(the stone analysis is still pending, and she has to go back to the vet’s for another urine sample. The diet changes will happen once we know what the stone was made out of.)

One of the questions that comes up in this house is which cat would survive if they were to get out.   They are both inside cats, but Izabelle has some wanderlust and dashes at the door from time to time.  She is never really sure where to go when she gets out, and so I have been lucky enough to scoop her up and bring her back inside.

Beazlie has no real interest in going outside – she has been out on a leash, but simply sits down and looks at me with a “can we go back in now?” look on her face. She’s not a fan of the great outdoors.

Both cats were running around the kitchen with more fervor than usual this morning. I let them be until the action moved into the living room, when I saw they were playing with something that looked like one of their toys.  I was content to let them be until Beazlie started growling at it and Izabelle wouldn’t back off.

I didn’t have my glasses on at the time, but when I approached them neither one moved from where they were. I moved a curtain aside and then saw that a mouse had jumped up onto my pant leg. I shook it off, but then realized it was now free to run around again. It took off towards the bathroom, but stalled behind a wardrobe.

Both cats took off after it and showed great interest until it ran into the bathroom. I chased it back to the living room while they sat still and watched me. I egged the cats on, even picking them both up at one point, hoping they’d “see” where the mouse was and go after it – but no luck. They’d meow and wriggle and then get down and run back to the rug, where they could watch it all happen at a safe distance.

Eventually I cornered it, and caught it in a drinking glass.  I took the little thing outside, and after whispering, “this doesn’t mean you aren’t going to die, it just means that you aren’t going to die in my house today,” I set it free in the backyard.

As for the question of who would survive it let out of the house? The only answer I’ve got is this:   I’d do just fine.

(chasing mice is hard work, and so long naps were had by both cats. Iz just happened to be napping where it was too dark for me to get a picture of her…)

- locally grown apples

- the tomato plant in my yard still growing/ripening tomatoes

- a check engine light that spontaneously resolved less than 24h after appearing

- the parade of socks that await my return home from work each day

- that things at work are finally resolved.

There was a meeting at lunch time today – just a few of us present, but the important people were there.  It was the sort of meeting I imagined happening many months ago – people who were trying to determine what they could do to help me, what schedule changes needed to happen, and encouraging me to slow things down as much as I needed in order to succeed.  (in fact, I had to convince them that I didn’t actually need to cut things in half, seeing as how I do okay once I’m caught up. A half day a week seems just about perfect.)

I’m not sure what changed, but at the same time, I’m going to try not to question it or over think it. At this point I honestly think that I will make it through the rest of residency okay.  I’m not sure when I last thought that was even a remote possibility.

This spot is named for my polydactyl cat Beazlie – she has extra toes on all of her paws and is the quieter (and sometimes more shy) of my two cats.  She and Izabelle  help me fill this space I call home, and I didn’t realize how much I loved having them until Beazlie started acting a bit off, and then started peeing on things to get my attention. She had a great deal of blood in her urine, and I was more than relieved (no pun intended) when she started using the bathtub as an emergency litter box instead of my piles of laundry. She was treated for a UTI twice earlier this year, and so I called the vet and got her started on another round of antibiotics. She was just over three weeks into the treatment this past weekend when I took her to the vet because I was continuing to see blood.

The vet was kind and once she found out I was a resident, talked to me realistically about what might be causing her symptoms. While Beazlie sat calmly in her carrier, the vet talked about causes of UTIs in cats, and other random things that they don’t see very often.  She tried to get a urine, but Beaz peed before she could get a sample, and on a whim they decided to take an x-ray.

(both the vet and the tech gushed over how sweet and cooperative she was, and I had to agree with them though I challenge them to think that after having to give her abx pills daily for three weeks….)

The x-ray showed that she has a bladder full of stones — I stopped counting at 15,  but the image that sticks in my mind is that of a bag of marbles.  This fully explains why she has appeared to be in pain, why she meows while she is using the litter boxes, and now, why I’m seeing so much blood.

She is scheduled for surgery next Tuesday, and I’m to give her daily abx until then. (I also asked them to remove the claws from her extra toes – they do not grow properly and in the past have become “ingrown” to her paws, and this will prevent it from being a problem in the future.)   I know that she will feel a great deal better once the stones are gone, and she has healed, but still. It kills me to think that she had no idea what will happen to her next week.

(she has a thing with laundry – and after dragging her toys [up the stairs at night (and into bed with me/us) and back downstairs during the day] got old, she started picking socks out of my laundry baskets. Initially she’d just bring a sock or two into bed at night, but now she takes it upon herself to spread out socks all over the house. Yesterday my mom came by while I was at work,  and saw firsthand a line of socks in the kitchen. Just evidence that Beazlie was busy when no one was home.)

She really is a great cat.

February: One month in Fort Collins, CO working on their inpatient peds floor and spending lots of time in the NICU.

March: home for three weeks, then a week in Little Rock, AK at a conference.

April: One month in Nashua, NH working on the floor of a “high volume” maternity ward. They have 19 inpt rooms and a triage room, and there were times when there were 9+ patients laboring (that I was to be managing).

May: immediately after returning from NH, start two weeks of night float. Night float is a system that lets us avoid all having to do a lot of call during the week, because for two weeks one person stays in the hospital from ~6pm – 7am the next morning. It’s hard for me to flip my days and nights, but it was even harder after I’d been away for a month.

May-June-July: The end of May I was on a Saturday on call. Then I was on call the next Saturday, then the following Sunday. That means that in a four week period I had a single day off,  because a Saturday call means doing the whole day and night, and rounding Sunday morning. I then had a whole weekend off (!) followed by another Saturday on call, and then ended the six week stretch with call in the hospital for my “holiday call” on July3rd and 5th (two more weekend days). So, in total I was on call 5 weekends in 6 weeks, and did 6 weekend calls in the same time period.

It’s safe to say that I pitched several fits during this time period, as I thought it was very unfair that I was doing so many weekends on call, let alone so many weekends in a row. My fits were largely ignored, or it was explained to me that “it’s how the cards fell.” I also was the recipient of many “better you than me” and “I’m glad I’m not in your shoes” looks from my co-residents.

That time period felt like hell, literally. I wasn’t sleeping when I was on call OR when I was at home. I was overwhelmed with all of my responsibilities at work and at home, and so I feel behind in everything. My bills were late and my charts were in the “I’ll never get caught up” category.

Then, July 7th, my dad got sick and wound up in the hospital.

He started out having a fever that came/went (before July 4th weekend), but soon was feverish, tired, and just all over sick. He was seen by the docs twice – the first time he was told to keep pushing fluids and take tylenol, but the second trip to the office resulted in bloodwork, and xray and then admission to the ICU for a large left sided pneumonia. At that point the bloodwork showed that his kidneys and liver were stressed (and that’s putting it mildly – his kidney blood results were in the “bad bad bad” range). He required oxygen and high dose antibiotics, and because of the elevated levels he couldn’t have tylenol or ibuprofen to bring his fevers down — so they packed ice around him and had fans blowing on him. He was miserable and it was several days before he stopped having 104F fevers and he started to turn the corner.

The other thing swirling in the background throughout the past year is a bit harder to explain. The short version: a few years ago I was in a pretty bad car accident (run off the road and flipped over bad) and I hit my head. Though I walked away from the accident, I have elements of a head injury. Some things have resolved, but others I’ll likely have to continue to face or adjust to for the foreseeable future.  I have a harder time paying attention now and from time to time I have headaches, ringing in my ears and feel off  balance. I am much less able to deal with sleep deprivation; after a certain point my ability to focus disappears and things take me 2-3x longer than they should. I also can’t keep things organized in my head as well, and am much more apt to mix up my words, substituting other words in their place.

As a result, I would get behind on my charting from time to time, then scramble to catch up when I was well rested. I had been meeting with my advisor and the program director to talk about these instances, and some adjustments had been made in my clinic schedule to allow me time to get caught up.

However, once the events listed above were going on, no amount of extra time in the clinic was going to be able to help me. The level of extreme tiredness was just too much, and so (partly at my request) a remediation committee was set up. The goal of the committee was to help me identify what the problem was (easy as that was) and then come up with a solution.  Over the months of July and August I slowly worked to get caught up, but found that when I was on call three times in two weeks, or twice in a four day period I’d fall behind again.

The committee was aware of this, and could report back to the program director that I seemed to do better when I was well rested.

The director reported back that he didn’t feel I was doing enough, and that I had failed remediation. He would present this to the faculty, but I may need to be put before a separate committee for “due process.” The whole point of due process?   promotion or dismissal.

Two weeks ago the faculty was presented with my case – my current committee shared what I had been doing, and then the director led a discussion based on his thoughts and the information he had. I wasn’t at that meeting, but it was obvious that it was heated because shortly after the meeting people wouldn’t make eye contact with me, even my advisor and other members of the committee avoided me. I finally pinned them down the next day – and each time I talked to someone I heard a different story.  The discussion sounded like it  was heated, and included identifying system-wide problems that needed further talking about. The decision was made to continue the conversations at this week’s faculty meeting.

I made the decision to attend the faculty meeting this week – the opportunity had been offered to me earlier but I wasn’t in a place to face the entire faculty and staff. This week, however, I made the decision to be there.

So Wednesday morning I walked into the meeting, pulled up a chair and sat front and center. I was a few minutes late because I waited until someone else walked in to make sure I was being discussed – there was no use in me being there if I had been nixed from the agenda. They waved me in, and my entrance stopped the speaker cold, as they shifted from a “she is not…” to “oh, here she is…”  There was a short bit of uncomfortable silence before they welcomed me, and the discussion started up again.

I respectfully and patiently corrected them when something false was said, and updated them on all that I had done. I sat up as tall as I could, despite the sweat dripping down my back and my inability to make eye contact – I looked over people’s heads into the corners of the room.  There were a great number of pauses on their end.

In about half an hour I went from failing remediation to passing it, and from needing to be worried about due process to being told that I could continue as I was with some modifications in my schedule (a half day off each week or every other week to catch up on charts/sleep under the FMLA). The discussion was focused and any/all problems were resolved.

I think I am good to go now – I have a meeting with the program director this week because he wants to meet with me before any changes to my schedule are made. I am no longer going to meet with him alone and so instead will bring people who support me. I will sit up tall, and not be afraid to correct him. Too many people were at the meeting last week for him to turn back on what he agreed to.

The Jewish new year started a week ago, and my hope is to stay updated here and on flickr. Here’s to hoping that it’s not another year before I’m back.

I was about to write that I don’t like this time of the year because I miss the sun and it feels like it takes me a long time to warm up once I’m cold…but the truth is that while I miss seeing the sun, I like the feeling of settling into my house, and look foward to climbing into my bed – the one that is piled high with quilts and a down comforter.  The idea of hibernating appeals to me, and I think I’d be happy to just stay home reading, knitting and drinking tea.

For the last few months I’ve been openly exploring Judaism. It has appealed to me for the last few years, and after almost two years of reading about the rituals and following the calendar, I met with the local Rabbi and have started the process of studying in preparation for my conversion.  I look forward to the Friday evening services, where the candles are lit and the prayers are chanted. Slowly I’ve gotten to know members of the community, and they have welcomed me with the proverbial open arms.

Lighting candles to welcome (and end) the sabbath means a great deal to me, even more so now that it’s dark earlier in the evening. This year I will light the candles of a Menorah, and I’m looking forward to watching as the glow grows over the course of the 8 nights. (it may have to be modified for the nights I’m on call, but I am still looking forword to it!)

What does this mean for my friends and family who celebrate Christmas? This year, it doesn’t mean things will have changed a whole lot. Next year and future years? I’m not sure. My immediate family has shifted the focus of the 25th of December over the last few years – it’s now about spending time together as a family with a few small gifts. I suspect that it will remain this sort of day until there are kids running around again.

I have been spending a lot of time thinking about a lot of things lately – thinking about where I’m at in my training, where I want to be in two years (or ten years?) and what, outside of work, I am looking for in life. I’ve also been trying to find the snooze button on my biological clock – the drive to procreate is alive and well, but I’m not in a place where I can realistically pursue it right now. There are a lot of possibilities out there, and I’m trying to be ready for whatever comes next – whenever and wherever it appears…

(more patient composites to come – they’ve been in draft mode and I’ll finish them up tomorrow.)

Yesterday a long day.  It wasn’t a long day in the sense that I left the house at 7:30 and returned home again at 5pm, but it was emotionally exhausting and simply wore me out.

(I spent the day in the presence of a doctor and his staff who all voted for the other candidate. They were upset, angry, hateful. It was hard to remain joyful and my tongue was sore from nearly biting through it…)

I returned to my parent’s house, as they live closest to the office I had been in, with the edge of a migraine that I thought would pass. I had plans to head home to my house so I could change and attend a gathering for friends and their year old daughter, but that all changed when I climbed into the guest bed at 5pm and slept for a few hours. I got up and tried to be sociable, but the nausea sent me back to bed. I woke up this morning in my clothes from yesterday, finally feeling a bit more rested but still exhausted.

I hope that this level of exhaustion is just a residency thing and it’ll get better once I am in an office with a regular schedule. It can’t get worse – right?

(this isn’t the tone of what I was trying to do this month, and daily posting is likely to be impossible, but I’ll try to keep up!)

The American people decided it was time for a change today.

I look forward to the change that is still to come.

(again this could be any of my patients, male or female, old or young, one who comes in by themselves or with a whole family group.)

“I know my body,” she says. “I have had this sinus infection for weeks and I just need an antibiotic.”

She won’t answer my questions and doesn’t take me seriously when I ask her what over the counter meds she’s tried. “You know, everything. You name it, I’ve tried it.”

Neti pot?  “No, I’m not putting anything up my nose.”

Humidifier? “no, we don’t have one, and I’m not getting one.”

Menthol, vapor rubs? “No, they stink and make me break out.”

Then she adds, “oh, I’ve had a fever. I got hot, sweaty, flush.”

I ask her what her temp was.
“I don’t know, I didn’t take it.”

I explain that a fever is a temp greater than 100.9 degrees F.

“It was at least that,” she says, shooting me a look that screams “don’t mess with me.”

I look in her ears, mouth, nose. I listen to her heart and lungs, poke on her belly and look for any rashes.

“I don’t know why you have to do that when the problem is in my sinuses,” she says, after nearly every point in my exam. “I just need antibiotics. Why don’t you people listen to me?” She puts the neck of her expensive turtleneck sweater back up with flourish and huffs as I pull it up to examine her abdomen. When I’m done she sits up, immediately putting on her jacket and standing up to check her makeup in the mirror.

I look over her medication list, updating it as we talk. She swears up and down that she always gets antibiotics from us, but I only seen one in the last two years, despite her claim that she’s had seven sinus infections in the last year.  I calmly explain that antibiotics are not the best way to treat a sinus infection, and that she will likely get better on her own faster then she will with un’needed medication.

She sighs a very deep sigh, and then starts in on a tirade about how long this has been going on (the magic term is “a month” as she’s probably heard before that she can’t get abx without having symptoms for 4+ weeks), how nothing else will work, how she can’t ever see “her” doctor and when she was seen at a different office they would just send abx to the pharmacy when she called.
I’d really like to ask her why she left that office, if she always seemed to get what she wanted.

I explain what she should do to prevent bloody noses; I don’t tell her that I saw evidence that she’s been picking her nose, but instead dance around that point and let her know that another bleed is likely at some point today. She denies that she’d ever put *anything* in her nose, as she’s “not that kind of person.”

I encourage her to put boiling water in a bowl,  lean over it with a towel on her head to help  open things up.

“But you’re going to give an antibiotic, right? I came here for an antibiotic.”

I then tell her that the best thing she could do would be to use a nasal spray, as it will get to work right where it needs to go, and will help things clear up faster.

“I’ve tried them in the past and they don’t work. I’m not using that stuff, it’s messy and just gets on everything.”

I take a deep breath, look away and start typing in the computer.

“I need amoxicillian because that’s what I had last time, and it worked great.”

I look back at her and say that it isn’t the best choice and that if she had that recently it’s a sign that it didn’t work.

“Oh it worked, this just came back.”

I enter another medication into the computer, and also send a script for a nasal spray to the pharmacy.

She has a new bounce in her step as she leaves the room as she pulls out her cell phone, dialing a number as she walks away from me. She then adds,  “I know my body. I know what I need. If you had just listened to me in the first place we wouldn’t have had to go through all that.”

(Where is the line between good medicine and keeping the patient happy? and why does that line change with every patient I see? )

There are several common reactions to what they see – some see me looking at them and look away quickly, as though they’ve been caught staring. Others continue to take me in, and it isn’t until I start talking that they refocus and look away.

“How old are you?” they’ll ask  Some will add an “I don’t mean to be rude and you don’t have to answer if you don’t want” and others will simply say aloud, “Are you sure you’re old enough to be a doctor?”

I try to feel them out – are they asking because they think I’m too young to be their doctor? Is there a chance that they have children my age and they can’t imagine their child being the one to take care of them? Was their last doctor much older or male? What were they expecting to see, I wonder, while I think about what I can say.

There are times when I take a moment to ask them how old they think I am, but this question is usually met with silence or a comment about how they’ve never seen a doctor so young.  I once asked someone how old they thought a doctor should be, but they weren’t able to give me an answer and I haven’t repeated the question. Perhaps I should.

Most of the time I simply answer 29, which I realize is only true if I round 28 and 11/12th up. I started saying that I was 29 when I started my second year of residency…maybe because it didn’t feel like it was enough to be a second year resident, and I wanted to feel a whole year older.

The patients who are my age are often taken aback – I can almost see them doing the math and their eyes sometimes squint as they wonder aloud how much schooling it took to get to where I am.
The older patients pause, before they start recounting what they were doing at my age. Some were housewives, and pregnant with the fifth, sixth or seventh child. Some were breaking out on their own, or travelling to other parts of the country. Some were returning from military service, or changing careers, or burying their parents.

Where am I from? Where did I go to school? are questions that are quick to follow, and I have come to understand that this means that my age is no longer an issue – I have “passed,” if you will. I’ll give the name of the high school I graduated from, or tell them I was born at the hospital across the street, rather then simply give the name of the town we’re in. There can be a subtle moment of pride here, especially if they are also from the area. This opens the conversation up for stories about how they played football or softball or how they were a part of the student-run production (that has been going on for 100+ years).  There is usually a visable softening at this point, as being from the same town/county/state must imply that I know how things are “done.” I must know them, and what is important and it makes up for my youthful appearance.

The whole conversation about my age and such may only take a minute or two, but it happens several times a day, generally with patients I’ve never met before. I’ve never had a patient say that they want to see an older doctor, but I won’t be surprised if it happens in the future.

I am hoping to post daily this month – not with the goal of posting daily beyond that, but to try and put some of my experiences from the last 15 months down somewhere. NaNoBloMo is a challenge that is perfectly timed for me because it’ll give me a chance to do just that.
Not a whole lot about me has changed in the last few months, but I thought I’d recap so I can bring everyone up to speed…

- I bought the house I grew up in from my parents. It’s a great house, with mostly great neighbors.

- Izabelle and Beazlie are still my cats/housemates

- I’m very much an introvert – I *thrive* on time to myself and become quite cranky without it.

- If it were up to me, there’d be naptime daily from 2-4pm. Followed by snacktime.

- I love to knit but haven’t finished a project in a very, very, very long time.

- My favorite color is deep plum.

- There are days when I wonder what I’ve done with my life, and I often wonder why I thought going into medicine was a good idea.

- I’m not sure I’d have gotten this far without my cats and their twisted sense of humor.

- I know I wouldn’t have gotten this far without my mom and her ability to help me keep things in perspective.

Here’s to this next month, and the stories it will bring. (all names/ages are not real and one person may be based on numerous patients I see or have seen.)

My time at home has been a balance between doing nothing (sleeping, napping and sitting around in the shade) and being very busy.  The yard has had to fend for itself (as it wasn’t high on my priorities this summer) and I think it took on the challenge with gusto. 

(figure 1: a lily that bloomed by itself. ) (note: I used to peel the unopened blooms like they were bananas, despite my mom’s urging to leave.them.alone.  I’m sorry mom. You can come over and enjoy them now.)

(figure 2: a better picture of what is actually going on out there. The pansy there in the front? the one growing in the grass? It was chopped down to nothing when my brother mowed the lawn last month. Now it’s back, without any help from me.    The primrose has grand plans to take over the whole flowerbed – it doesn’t know that the coneflower is getting ready to put on a show too.)

4/5ths of the neighbors I have now are the same people who have lived on this end of the block for the last 20 years. The guys have plows on their trucks and are happy to accept cases of beer in exchange for making sure I can get in and out of my driveway in the winter.  This known, I shouldn’t have been surprised to come home after a night on call to find that my lawn had been mowed. (only problem being that I have no idea who did it – beer for everyone!)

Izabelle has tasted the world on the other side of the screen and would like everyone to know that it’s horribly unfair that I am allowed outside while she is not.

(figure 3: Izabelle, mid-miaow.)

There has been spinning.

Thanks to a great morning with friends, I now know how to ply yarn.

And! I know what I had to do with my wheel to fix it, so I can ply yarn on my own.

(it’s easier to see in my flckr account – the left hand section of the cross piece was screwed into the clear piece too far down; now it’s even and spins evenly both directions, which means I can ply.)

It’s the little things that will make this year do-able.

Simple, little things.