Nocturnal Urban Sledding

My family has engaged in a new winter activity this year: nighttime urban sledding. I was out-of-town the first snowstorm/night the sled came out. I had to fly to Philly to take a very secret test with pretend patients and I can't tell you anything about it because it is considered top secret and very "high stakes" in the world of medical education. What I can tell you is that it was very long and exhausting (the whole process of getting there and taking the test), the food was hideous and the hotel I stayed in did not have hot water for my shower. We had to circle Philly an extra time before landing because of high winds which was a bit nerve racking and I was going to be really pissed if I died because of that stupid test. And to top it off I had to miss the first night of urban sledding.
But I got to go tonight! I don't have any pics because our camera does not have working flash. We found alleys, empty lots and snowbanks to sled down about town. It was really fun to just walk around and look for places to "catch a hill". And when we didn't have a good/safe hill to sled down Ms Perpetual Motion plopped herself in the sled and we parents ran while pulling the sled down the sidewalk. She only flipped out of the sled and did a faceplant once.

Sledding

Important to make sure you live in a town with adequate sledding hills in the vicinity.

The patient is a whole person who pees out their meds.

The good stuff always comes towards the end. After the "pertinent" information has been gathered: how long noticed memory problems, episodes of falling, do your own cooking, shopping, manage finances, med list, orthostatic hypotension, focal neuro findings... Then we fill in the gaps and add some color to the snapshot. Sometimes we hear about a traumatic event from earlier in their adulthood, travel between countries and continents, impressive careers, hearts broken, love lost. I like to save my notes from these evaluations because they become experience for me. They have the potential to stick with me for the rest of my life. The header is just an age and a sex. The rest of the page is the beating heart as told by the patient and if we are lucky by the patient's family too.
I think it is the ultimate goal of the family physician to get to a point in the relationship with the patient where you can acknowledge all the aspects of a person's well-being. You will probably not be able to fix everything. But you can always address things. And what we should really be doing with people is having conversations; letting the patient tell their story and interpreting it back to them; commenting on their story; giving our (hopefully) experienced opinion. Unfortunately our primary source of "opinion" has become the faxing of a script for a pill. And people, hold your hats because I am about to write something very disturbing. You know how people go fishing to relax and feel better by being in the outdoors, maybe relieve some depression? Well fish are now showing up with levels of prozac. That is just one example. I like the irony of the whole relaxing fishing vacation/depression med thing. But the thing is is that there are a lot of meds in our water now. And it is not just from flushing unused meds down the toilet but it is also from excreting swallowed meds via the flush. FYI

No Starving Pilgrims Here

Our locally raised slate turkey.


Locally grown cranberries prepped for cranberry pie. I forgot to add the almond flavor so it was a little more tart than usual. Excellent with vanilla ice cream.


I am thankful for all of the great food available to us either from local farms or generous gentlemen farmer friends.

I am thankful that my 1st choice residency interview is over and went pretty well, if a little unorthodox. I was the only candidate not wearing a black suit. I went to medical school, not business school and so I decided a smart gray skirt and sweater would be fine with my purple danskos and tights. So of course the doctor and geriatrics fellow I have been working with during this rotation tease me first thing in the morning about not wearing black. The interviews were my favorite part of the day. I received a few compliments on my personal statement and I felt I was able to be myself throughout the interviews. Now I will have to just wait for February.

I am thankful for the amazing support provided to me unconditionally by my family.

I am thankful for the invaluable teaching and autonomy offered upon me during my geriatrics rotation.

Ms Perpetual Motion was thankful for maple syrup and cookies.

I am thankful to Cooks Illustrated for enlightening me as to how to make a flaky, prize winning, crust by substituting vodka for water. I won the crust category of the pie contest two weeks ago at work.


Locally grown eggs with non-local milk for custard pie.
Happy Thanksgiving Everybody!!!

Euphrasia officinalis Morning

Upon awaking to L-sided conjunctivitis.
And trying to take a history from a three-year-old.
Without the parent from the night before around (hunting).


And no milk for pancakes.
Should have known there was no milk because I am mother.
But I was out last night with friends. Ha.
And going out again tonight.
After getting one solitary eyedrop into Ms Perpetual Motion's hurty eye.
She cried herself to sleep agonizing over another potential eyedrop.
Luckily I will have a beer to cry into soon.

Lipizzaners

After a week of a new, great rotation how better to celebrate than acrobatic, dancing horses? This is how pathetic I am though. During intermission while waiting in line at the snack bar for some juice and water I found myself visually inspecting a large skin lesion on the upper back of the person standing in front of me. Then I found myself looking around for one of the attendings I had seen earlier who was also watching dancing horses with her son because I really wanted a preceptor at that moment.
DDx:
giant seborrheic keratosis
melanoma
giant nevomelanocytic nevus
epidermal nevus
burn
french clay mud (on the upper back)

I was able to accept the fact that I would have to let this one go and return to being an attentive mother.

My favorite holiday-Halloween

Tigers prowled around our neighborhood stalking little old ladies holding baskets of goodies.
After the kill.

My favorite holiday-Tuesday

Treat bag. Getting closer. Lucky for us our town is full of nice witches and nice monsters.

My favorite holiday-Monday

Finished. Just needs a few safety pins here and there and some wooly long johns underneath.

Jack

My favorite holiday-Sunday

Former massage therapist turned osteopathic medical student and mother uses former massage table turned osteopathic manipulative treatment table as Halloween tiger costume prep table.


I would have finished it tonight if I had not run out of thread. Stay tuned...

Old-Timey Osteopath

Sphenopalatine Ganglion Treatment:
Yesterday before I left the clinic early because I felt too snotty and coughy and wasted to be hovering over patients I asked one of the providers to treat me with some OMT (osteopathic manipulative treatment). She did some cranial osteopathy including a sphenopalatine ganglion treatment. Stimulation of this parasympathetic nerve ganglion by the pinkie tip of a trained provider can be quite painful in the back corner of your mouth behind your molars and off to the side a little. But a little pain is better than thick, sticky mudslides of mucus down the back of your throat. This treatment helps to thin secretions. This is the kind of OMT I like the best, for complaints other than chronic low back pain that will really only respond long-term to better physical conditioning. Through my career as an osteopath I hope to develop a skill set of OMT that I can use for things like upper respiratory infections, bowel complaints, chronic sinusitis, colic and reflux.

Colored Queen Anne's Lace and other joys in life

One day this past summer Ms Perpetual Motion and I were walking down the road when she looked over at some QAL and said, "Mama, let's color the flowers."
My Great Aunt Helen used to do this with me.
I thought it was magical.
I do not remember ever discussing this with my wee one. And Nana said she never did either. So with a chill creeping up my spine on a hot August day we collected flowers and took them home to drink the colored potions we lovingly brewed with food coloring and tap water in funky seventies style glasses.

I have Internet again again after six months!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

In three days I will be finished with a challenging rotation and in five days will begin a new one at the place I hope to be a resident next year.

I did something nice for myself today, got a physical. It had been way too long. I got to be the one who got to talk all about themselves and have someone interested and caring listen. I got to stop feeling like quite so much of a family medicine/preventive health care advocate/hypocrite. And those ladies at FamPlan are so nice and considerate.

Transformation

Moving from third year to fourth year: Regular people might not realize the significance of this but other doctors and residents and nurses know that there is a difference between third year medical students and fourth year medical students worth noting. Third years are new to the whole clinical scene. Third years are not only learning medicine but they are learning where the bathrooms are, how to write notes and orders, how to get a list of really handy phone and beeper numbers, passwords for all kinds of electronic medical records systems, how to present cases. Fourth years are still learning all of this but they have been through one year of it already and that counts for a lot.

I remember sitting in the ER during one of my first admissions in Internal Medicine and painfully, slowly struggling through trying to figure out how to write the orders this guy would need to get admitted for his heart failure or COPD exacerbation or whatever was going on with him (still not 100% sure). And I remember being aware of the resident and attending who were graciously sitting there with me while I painfully, slowly struggled. They had to make themselves sit there and let me get through it. They had to literally sit on their hands and I am eternally grateful for that.

A few days after that I picked Ms Perpetual Motion up from grammy's at the end of another long, tiring day and just wanted to get home where it would be time to feed the dog, make supper, try to herd a wild child inside while I cooked so she would not drown in the lake while unattended and of course Ms Perpetual Motion wanted to buckle her car seat buckles herself. And she could do it, I knew that, but it would take longer and I had to sit on my hands and let her struggle through it so she could learn how to function in this world and my tired ass would just have to wait (supported by my hands of course).

I will be starting my fourth year rotations soon and Ms Perpetual Motion will be going to an organized preschool type deal soon as well. I am just hoping we are both prepared enough.

I Don't Study Everyday

After a few hours of studying or doing Kaplan Q-bank questions my brain feels like these cups of swirled paint. So this is what I do on some days to reboot.




Wicked good Chocolate with rainbow sprinkles.


Water can be very healing. That was not in the board review book, I learned that on my own.

The Cat Came Back

I walked all around the house and all through the yard cooing, clucking and calling 'here kitty kitty kitteeeeeeeeeeee.' I called down into the heating vents, into the bushes, into culverts and throughout the musty basement. Nothing. It was time to go get Ms Perpetual Motion but I could not give up. Husband had seen her. She was alive. I would get Ms PM and come back. I left the bag-o-tuna out and drove over the bridge to the calm serenity of Ms PM's baby sitter's house. When we returned I decided to try the trail out behind the house. Maybe, just maybe she was out of earshot. I thought it was a long shot but had to try. I got the stroller that we had left in the garage and put Ms PM in it. It would be easier to search for the cat if Ms PM was somewhat confined. We walked a lot further down the trail than I thought necessary but I just needed to clear my head a little, when who should spring out of the bushes with a chirp but the mangy gray cat that was our pet. "Crescent!!!" squealed Ms PM. My cat is no ordinary cat. She loves us but does not know how to show it. I could tell she desperately wanted to come home but she refused to simply come to us. We had to slowly walk back towards the house, continually calling 'here kitty kitty kitteeeeeeeeeeee.' She slowly walked back through the woods parallel to us but about 15-20 feet away. When she was close enough to smell the tuna she took off like a shot across the yard.
Now how was I going to actually catch the cat and put her in the car while keeping Ms PM at bay?
"Ms PM," I pleaded, "Please wait here while I get Crescent."
"No mama, I wanna help."
It went on like this, me pleading and Ms PM refusing to sit idly by.
Eventually I had the clever idea of opening the front door of the house which Crescent could not refuse. She really wanted inside. And I was able to trap her in the tiny mudroom.
Now Ms PM could be of use. While I tried to keep from getting shredded by the scared, hungry kitty I asked Ms PM to please open the car door. She did, but bonked her head in the process. Now I had a crying child and a scared cat getting more and more agitated by the moment by the cries of my child who I could not help because my arms were full of terrified cat.
"Just get in the car," I cold-heartedly demanded. "Just get in the car so I can put Crescent in too." We all piled into the back seat in a sweaty, pained mess. I slammed the door shut. We had her. The cries faded with the excitement of having a cat in the car. I managed to get back out of the car to shut the front door of the house and back into the car without the cat escaping. As we pulled out of the driveway I spotted the stroller.
"Damn, I left the stroller out."
When we arrived home with the hungry, skinny cat and Ms PM doing just fine I asked husband to swing by the house tomorrow and get the stroller.
"Don't forget," I emphasized, "The blanket and sweater Nana made (by hand woven blanket that probably took about 8000 hours and knitted sweater) for Ms PM are in the pocket of the stroller."
I swear to goddess he said, "ok."...

Lost

Moving becomes more and more traumatic each time, since having Ms Perpetual Motion in our lives. There is so much more stuff: blocks and books and old ratty cloth diapers and adorable onzies I can't part with even though they have not fit for two years. The poor dog and cat get awfully neglected during these weekends of utter chaos. During the second to the last move, in August of 2006, the dog practically went into respiratory distress between the humid, miserable August heat and the inevitable dust whirling through the air during the packing process. He fared better this last move but the cat suffered instead. We had decided that we would just get her loaded at the very end, after everything else had been dealt with. It was a pretty complicated move because some stuff would go with us for five months or so and some stuff would go to a few different storage facilities. The owners of the house to be moved out of were there fixing, painting, cleaning, mowing and such in preparation for re-entry onto the housing market. I was in the middle of one of my tougher medicine rotations. And in and out and all around amongst all of this was a wild-child zipping here and there, feeding voraciously off of the madness of her sticky, filthy parents. This time it was the cat who got left in the dust. She was not actually abandoned. We looked for her at the end and we suddenly realized she was nowhere to be found. I sent everyone away and tried calling her all through the house and all around the house and yard. This technique had worked in the past. She has a history of only coming to me and only when there is an ire of calm. But I heard nothing. No mews or meows or chirps which she sometimes makes when sprinting across the yard or living room. It seemed as though she had become fed up with us and our hectic life and just took off to live out her days in an undesirable town.

I went back to the house three or four afternoons in a row after work the following week and tried calling her. We had left tuna out. I went down into the basement and tried to listen for any little kitty footsteps in the extensive duct work. Nothing. I worried she had wedged herself into the drier vent, got stuck, suffocated and expired. There were no real signs of this except for my paranoia. (She had done this before when my parents moved out of one of their houses, but that drier vent had a larger diameter and less tortuous course.) Into the second week of the disappearance I had given up hope. She was a fifteen year old cat, seemingly in fair health but maybe she had just gotten tired and decided to take that last venture into the shrubs I thought.

At the beginning of the third week missing I got a call from my husband saying he had gone to the house in the morning (doing a little post-move-out turd-polishing for the owners) and he saw Crescent streak across the yard. He attempted to call for her but knew it was pretty much futile. I managed to release myself from the chains of the hospital world a little early that day and made a stop at the market for some tuna in bag on the way. I had about 30 minutes before it would be time to pick up Ms Perpetual Motion from the baby sitter's. It would be so much harder to catch the cat with her at my side. I knew I had to work efficiently.
To Be Continued...

The Pirates Have Landed

After moving among boxes and contractor size plastic bags of clothes for a week we have finally settled into our new home for the warmer months. We have not moved far from our previous abode. If I had to deal with moving more than twenty minutes away I think you would find me on that psych ward I rotated on a few months back. The beach needs to be cleaned up a little and it is pretty chilly in the mornings now but it is going to be a very nice place to come home to after staring at sick, leaking, coughing, infected people all day.

Moving

Moving for roughly the 19th time in my life.
Goodbye to river valley life.
To someday permanently affix a framed picture to the wall is a dream.

Learning How To Take Of

This Internal Medicine rotation is really great because I feel like I am learning, learning, learning a lot, all the time. I go see patients on my own, write notes, go back and see what the residents and attendings wrote, read about stuff, order something if I think it is necessary (have it cosigned of course), read some more, review the notes and the lab results, attend teaching rounds and conferences. There is a lot of repetition and that is good for me because I feel like it takes me awhile sometimes. I have to feel like I am experiencing something to learn it.
As I was driving home from my weekly 30+ hour "shift" I thought about how sometimes when I am presented with a question I sometimes have the right answer in mind, or a gut feeling about the right answer but I freeze when it come to actually saying the answer out loud. And then I thought about how this rotation feels like being a mom. I see patients in bed, during the day, at night, in the morning when they just wake up or I wake them up. I ask them about how they slept or ate or pooped. I look at their feet and then tuck them in again. Sometimes I check on their or their labs in the middle of the night. I walk down the halls past their rooms while they are sleeping, I peek in their rooms. I have a lot of confidence taking care of my daughter when she is sick and well. I can gage her fever and how she seems and decide if she needs medicine or not. I can assess her nutritional needs and what would be a healthy and good-tasting snack. I can tell if she needs to go to the bathroom or if she is a little constipated or hungry or tired or hurt or if she should drink some water. It took a while to gain that confidence and it is not there 100% of the time. So I realized that I need to just gain the confidence to make decisions about my patients in the hospital because I am taking care of them too, sort of like like a mom. Instead of deciding about a carb snack or a protein snack I am choosing an antibiotic. In addition to learning the medicine this rotation has taught me about my role as a caretaker and decision maker for my patients.
It has seemed scary in the past to let my then one year old go outside without enough clothes on for a clammy, rainy day and splash around in the puddles. And it is really scary to pick out drugs for people to take and invasive tests for people have but that is how they get taken care of in the hospital.

Happy Earth Day

I celebrated Earth Day and the two day interlude between Family Medicine and Internal Medicine by going to a really beautiful part of the world with Ms Perpetual Motion. It turned out to be the perfect mix of sun, fun activities for kids, and hands-on with sea creatures. We both returned home a little brighter and little sleepy from a whole weekend of walking!!! After arriving we did not drive once until we got in the car to go back home. It was really nice because now I am driving about 40min. each morning to go learn from really, really sick people. Yesterday I felt a little overwhelmed after spending several hours in the afternoon in the ICU struggling to understand the dynamic process of multiple organ failures...cardiac, lung, renal...in the same person. OK, since I was raised a Human Ecologist, I should be able to grasp this concept pretty easily. Everything is interconnected. The heart is like the watershed, the lungs are like the trees and the kidneys are like the wetlands. If you destroy the wetlands, then silt and junk builds up and becomes toxic. When the trees are gone the world becomes hypoxic. And if the watershed is interrupted plants and animals starve or get flooded out.
Today was a little better. I was able to find my way around the hospital a little more. Mother Earth was stable on her ventilator. But one big lightening strike could settle things down to a depth deeper and more still than Death Valley.

Texture

I love seeing patients out in the community. I don't acknowledge them unless they acknowledge me first and then I just say hi. I don't engage in any conversation about their health. I just like seeing people in little snippets of their lives because it adds texture to the picture I have of them in my mind. Occasionally I see patients at stores around town, walking down the road, at the park or playground, at community events or waiting for a bus. Most of the time I assume that patients don't remember me because they may have just met me once when I was shadowing another doctor. I have not had many patients of my "own" so far so I don't run into those precious gems often. The context in which you see a patient can highlight aspects of their history or medical issues. I like to see a patient, who has been working on things like lifestyle changes or stress reduction, out for a walk. It can be telling to see a patient who claims to be in 10 out of 10 pain with a terrible limp, walking easily up a hill.

Once I saw a patient heading into a pharmacy a few hours after getting a prescription for antibiotics for her child. It was a freezing cold day. A few days later I saw that same patient on the other side of town near a part of town that she probably lived in. I knew she didn't drive and that she had had to walk a few miles, pushing her son in a stroller on a cold, windy day to go get those antibiotics. I think it helps to have as telling a picture of your patients as possible. You can ask all kinds of questions but actually seeing people in moments of their daily lives adds a much more tangible element to the care that they can receive from you. A psychiatrist once told me that you have to care about a patient in order to help them. For me that continuum comes more easily the better I know a patient and the more connected I feel with them.

Once I saw a patient who I felt I had completely blown it with in the office. Her kids were actually the patients and she was a tired mom who had been up all night with a sick child. I just managed to fumble through the visit, probably adding to her already fatigued level of elevated stress. I happened to be with my daughter when I saw her out in the community and found myself wishing that she would see me and remember who I was and see a snippet of my life, as a mother, and maybe see that I could relate to her a little even though I was not the best student doctor that she saw that day with her sick kiddo.

To me this is part of what family practice is all about. I envy the doctors I work with who have been seeing the same patients for ten or twenty years. The doctors know a lot about their patients and the patients know a lot about their doctors. They see each other in and out of the office. Their kids might know each other. They might have the same mechanic or hairdresser, and they might fight for the same issues at town meetings. Or they might have very different opinions about the community they share. When I grow up I hope I live in a community where some of my patients live.

Happy Bunny Time of Year

The sugaring is drawing to a close but we have lots of colorful eggs, eggs, eggs to make us feel better. And that adorable bunny who manages to make the rounds without a sleigh or the help of dozens of elves or reindeer. Ms Perpetual Motion was thrilled with her basket, it had a farm theme this year, and she didn't even mind the bunny poop. She insisted that it was not bunny poop, but chocolate covered blueberries. I'm still not sure. It looked a lot like bunny poop. We went for a toboggan ride, yes a toboggan ride on Easter, searched for tadpoles and released several million cattail seeds into the blustery April sky.

Vernix Queen

There is no better high for a medical student than being able to correctly answer a question asked of you by an attending. Today I had the correct reply to "What is that white , cream-cheesy stuff that covers the baby when they come out...?" "Vernix," I replied with confidence and a spring in my step. A small thing, I know. But it does not take much these days. I know some stuff but I am continually disappointed by the periodic realization of how complex patients can be and my baby steps toward being able to handle and just be aware of that. But that is the great thing about family practice. It is not just low back pain or just a tickle in the throat. The back pain and the sore throat come with many strings attached. Some strings are attached to heroin abuse, some attached to an abusive husband. A lot of the time strings are attached to depression and/or anxiety. Chronic medical conditions get attached, like diabetes, hepatitis C or lupus. Some strings attach to a spouse's medical condition, like migraines, or a spouse's substance abuse, like second hand smoke exposure. These strings go in and out in all directions until you are left with a picture of a big sticky spider web sketched out in the chart. It can be overwhelming when I am having a hard time just remembering the names of a few medications. It is fascinating to watch seasoned doctors weave their way through these webs. And then being able to dictate that all from memory is another feat.

Mental Health

The sweet steam of spring has begun to waft through the air and temp taste buds toward fresh green shoots and warmer weather. Soon summer will be here. Between quarts of maple syrup lining my pantry shelves, being fabulously entertained and rightly challenged by my family practice rotation and watching four kids under the age of six churn through a bubble bath like a pod of wriggling tadpoles, I'm enjoying every minute of life these days.

Family Medicine

Knee deep in family practice right now. I was a little worried before the rotation started that maybe I would not like it and then what would I do because I've always thought that family practice is what I want to do. No worries so far, I am loving it. I'm even having fun with the overweight men with diabetes, high blood pressure and high cholesterol. I think family practice has the perfect blend of talking with patients, examining patients and doing small procedures. The brain and hands both get a workout. In one week I have had a plethora of interesting patient encounters: Intractable crying, except when lying down, Kids with hurty ears, Buddhist with schizophrenia, Lots of high blood pressure, Lots of depression, I got to do a pap!, Knee injuries, Vague chronic pain, you name it and it will probably walk through your door eventually. If the psych ward is like a pirate ship (not my analogy but I like it) then the family practice clinic is like a circus.
Everyday I laugh, want to cry, am challenged, feel incredibly naive. I don't think my naivety is a completely bad thing even though it feels like a hindrance sometimes. I think it can be valuable to come at medicine or patients with a lets call it fresh perspective. Here is an example of where I am naive, I mean fresh. People can get really sick. I am totally new to the idea that someone can have so much edema/swelling that it can seep out through their skin. I don't think I really knew this a month ago. And I have been interested in health care for about 17 years, I've been thinking about medical school for about 10 years, I've made an actual commitment to becoming a doctor for 7 years now and I didn't fully realize that you could soak your pants and shoes with fluid seeping out your skin. I feel silly and thankful that I've had such a healthy family. In other words, this never happened to any of my grandparents. I also feel really naive about medications. They have never really been a part of my life and I have a hard time relating to them. I also have a really hard time imagining myself actually prescribing them without freaking out about it. I am a not pill person myself. I don't even like to take ibuprofen or tums. I do sometimes, but very rarely. It just doesn't occur to me to take things, except a multivitamin and a fish oil capsule. Does that sound weird? It feels weird in the world of medicine. So these are a few things I have thought about this week.

A Crafty Blogger I Will Never Be

As much as I would like, a crafty blogger I will never be. I love to escape into the beautiful, artful, original, creative, crafty blogs that sparkle and dazzle and make me feel like a complete loser. The crafty toys my daughter has were purchased, the homemade skirt I own has little threads coming out the bottom because I am too lazy to do a proper hem, I can't find the time or energy to seek out thrift store and yard sale gems. But I still love to wander slowly through those blogs of amazing ingenuity and adorably cute creations and just be taken away by it.
I can write though, a little. At least my sixth grade teacher said I was good at it. And I always feel better after writing a little about my day so I sweatingly decided to start a blog. Shhh, don't tell anyone.
On reason why I will never be a crafty blogger is because my time is spent trying to make myself go insane by being in medical school, not giving my daughter up to an orphanage or running wild on the streets and trying to slap together some semblance of a homelife with my husband. Here are some more reasons why I will never be a crafty blogger:

It seems like crafty bloggers, in addition to creating their crafts, always have really clean homes, even when they have two or three kids running around. Here is a typical mess in my house after daughter squirt has used my neatly stacked pile of books like a treadmill.



This is our craft area, a mess.



This is the most crafty thing I have created in the last several months, a bunch of paper hearts glued to a thread and hung up for Valentines Day.


Another reason why my home will always be messy...and full of wet kisses.