation in emergency medicine. Looking back it's hard to come up with a summary of this rotation. I worked 17 shifts, saw 100+ patients, had only a few repeat diagnoses, and performed quite a few procedures. I suppose the only general statement I think I could make is to say that the ED does not lack in variety. Sure, there are particular conditions that are seen commonly, but you show up each day for your shift not knowing what you will see. Even the "common" conditions aren't always that common, or don't present in the same manner each time. Take appendicitis for example. During my surgical rotation I saw a woman with appendicitis who presented with left-sided, rather than right-sided, lower abdominal pain. It turned out that she had a long, midline appendix that extended into the left abdomen. Then on this ED rotation there was a man with right-sided diverticulitis and a boy with a right-sided abdominal abscess who both presented similar to acute appendicitis. It wasn't until my last day in the pediatric ED that I actually saw a case of appendicitis that fit the "classic" presentation, and even then the patient had not yet developed a fever, as is common. 

Being woken up by solicitors
after my last overnight shift.

     The variety of the ED was also aided by the fact that, for this rotation, I didn't stay in the same area of the ED for all shifts. My schedule was 3 days on/3 days off, and for each group of 3 days I was in a different location. I had six 12-hour shifts in the main ED (3 overnight, 3 during the day), three 9-hour shifts in the more psych side of the main ED, four 8-hour shifts in the pediatric side (I covered one shift for another student), three 10-hour shifts in the fast track, and one 8-hour shift on an ambulance. It's really no wonder that this rotation seems to have flown by. I actually enjoyed all areas of the ED, but it was nice that if a student really didn't like one area, they only had to do three shifts there. That was definitely nice in regard to the overnight shifts. I actually saw a lot of interesting things on those shifts, but man did they mess with your sleeping and eating schedules. I spent the next 1-2 days after those just recovering and trying to remember what day it was. It didn't help that there were mandatory lectures two days each week, so for two of my overnight shifts I couldn't even go home when I got off at 7 AM, but had to go to lecture and finally leave around 9 AM and 11 AM. That was painful. At least when it was quiet I had the opportunity twice to head over to the fast track side and nap in a bed for a bit. It was actually quiet enough that I got about 2 hours of sleep/nap one day.

How I got a few winks during overnights

     If you're surprised that I got any sleep while working in an ED, I should mention that E.R. and other medical dramas on TV can be a bit misleading about the day-to-day life in emergency medicine. There are quiet times when the only patients in the ED are ones waiting to be admitted. There's also just a lot of waiting. One of the attendings with whom I worked quipped that a more accurate TV show about the ED would just be a lot of people sitting around typing on their computers and waiting for lab results to come back. That's often a fairly accurate description. The waiting can be very frustrating for both providers and patients (and certainly the patient's family members), but it is a regular part of ED life. Later at night in particular it can take longer because there are fewer staff in the lab or imaging. Particular days, like Mondays (apparently everyone waits out their illness on the weekend and then comes in), will have longer wait times because there are simply more patients waiting to be seen. On that note, many patients who come to the ED, would be much better suited for an urgent care, or even their primary care. Now sometimes it's hard to tell who is truly an emergent case, but I will warn future ED patients that if they come in for a neck strain and other patients are there for potentially life-threatening illnesses, the neck strain will be waiting. Complaining will not get you seen faster if other people are in worse shape, and being disruptive might actually hurt your case because no one likes to deal with unpleasant people. So, when you're in the ED, be patient, and be observant. If there are patients being seen in hallway beds, or you hear a provider mention they haven't eaten or used the bathroom since their shift started, it's probably a busy time and you might be waiting longer. Sorry. Enjoy the free TV and snacks (if you're not NPO, that is). 

     Of course, there are moments in the ER when there's not enough time, moments when you are running because even the seconds count. These moments might not be as frequent as TV would make you believe, but they happen, and they can be terrifying. There were four times on this rotation when I thought a patient's life was in immediate danger. The first time was a young man, a healthy-looking fellow with nothing but a right-sided chest pain that he said he almost didn't come in for because it didn't seem so bad. In fact, his pain didn't seem so bad to us at first either. If you looked through the notes written about him that morning, you would see the same phrase over and over: "no acute distress." This is essentially a description saying that this man did not look sick, and gave no indication that, less than an hour after being brought to his room in the ED, he would need an emergency procedure to save his life. Physical exam however, revealed that the patient had a pneumothorax, also known as a collapsed lung. It can happen for numerous reasons, but in young, tall, thin males, like this patient, it's often a spontaneous occurrence and is not necessarily life-threatening. In fact, some studies recommend that if that the lung is not too collapsed, the patient can be managed conservatively* (i.e. they're allowed to go home and told to return if things become worse, rather than having a chest tube put in to let out the air that has escaped from their lung into their chest) because they'll likely heal on their own. In 1-2% of cases however, spontaneous pneumothoraces can become tension pneumothoraces,** meaning that the air flowing from their lungs into their chest cannot escape and begins putting pressure on the heart and other lung. This is an emergency. In the case of my patient, less than 15 minutes after getting the x-rays back that confirmed his diagnosis, and while thoracic surgery was on the way to the ER to put in a chest tube, his heart rate and blood pressure suddenly plummeted. While the nurse and doctor quickly sterilized and numbed the patient's chest, the PA and I tried to keep him talking so we could gauge his mental status and whether or not we actually had time to hit all the proper steps. I wasn't sure that we did because, as a witness later said, the patient "looked like death" and was struggling to focus and respond. Even as my worry and fear grew, the other providers remained calm, and in what seemed like eternity but was really 2-3 minutes or less, the patient's chest was cleaned, numbed, a needle was inserted between his ribs, and a rush of air came out. His vitals began to stabilize immediately, and he began to talk normally again, telling us that his pain was gone. Shortly afterward the thoracic surgery resident arrived, a chest tube was placed, and x-rays showed that the patient's lung had reinflated. He had to stay at the hospital for a couple days, but he was just fine. Unfortunately, not all my patients had happy endings.

The view on my ride along

     I worked three codes during my overnight shifts. Two were only an hour or so apart. None of them survived. It was the first time I had actually watched a patient die. I'd come close during my last day of my surgery rotation when one of my patients requested to be put on care measures only after contracting an infection, but if she did pass, she did so after I was gone. This was different. The first patient had arrived in the ED in bad shape after an overdose, but still very much alive. Once his lab work came back though, it was clear that he was not a simple case of administering naloxone and observing until better. A lactate level of 4 mmol/L (typically the highest level mentioned in most studies of lactate levels) is 55% sensitive and 91% specific for death in the next 3 days. This patient's level was 15 mmol/L. Within a few hours of arriving, he went into cardiac arrest. I ran into the room, joined the rotation for chest compression, and was shocked at how pale, blue, and still he looked. Minute after minute everyone worked, administering medications, performing compressions, and delivering shocks. Nothing helped. An ultrasound machine was brought in and we paused long enough to stare at his heart as it appeared on the monitor. Nothing moved. We tried a bit longer, but eventually the doctor told me to stop compressions, felt for a pulse, and declared the time of death. The patient's family, who had chosen to stay in the room and watch, were composed and graceful as they thanked us all for doing everything we could and then said their goodbyes. I went back to my desk and stood there, my hands shaking, as I tried to compose myself and process what had just happened. A friendly tech brought me a cup of water and told me I'd done well. When, after a few minutes, I was ready to face other people again, the doctor who'd run the code asked me if I had any questions and kindly walked me through the events of the night. I am so grateful to that tech and that doctor. I needed a bit of kindness and gentleness to get me through the shocks and experiences of that first code, and less than 5-10 minutes was enough time to get me functioning like normal again. It had to be. The ED was packed that night, so there were still more patients to see, and, though I didn't know it at the time, in less than 2 hours I would once again find myself performing CPR. That time it was an elderly woman who'd fallen and hit her head. Though her heart seemed healthy, we lost her as well because we could not fix the damage to her brain. The next night I was part of another code, and, once again, was asked to stop compressions and step back so that a time of death could be called. 
     It sounds sort of horrible to say it, but the codes became easier. Already by the second one I was used to the routine and rhythm and could perform my role without having to continually remind myself to focus on my compressions rather than being distracted by my patient's face. I also learned how to recover. You had to. One can't have a mini-breakdown after each rough case because there's always another patient counting on you. So I learned to get some water and take some deep breaths, as well as pick an easy or pleasant patient to see next, if I had a choice. Letting a 3-year-old with pneumonia play with my stethoscope was a welcome change after hearing agonal breaths, and an injured toe seemed an easy fix after watching a heart monitor show asystole. 
     I don't wish to leave this post on a low note. The truth is that the vast majority of the patients I saw did just fine, and these codes only occurred on my overnight shifts. My fast track shifts were full of sprains, lacerations, and fractures, so I had plenty of practice suturing, stapling, splinting, and performing orthopedic exams. Patients in the pediatric department could pull at your heartstrings, but the good news was that pediatric patients tend to bounce back quickly, and once their diagnosis was determined and treatment was started, the parents often needed more care and reassurance than the patients. Yes, the patients in the main ED on my day time shifts could be serious, and I still wish that I had been wrong the first time I correctly made a complicated diagnosis (a small bowel obstruction caused by an incarcerated hernia in a patient with a massive ovarian tumor), but, for the most part, my patients were treated and returned home to their normal lives. In the end, the lives of me and my patients only intersected briefly, and these encounters could be terrifying or frustrating, but for those hours I had the chance to meet an immediate problem and do something to fix it, and that is a wonderful thing. 

*Light, Richard W. Primary Spontaneous Pneumothorax. In: UpToDate, Polly E Parsons (Ed), UpToDate, Waltham, MA. (Accessed on October 22, 2015.

**Noppen M, De Keukeleire T, Pneumothorax. Respiration 2008;76:121-127

Making Time to Enjoy Autumn

Apple-picking at Russell Orchards

     If I've said it once, I've said it a hundred times, but clinical rotations are crazy. The schedule changes every 5 weeks, if not weekly or daily, and free time tends to be a precious commodity. After all, if you're not actually at your rotation site, sleeping, or commuting, you're expected to be studying and learning. There really are times when you sort of have to tell friends and family that they won't see you for a while. Despite the craziness though, you really do need to take time for yourself. It's not healthy to live constantly on the go, and without any time to do the things you enjoy, be with the people you love, or even have time for self-reflection. So you have to learn to make the time, and to seize the opportunities that arise. 

   My last rotation was in the emergency department, and I had a schedule of 3 days on, 3 days off. It was so amazing to actually know from the first day of rotation exactly what my schedule would be for the next 5 weeks, and I tried to make the most of it. Sometimes this meant catching up on more "grown-up" tasks, which is why most of my Halloween was spent cleaning my apartment, doing laundry, making pie and apple butter, paying bills, and listening to podcasts and audiobooks all the while. You can make time for fun though too. October is the time of peak fall foliage for New England, so I took walks on my days off, scheduled in some activities with friends, and when my parents came to visit, I'd already arranged my schedule in the ED so that I had time to spend with them. I love both photography and poetry, and since this month I actually had time to indulge both those loves, the rest of today's posts will simply be pictures from the last month or so, with poems about autumn interspersed between.

Salem Woods

Thompson's Meadow

The morns are meeker than they were,

The nuts are getting brown;

The berry's cheek is plumper,

The rose is out of town.

The maple wears a gayer scarf,

The field a scarlet gown.

Lest I should be old-fashioned,

I'll put a trinket on.

-Autumn by Emily Dickinson 

Willowdale State Forest

October turned my maple's leaves to gold;
The most are gone now; here and there one lingers:
Soon these will slip from out the twigs' weak hold,
Like coins between a dying miser's fingers
-Maple Leaves by Thomas Bailey Aldrich

Harmony Grove Cemetery

Willowdale State Forest

The autumn's a gorgeous golden cup,
With a warm, empurpled rim;
The sunset lavishly fills it up
With rosy wine to the brim.

And while the wind so wearily grieves
Through the grasses parched and dead,
It spills the wine on trembling leaves
And turns them yellow and red.
-A Cup of Nature by Richard Kendall Munkittrick

Willowdale State Forest

Harmony Grove Cemetery

As dyed in blood the streaming vines appear.
While long and long the wind about them grieves:
The heart of Autumn must have broken here.
And poured its treasure out upon the leaves.
-Woodbines in October by Charlotte Fiske Bates

Greenlawn Cemetery

Oh, Autumn! why so soon
Depart the hues that make thy forests glad;
Thy gentle wind and thy fair sunny noon,
And leave thee wild and sad?

Ah! 'twere a lot too blest 
For ever in thy colored shades to stray;
Amid the kisses of the soft south-west
To rove and dream for aye;

And leave the vain low strife
That makes men mad-the tug for wealth and power-
The passions and the cares that wither life,
And waste its little hour.
-Excerpt from Autumn Woods by William Cullen Bryant

Greenlawn Cemetery

Willowdale State Forest

 Now in golden glory goes
Autumn toward the time of snows:
Ere white winter come indeed,
Speed the hours, with music speed.

Heed not winter's mournful breath,
Sighing at the thought of death:
Make but music, dearly sad;
Make but music, gravely glad.

Music is a king of kings,
Mightiest of immortal things:
Music is a lord of lords,
Ruling all with royal chords.

Though the woodland ways be chill,
Though the woodland choirs be still:
Music moves the starry choir,
Music sets the soul on fire.
-Song I by Lionel Johnson

Willowdale State Forest

I find sweet peace in depths of autumn woods,

Where grow the ragged ferns and roughened moss;

The naked, silent trees have taught me this, -

The loss of beauty is not always loss!

-Except from November by Elizabeth Stoddard

Willowdale State Forest

Cut to Cure (23/30)

     Before starting my surgical rotation, I was both very excited, and very nervous. I knew from my time in Kenya that I enjoyed observing and assisting with surgeries, so I was looking forward to the chance to do it again. Plus, it's a rare thing in medicine to be able to cure a patient's problem with one procedure, but this is a real possibility in surgery. If a person's issue is an inflamed and infected appendix, we can just take it out. Boom. Problem solved. However, I knew from my women's health rotation that surgery can also be stressful, and I was all too aware that we had not spent much time covering suturing and surgical knot tying in lab during my didactic years, so I was a bit terrified of screwing something up. I also wasn't too thrilled about the ice box ORs (60 or 62 degrees was the norm) or long days (shifts were could be as short as 8 hours, but typically lasted 12-14 hours, depending on how many operations were scheduled) or all the procedures that hadn't been covered in depth during didactic ("treatment: surgery" doesn't cut it as an answer when you're actually in the surgery),  but I prepared myself to try to learn as fast as possible. There was definitely much to learn.

From Medcomic

     One thing I learned right away on the surgical rotation is that, in surgery, more than in any other of my rotations, the hierarchy and divisions of medicine are clear. As a student (whether PA or MD), you are at the bottom of the totem pole. Above you are attendings, PAs, NPs, residents, interns, nurses, and basically everyone else. When you're actually in the OR, there are even more people, like the anesthesiologist or nurse anesthetist, circulating nurse, and, of course, the scrub tech or scrub nurse (a quick note on the scrub tech/nurse: you do not mess with them. You give their table a wide berth, you follow all their commands, and if they say you broke sterile field, whether or not you think you did, you had better apologize, make it right, and then promise never to do it again. Some scrubs are nice and friendly and will ease you into everything if you seem unsure. Others will watch you for signs of weakness and will put the fear of God into you if they sense you have the potential to screw something up, which is necessary since a patient's life could be on the line. You just have to figure out how to live and learn with both, and focus on doing the best you can do.).  In short, there are a million people who can, and likely will, order you around. That's part of being a student, just like coming in at 5AM to do pre-rounds before actual rounds, or having the freakish 24+ hours overnight shift. Some students hated this, but everyone had to deal with it. 

     Beyond the hierarchy, I also learned to recognize the other divisions in the medical fields, specifically the divisions between providers who chose to go into surgical specialties, and those who chose to go into medical (aka non-surgical) specialties. Anyone who has watched the TV show "Scrubs" knows that the surgical people (typically portrayed in green scrubs) are known as the jocks, and the medical people (typically portrayed in blue scrubs) are known as the nerds. This is a stereotype actually perpetuated in real life as many of the surgeons would jokingly refer to themselves as "dumb surgeons" who just knew how to take things out of people. Obviously, this was a gross misrepresentation, but it was funny to actually hear them say it. It was even funnier to hear the general surgeons talk about the orthopedic surgeons, because the general surgeons often referred to their compatriots in orthopedics as being the true "jocks" of medicine. However, I will admit that it is true that orthopedic surgery is in a different class from general surgery.

The Todd... jock surgeon extraordinaire

Orthopedic surgery sometimes felt like a workout as I stood there holding up a limb for what seemed like an interminable time (fact: unless you look like a pathetic weakling, this is the student's job and, fact: whether it's an arm or a leg, they get very heavy, very quickly, especially when you can only support them with one hand lest you accidentally touch a sterile area while not yet scrubbed in yourself), and it is also more violent then general surgery. There is truly elegance to any surgery, and sometimes I loved simply watching the surgeons as they deftly made incisions, tied off vessels, etc., all while making it seem like a dance. The dance is just rougher in orthopedic surgery. It's hard not to be when a typical set up for an orthopedic procedure includes mallets and saws. Yes. Mallets and saws. I enjoyed scrubbing in for any surgery, but I am not sure I'll go into orthopedic surgery in the future as I have learned that the sound of bone crunching kind of freaks me out. Go figure. 

Expressed calcium deposit.
Image can be found here.

     In case I wasn't sure before, this rotation reminded me that it's ok to have fun in surgery. I could give multiple examples of this, but the one that comes to mind right now is from my time in orthopedic surgery. There was a patient with shoulder pain because calcium deposits had built up in the tendons of their rotator cuff, and they needed to be removed. We did that by inserting a camera, finding the deposits, making a small hole, expressing (aka squeezing out) the deposits, and then stitching up the hole. It turned out that this procedure is surprisingly satisfying and entertaining. This might weird some people out, but it's a bit like squeezing a zit, only you're squeezing out calcium deposits (which can either be hard as a rock or more like toothpaste) rather than pus, and there's much more to squeeze out. During the surgery I observed, nurses from other rooms came to tell my room to quiet down because everyone was laughing too much and getting too excited whenever we found another deposit. It was very, very weird, yet also very fun. I guess you could say I learned to embrace the weirdness. 

The coffees of my overnight shift

     I talked in a previous post about how much of clinical rotations is just learning to be flexible. This is another part of the weirdness, especially as you have to learn to handle a schedule that changes daily. My schedule for this rotation was divided into four sections, each lasting just over a week. These sections were general surgery (primarily gastrointestinal surgeries, each time with a different surgeon), orthopedic surgery (we found out our assigned surgeries in the morning on the way to the OR), orthopedic office (each day was spent seeing patients in the office of a different orthopedic surgeon), and general surgery office, which I actually spent in the weight loss clinic. This last section involved the unexpected realization that there's quite a bit of psychiatry in surgery, at least in bariatric surgery. I'm not sure about other weight loss clinics, but if someone wanted to have bariatric surgery done at my site, they were required to meet not just with the surgeon, but also with a nutritionist/dietician and psychiatric nurse, as well as attend meetings held by other people who had undergone the surgery. The goal was to make sure that the surgical candidates were really prepared for the operation, that they understood what life changes the operation required, and that they would actually be able to stick to those changes. I learned that it is possible for someone to "fail" a gastric bypass or gastric sleeve (i.e. still gain weight), and that there were good indicators of who those patients would be. Specifically, any patient suffering from an uncontrolled psychiatric illness was told to wait on their operation until they were mentally healthy, patients who had been obese since childhood did worse, and patients were reminded over and over how important it was that their family supported their decision since the lack of encouragement (or even downright enabling of bad habits) from family members was often a major deciding factor in whether or not a bariatric surgery had the desired long-term effects. On that note, patients were also counseled that their family not only had an effect on them, but that they also had an effect on their families. Overweight parents in particular were reminded that much (some might even argue most or all) of a person's future eating habits are set by the time they turn 8, and thus the importance of developing healthy eating habits in children could not be overemphasized. If you want to see a video that makes this point in a vivid way, I present this ad: 

     On the subject of making life choices, I should mention that I was tempted to title this post "Lose Weight, Stop Smoking, and Exercise: Primary Care Part 2" because it seemed like much of my rotation was simply spent dealing with the consequences of people ignoring the advice of their primary care doctors. Orthopedic surgeons would lose much of their business if people were not carrying around extra weight that wore and pounded on their joints. Cardiac surgeons would have less to do if people exercised and kept their hearts fit. All surgeons would have easier jobs if people just stopped smoking because (contrary to the popular notion that smoking just affects your lungs) smoking affects every organ system in the body. I have a post on smoking in the works because it comes up so frequently, but right now I'd like to mention one aspect of smoking closely tied to this rotation: there are surgeons who will refuse to perform surgery on a smoker, and they have good reason for this. Smoking causes narrowing of the small blood vessels all throughout the body (vasoconstriction), which means that those vessels are no longer delivering much needed nutrients and oxygen. After a surgery, this can mean an increase in both healing times and failure rates for the procedures. Now if a patient comes in with acute appendicitis and they need an appendectomy before the appendix ruptures, of course they will get the surgery, whether or not they are a smoker. For more elective or less emergent procedures though, there's a good chance that surgeons will require that patients quit before they'll operate. Orthopedic, cosmetic, and bariatric surgeons in particular are strict about this, and some will even test their patients for nicotine before the operation to ensure that the patient has been compliant. So please, just quit smoking now. Soapbox over (for now).

Some advice for PA students preparing for their surgical rotation:

Knot tying on my overnight.

• Sometimes residents bribe you with chips and a cookie to stay late and assist with a surgery. This is completely ok. Take the food and eat it while you can.
• This follows the last point, but please eat. You might have very weird hours, but grab at least a snack, even if it isn't a full meal, between surgeries because you do not want to pass out in the middle of a surgery. That being said, if you do feel light-headed in the OR, tell someone ASAP.
• If you know ahead of time what surgeries you'll be assisting with, look them up the night before and become very familiar with the anatomy you'll be seeing. 
• Practice your suturing and knot-tying whenever you can. Keep string on your keys, your steering wheel, your scrubs, wherever. 
• Be flexible. Different rotations are set up differently, but chances are good that there will be a lot of uncertainty. You might work with a different surgeon each day (or even each case), or surgeries might run late or be added on, or complications might arise intraoperatively. No matter what happens, you have to be prepared to roll with it.
• Embrace the experience. Even if you hate surgery, this might be your only chance to actually see the inside of a person while they're still alive, or to cure a problem with a single procedure. You can acknowledge the difficult aspects of the rotation, but take time to recognize the incredible things you are witnessing and enjoy them. 
• Always go with your patient to the recovery room. You should also introduce yourself to them before procedures.
• Realize that sometimes you will feel like an idiot. Some surgeons are jerks. Some residents enjoy hazing. Sometimes people just don't explain everything and yes, there really is a purpose to you rubbing a woman's breast for 5 minutes while everyone else leaves.* You just have to do your best, ask questions when you don't understand, and not let the jerks get to you. 
• Surgeons like to quote the saying, "all bleeding stops eventually." This is 100% true. It is also 100% terrifying. Bodies are complicated, and everyone is a bit different, so chances are good that, no matter how careful everyone is, at some point during your surgical rotation an artery or vein will accidentally be nicked. The most important thing is to remain calm. If you can take a deep breath and continue retracting, or whatever it is you are supposed to do, this will allow the surgeon to find and fix the bleeding vessel that much sooner, and a crisis can be averted. 

Elf ears happen

• Surgical caps can make your ears point out and turn you into an elf. Deal with that, or settle for the silly bouffant. It's your choice.
• Keep the safety of the patient foremost. If a patient has a penicillin allergy, yet you hear the anesthesiologist say they're going to give prophylactic cefazolin, speak up. You might have misunderstood about the patient's allergy, or the anesthesiologist might have missed it, but no one will fault you for double-checking, especially if you do it respectfully. You should also make sure the patient is safe on the operating table, especially in the times right before and after the procedure when they're half-conscious and possibly not always surrounded by nurses and doctors. I saw big patients who we had to make sure didn't drop or roll off the table, and I helped with another patient who tried to fight his way off the table as the anesthesia was wearing off. 
• Know GI! My rotation was predominantly GI and ortho, and I think that's pretty typical. Any neurosurgery usually has to be done as an elective, OB/GYN surgery is saved for the women's health rotation, and most thoracic surgery is reserved for students who know that's what they want to go into, so it's not typically an option for the general clinical year.
• Enjoy the scrubs. Scrubs are basically professional pajamas and they are wonderful. Your surgery (and possibly ED) rotation might be the only time you get to wear scrubs during the clinical year, and you might never wear them again unless you go into surgery or emergency medicine, so enjoy them while you can. 

     In case anyone is still bummed by the dire consequences of poor eating* or smoking (and also just because I love Scrubs), I have decided to close this post with this cheerful gif and video compilation to celebrate the beautiful friendship that is JD and Turk.

via GIPHY

*I had to do this before a breast lumpectomy and biopsy. The resident had injected blue dye that we hoped would drain to the sentinel lymph node so we'd know which node to remove. Even though I was pretty sure I knew why I was doing it and that it was actually an important part of the procedure, it still felt very weird to be massaging an unconscious woman's breast while everyone else left the room to scrub in. 

*When we talked to patients about simple ways to lose weight, the doctor I was with always shared the same four principles: 1. Don't drink your calories (i.e. cut out sodas, iced coffees, cocktails, etc.). 2. Have protein in all your meals and eat it first. 3. Don't eat processed foods (i.e. go for whole foods and avoid junk foods, even the healthy-sounding crackers). 4. Don't skip meals. Another thing that also came up all the time was that exercise is great for improving the health of your body as a whole, but the deciding factor in losing weight is simply eating fewer calories. In fact, many times people GAIN weight when they exercise, not because (as so many people believe) they are gaining muscle, but because they use their exercise to justify eating more, and they end up consuming more calories than they burned. The more you know.

PSA Update: Donating

     Today's post is just a super quick update on my previous post PSA: Donating. The first thing I have to say is that the Red Cross seems to have taken a cue from Sweden, and are now letting donors know when their blood is used, which I think is pretty excellent. I feels like a much better way to motivate people to donate again than to call them every. single. day. When it comes to donating your body to science, this recent podcast from Stuff You Should Know provides a lot of information about just what that means and the different ways you can do it: How to Donate Your Body to Science. Lastly, even if you can't, or don't want to, donate blood, marrow, or organs, there's still another way to donate your body while you're still alive: let medical students (no matter whether they're future PAs, MDs, NPs, RNs, etc.) examine you or be present during your exams. I cannot express enough just how valuable it is for me to practice examining real patients or even simply observe as my preceptor examines them and explains their findings and the patient's conditions. For an example, Charcot-Marie-Tooth is no longer a vague concept in my head, but a disease whose symptoms and treatments I can easily remember because I can associate them with the kind woman who said yes when my preceptor asked if he could use her as a teaching tool. Yes, it can be awkward, yes, students will make mistakes, and yes, your appointment might go a bit longer, but the experience you give to future healthcare providers is invaluable. Really, in the long run you're helping yourself, and everyone else, by helping make tomorrow's clinicians the best they can be. There's an added benefit for you as well since things are less likely to be missed if two people are covering your history and exam, and there's also a decent chance that you'll understand your own condition better once you hear it explained to someone else. Consider it. 

Primary Care (22/30)

     Primary care is an odd duck.  It's certainly not the most glamorous part of medicine. Patients come in complaining of colds and acid reflux, not trauma wounds and surgical emergencies. It's not exactly the stuff of primetime medical TV shows. It can be tedious and monotonous, and it's no wonder that many primary care doctors become burned out over time. A large part of the burn out is the feeling of repeating yourself over and over without being heard. Much of primary care deals with treating chronic conditions and, more importantly, using preventive medicine to prevent these conditions in the first place. The focus on preventive medicine means that the same topics (e.g. exercise, healthy eating, safe sex, smoking cessation etc.) are covered with almost every patient, yet it can feel like an exercise in futility. It can seem like the patients who are doing well already know and follow the advice you're giving them, and the others have heard it all before and have ignored it. You can't help but ask why they would suddenly listen to you now. 

     A big part of the problem is that primary care battles against silent killers. The diabetic doesn't see the importance of keeping their blood sugars under tight control until they discover the foot ulcer they couldn't feel and suddenly face losing their toe. The patient with high blood pressure doesn't take their medications consistently until they have a hypertensive emergency. The alcoholic doesn't cut back on their drinking until they develop cirrhosis. The patient with high cholesterol doesn't change their diet until they have their first heart attack. The morbidly obese patient doesn't try to exercise until they realize it hurts too much too move. When you try to prevent problems rather than treat known issues, it's easy for patients underestimate their risks or think that they will be the exception. There are some tricks to get your message across, such explaining to the man with high cholesterol that his eating choices and smoking habit not only increase his risk of a heart attack but also decrease his ability to achieve and maintain an erection, yet all too often primary care can feel like an uphill battle, fraught with frustration.

This is not good.

PA-Cat Bob approves of PCPs

     Here's the thing though: primary care might not seem like the most interesting or the most glamorous, but it is arguably the most important specialty in medicine. A primary care provider (PCP) might not be using their fingers to plug lacerated arteries and they might not be compressing a chest just to keep someone's blood pumping, but they are saving lives. They're helping to prevent patients from ever getting to that point of crisis. PCPs are the gatekeepers, responsible for recognizing the difference between when a patient has a common or manageable condition, and when they need to seek a specialist's help. They are the providers who are there for their patients at all stages of life, who get to see their patients in sickness and in health, and who have a truly awesome opportunity to get to see the whole picture of their patients rather than simply how a patient presents in a crisis. And who knows? PCPs might just make that once in a lifetime save after all. The man a PCP works up for iron deficiency anemia might turn out to have esophageal cancer causing an upper GI bleed (and thus the low iron levels). The young guy with pneumonia might have a carcinoid tumor that no one else caught before because they treated the immediate problem and didn't notice the suspicious recurrences of lung issues. The PCP who actually takes time to listen to his female patient and not be biased by the opinion of previous providers might recognize that her malnutrition and frequent bouts of vomiting are actually due to celiac sprue and not an eating disorder.* 
     I don't know whether or not I'll end up in primary care, but I do know that after my rotation I appreciate it, and the potential impact it can have, more than I did before. With this in mind, I have some suggestions now for anyone who will ever be a primary care patient (aka everyone).

• Find a provider you like -I'm not saying you have to be picky and find the best clinician ever, but this is a potentially lifelong relationship you're starting, and there are certain characteristics you should look for. You should find a PCP who listens to you, addresses your concerns, and takes the time to make sure you understand any conditions you might have. Find a provider who is open and honest with you, and is willing to let you seek a second opinion if you're not sure about their advice. If a provider spends less than a minute with you, that's a bad sign. If they spend more time with drug reps than patients, that's a bad sign. If you feel like you're nothing but a nuisance to your PCP, that's a bad sign (unless you are being a nuisance; don't be that guy). You should know what your conditions are, what your medications treat, and why tests are ordered. Now, this last statement certainly requires you, as the patient, to actually pay attention when your PCP explains everything, but if you still have questions, you should feel safe asking them. 
• Get screened -A large part of preventive medicine is screening for certain conditions before they become a problem. While some PCPs may differ slightly in some of their screening techniques (e.g. getting blood work on all patients annually at any age vs. periodic checks after age 40), there are standard guidelines for many conditions which are continually reviewed and revised if necessary. For example, in general, sexually active women should be getting pap smears, women over 40 should be getting mammograms, and adults over 50 should get colonoscopies. The exact timing of these screenings might vary somewhat from person to person based on each individual's risk factors, but your PCP should know the guidelines and how to apply them to each patient. While I know that many people are afraid to be screened for medical conditions because some screening methods are uncomfortable and because sometimes it seems like ignorance is bliss, but the truth is that even if a screening test comes back with an unpleasant result, it's far better to detect conditions early when they're asymptomatic and there's hope of potential prevention or treatment, than later once they've become symptomatic and treatment is much more difficult or merely palliative. 
• Show up on time to your appointments, and call if you're not going to make it -This isn't some huge, life-shattering advice; it's just a courtesy that can be easy to forget. Both in my women's health and primary care rotations I experienced time after time of waiting at an office with all the MAs, nurses, and the PCP because a patient ran late or didn't call to say they wouldn't be coming. If there's limited time for lunch, or if it's at the end of a long day, you can bet most of the people in the office are pleased as punch to have patients who show up right on time (or even a little early), or who call to say when they're running late or can't come.

     There's more that I can (and probably will at some point) say about primary care, but tomorrow starts my week in orthopedic surgery, which means I'm back to a 3:15 AM wake-up call rather than my leisurely 5 AM alarm for my weeks in the surgical offices, so it's time for me to go to bed.

*These are all true examples, by the way. The first two come from a PA and an MD I know, and the third comes from the book How Doctors Think by Dr. Jerome Groopman.