End of the Month

1) Double Espresso-Hold the baby: I couldn't resist. One of our last newborns of the month was born in a coffee shop. I happen to think that this is a sign of divine greatness for this child, and I resisted the urge to ask about naming the kiddo Mocha, or Latte, or Kenya, or Doppio. Happy to report that the kiddo is doing well.

2) 140: If it felt like a busy month, it was. We (my two star first year residents and I) rounded on 140 newborn babies. Of those, we only had one go to the NICU (who did great), 2 to the custody of DSS and the remaining 137 were discharged home to their parent/parents. I skimmed the list this afternoon of those 140 kids, and it's pretty amazing the number of names which I don't recall, but also there are many names which evoke visual images of proud new parents holding their precious new children.

3) Pager Off: Finally, and for another 17 hours I am off/free. Today was day #5 of a 10 day stretch.

4) Pedi ER: Tomorrow I switch to the Pedi ER. I'm actually looking forward to it. It's a 4pm-1am shift all month long. It's been almost 2 years since I was in the pedi ER, and I feel like I've learned a significant amount in those two years. I feel like this is a time to hone in on clinical acumen, as well as a great chance to brush up on some ortho and other topics. I am also approaching this as a warm-up to Bara.

5) Dropping off the grid: Heads up on the upcoming 2 months... I'm working late shift this month, and days will be spent studying for part 3 of boards (USMLE) as well as doing some review for Cardiac ICU in October. It's a bit frustrating because I already feel slightly out of touch with a bunch of people, and know I'm headed into a long 2 month stretch, where it's going to be tough to keep in touch. Did I mention that in October we do overnight call every third night?

That's about it really...

Enjoy labor day.
B

Jen & Dawn

I spoke to my cousin Jen tonight, and got to hear the great news. (They were one of the 6 couples who brought about the lawsuit for same-sex marriage in Iowa). I hate to admit that when I saw the headline on CNN I had this intense feeling of guilt because it has been a long, long time since we chatted on the phone. This photo is from June 05, (I stopped by on my way from Colorado), so it is a bit dated-but it captures what great parents they are. It was nice to catch up on family news as well. Anyway, Jen is incredibly special since she was actually the first family member I came out to, and she has been such a great support and role model. She was funny, when one of the reporters called her this evening and asked her how she was going to celebrate, she said "make dinner and get the kids to bed."

B

The Family

Finally got some pics from my trip to Chicago last weeekend (combined 90th/85th birthday party for my grandparents). It was great to see the entire family. Look at my amazing niece and nephews. Aren't they adorable? Even playing in the rain water and getting all dirty...

Home to DSS, PPI, Pregnancy Testing

1) Home to DSS: This morning we discharged 2 of our newborns "home." For them, home meant into the custody of the Department of Social Service. On many levels, this situation is less than ideal. Less than ideal because it means that these kids came into the world, and their biological creators were deemed unfit to take care of them. Deemed unfit by the pediatricians (us), who notified the state about our concerns for the welfare of these children. The state then investigated and went to court to take custody of these precious 2 and 3 day-old children. The children then end up in a foster care for the night, or for their life, or get adopted, or maybe get re-united with their parents. We gamble that going into the world of foster care means that these children will be loved, sheltered, and fed to the extent that they wouldn't have received from their bio parents. I think it is a shitty way to start life. The protective pediatrician in me almost would have preferred taking these kids home myself!

2) PPI. Or proton pump inhibitor (ie, omeprazole-Prilosec, esomeprazole-Nexium). I was chatting with a fellow resident about my upcoming month in the CCU. I start in October, and it's a bit anxiety provoking. She was kind enough to point out that she had to start taking meds for ulcers during that rotation. Comforting. Thanks.

3) Pregnancy Testing. If you walk into a clinic, and you ask for a pregnancy test, and while waiting for the results you GIVE BIRTH TO A BABY-is the test positive? I kid you not. And, this woman has had a baby before. I know there is some serious comedic potential here... What bothers me most is that there has been no prenatal care. I've thought about this for a few hours now.. no prenatal care. We've done such a good job medicalizing a normal process like pregnancy and birth that I had to stop and think this afternoon about what to do for this kid. The kid looks great. But what if mom has hepatitis B, or HIV, or untreated group B strep, or or or... Or the fact that this woman, who admitted that she "knew but didn't know" she was pregnant made no attempt to ensure that the child she was carrying was healthy. Is this woman fit to be a parent? Am I passing judgment or am I really just focusing my concerns on the welfare of this child? hmmm

Coffee Culture Withdraw

I was suppose to go hang out with my friends Jess and Amy and roast coffee this morning. We roasted a few batches about 3 weeks ago, and compared notes about a week ago. I normally have brunch with them and their adorable almost 2 year old daughter twice a month. It's usually an all day affair, with the consumption of multiple pots of coffee. Anyway, since they have a garage, and since roasting coffee makes a good amount of smoke, my coffee roaster is now up at their place...

 

I went to Amherst Coffee last night. The serve probably the best cup of coffee in the immediate area (ie, less than half an hour away). I'm pretty sure they are serving coffee from the Great Barrington Coffee Company. The ambiance was pretty good as well (though there is a wine bar which is always a bit weird to me, but I guess it's kind of chic and trendy). They have a community table, which I always love. Even better, the place had newspapers strewn all over..

 

That's what this post is about this morning. I really just want to pluck myself out of here and magically appear in a buzzing coffee shop, with lots of copies of the New York Times, and plush couches, and fun people watching. That's the ideal Sunday morning for me... I'm meeting a friend for coffee in a bit, and I think I'm going to give Blue Moon another chance. I recall their coffee may have been a little weak, but they definitely have the best ambiance. Sadly, the Starbucks around here just don't do it for me anymore..

 

Then it's home to study.

 

Bara on NPR

People have been asking about Bara (short for Chris Hani Baragwanath), the hospital that I plan on going to next July. Here is a clip of a piece that NPR did a while back. There is a photo-essay part as well. Worth checking out..

A Week of J2 & Neonatology

I'm on pedi second jeopardy. For a week, which started at 8am on Friday. So far, so good. I'd be surprised if I get jeopardized this time of year. It's quiet in pedi-land. That being said, the head neonatologist said he was going to try and jeopardize me this weekend for a transport. He was, of course, kidding. They would essentially need to have 3 transports going at the same time for the second jeopardy person to get called in. Usually the NICU team can cover a transport, and if needed, they call in the Jeopardy resident to go on a transport if the NICU is busy. Or, if there is an intern working overnight in the NICU, then a senior resident will get called in to go with the intern on the transport.

I've been in the NICU a lot this month, more or less hanging out since the transitional nursery is next to the NICU, and there is a resident call room in the NICU. I've also been hanging out in the afternoons trying to improve my neonatal IV skills. (I suspect that next year in Johannesburg I will be responsible for doing a lot more procedures than we do here).

The NICU staff have been asking when I will be back in the NICU. (It won't be until January). A few have asked if I'm considering a NICU fellowship. I guess after everything that happened in February, I have a bit of a fan club in the NICU. I have actually pondered a NICU fellowship, more than once. From an international perspective, infant mortality is a significant issue and neonatology would be a great skill to take abroad. But, the idea of adding three more years of training is not appealing. Maybe if there were a combined NICU/Pedi ICU/Adult ICU fellowship, I could be tempted to consider it...

If you hear me talk about applying for a fellowship, knock some sense in me. I can easily see myself applying for a fellowship to defer figuring out what I want to do after residency...

The right start to the day

The nice thing about this month: I get to spend the better part of my morning holding newborns.

There is something inherently calming about cradling newborns, and just watching them. I find myself often wondering what will come of them. I know my nomadic tendencies will keep me from taking care of kids for long enough periods to watch them grow up, and see who they become. (Although, my niece and nephews will give me that joy). So, I just hold them and try to imagine them growing up, and hopefully living happy, healthy lives.

More Bats

This is the most recent Bat sighted in my apartment. Granted, this one arrived from a twisted (though dearly twisted) friend, via Fed Ex.

Good thing I have my rabies shots.

Failing Teens vs Failing Systems

"You look like a smart kid, what's really going on with school." And the tough 17 year old started to cry. I felt my visit grind to a halt. I was consciously aware that this would add on an extra 10 minutes to my visit with him. And in that 10 minutes I was scheduled for another "Well Child Exam." I moonlight (sort of) in this evening clinic every now and then (or as much as possible given my future year of poverty), and we're booked 10-15 minutes for well child visits. (Thankfully with a no-show rate of 25% or so, we usually have a bit more time).. You just can't provide good care when in the middle of a jammed pack schedule you have neat teenager, with little support, who at the age of 17 thinks his future hopes are diminished cause he's been screwing up in school. No father figure. No mentor. In a school system that could care less about his future. And he sits in front of me, finally at his breaking point, finally having the courage to admit that he has this inner turmoil. Some of my colleagues wouldn't have gone there. They have the mentality of divide an conquer. And I am learning to do that more and more, that I can't really solve every problem for every person at every visit.. But most days I think that is a pathetic approach to taking care of people. To make a profit, a primary care physicians must see a ridiculous number of patients & triage complaints... They are sorely missing out on the Art of Medicine, and that is tragic. Outpatient primary care is not for me. I can't operate on a schedule mentality. Knowing that somebody needs an extra 5 or 10 minutes of my time should not jeopardize a schedule. And since when does a "schedule" have more priority than taking care of "people."

Hmmm.

Boston and Life...

A friend of mine and I made an impromptu break for Boston on Friday night. I really (no, really) needed to get out of dodge and have some drinks and be around some gay men. Well, gay men with taste. Sometimes it is just so suffocating living here. I can't believe after 5 years of hating the scene in Dublin I moved to somewhere with even less of a scene. Well, not that there is even less of a scene here, in fact there is no scene. (I have to remind myself I came here because I'm in a great residency program). We had a lovely (albeit expensive) dinner, and then plucked ourselves down in a lounge and enjoyed a night of catching up and enjoying some strong Jack and Cokes. (Jason would be proud)! I think I got home about 4am. I think of it as a night of being on call. Being awake fore 22 hours is really no big deal anymore. We made a pact to make it a point to go to Boston (or NYC) monthly. Life is too short to not take advantage of getting out of Dodge more often...

The rest of the weekend was mellow. I spent a few hours working on my application for South Africa. I loathe paperwork. Sadly, work email has been down all weekend, and one of the documents I need to fill out is trapped in my work email. Fingers crossed, I think it will probably take about 2 months for all the paperwork to be completed. Once I get registered with the Licensing Board and the Foreign Workforce Management Program, it should be mostly smooth sailing from there. And then it will feel real.

As for dates, I should be flying to Johannesburg at the end of June (2008), and will return to complete my final year of residency in June 2009, and will finally be finished with formal medical training on June 30th, 2010.

Wow, I just had to sit for a few minutes and look at that date. June 30th, 2010. Wow. It still seems so far away. Ironically, one of the nurses asked me on Wednesday if I was already an attending. I laughed out loud. "No, it just feels like I have been here forever."

Anyway...

I am really looking forward to seeing the family next weekend. We're meeting in Illinois for the grandparents 90th and 85th birthday celebration. I'm really looking forward to seeing my niece and nephews!

Alright, time to go for a bit of a run. I'm trying to run outdoors once a week...

Cheers,
B

Newborn Nursry

Newborn nursery has to be one of the most delightful months of residency. It's a happy day, every day. Well, more or less. It's nice to be in the nursery again. Now that I've had 2 year of pedi under my belt. I finally know what's normal, and what's not. I finally feel like I have a little authority/insight when talking to new parents about how to parent.

As I was examining a kiddo yesterday, it dawned on me that I was the first physician to ever examine this new human. I was the first physician to listen to his heart. I was the first physician to look in his eyes (not that you can see much at this age). The first to feel his femoral pulses. The first to make sure his hips were normal. The first to make sure his back was straight. There's a sense of responsibility that goes along with being the first physician to examine a patient. And then, when I told the mom that his exam was completely normal, I had this sense of responsibility wondering what would it mean if I had missed something on my exam... Who would catch it? (Well, likely the attending)...

I almost did battle with a nurse yesterday. I find L&D nurses can be extremely judgemental-passing judgements left and right about parents and their capabilities to raise children. It's pretty gross really. I almost feel like unless the parents are middle-upper class, English speaking caucasians who kiss ass to the fucking nurses, the nurses tend to have less than favourable opinions about the parents. Don't get me wrong, I'm not a (total) saint, I don't believe that just because you have a pulse means that you will be a decent parent, but I'm all for giving the benefit of the doubt. It's my job as a pediatrician to help these new parents (and all parents) be as successful as possible in raising happy, healthy children. Being a good parent has nothing to do with money, or with the ability to speak the national language. I looked at this nurse, and thought of how my brothers and I were raised, and I think we turned out ok. (Certain sister-in-laws may feel different). I was embarrassed for this nurse. She doesn't have a fucking clue. And she doesn't deserve to be in the L&D ward.

B

Rabies Shots...

HURT! All 6 of them. I have new found sympathy for the kiddos when I order up the 3 or 4 shots at a time. I started the Rabies vaccine series (4 more shots to go) and also go the immunoglobulin today, and that was what made it 6 lovely shots. I referred to it as the mackerena of immunizations.. Shoulder, shoulder, butt, butt, thigh, thigh, oomph!

Fucking Bats.

More Bats

Bat #2 just made a guest appearance. I'm annoyed. And now am DAMN WIDE AWAKE. How am I suppose to save lives tomorrow given the lack of sleep? Oh wait, it's adolescent clinic... don't need much sleep for that..

The answering service didn't consider "bats" to be an emergency... It will be an emergency when I go ballistic if I get a third visitor tonight. I called MS, who suggested that they may be coming from the vent in the bathroom.. which doesn't work, and never has, and may be providing a nice one way ticket into MY DAMN APARTMENT. Retrospectively, the noise from the ceiling, which I always assumed was from a squirrel, may have been, in fact, FROM BATS. Holy Bat Shit! (is that guano?).

So, what does the CDC say about bats??

Q: How can I tell if a bat has rabies?
A: Rabies can be confirmed only in a laboratory. However, any bat that is active by day, is found in a place where bats are not usually seen (for example, in a room in your home or on the lawn), or is unable to fly, is far more likely than others to be rabid. Such bats are often the most easily approached. Therefore, it is best never to handle any bat.

Q: What should I do if I come in contact with a bat?
A: If you are bitten by a bat -- or if infectious material (such as saliva) from a bat gets into your eyes, nose, mouth, or a wound -- wash the affected area thoroughly and get medical advice immediately. Whenever possible, the bat should be captured and sent to a laboratory for rabies testing (see: How can I safely capture a bat in my home?).
People usually know when they have been bitten by a bat. However, because bats have small teeth which may leave marks that are not easily seen, there are situations in which you should seek medical advice even in the absence of an obvious bite wound. For example, if you awaken and find a bat in your room, see a bat in the room of an unattended child, or see a bat near a mentally impaired or intoxicated person (NOT ME TONIGHT), seek medical advice and have the bat tested.

Bat #2 is currently flying in the hallway of the apartments (ie, not my fucking problem right now).. thank god other tenants are leaving for work before me tomorrow..

Argh,
B

Bats

I came home, and there was a bat flying in my room. From where, I cannot tell. It freaks me out. I may sleep in the living room. Where the hell did it come from?

Stacking Stones: A Year Off... Going to South Africa

I've read my post from April 14th, numerous times... There was nostalgia. And then I remembered thinking one day how I wanted to return to Bara to learn at some point as a resident. I had been debating if I would go to South Africa or Peru for my away elective in my 4th year.. And then I began to entertain the notion of going to Baragwanath, but not for a month.. what about going for a year. Yes, what about taking a year off of my residency to go train at Bara for a year... and I got excited... and ran the crazy idea by a few friends, who didn't think it was so crazy...

Here's the deal:
I was offered a 6 month pediatric training post, and a 6 month medicine training post. My program director supported my idea. And today, the chair of academic affairs granted approval for a year leave of absence from my residency program.

I'm going back to Johannesburg, for a year, to train in the most amazing hospital. I am lucky.

I took the stones and re-stacked them, and to my amazement, they didn't fall this time.

Wow.
Brian

EBM is bullshit...

I have to present a patient at pedi morning report on Wednesday am. It has to be an adolescent topic. This is what kills me... I wanted to talk on some relevant topic. Something, oh say, big picture. Something that applied to many adolescents. I wanted to do some teaching about choosing appropriate contraceptive methods, (and review Plan B). Some simple spoon feeding. There are a lot of choices.. pills, patches, injections, rings, all with pros and cons, some with contraindications... My preceptor wanted it focused, and, and wanted something that was topical in the current literature, ie, bullshit "Evidence-Based Medicine" (EBM).

EBM should be renamed boring mental masturbation. What the fuck is the purpose of looking up minutia bullshit when people don't even understand the damn basics. I asked around earlier this month, and realized that we residents (both internal medicine and pediatric residents), had a weak grasp of the basics on contraception. And some spoon feeding (oh sure, I would have done it in a case-based format so it was applicable and interesting), would have really helped to increase knowledge. But instead, I have to talk about some fucking random question that most of us won't have to deal with when we talk about contraceptive methods, and to top it off, there is no official consensus on the question that I am presenting on Wednesday morning.

Mental Masturbation without a climax. Isn't that worth it?!

I'm calling it BEBM from now on... Yep, you guessed it. Bullshit Evidence Based Medicine.

The more I train in the US system, the more I am beginning to think that I'm not being prepared to really take care of patients. I'm being trained to look shit up constantly and to fill out fucking forms.

Back to BEBM.

Brian

HtoTD

How to of The Day:

How to stop being a people pleaser.

Just for fun.
B

View of the East River & Stacking Stones II

On the 33rd floor of a friends flat here in Manhattan looking out over the East River. Walking the city today. Walking through the West Village and Chelsea. People everywhere. Street festivals. dIvErSitY. People of all colors. Admiring the men in the city. The view is addictive. Watching barges, boats go up the river. Looking out to Brooklyn.

Tomorrow at this time, back home. But it's temporary. Finally, I'm coming to terms with the decision I made before residency. I decided to choose the best med-peds program for me, knowing I wouldn't like where I lived. I tried to like the place. I explored the mountains. I looked for good coffee shops. I looked for a solid base of friends. I looked for love. I looked for a group of gay friends. I looked, I looked, I looked. And didn't find these things. I am sitting here in my friends flat, which has a couch, a table, some chairs. It is one bedroom. It is simple. I fell into the trap of accumulating a ton of shit in my apartment, and in truth, what I needed was a simple space.

I am stacking stones (see July 4th entry). I am going to keep stacking stones; I am stubborn and will persevere. But stupidly, I couldn't use my imagination when re-stacking stones. I kept placing them in the same order, looking for the same things, and watching it all crumble. I've started the re-stacking. I think I finally have some peace about my decision about where I live, and quite honestly, I'm done complaining about it.

I have gotten past this unhappy hurdle which kept tripping me up.

Now, I am going to read here in my friends flat, and watch the view.

Cheers,
Brian

1) Shattering ones own confidence 2) Reading

I had been feeling pretty confident lately. In fact, recently I've had a few conversations on how a few of us in our program have hit that stage where we begin to feel like we do, in fact, know a few thingsThat's the tough part about acquiring knowledge, especially medical knowledge. It's impossible to explain what you know. Sure, you can recall some stuff off the top of your head. But in a larger sense, a large part is the application of knowledge. We residents tend to spend a fair amount of time looking things up. And not just looking up, but also printing up stuff to read "later." Like later when I'm bedridden in a nursing home, because that's likely about to be the next time I have leisure time to read.

Tonight, I have decided to throw away all the stuff I haven't read in the last 2 years. (It's a fucking shame there is no recycling in my area. I'm killing trees here)! It's haunting to see the vastness of knowledge I am throwing away. I feel like, OH MY GOD, I DON'T KNOW JACK SHIT LOOK AT ALL THIS STUFF I HAVE NEVER READ, I AM DOOOOOOMED! (The corrolary to this is: OH MY GOD, I DON'T KNOW JACK SHIT LOOK AT ALL THIS STUFF I HAVE NEVER READ, MY PATIENTS ARE DOOOOOOMED!)!

Sometimes I want to gag when I hear the term "Lifelong-learning." I thought I was signing up to learn the bulk of stuff during residency and then do some little learning here and there, preferable at medical conferences in nice hotels, surrounded by ski slopes or warm sandy beaches.. but the closer I get to the end of my residency, the more I realize that residency is preparing me to 1) Not kill people 2) be able to treat the bulk of patients, and treat to a minimal-moderate standard 3) know when to call in backup.

As for reading... between the 4-6 journals a month that I feel compelled to try and read, plus the shit I print regularly, plus the books/study guides for that months rotation, plus the few pedi books that we recommend to parents, plus the stack of books that have nothing to do with medicine, but are a nice escape, I need about 5 more hours in a day to read. Remember when you read a book and had to do a book report in junior high. You wanted to mention some small specific details from the middle of the book so that the teacher knew that you actually read the book. That's how I use to feel about journal articles.. now I read the beginning and the ends.. the boring shit is in the middle... who cares what the delta co-efficient raised to the sputum power of the random blah blah blah... I need to now the level of detail so that I 1) Don't prescribe a drug that will kill somebody 2) can stay current on treatment guidelines so that I can give the best care possible to patients, and 3) what what drugs the back-up docs are using so that when the patient comes back to me from the specialist, I don't look like a fool.

No wonder I almost need bifocals.

Cheers,
I'm off to read.

Brian