Thursday, 23 February 2017

By the By in Bytown

I've really been enjoying my elective here. That is, until today.

I woke up feeling a little off - just that sort of half-sick, not quite awful feeling. My throat was a bit scratchy but that often happens in the winter. So I just got on with my day.

By noon, I'd spiked a fever (max temp I measured was 38.8) and was shaking and sore and my tonsils are scarlet and awful looking. Centor Score: 4. 53% probability of strep pharyngitis.

The residents I was with, understandably, had me leave. I'm holed up in my hotel room, under a pile of blankets, feeling pretty sorry for myself. I have bottles of water, acetaminophen, benzocaine lozenges, and my pajamas.

I only missed 4 hours of today, and my residents said I could return if I'm afebrile tomorrow so I'm just trying to will my body into health. There's sort of an unspoken "Thou Shall Not Take Sick Days" culture in medicine (I actually was told explicitly by a physician that doctors can't take sick days so I suppose it's not truly unspoken.) It's understandable, particularly for specialists who might have patients waiting months or years to see them. Cancelling your clinic or OR day may result in unacceptable waits for rescheduled patients.

But I'm just a student. The care I deliver is not so critical that my being absent for an afternoon will cause unacceptable issues for patients, and it's just plain irresponsible for me to stay there if I could make a newborn sick because they go downhill reaaaaally fast.

I'm hoping that my fever breaks overnight because I really, really want to work tomorrow. I had planned on returning to Hamilton tomorrow after work, so I didn't actually book my hotel for tomorrow night. I have to check out in the morning. But if I end up working a long day tomorrow to make up for today, I'm going to need to sleep before I make the 5 hour drive back. Honestly may just kip in my car for a few hours, or ask a friend if I can conk out on their couch for part of the day.

Right now I need to get my hotel room ready for the morning. Have to take my suitcase out to my car and lay out my clothes, make sure I've done my going-over of the room because I would hate to forget something.

It's been nice being back in Ottawa. I like this city a lot, and have missed living here more than I realized. I'll be a bit sad to leave, to be honest.

I just really hope that I'm feeling better in the morning so I can at least work on my last day here.

Wednesday, 15 February 2017

Happy Birthday!

Today is my husband's birthday. I'm rather sad that I can't be with him tonight. He's sick, and the baby is just getting over being sick herself, so he's also tired. But from here I couldn't do anything for him for his birthday and I'm sad.

I will be seeing the family tomorrow. My husband is driving up with the kids tomorrow evening. I'm switching hotels as well, since this one isn't really ideal for having the whole family here for 6 days, though it's been workable for me for the last few days. It doesn't cost much more, but I wanted to save money where possible. There's actually a program that reimburses clerks for travel for one elective per year within the province, so I'm going to be reimbursed for my travel and accommodations, but I still wanted to be reasonable with my costs (even though my nightly rate at both hotels is below the cost limit.)

I'm a bit tired at the moment but it's more because I'm not sleeping well rather than anything to do with my elective. I'm not doing any call or anything, so it's just a normal 7-5 schedule (which I find amusing. A 'standard' week is 50 hours. Plus whatever call shifts you are scheduled for.)

The residents and staff I've been working with are amazing. Not that anyone at Mac wasn't awesome, but I really like the atmosphere here. It's different. Not better, but from my first few days I think I've just gotten my feet under me a bit better. I also really like being back in a bilingual environment. It hadn't occurred to me until I got here how much I'd missed hearing French regularly. My expressive fluency has also taken quite a beating over the last couple of years since I've not had many opportunities to speak with adults in French, so it's nice to be where I can use it. I think my desire to come to Ottawa for residency is certainly increasing.

This is a good city. My husband grew up here and I did live here for ten years, so we both know it well. While we did move to my home province after some rather difficult events (I knew multiple people who were murdered in a very short period) I have always liked Ottawa. Plus I know my way around well enough.

I'm very excited for my husband to get here tomorrow and be able to revisit his old stomping grounds and see his old friends. I think he's been wanting to consider coming back here himself, so I have a feeling he'll agree with me that this'd be a good place to go.

Not that I have complete control over that.

Still, it's so-far been a good trip. I'm enjoying myself. I just wish I could be home with my husband. At least the kids insisted he buy a cake, so they had that for dessert.

Sunday, 12 February 2017

Canadian Warp Speed

Ever driven quickly through heavy snow? My husband and I jokingly refer to this as going warp speed, because the effect is similar to how they illustrate entering warp speed on Star Trek.

We're nerds and we make no apologies for that fact.

I'm just settling into my hotel in Ottawa right now, having washed off the road after a very long drive. According to Google, the drive should take almost exactly 5 hours from my house to this hotel. I left my house at 1pm. I got here at nearly 10pm.

The weather sucks.

At the moment, I'm just reviewing hospital policies and my orientation guide for the morning. I am very much looking forward to getting started on my first visiting elective, though I am quite nervous. This is definitely a program I'd rank very highly, given the opportunity, but I know sometimes Mac students have a bit of a reputation of being less prepared than other clerks. It's something I've only really heard rumoured, and seen on the Internet, but I can't help but worry. Not only am I only a year and a half into med school, instead of 3+ the way other clerks on visiting elective would be, I only have one core under my belt at this point. I'm still learning the ropes as a clerk.

But I just have to roll with it. I think I'm very strong material-wise for this specialty, but it's the ins and outs of being a clerk that I'm still navigating. Learning exactly what is acceptable for me to do on my own, what residents and staff expect me to take initiative on, how much I'm allowed to do paperwork-wise before having something checked or signed off ahead of the next step. I know some of this is going to vary service to service and place to place, but I don't even really have a range of what's normal at my home school yet.

I generally prefer to lean towards 'check more/don't assume too much' but I know that can annoy residents and/or staff. I don't ever want to overstep, but at the same time I don't want to create more work than a clerk should.

It's a bit of a balance, and one I'm still working hard to find.

Still, we'll see how things go tomorrow!

Monday, 6 February 2017

Delivering Futures

I finished my last OB/Gyn core clinical shift yesterday morning. While I'm glad to have a bit of a break from clinical activities for the week, I'm looking forward to getting back to it next week.

OB is definitely an incredible specialty. Mostly fun, but it's also sometimes very sad.

During my time there, I saw the alarm activated for obstetrical emergencies more than once. It was incredible to see the nurses all swarm together, the residents jump to action, everyone finding their way to a place of usefulness (while I stayed out of the way as much as possible, which is how a medical student can be useful in these moments.) I was not in the room for the emergencies, but just seeing how all of these experienced care providers reacted to hearing that sound was pretty amazing. Everyone drops what they are doing to leap in and help these patients.

That is medicine at its most raw; when everything else takes a back seat to preserving life and limb. Time is brain. Especially for those tiniest brains connected to life by a half inch rope of jelly.

As a final assignment for this rotation, we have to write up a paper on an ethical scenario we encountered. I'm not having trouble finding one - I'm having trouble deciding which one of the many to write about. It's due tomorrow and I am absolutely not at all feeling bad about the fact that I haven't done it yet since I have been thinking about it.

The case I think I'm going to write about is one that was one of my two personal test-cases. My "if I can handle this, I think I really will be able to handle becoming an OB/Gyn" cases. I thought about writing about one of them here - in a roundabout, many-details-changed-for-privacy sort of way - but I decided against that since I don't know that I could sufficiently anonymize the story.

My thought about how much I need to change something for privacy before I even consider talking about it here is that I want to change it so that if the patient themselves were reading it, they would not recognize that I am writing about them. Because I'm still so new to clinical activities, I don't think I'm reasonably able to do that yet, so I will always, always choose to just not talk about a case rather than risk even the slightest possibility of posting something I shouldn't.

The only detail about the case I think I'm comfortable sharing is that it involved one of those difficult decisions that is unique to OB/Gyn: how much do we risk this patient's outcome to improve the potential outcome for that patient?

I suppose other specialties might see that in roundabout ways when they're dealing with resource limitations or in something like a mass casualty situation, but I think it comes up far more often in obstetrics. Really, it's interlaced with everything in obstetrics. The risk/benefit balance goes four ways instead of two.

The case I saw that most challenged me wasn't the one that I'll be writing about for this assignment, but it has been on my mind a lot. It was a cruelty of nature, not a failure of people or of medicine. Mother Nature is not a benevolent matriarch. I'm comforted, though, by the fact that there are so many skilled hands, at the ready, prepared to dive into the action when that alarm blares, when nature fails, when the blood hits the floor and all else is forgotten, to guide tiny lives through troubled moments and into the arms of their mothers.

That is where I want to be.

Wednesday, 1 February 2017

Chalkdust

On the wall outside a theatre back home, there was a big, black chalkboard. I think it may be gone now.

Up top, it said "Before I die..." and the remainder was a blank field of possibility. A box of chalk was attached to the wall nearby, tempting passersby to share pieces of themselves.

A few years ago, I was walking by and I stopped and read some of them.

Before I die...

...I want to get married.
...I want to have children.
...I want to go to Disney World.
...I want to have tacos for supper every night for a year.
...I want to see my children grow into good people.
...I want to fall asleep beside my wife every night.

They ranged from the mundane to the absurd. Some were clearly there as jokes, and some were profound.

I found a scrap of space where the ghost of someone else's confession remained in the scattered dust and with the dry rasp of chalk on slate I added my own words in a vibrant yellow cursive.

Before I die... I want to become a doctor.

So here I am, fifteen months from doing just that. I wonder if other people read that and thought it sounded silly. Or if they saw it and imagined some hopeful youth, in high school perhaps. I doubt someone would see that and imagine an exhausted, poor, fat, overly anxious woman who runs herself ragged between school and work and family.

I don't think I'm anyone's first mental image of a medical trainee.

But here I am.

In the last weeks, I have had the immense privilege of helping care for people, and there is no part of it that I have not enjoyed. I love deliveries, I enjoy suturing. I like observing surgery. I like assisting with surgery (even though at my level of training 'assisting' means suctioning, cutting sutures, retracting, and sometimes helping close. Still cool, though.) I like talking to patients and their families. I like rounding.

I like all of this.

Even the paperwork. Once I figured out what needs to be done, I'm glad to do it. I know the residents and staff have less time for that part of things, so I'm glad to do it to get in the practice.

I've not yet encountered anything that makes me go "ugh, not again." I realize it's only a few weeks so everything is still fresh and new to me, but I can easily picture myself doing this all the time. Days in, days out.

I do not feel that way about every part of my other clinical exposures. I think it's telling that I'm at the end of my core and I am really, really happy that I have 6 more weeks of OB/Gyn ahead of me.

Before I die... I'm pretty sure I want to be an OB/Gyn.

Perhaps, when I'm home for my two week emerg elective this summer, I'll take a walk downtown and see if that chalkboard is still around.

Sunday, 29 January 2017

Sowing

I don't typically post about politics on here. Just reading my blog, one might think that I'm one of the many people who distances themselves from disagreements that happen because of political beliefs, but I'm not. I so am not. There's a video out there of a rally I attended where I'm up speaking - holding my baby daughter on my hip as I spoke to a nodding crowd through a megaphone. That is who I am.

My blog here has always been intended as a relatively neutral platform. I think I've commented on my political leanings only once, in passing, when encouraging people to vote.

But today, I am breaking with my nearly five years habit and I'm writing a very political post.

With about a quarter of my traffic being from the US, this is for you guys, but I'm reaching out to my Canadian readers too because I expect that like me, many of you have a lot of American friends and/or family.

Ahem.

RESIST, DAMMIT!

Last night, someone I know well - an incredibly sweet soul of a woman - posted that she cannot now legally enter the US because she holds a dual citizenship. Born and raised in Canada, but because she is a child of two countries, she is unable to cross the border. While last night's judicial stay means she could now, it is temporary. It's a bandaid on a bullet wound. There is so much more to do.

I have friends with complex medical needs who are terrified that they are going to die because they are going to lose their insurance and, with pre-existing conditions, be unable to get any more.

The reinstatement of the Mexico City Policy means that money that helps save the lives of women and babies will be withheld. It means that while paying lip service to protecting life, the US government is willing to withhold funds that go to prenatal care, emergency obstetric care, contraceptive care. They so disagree with abortion that they will let women bleed to death in childbirth, or suffer from labour so obstructed for days that they die of infection because they can't access a C-section.

Trump tells the media that the US should "take Iraq's oil." He said that maybe they'll "get another chance" to do so. A president, standing in front of the cameras of the world and telling people that national policy should be theft of resources. There is little else he could say or do that would more thoroughly damage the tenuous relationships between Americans working in Iraq and the people there. He has painted targets on the back of American servicepeople overseas.

People call him stupid.

He's not stupid.

He plays the fool to make people underestimate him, but it should be clear by now that he's good at playing the long game. He is a shrewd and calculating man, well practiced at pulling strings. His actions, I am almost positive, are intended to try to provoke actions that he can use to justify further violations of human rights. It's as though he's drumming up for war. I dearly hope I'm wrong about that, but as the days pass, as he insults more and more governments from the comfort of his office, as he authorizes rights abuses, my apprehension grows.

The US is a nation built on a base of protest. The most beloved stories of that nation are of people resisting unjust rule, of fighting against tyranny. Attend rallies. Support with your voice if you can't with your funds. Write emails. Sign petitions. Make phone calls. Talk to people. Show kindness in the face of hatred. Show inclusiveness in the face of exclusion. Sow love where hate grows.

The narrative of America is one of resistance from its birth, and the seeds that grew to revolution are still there. Water them.

Rise up.

Resist.

Some Resources:

The Council on American-Islamic Relations: https://www.cair.com/
- Helping to protect the rights of Muslims in America.

The American Civil Liberties Union: https://www.aclu.org/
- Has been helping detained persons access legal protection.

This page has summarized a number of resources and ways to get involved (primarily for Americans) on the immigration issues:
https://www.thenation.com/article/how-to-fight-trumps-racist-immigration-policies/

Donate to the Planned Parenthood Federation of America: https://www.plannedparenthood.org/ or
The International Women's Health Coalition: https://iwhc.org/

This is just a tiny sprinkling of resources. There is so much more that can be done to counteract the harm that is going to be done by this administration. Check out the Bill & Melinda Gates Foundation's projects, spread the word about the GAVI Alliance since even vaccination will be under fire.

While I'm aware this is drastically out of step with my usual posts, I can't not say something as I watch malignant nationalism metastasize in the very last place it should ever take hold.

Saturday, 28 January 2017

When Demand Outstrips Supply

I have all of today and all of tomorrow off. I'd only had one day off since the 9th of January, so I was getting pretty run down. I got 7 hours of sleep last night and then took a 4 hour nap this afternoon. For the first time in about two weeks, I actually feel pretty normal.

This schedule has meant a lot less time with my family. I'm leaving before most of them wake up in the morning and most days I'm not home until nearly 6 if I don't have call. The older kids go to bed at 8pm, so I'm barely seeing them at all. That's hard to get used to.

Fortunately M is such an easy baby we have no problems going back and forth from bottle to breast, but my milk supply has taken a beating. My opportunities to pump are irregular and it's often hard to get away when I need to so I often end up going longer than I should and so my supply is reducing. In the last two weeks, I've pumped less than she has taken 11 days.

I have no problem supplementing with formula and we have been since the beginning (though out of preference, not necessity. I was producing as much as she took and was just freezing the milk to have a freezer supply for longer separations.) While everyone is very supportive of me breastfeeding, the nature of OB/Gyn doesn't really make it easy to run off for 20 minutes every 3 hours.

It's messing with me a bit, to be honest. I had oversupply with my other kids. While my milk was delayed coming in all three times and we dealt with thrush and mastitis with my second, I have never really dealt with supply issues because I was home with my other two and fed on demand. I've never pumped much before. Quite honestly, I hate it. I will probably only pump during day shifts for the first six months or so and after that I'll only pump overnight when on call or when away from home. It'll take a while to adapt to no daytime pumping, I'm sure, but other mums do it successfully.

On Monday I'll be entering my last week of OB/Gyn clinical for the core, and then we're back into an academic week which should be nice. After that, I'm off to Ottawa for two weeks and am very much looking forward to it!

Tuesday, 24 January 2017

The Nighttime Hours are Shrinking

I am absolutely loving my OB/Gyn core. I am very, very tired, but it's worth it. I'm learning a great deal. As is evidenced by my near absence of posting, I'm spending most of my waking hours at the hospital.

My preceptor is amazing. She has high standards, and is fiercely protective of her patients, and I think that's incredible. Every time I meet patients with her, they tell me how lucky I am to be working with her, and they rave about her bedside manner. It's left me smiling many times.

She expects a lot from her learners, but she also gives a lot. It's clear she expects me to demonstrate interest and an ability to learn quickly. but she is ready to take the time to teach and ensure I have the opportunity to learn. She won't force the information down my throat, but makes it available for my consumption.

I am incredibly grateful to have someone who is so willing to offer guidance as a preceptor. I really lucked out. Perhaps it helps that I'm actually interested in the specialty and demonstrate a legitimate interest in what I'm learning. But I do try to be interested in everything, even stuff that isn't my favourite topic (I wouldn't say that anything qualifies as boring to me, at this point.)

While I may not be able to do many things well right now, I am a willing and enthusiastic learner so I suppose that counts for something. It may also help that I'm not all "yay babies!" I actually like the gynae half of the specialty too. Obstetrics is just a part of OB/Gyn, and I actually think I might like the gynae stuff a bit more.

I definitely like surgery and want to learn to do it, which is less of a surprise than it would have been before last summer but still bowls me a bit. It's definitely pushing me further away from family. I don't know if I'd be happy doing just the occasional punch biopsy, Paps, and nothing more procedural than that. I've got a surgery-heavy OB/Gyn elective coming up in March to explore that further. 

It hasn't all been happy moments, and I think I'm getting to see a very good cross-section of the specialty. My preceptor has really been helping with that; making sure I see a very wide variety and get to by as hands-on as is appropriate for my level of training.

The fact that I'm exhausted, have worked somewhere near 200 hours in 2 and a half weeks but am sad that I only have a week and a half left in the clinical part is rather telling, I think. I'm having a blast.

Given my current state of exhaustion (not helped by the fact that I actually have to wake up to pump in the night now because my supply was tanking from the irregular hours) this is perhaps not my most coherent post, but I hope I've at least communicated my enthusiasm.

When you really need to study, but also want to snuggle.

Saturday, 14 January 2017

The Calm and the Storm

As might be obvious from my lack of posting, my first week of call is kicking my butt.

To be fair, I actually have three 25 hour call shifts in a 7 day period - making it a nearly 100 hour week when you add my non-call shifts- so it's pretty brutal. Last night in particular was rather intense. My first call shift was pretty quiet, but last night most definitely was not.

Today, though, is my son's tenth birthday. It's absolutely incredible to me that he's already 10 years old. When did that happen?

It made me reflect a bit on the nature of delivering babies. I remember the name of the attendants at each of my childrens' births. I remember in detail how the days went; my birth stories, like those of every woman who has given birth, are a part of the fabric of my life and I will never forget them. The fact that I am part of those stories for other people now - not that I really expect most people necessarily remember the medical student - is pretty cool.

But I also really like gynae surgery. My supervisor typically does two OR days per week and I get to attend with her. I was post-call one of her OR days last week, but when I attended the other it was fantastic. The whole time, I was just thinking "I have to learn how to do this." It was nothing terribly complex, just routine stuff, and there were no complications, but I still very much want to learn it,

Six days and 2 call shifts in (I have another tomorrow) and I haven't actually found anything I don't like to do yet. I realize that I'm still at the point of everything being new and shiny and exciting, but I can very much see myself doing this as my career. I've been told by a few people that the specialty you should pursue is the one where the most 'boring' part (I think 'less stimulating' is probably a better term than 'boring' since I don't think anything in medicine is boring, but I realize that may change.) is something you still don't mind doing. For OB/Gyn that's largely low-risk prenatal appointments. I enjoy them. It's nice to talk to patients, to hear how they're feeling about their pregnancy, to alleviate concerns about what they're experiencing. It's probably the lowest-stress part of the specialty.

It's a very flexible specialty, and I like that. It's medical and surgical. You can focus more on obstetrics or more on gynae or do an equal amount of both. In some areas, they have labourists who just do deliveries and emergency gynae surgeries.

So far, I'm definitely enjoying it as much as I thought I would and that's promising. I seem to be getting on well with the team. I'm rather nervous when it comes to paperwork because I definitely don't want to risk screwing anything up, but I found my nerves were slowing me down quite a lot so I'm relaxing a bit and realizing that I do actually know how to do stuff decently well for the small amount of training I have, I just have to make sure I keep the most important information in mind and always, always double check something if I'm not sure. 

Today did mark a big first, though. For the first time ever, I didn't immediately greet my son on his birthday and I've not spent much of the day with him as I had to sleep. I know this won't be the last time that happens, and I may completely miss birthdays in the future.

But we're going out for supper soon, so there's that.

And tomorrow, back into the fray. Hopefully for a quieter shift, but even if not, it's not the end of the world. It's an awful lot of fun, even if the excitement is at 3am.


Saturday, 7 January 2017

Needs Must

Monday is my first day on the wards and in clinic. It is also my first call shift. I'm a bit nervous about that bit since it'll be my first night away from M since she was born. I've been careful to try to avoid getting in the habit of nursing to sleep since I knew I'd be away for a lot of nights so fortunately there shouldn't be any issue with getting her to bed.

Working out my pumping schedule should be interesting, particularly given that OB/Gyn doesn't really lend itself to having anything scheduled during a shift. My plan is that every 3 hours, I'll take the closest moment to go pump (Except between midnight and 6am.) So sometimes I might have 3 hours between sessions, sometimes it might be 4.5. I can't really go longer than that during the day or I'm in pain. I should need to pump about 5-6 times during 24 hours if I'm away from M the whole time.

I am really excited to get working. Especially because this is my favourite area. I know this material very, very well. Not just because it's been directly applicable to my life many times over, but because it's a major area of interest for me.

Must admit that I'm a bit nervous about how I'll manage when I'm on different rotations. Because I'm doing six weeks of OB/Gyn electives immediately after this core, I'm starting my clinical part of clerkship with 12 straight weeks of OB/Gyn. While it is a very comprehensive specialty - medical, surgical, across the lifespan, with patients of varying complexity - it's also very specialized in that in the obstetric part of it you're seeing primarily younger, mostly healthy women for a normal physiological process. I'll likely not be seeing many elderly patients (although some certainly come up in gynae, of course) and probably won't be seeing a whole lot of extremely sick individuals the way one might on ICU.

Every patient population has a different general approach; that's what we learn in preclerkship. There are some clinical skills I'm just not going to even consider over the next 11 weeks so I'm going to need to spend some time making sure I don't forget important things that will come up on my future cores. And, you know, my LMCCs.

As it is now, though, I'm just trying to focus on being a good clerk. Be helpful. Be cooperative. Be useful. Be ready and willing to learn. Support your resident. Be professional.

Let's see how well this works out at 3am, shall we?


Thursday, 5 January 2017

Tied Tongue

Most of the way through the first OB teaching week, and I'm having a blast. Today, breastfeeding, prenatal diagnosis, abnormal labour, and low risk OB. We've had suturing practice and great lectures on fantastic topics. 

I did some suturing practice at home too, using pig tongue. My daughter, who is easily grossed out and terrified of anything needle-like, enjoyed it a lot. She actually did a couple stitches. I was so proud of her for letting her curiosity overcome her fear. My son kept asking me to cook the other tongue for him. Can't say I've ever cooked tongue before. Not that I'm planning to; I need lots of practice. 

Aside from the fact that things are busy, I've been posting very little because I'm dealing with some pretty awful insomnia at the moment and it's taking me a lot just to get through the day and try to get done what I need to do. I'm only getting about 4 hours of sleep a night, on average, and so I'm feeling very run down.

Being very 'off' in January/February is rather normal for me - in fact I think I've made a post to this effect at some point every year - and so is postpartum insomnia for the first few months, so I'm just sort of riding it and hoping that it gets better soon. It may actually work in my favour a bit now because of this: 

So 90s. 

Call.

I start call shifts next week. There are four students in my stream together on the one unit, and so we made a call schedule (well, I made it because this sort of thing is fun for me, and they agreed with it) that meets our requirements and will hopefully not be too brutal. There are 28 shifts and we each get 7. I have two weekends fully off (we all do; I arranged it that way) and I've strategically positioned my post-call days to ensure I'm off for a few important things without needing to actually schedule time off.

Given that I'm still dealing with insomnia, I expect I'll probably do fine with call. Can't sleep anyway, might as well just care for mums and learn.

I am really, really excited to get started on the unit and with clinic. I feel like I'm actually going to be good at something. It'll be important, I think, to be careful to not come across as a total know-it-all in my enthusiasm. The goal is to be a good clerk. Be helpful. Be enthusiastic. Seek out learning opportunities. Be a good team member. Learn from everyone, including the patients. Especially the patients.


Wednesday, 28 December 2016

The Doctor Who Treats Herself Has a Fool for a Patient...

About five weeks ago, I saw my family doctor about my headaches. I had basically had a headache nearly every day since July, with just occasional days off. I was having relatively frequent migraines on top of that, worse than when I'd been pregnant with my other kids. This isn't uncommon for migraine-prone individuals. Around a third get worse during pregnancy. There were no red flag signs and I didn't have pre-eclampsia, so it was almost certainly just down to hormones and I just had to cope and try to avoid overusing OTC meds (because you can get medication overuse headaches too, which is just cruel) while waiting for it to get better on its own. 

After the baby was born, my migraines really picked up and I was up to two a week - on top of the ever-present underlying headache - by the time I saw my doctor. She gave me an abortive therapy (a powdered NSAID) and put me on a medication commonly used to prevent migraines. 

Since the cold weather hit, I've had my usual uptick in asthma flares. This happens every year since my asthma is cold-triggered (well, it's everything-triggered. My lungs suck) but it's been extra sensitive this year. I commented to my husband recently that it seemed like I was using a lot of my rescue inhaler and it just wasn't relieving the tightness very well. 

Now, if you are not a medical person, it likely won't occur to you why my asthma and my migraines are related. They aren't. But the drugs are.  

The most common migraine prophylactics are beta blockers. That is, drugs that inactivate the beta adrenergic receptor by blocking the binding site. They're mostly used for blood pressure, so there are cardioselective ones (ones that work primarily on the types of beta receptors found in the heart.) I wasn't prescribed one of those. I was prescribed a first generation, non-selective one. 

This matters because the drug that is used as a rescue bronchodilator acts on... (I'm sure you can guess) BETA RECEPTORS!

It's a beta agonist - the exact opposite of a beta blocker. So is the long-acting drug (a LABA - long-acting beta agonist) in my maintenance medication.

This is why you don't give nonselective beta blockers to asthmatics (or patients with COPD.) I know this. I am entirely aware of this fact. If I saw these meds together on a patient's list I'd ask my staff about it because of this. It is something I know and would clue into in a clinical setting. 

But for weeks I've been lamenting my crappy lungs while taking a medication that blocks my lung medications. 

Now, my family doctor - who is aware of the severity of my asthma - should have clued into this too, obviously. Most patients wouldn't be aware of this and would probably be worrying quite a lot in my position given how much it sucks to not be able to breathe. But I really, really should have picked up on it earlier. 

I probably would not have realized this for a while longer until a med student friend asked me a question (a helpful learning activity) about beta blockers and asthmatics and I had a face palm moment. 

I feel like a complete idiot, really I do, because this is something I absolutely should know as both a severe asthmatic and a medical trainee. Guess I'm just so used to blaming my awful lungs for things that it didn't even occur to me that my worse-than-usual symptoms are essentially a drug interaction. 

So a phone call is in order, obviously. 

Hopefully I've bought enough time for the pregnancy hormones to peter out and my headaches and migraines don't come back. The beta blocker was actually quite effective for that in my case. 

This is why you don't treat yourself. It's possible to completely miss very obvious things. And obviously I can't be relied on to remember the most significant aspect of my medical history. 

Tuesday, 27 December 2016

Gratitude

Last week, I bought a lottery ticket. A simple, colourful scratch-off ticket covered in promises of vacations abroad and freedom from the drudgery of daily life.

It was the first time since I got into medical school that I bought one, whereas we used to buy one or two a month. I know the odds of actually winning anything of significant value are astronomical, but when you live as we do, a lottery ticket is a small price to pay to be able to dream for a short while about what if..?

What if I could finally pay all my bills on time every time? What if I could put my kids in the activities they've been asking for? What if we could buy nutritious, high quality food instead of whatever is on sale? What if I could buy my kids the presents I think they deserve?

What if my life changed completely overnight?

And then mine did. I got into medical school.

While we do still live on a budget, of course, my husband and I agreed that it would make sense to make it a modestly more generous 'income' than we had previously existed on. Part of that is just to account for the fact that we pay more than double the rent here than we did back home, but part of it is to allow us to have some fun together as a family, to allow our kids some extracurricular activities, to get the kids decent presents for birthdays and holidays.

Our children have to give up so much for me to go to school, it didn't seem fair to make them wait another 5-8 years before they could enjoy having some extracurricular activities or a birthday party. We certainly aren't living like I have a physician's income yet, but modestly better than we were.

But the generally modest lifestyle we have enjoyed has shaped who we are, and it has shaped our kids. On the solstice, as we opened gifts, I had a moment of absolute parental joy that was shadowed by the spectre of our difficult past.

We had purchased our son a little programmable, Lego-compatible robot as his major gift. My husband, being a silly sort, decided to wrap it in layers. He pulled a number of boxes from the pantry and the recycling and sequentially wrapped the little robot in 5 different boxes, plus its own. The largest one was a Rice Krispies box.

So my son, full of the excitement only a pile of gifts can bring to a child, tore into the paper. And his eyes lit up. "Rice Krispies! Thank you. You know I love cereal!" He smiled at us and there wasn't a trace of disappointment in it.

He was very grateful for a box of cereal.

He was even more excited when we prodded him to unwrap it (again and again and again...) and he found his little robot.

He's a good kid. For all the challenges he copes with, he's definitely a good kid.

It also reminds me that the important lessons that we're trying to teach are sinking in.

I hope that all my work enables me to give my kids the gift of a bright future; one where they don't need to buy a $3 scratch off ticket so that for a brief while they can have some small chance at a dream of better things. But I can see that they'll still find their happiness even in the smallest places. Like a box of rice cereal.

Sunday, 18 December 2016

On Son Schooling

My son basically hasn't done any meaningful amount of work at school since September. By the start of October, he was completely non-functional in the classroom, then he was in the hospital for a week, then excluded from the school for a week after that (because, to quote the principal, "staff are nervous.") We met and planned and instituted new approaches and the school accessed some additional resources before he started back.

He started by attending just over an hour a day, just to see if he could be in the classroom without escalating. That eventually increased to almost 4 hours a day and he's been at that point for about a month.

At school, he usually does one math question from the board. Sometimes he'll write a sentence. Otherwise, he plays on his school-provided iPad - which is supposed to be locked down to only certain educational apps but he still manages to watch YouTube on it - or he spends his time playing Lego on his own.

He didn't even get a report card for the first term because they didn't evaluate anything so had nothing to report. His teacher has no idea what he can do. Because of the behavioural challenges, his actual skills haven't been fully demonstrated in school. Ever.

His kindergarten teacher saw a bit of what he could do and she was amazing with him, but things sort of crashed and burned (literally - we had a house fire) in September of grade 1 and here we are three years later still trying to make up lost ground.

We're basically homeschooling him at this point. We bought some workbooks and we set him daily assignments. We expect him to be doing academic work during the hours he would be at school, with a recess.

We started with the grade 3 curriculum just to review. He started this year still officially on an adapted grade 2 curriculum according to his IEP (see my comment above about no one actually knowing what he can do) but I know that was ridiculous because he's been able to do that stuff since before he started kindergarten.

He usually only needs to be told how to do something once, and then he can globalize it across multiple applications.

He's pretty much flown through the grade 3 skills, as I expected he would. He's picked up all the grade 4 (and higher) skills I've demonstrated to him pretty much immediately. Because he is interested in computers, I introduced him to binary and compared that to our base ten system and he was doing all the multiplication in his head to figure out binary place values. I introduced him to scientific notation and how that plays into place value. He got it right away, and of course understood what exponents mean based on this.

We currently expect him to do at least 3 math worksheets (around 20 questions each) per day, and fill the remainder of time he would have been at school with reading. The math worksheets are pretty much a joke for him - usually less than 30 minutes to finish all of them - and since he reads at a rate around 200wpm he's able to cover quite a lot of ground in an afternoon. He doesn't like doing this, but he has to do it to get his screen time, so he just sits down, powers through, and then is off on his merry way.

But his teacher has never once heard him read out loud. She had no idea if he was even at grade level, let alone how far past it he is, until we told her.

He pretty clearly has some exceptionalities and that's what frustrates everyone - he just won't engage with them. Everyone at school is too afraid to push him to actually do work because they worry he'll escalate. He hates school.

No matter that I love university, I also hated school when I was a kid. Haaaated it. While I certainly don't want to sound like I'm bragging at all because I'm not and this has actually been a source of many challenges, I was identified as exceptionally gifted very young. I experienced the whole 'asynchronous development' issue that tends to be a problem with very gifted children, and I think we're seeing a bit of that with him. People tend to expect gifted kids to act mature, but it's really not fair to expect and some actually may have significant social/emotional/behavioural delays despite strong cognitive abilities. It means kids like I was tend to explode, opt out, or shut down. Highly gifted kids often also tend to have issues with authority as well and will often just choose to ignore whatever rules they disagree with.

I lost interest in school by grade 5 and pretty much gave up on doing anything but the absolute bare minimum after that. My son beat me by four years. He tried in kindergarten. He shut down in grade 1. Unfortunately he lacks that little tiny sliver of desire to comply that I had.

I'm trying to figure out how to help him have a better time at school. Right now, essentially homeschooling him and treating school hours as 'practice social skills time' is pretty much the best option we have so that's what we're doing. I just wish I could actually get him enjoying school, or if not actually enjoying, at least participating.

Tuesday, 13 December 2016

On Surgery and Sleep

I went to a minimal access surgery workshop this evening. Unfortunately, due to the fact that there was a fair bit of latex in the sim room, I wasn't able to participate in the sim activities, but I did get to use a da Vinci surgical robot. It wasn't for long, but it was very cool. I'm amazed they even let med students touch it let alone practice with it. 

Yeah, med school really does have its amazingly cool points. Props to the Technology in Medicine IG for that.

Speaking of surgery, my daughter is getting tubes in the morning. Her pre-op appointment was last week and it was pretty fantastic. The child life worker showed her the equipment they'll use and showed her what she'll experience. She gets a little passbook so she can get a stamp at each step of the way - checking in, getting gowned, waking up, etc. I get to go in with her for the induction phase. I'll need to have the baby with me at the hospital tomorrow (nowhere to pump privately when I'm supposed to be staying with my daughter, so I need to bring the baby) so I'm currently trying to find a classmate to hold M while I go in with C.

It's rather convenient to know a whole bunch of people who spend a ton of time in that building and people are often quick to volunteer to hold a baby, I find.


Wouldn't you want to snuggle her?
As it's nearing 1am I should probably get to sleep. I've been staying up late to work on my lit review because I've ended up doing so much during the day. It's really affecting my sleep. Tomorrow is going to be another such day. I'm going to be tied up at the hospital basically all day so I'll just have to work once I get home. I really want to have a draft writeup prepared by end of day Wednesday. I'm not required to have it done by then, I just want to.

And honestly, considering I'm three weeks from starting my OB/Gyn rotation, I really shouldn't be complaining about screwed up sleep right now because a month from now I will laugh at myself.


Monday, 5 December 2016

On Being Home

I lamented a great deal about my difficulty finding electives for this period because I had no idea what I'd be able to do physically so soon after giving birth.

I was extremely fortunate to be able to set up a reading elective and the research elective I'm currently on. I'm working on a literature review for a particular technique for a particular application. It's actually really interesting stuff.

But I'm finding working from home very difficult. For one, I have a super cute, snuggly, tiny baby upstairs and I want to spend time with her. There's also my other kids, who are both having a hard time and I want to try to help. I've been ending up with a lot of morning appointments and stuff, so I'm typically working from late morning or early afternoon into the evenings (with a break at suppertime) so I'm not getting to spend a ton of recreational time with my family, even though they're *right there.* That's hard.

While I know I'm learning and I'm contributing to my education, I'm still feeling a bit disconnected from being a clerk. My colleagues are on the wards, they're in contact with patients. I'm in contact with my keyboard. As immensely and extraordinarily grateful as I am for the opportunity to do research and for my reading elective, and for the wonderful supervisors I am lucky to work with, I am feeling like I would be able to do some clinical work right now.

Of course there was no way to know ahead of time that I'd be capable of doing clinical work so soon after having a baby. There was no way of knowing that I'd have a baby who has slept from 11pm until 7-8 am since five weeks old  (yes, really. My OB told me when I mentioned it "don't say that too loudly in this office.") There was no way of knowing any of this ahead of time which is a big part of why I booked the electives I did, in addition to also wanting some research elective time.

I'm grateful for the opportunity to be home, to have a very flexible schedule during this period. I very much do need this, and I expect I'd probably actually be having a rough time with clinical work particularly since I've been dealing with a pretty significant increase in the frequency of my migraines since delivery (I've seen my doctor, don't worry. I'm on a beta blocker as migraine prophylaxis now and I have an abortive therapy that works fairly well.)

I suppose I'm suffering from a bit of 'grass is greener' syndrome. If I were doing clinical work, I expect I'd be feeling a bit wistful at not being home. Even though I am in my office much of the day, I'm still able to go and nurse M. I still see my daughter get off the bus, and still eat supper every day with my family. And I don't have call.

My OB/Gyn core is only 4 weeks away. I'm certain once I get into the groove of that, working very long weeks walking the halls of the hospital where I was only just recently a patient, I'll probably look back on this time at home, in my office with my family just upstairs, and be rather sad about it being gone.

But for the moment, I'm finding it a bit of a challenge. I think tomorrow I'll make the time to get out for a long walk. I need it. 

These kids will never be mistaken for anything but siblings. 


Friday, 2 December 2016

The Imposter in my White Coat

In less than a month, I'll be able to say "I'll be a doctor next year."

I'm just letting that sink in for a minute, because typing the words out was enough to make my blood pressure increase.

This entire journey has been an exercise in how often I can freak myself out over how fast every phase of my training just zips by.

The other day, my daughter - who we strongly suspect has fairly mild asthma - was complaining of breathlessness at school and was in the office. So I shoved my stethoscope in my purse, drove over, and took a listen right there in the office. The school secretary said "I knew you'd know what to do."

And the thing is... I did know what to do. Not that assessing breathing is hard; I've been able to do it since long before I started medical school. Being taught how to use a stethoscope to listen to my own lungs when I was younger than my daughter is now is what set in motion the snowball of my interest in medicine. But I am much more confident in my skills now, though I don't show it well, and I am expected by others to have these skills. A few years ago, showing up to my kid's school with a stethoscope to assess their breathing would have sent some eyebrows skyward. Now, it invites relief.

The summer before I started med school, I was in a restaurant and a man in his late 20s passed out in front of me. He just dropped without warning and hit the floor pretty hard. As someone trained in first aid, something I needed for my volunteering, I took charge and followed my training (direct a specific person to call 9-1-1, ensure ABCs, etc.) A volunteer firefighter showed up after about 5 minutes and I handed off the situation to him because he has proper first responder training. That's the point of first aid - assist until you can hand off to someone with more training.

Very soon, I'm going to be one of those people with more training that receives someone from the first responders. I suppose I technically already am, given that I have over a year of medical school under my belt. But I'm not really expected to be able to do much on my own with a great deal of skill yet, the confidence of my kids, friends, and my daughter's school administrators notwithstanding. I'm still protected by the soft cotton wool of being just a student.

I am someone who has trouble believing in myself. It's probably rather apparent after four and a half years of writing this blog that my self-confidence is most generously described as absent (or more realistically as 'wandered off in the woods of northern Ontario twenty years ago and hasn't been seen since.') While I realize that I actually do have some knowledge and skills, I still feel very surprised any time I turn out to be good at something. I suffer from a terrible case of Imposter Syndrome and often feel like any day now, the administrators are going to realize I was only offered admission as a mistake.

This isn't uncommon, particularly in high-achieving women. Even writing that last sentence, I see "high-achieving women" and I take that to mean other people, not me.

But as I move into clinical activities next month, where I'll be involved in the care of women during one of the most significant phases of their lives, I feel like I need to seem at least somewhat confident, even if I don't quite feel it yet.

Monday, 28 November 2016

To Visit or Not

I've been trying to get OB/Gyn electives, but it's been proving difficult to get any in Hamilton. They're popular. I'd had a number that had been declined because of no availability, and since I was getting desperate for OB electives, I applied to visiting ones.

I have 10 weeks (well 8 plus 2 vacation) elective time next year, and my next elective block isn't until January 2018, after I've applied to CaRMS.

Currently, I have these booked:

February 13th to March 26th block
1. OB/Gyn in Ottawa (2 weeks)
2. OB/Gyn (RE) in another city (2 weeks, different subspecialty)
3. Diagnostic Imaging (2 weeks, home-school)

July 17th to August 13th block:
4. Family medicine (2 weeks, home-school)
5. Emergency (2 weeks, visiting, only informally booked. Will need to apply through the portal when it comes available)

I'll be honest, I really don't want to be away from my family for a month for those first two if I can avoid it. We went through having our family broken up for months at a time when my husband worked out west and it was incredibly hard on our kids. I'm already going to be away for my paeds rotation, and could end up away for more. My kids already deal with a lot and I don't want to make things harder on them.

During the Ottawa elective, my husband and kids will be there for almost half of it. He's going to bring the kids up for Winterlude over their Family Day long weekend plus a day either side, so I'm not actually going to be away from my family for more than a few days during that one. I really wanted to ensure I do a visiting elective in Ottawa because it's #2 on my preferred locations since we like the city. My husband grew up there and I lived there for ten years, so we know it well and wouldn't mind moving back temporarily.

To my surprise, I just had two OB/Gyn electives approved locally, for the second and third elective spots above. The one in the #3 spot is with a preceptor I would REALLY like to work with, and it's primarily surgical and I'd like more surgical exposure.

I'm not sure which to take, or whether to take either. Visiting electives are the major way we demonstrate interest to prospective programs, but we also need to keep things varied. Not sure if my preclerkship electives will be considered in looking at how broad my electives were.

I do think I should probably do 3 OB/Gyn electives pre-CaRMS, but doing two at Mac might be a bad idea.

Debating whether I should take the one in the #2 spot, and then try to book another down East - again, my family will be with me - instead of that Emerg elective in August.

Honestly, I've no idea. With just a few days left to decide, though, I have to figure it out soon. 

Super happy baby!



Thursday, 24 November 2016

Competing

After I'd done what I felt was a sufficient amount of reading on my elective topic yesterday, I ended up spending some time looking at CaRMS stats.

When I was in undergrad and working on my strategy for applying to med school, I spent a lot of time looking at the statistics that I was able to find. I'm a numbers person and I often find comfort in looking at numbers while I find anecdotes tend to be more intimidating. For a time, I would go look at the posts on premed forums to see what types of people got in and obsess a bit. It was often disheartening, because I knew there were many ways I'd never measure up. I just did not have the time or means to do as much in the way of ECs as they did. I didn't have access to the same sorts of opportunities because of where I lived, and even if I did, the fact that I had issues with childcare and so on made it hard to actually do anything.

Still, I did get into med school. On my very first try, at that. So it's not like all of my stressing about being inadequate actually meant anything in the long run.

However, with just a year to go until CaRMS (my classmates hate it when I point that out) I'm finding many of those old feelings of inadequacy returning. I am a good student, sure, but so is everyone else in med school so it's not like I stand out that way. As with my med school applications, I don't get gold stars for balancing a family while attending school. As with my med school applications, actually, having a family may hurt me in that it means I'm less involved outside of my mandatory activities. Extracurricular activities are still a thing when it comes to CaRMS applications.

OB/Gyn - which I am increasingly convinced I will be making my first choice - is competitive to get into. More than several other specialties often considered competitive, actually. On average, roughly 90% of applicants overall match to their first choice specialty. For OB/Gyn applicants who rank it as their first choice discipline, the percentage who match to it is much lower, and falling. There's very little change in the number of applicants to OB/Gyn year to year, but the number of spots for CMGs has fallen by 20% since 2010.

What bugs me a bit about CaRMS applications is how much of the selection process really seems non-quantifiable. Like I said, I'm a numbers person. But with med school there's no GPA, we don't have any sort of standardized testing score like the MCAT at this level in Canada. There's no way to compare myself to the successful applicants on a numbers basis, I can only look at overall trends in matching. That's something I find challenging.

Realistically, my chances of getting into OB/Gyn are way higher than were my chances of getting into med school. I just have to try. Agonizing about it isn't going to get me anywhere. It's a bit different in that I really only have one shot to make it work (unless I go unmatched, but let's ignore that possibility for the sake of my blood pressure.)

Keep focused on the goal and do my best. That's all I can do.

Four and a half years ago, I was talking about this very same thing - about how I psych myself out by comparing myself to others - and wrote something that I think I'm going to put on my wall.

To rework it a bit: I often feel thoroughly inadequate in the face of people who do things far better than I do. It's a bit discouraging, but I don't have to be the best, most impressive applicant ever to realize my goals. "You don't have to be the fastest gazelle to get away from a hungry lion, after all. You just can't be the slowest."

That said, I still went and made a few figures with CaRMS data, because I like visual representations of trends.
What happened in 2012 and 2013?!?


Tuesday, 22 November 2016

Other Pursuits

During the transition to clerkship rotations, we had a suturing station. I like suturing. A lot. It probably should not have surprised me as much as it did given my hobbies, but it did.

I'm an artsy sort. It's not that I have any particular natural talent in artistic pursuits because I do not, but I enjoy artistic expression in a general sort of way and have a lot of enthusiasm for it. Any ability I have is entirely acquired through a lot of practice but I'm not exceptionally good at any one thing since I've never felt the need to completely dedicate myself enough to any one field to develop significant skill.

When it comes to music, I am very out of practice with my instruments but used to be pretty good. I am an enthusiastic if not particularly talented singer. I do sing Broadway musicals constantly in the car when I'm driving my kids around, to the dismay of my son. Currently I'm on a Hamilton kick. It was Les Mis until recently, so I think my kids consider this an improvement.

I took up a number of my hands-on artsy hobbies partly as ways to increase my fine motor control. I've mentioned before that my finger coordination has always been pretty terrible as evidenced by my awful handwriting unless I write very slowly. I started sewing when I was ten, then eventually I took up calligraphy in my teens to discipline the muscles in my hands. Then I took up yarn arts - knitting and crochet.

How does this at all relate to my enjoyment of suturing?

Well, think about it.

My wall of British actors.
While I will never be steady enough to do microsurgery, I can make neat, evenly-spaced sutures relatively easily (in practice scenarios.)  Crochet taught me how to make smooth rotating and hooking motions, which helps drive the needle smoothly. Knitting taught me how to coordinate my finger movement timing without tangling a thread. Sewing taught me to be comfortable working with needle and thread without stabbing myself. Calligraphy reduced the tendency of my fingers to tremble when doing fine work.

I've spent many years working on steadying my hands and being able to exert fine control over them. I have sketchbooks full of pages where I have just written words out over and over, trying to neaten my writing into legibility, then some semblance of presentability. I've spent many days with inkstained fingertips after evenings of trying to eke some amount of beauty out of pigment and pen. I've spent hundreds of hours trying to train my eyes and hands to work together well enough to put recognizable images on paper.

And it worked. It proved possible to teach my stupid fingers something useful. 

Now, this may all fall apart completely when I am actually suturing a living human, but it is still incredibly satisfying to see something I put a lot of work into have practical applications.











Obligatory baby picture (unrelated to the rest of the post)
This shirt was a gift from my ProComp group (a lovely group of individuals.) Her initials are M.E.D., so the shirt is not entirely about my career choice!