Saturday, 18 May 2019

The Crunch

People always tell me how busy I must be and usually I can just brush it off because despite having a generally busy life, I do fine. 

But when something gives way, stuff piles up very quickly. I need to stay organized to stay on top of things, and right now that’s proving difficult. 

At the moment there’s more riding on me than usual and I also happen to be in one of the most intensely scheduled rotations in my program. As much as I love the work, I’ve got a lot going on and I’m feeling the stress, which I usually don’t. 

My husband is having a rough time with his recovery. Things aren’t great on that front. 

My RA is completely uncontrolled right now which is why I’m awake and complaining at almost 3:30 in the morning. 

Miss M is going through what’s probably the most challenging phase of toddlerhood and while it’s expected and developmentally normal, it requires a lot of emotional resources to help her grow through this phase. 

Plus I’m a resident and I’m not feeling as prepared as I would for my shifts, and I have to do my QI project. 

I’m also still dealing with this monitoring contract nonsense so that’s just one more thing on the pile. 

So things are just rough right now. I’m coping, because I have to and it’s my job to keep my stuff together so that I can support everyone else, but I’m feeling the strain more than I usually would. 

Thing is we all have these moments in our lives where everything just drops on us all at once and unexpected stuff occurs and life goes on despite the added demands. My ability to cope when this kind of stress hits has been what has gotten me through this whole wild ride to this point, and it is what will carry me through to when things get a little easier again. 

I’ve got several things going for me which help.

- I have some really amazing friends who are supportive and also able to remind me to take care of myself. 
- my incredibly sweet co-residents sent us a very thoughtful gift that gave me something less to worry about. 
- my oldest has really come into his own and is growing up into a reliable and responsible young man. 
- I’ve gotten back into swimming which helps with pain management. 
- discovered recently that Costco sells Diclofenac gel in large tubes so I have a constant supply nowadays 

And lots of snuggles from kids and pets and words of encouragement from wonderful people all make it easier. 

Things are a bit rough right now, but they’ll get better. They always do. 

Friday, 10 May 2019

Taking On Life Stages In Order

I start my OB/Gyn rotation on Monday and I’m pretty excited. After that is paeds, then EM, then several blocks of FM, then care of the elderly. They scheduled me to learn about the life stages in order. 

Because I had a week of vacation and a week of professional leave to use up by the end of June, plus a floating holiday, I actually have a bunch of days off during my next rotation and despite the fact that it means I have fewer weeks with 24 hour call, I’m actually a bit bummed. This is one of my favourite areas of medicine and my eight week rotation has become six. 

This also isn’t a great time to be doing 24 hour call. As I mentioned in my last post, my husband had a heart attack. He’s recovering well but still feeling fairly weak and a bit anxious. Obviously this isn’t a great time for him to be caring for a baby and toddler on his own all day so we have started the youngest two kids at a sitter’s house during the day. Conveniently the sitter lives just across the street so they’re close by anyway. We are trying to ensure there’s always someone home to help my husband with the younger two kids so he’s never on his own managing them. So me being on call means that the older kids need to help out most of the evening (M and R go to bed at 7) plus I’m going to just be exhausted all the time. I know I get tired even on normal days when doing overnight call and it’s going to be worse because my RA is really not well controlled at the moment.

So I’m a bit worried about how tired I’m going to be and how much that may impact how good a support I can be to my husband, but I’ll be okay. Recently I’ve managed to get back into swimming regularly and it’s helping with my energy level and pain control so that’s a really good positive change. It’ll probably be something I’ll do on post-call days. 

It’s actually interesting to me how much exercise helps my pain level. I do not routinely take any oral pain medication, although I use a topical NSAID gel most days. While I do get a bit of pain relief from the gel for my smaller joints (it doesn’t penetrate deep enough to make much difference for my elbows or ankles) the thing that makes the biggest difference is going for a swim or a walk. Getting moving is really hard when you hurt so much. I absolutely do not feel like I have the energy to go do it. Fatigue is a major symptom with autoimmune disease and it’s probably one of my biggest hurdles personally. But once I get over that inertia, I feel so much better. 

It always makes me think of how many patients I’ve talked to about movement as therapy. It only seems reasonable to take my own advice and I’m constantly telling patients that bodies do better when they move. So keep moving. 

Even though I’m a bit concerned about how rough this upcoming rotation is going to be, both from a physical perspective as well as managing things at home, I’m just going to keep that thought in mind as I go through my 24 hour shifts. Keep moving. 


Also I started a new hobby, because I needed more of those. Doing some metal stamping. It’s actually a lot harder than you’d think!

Saturday, 20 April 2019

Back In Back Out

I started back at work on April 9th and aside from the fact that I felt like an absolute idiot my first week back, it was super enjoyable to dive back into medicine. Seeing patients again was fantastic.

Then on Wednesday as I was getting out of my car at the hospital for academic day, my phone rang. It was my husband. 

“Hon, I’m going to need you to come home. I’m having severe chest pains.”
“Okay, I’m getting back in my car.” 

I hung up, got back in and started driving back home. I hit the button to call him on the car’s Bluetooth. 

“So tell me about this chest pain.”
“It’s right in the middle and it’s in my neck and my arm hurts. I feel like I’m going to pass out.”
“That sounds like it could be cardiac. What I want you to do right now is go wake up (Oldest) and tell him what’s going on and that he needs to help with the others. Then call 911.”

So he did. The ambulance was pulling away right as I pulled up. I got the older kids ready for school and then tried (and failed) to find somewhere I could take the other kids. 

Turns out EMS thought they might have seen ST elevations so he was protocol’d in as a STEMI and went right to the cath lab, bypassing the ED. By the time he arrived at hospital the pain was starting to subside, and the angio supported there was no ongoing occlusion, fortunately. 

But he had a clinically significant trop rise as well so he had an NSTEMI. They found a small PFO on echo as well. And someone has *finally* addressed his baseline tachycardia (he’s had a resting heart rate over 100bpm as long as I’ve known him.)

He’s home now and aside from feeling very tired, he’s doing okay. 

This whole episode has been a bit of a mind mess. My husband is my rock. He’s the strong foundation our family is built on, and having him go through something like this has shaken all of us. The kids were definitely freaked out and have been clingy. 

Right now, we’re working on logistics. He’s been referred to cardiac rehab and will be followed by cardiology. Obviously he’s going to need some time to start feeling better before he should be chasing after the littles, so we need to find daycare for the younger kids for a few months and figure out some way to pay for it (we just transitioned to only my income since he’d elected not to return to work after his parental leave.) 

Thankfully my program is being incredibly understanding. While he was in the hospital my husband was wracking himself with guilt thinking I was going to get in trouble for missing work because of this. It was nice to be able to put his mind at ease and remind him that part of why I made the career decisions I did was because I never wanted my job to come before my family’s needs. 

I’m beyond grateful he’s okay. That phone call is one I won’t forget for a long time. I’m glad that my program understands that I’m needed more at home right now and is willing to advocate for me to have some time to get things together. 

The logistics of responding to a medical event like this are something we don’t often think about in medicine. But getting child care arranged and ensuring my husband can get to all of his appointments and worrying about income and getting the bills paid and all of that is the stuff that piles on the stress after an event like this. We’re independent people; we can get stuff managed and we’ll be fine. But it does make me think of patients who don’t have the sorts of resources we do when faced with something like this. 

We’re lucky. I’m so glad my husband is okay and I hope he never has to make a call like that again. 

Friday, 29 March 2019

Let each man exercise the art he knows

(Title from Aristophanes)

I’ve been doing some teaching and I’m really enjoying it. I had not originally intended to do much teaching in my eventual practice but I think I might reconsider my feelings on the topic. 

We’re halfway through MF3 clinical skills now and I had the opportunity yesterday to teach the newborn exam with young mister R as my assistant. He was varyingly cooperative, and definitely both louder and more drooly than the baby models, but I think the students got a kick out of his presence. I also suspect it may help them remember a bit more now that they’ve felt a fontanelle and femoral pulses on a real baby. 

Plus R (mostly) enjoyed being the centre of attention. He’s a pretty social baby. 

That said, while I’ve definitely breastfed in the sim lab as a medical student before, it’s definitely a new experience to nurse a baby while simultaneously using him as a model for how to assess for dysmorphic features. And I guess I sort of gave the students a bit of a crash course on how not to be awkward with someone breastfeeding while talking to them. Welcome to medicine. I’m not the last person who’ll do that. Just wait for your OB rotation. 

Last couple of days we had the opportunity to see my husband’s family. His sisters and mother live in Manitoba and have been on a road trip for the past couple weeks. They stopped over here for a few days and had an opportunity to see the kiddos. None of them had met the youngest two kids and they’d not seen our older kids for four years so it was nice to meet up. My oldest is now a couple inches taller than his grandmother and almost as tall as one of his aunts. 

My sisters-in-law were kind enough to drum and sing for the kids, and included my older daughter as well. Miss M danced and R was entranced. It’s fantastic for them to get to experience such a welcoming. SIL invited Oldest to come spend part of the summer with them on the Reserve and we’re considering it. He wants to learn his culture and learn to fish and hunt. It could be quite the experience for him. He’s not had much time with that side of the family but he’s old enough to kind of hold his own in a new environment so it might be an amazing chance for him, especially as he’s lately been really developing his identity as an Indigenous person and I want to help him with that as much as possible. 

Identity is such a funny thing. It morphs and shifts throughout our lives in so many ways, but there are always some key pieces that never change. Watching my kids build those solid centres of who they will be is probably one of the most fulfilling things about parenting. My suspicion is that if I do it long enough, I’ll get to observe something similar with teaching. Watch students grow into clinicians. What fun that could be.  




Unrelated photo of Sakura ‘Too being fluffy. 


Sunday, 24 March 2019

Chewing the Fat - The Fat Lady Sings

I’ve made no secret here of the fact that I’m fat. It has been a fact of my life since I was a very young child and is kind of pointless to hide the fact. The last time I was at what is considered a normal weight for my height, I was a toddler. 

I have two normal-weight siblings and we were all raised with the same approaches to food. I’ll spare you the long story about how I ended up fat but the fact is it happened for a lot of reasons and remains so for a lot of reasons. Anyone who knows anything about the medicine of obesity knows that there’s a lot of factors at play in why people end up my size and why sustained weight loss is not simply a matter of just not being lazy.  

Considering the immense effort I went through to make my dreams a reality, I’m certain if you’re reading this you’ll understand that I am not by nature a lazy or unmotivated person. I’m actually really good at setting goals, changing habits, and working hard. 

So if that’s the case, why am I still fat? Did I just not want to change it hard enough? Maybe I just need *one more person* to make fun of me, or one more internet commenter to make some concern-trolling comment about how fat people are undeserving of human dignity (“...but really I’m just worried about their health!”) I’m sure that’ll fix it! 

Nah. 

What I need is another tool in my toolkit. Because the tools I do have kind of suck and for me and millions of people like me, they’re not enough. 

I am not uneducated about diet. In fact, if you’ve ever been in my kitchen you’ll know I keep my measuring cups and my little digital scale right beside where I prepare food because I’m particular about knowing exactly what I’m eating and I can rattle off the nutritional content of most foods without even checking my notes. I’ve tracked my intake in detail for around six years, with the exception of during my last two pregnancies because I would tend to restrict too much.

I am well aware of the scientific research out there on long term weight loss, and so I decided a long time ago that I’d follow the evidence once I was done having babies. 

So this fall I’m having bariatric surgery. 

My referral was sent in November and I had my first two appointments this month. I have another one in April and three in May and there are at least five more to be scheduled. It’s quite a process. 

Why am I going this route? Because almost everyone who loses weight by lifestyle management alone gains it back, plus more. I have lost up to eighty pounds before. I know HOW to lose weight. The basic approach is a simple one; the execution is not. This is not a matter of simple willpower. Willpower I have in spades. The issue is that cutting my caloric intake enough to lose significant weight and keep it off means feeling so hungry all the time that I can’t focus on basic tasks. It means food becomes a constant fight every second you’re awake. It meant I took up smoking when I was 18 to suppress my appetite so that I could actually get things done (I quit years ago, just to be clear. Smoking = bad.) It meant that I could not enjoy food socially without profound mood effects because of the need to starve myself to ‘make up for it’ afterwards. 

Yes, the basic premise is to eat less than you spend calorically but if you have never been very overweight and lost a significant amount of weight with your body fighting you every step of the way, you have absolutely no idea whatsoever what it is like when your body is developing whole new ways to be energy efficient when you need it not to be. 

Bariatric surgery helps remove that element of the process. It lets you restrict without your brain screaming that you are dying. It lets you re-train your body. It’s not a magic bullet, but it absolutely is the best tool out there for long term success with weight management. 

This isn’t a vanity thing. I’ve never been conventionally attractive and it’s not the goal.

I’m doing this because I have been at odds with my body my entire life and I’m fed up with it winning. 

I can’t fix my lungs. I can’t fix the crappy collagen in my joints. I can’t make my immune system stop being an idiot. I couldn’t stop all the miscarriages. I can’t make my chronic pain go away. 

But this, this I can fix. I can reduce my risks. I just need a new tool, because the ones I’ve got already aren’t enough. 

I am only 32. My future isn’t written yet, but I know I don’t want it to include early heart disease and diabetes if I can help it. I know what obesity costs patients as they age and I’m not letting that happen to me if I can do anything about it. 

This is not an easy process. I have to be run through a full gamut of assessments and then be on a liquid fast for a month ahead of surgery. Then after my insides have been cut apart and stapled back together I’ll spend months sipping and nibbling my way back to being able to consume real food again, all in the hopes that my newly abbreviated stomach will finally tell my brain to shut up and let me get on with my life. 

I have to give up NSAIDs - not an easy thing to do as someone who has RA and gets migraines - for life. Can’t have pop ever again (I don’t drink sugary pops, but I do love carbonation like Diet Coke and sparkling fruit waters.) I have to go 5-6 months with absolutely no caffeine. 

This is not, regardless of how people from the outside may view it, an ‘easy way out.’

I really waffled about whether to talk about this at all. I wasn’t sure if I wanted people to know about the surgery because of what they’d think. My decision to share has to do with the fact that I want people to understand that my being fat has never been because I’m lazy, stupid, uneducated, or undisciplined. It is a complex state that is not easily changed. When I do finally change for good, it will be because my body itself has been significantly altered, not that all of a sudden the approaches that’ve been failing people for decades finally worked. 

Nature has not been kind to me, but fortunately there are many talented surgeons who will help me flip the proverbial bird to the hand I’ve been dealt and change what my future health looks like. 

Tuesday, 12 March 2019

À musée

We’ve been trying to give the kids more educational and cultural experiences in general, and with the kids being on March break it’s a good time to get in some. Much as I’m not a fan of huge cities, living within spitting distance of Toronto has its perks. Lots of museums. 

Today we hit up the Royal Ontario Museum. I’m surprised it took us so long to go. We’ve lived here three and a half years and hadn’t gone until today and the ROM has exhibits that appeal to basically everyone in my family. 

There is one thing about me that becomes very obvious to people very quickly: I am a nerd about many things. As a kid, I was obsessed with dinosaurs for a long time. I was six when Jurassic Park came out and to six year old me, that was one of the best things ever. Loving dinosaurs as a kid is why I love birds - which *are* modern dinosaurs - even now. 

Both of my daughters love dinosaurs too. The ROM has a huge collection of fossil specimens as well as incredible cast reproductions, so of course we hit that gallery first. 

My son really wanted to explore the First Peoples’ gallery and that was a fantastic one as well. It’s a bit hidden off to the side it feels like. We had a tough time finding it. But the specimens are beautiful and the stories fantastic. It was amazing for my kids to see traditional artwork, clothing, tools, weapons, and ornaments from their own nations. My son is really developing his identity as an indigenous person, so he’s been asking for more exposure to First Nations history and culture and I love to make it possible for him. 

My husband and I love to do these sorts of daily outings with the kids. Even when it gets a little loud and wild, it’s the best sort of experience to share our love of learning with our kids. It is incredible to see their eyes come alive with surprise and wonder. Watching them discover new things is one of my greatest joys. 

We won’t have as much time for our adventures when I get back to work next month, but we have a few more planned at least. Next one will be to the Aquarium!



My oldest was smiling all day... except when I took photos, and that was intentional. M was yelling “Di-o-saur!”



R was less than impressed at the exhibits. 

(I blacked out other people’s’ kids.)

Thursday, 28 February 2019

Unexpectedly Difficult Directions

Back in December, I was hit by a wave of absolutely staggering fatigue.

This has happened a few times before, in fact I've mentioned it here before; a few months after Miss M was born I started dealing with it and it lasted several months. It had happened before that too, before we moved to Ontario. I'd had all the lab work you'd run for fatigue run several times but there was never anything particularly remarkable except for a mildly elevated CRP which was attributed to my size.

The last time this happened, my hands hurt a lot, but that was when I was doing my OB core and all those electives so I was in the OR a lot and just figured it was all the retracting and assumed the fatigue was clerkship exhaustion and PPD.

Well, this time, I'm obviously not in the OR and did not have a clear explanation for why a bunch of my finger joints were red, swollen, and so stiff in the morning I had to do physio exercises for the first couple hours after I woke. I just kept waiting for it to go away, but it kept getting worse.

A few weeks ago, I started to put it together and realized it all makes sense in the context of an autoimmune condition, particularly rheumatoid arthritis.

So I saw my family doctor who agreed and she referred me to see a rheumatologist. It was the fastest outpatient referral in my life: it took four days from my appointment with my family doc until I saw the rheum. I did the blood work on Friday and saw the rheumatologist on Monday and I do indeed have a seropositive inflammatory arthritis.

One of my first thoughts was actual surprise, even though this is a pretty classic presentation and obviously I knew it was likely as I'd seen my own labs beforehand. I'd been hoping I was just imagining things and that the soreness and fatigue were just a different presentation of postpartum depression than I usually have. Nope.

See, even when assessing myself, I'm not free of the biases that run rampant in my profession. I knew enough to suspect RA was on the differential, but very much felt that I'd be brushed off again and told it's just my weight or my mood; things I've experienced many times. So I was doing it myself.

Big women with psych histories get used to having everything blamed on their weight or mood.

It was nice to see a specialist who didn't immediately do that and actually assessed me.

We got a treatment plan in order. Because I'm breastfeeding R, I can't take the usual first line medication but I'm taking two others that are usual for RA management which are safe for breastfeeding. Having a doctor who knew off the top of her head which medications have good lactation safety profiles was actually a very pleasant surprise because this is not common and gave me an idea for my QI project.

I'm also on a bit of prednisone this week just to see how things respond. I started it Monday night and by Wednesday morning I woke up with very little stiffness, the swelling in my joints is visibly reduced, and the pain is very minimal. That supports the diagnosis quite strongly, I think. I'm ridiculously hungry and my sleep is awful - pretty typical side effects of prednisone - but it's nice to actually be able to nurse R without being in a lot of pain. 

This diagnosis does reinforce that I made the right decision going into family medicine instead of OB/Gyn. I'm not sure RA and a surgical career are necessarily the best mix. Also, the fatigue and brain fog is very intense and 24 hour calls would be extraordinarily draining, particularly as a staff who doesn't get post-call days. I love my job, but I want the energy to enjoy life outside of work too.

I'm hoping the DMARDs work quickly and that I'm not symptomatic when I return to work. Fortunately I'm in my clinic for my first block back so I'll have a very reasonable schedule to ease into things. For one block, anyway, then I'm on OB so all bets are off.


Tuesday, 22 January 2019

Ending Up

It may come as a bit of a surprise to anyone who has read anything of this blog or spoken to me basically ever, but I’m no longer certain I’ll be going home to practice. I’m not certain I won’t be either. 

This lack of certainty is driving me just a little bit around the bend, but I think it’s good that I’m keeping my options open. 

My husband and I decided that in the interests of long-term planning, we’ll have one more year to decide but we want to be sure where we’ll go by the time I start my last year of residency (which is next February.) We are going to need to take time to prepare the kids for whatever we end up doing, we’ll have to make plans to transfer care of our son and apprise the school system, so it’ll be a long process which is why we’re trying to ensure as much lead time as possible. 

The fact of it all is that where we go when I finish residency is almost certainly where we will stay permanently. We want to settle somewhere so I can build a practice and we can raise our kids in a home we own. 

We know we want to go to the Maritimes. Ultimately we’d prefer to go back to our home province, but there are a bunch of things that worry us. Opportunities for our kids. Mental health care and support resources for our son. The ability for me to practice the way I wish to is a big one, as are things like practice remuneration models. 

Money has never been why I went into medicine, but I live in the real world and I have a family of six to support so yes, I freely admit that money is part of my decision process. I also have a boatload of student debt, and my oldest will be entering high school soon after I finish residency and so I’m very interested in incentive programs and they vary considerably. 

There’s a lot of stuff to think about. Deciding on my rank list was far easier because I was only trying to decide where to live for two years, not the rest of my life. 

I have a year to decide where to go. 

Why doesn’t that feel like enough time?


Sunday, 20 January 2019

This Year

Welcome to 2019. 

I’ve been enjoying my parental leave. It’s been fantastic to spend so much time with the kids, although I am very much looking forward to getting back to work. 

Fortunately I’m going to have a bit of a trial run: I’ve been selected as a clinical skills instructor for MF3 which is renal, reproduction, and genetics. It’s only a few hours a week, but it’ll be nice to get to doing something medical before I get back to work. MF3 ends about a week and a half after I return to work. 

My first rotation when I get back is a block of family med, so I’ll be able to ease back into things with a nice schedule and lower acuity patients. 

Then I have my OB rotation which is probably the worst one schedule-wise during my program. It’s our only rotation with 1:4 overnight call, and I’ll be doing that for two blocks. The call stipends will be nice anyway. Plus I love OB and can’t wait to get back into it. 

The one challenge will be managing pumping. It was a little easier as a med student; I wasn’t necessary to the work. As a resident, I have actual responsibilities and on OB there will be plenty of times I can’t leave. Figuring out how to keep my milk supply up during that rotation will be a tough one. Not the end of the world if I am a bit short - R will be 7 months old by then - but I still don’t want to end up with supply issues. 

With just eleven weeks of my leave left, I’m trying to cherish the time I do have home so that I can work on the goals I set for myself and my family. It’s probably the last time during my kids’ childhoods that I’ll be home for this length of time, so it’s precious and I need to make the most of it. 


Today is R’s third-day. He’s a third of a year old today. 



Saturday, 22 December 2018

Raining in December

I’ve been kind of quiet because I honestly don’t have a lot to say just yet. My life at the moment is incredibly normal and a bit boring. We spend the day taking care of the kids, relax in the evenings, cook a lot, exercise some, and plan last minute cross-country trips. 

We’ve been trying to plan to head back home since the summer, but things have never quite aligned. For it to work out. My pregnancy was pretty rough so we decided it was best not to travel far during it, then we couldn’t really have the kids miss school, when we tried to think about making it work over thanksgiving or their PA day long weekends. 

So about a week ago my husband and I decided we’d make it happen over their school break. Their last day of school was technically today, but we kept them home since today is the solstice and that’s when we have a family celebration. 

We started preparing for the trip, planning to leave Sunday night. Then we found out today that there’s a rainfall warning (oh Maritimes in the winter, how I miss your capriciousness) followed by an overnight freeze Sunday night, which just makes the road a mess for a few days. We decided it’s best to get ahead of that, so now we’re leaving tomorrow. 

I managed to get six people and a dog packed for an eight day trip in less than four hours. 

Skills, I have them. 

The pet sitter is arranged, the house is if not perfectly tidy, passable. All laundry is done, anything perishable is now frozen, coming with us, or will be eaten in the next 24 hours. 

I just pulled a family trip out of my back pocket, and I’m actually kind of proud of this. The kids really want to see their grandparents, whom they’ve not seen in almost a year and a half, and I’m wanting to touch base with some recruitment officers and doctors. ‘Tis the season of medical society socials. 

We won’t be hitting the beach, much to my sadness, but at least we’ll get to see my grandmother, who nearly died earlier this year and continues to be poorly, and my friend who is now rocking at medical school. 

Life is good. Today started with my kids excitedly tearing open presents, and ended with them sleeping soundly and happily in their beds, looking forward to a snowy road trip East. 


This book exists. 


I gave up trying to get nice pictures of all my children at once around Kid #2. 

Naturally, she thought the tree was hers. 



Sunday, 25 November 2018

Being Medical

I helped with the first year mOSCE this past week. 

It was fantastic to do something slightly clinical again, even if it was grading first years on their history-taking. I was pleased with them, anyway. They were where I’d expect them to be for first years just a few months in, and it helped me realize how much I’ve grown as a clinician since then. 

I miss work. I love being home with my kids and all... but I miss work. I miss medicine. I’m looking forward to getting back in April. My emerg rotation would have been in mid-January and I’m kind of bummed that I’m going to go almost a whole more year before I get to do it. 

But I do need the time to recover. While the initial few days after delivery weren’t bad, I’ve actually been having a really rough recovery this time. I had a spinal headache (post dural puncture headache) which I just kept waiting on to get better, since they typically do. It hadn’t gone away by my six week postpartum visit, so I finally got a blood patch at that time, which is the treatment for a spinal headache. It was only partially successful. I still have a spinal headache. It only gets better if I lie down flat on my back. It’s not as bad as it was before, so I haven’t opted for a second blood patch. I passed out completely during it and my heart rate went into the 40s. It was an interesting experience and I’m not keen to repeat it. 

But it’s still exhausting to have a constant headache that gets worse whenever you bend down. It’s about 60% of the strength of my migraines. Every day. 

It will probably get better eventually. They typically do. There have been cases of them lasting many months, but that’s rare. I’m just waiting. It’s refractory to pain medications so I don’t bother taking any. I just lie flat whenever I can. 

Honestly I’m not at my most functional state, so it’s a good thing I’m not working at the moment. I need more time to recover, and that’s what maternity leave is for. I’m glad I took the time off this time around. 

Even if I really do miss working and feeling like a doctor. 

Today I had a moment where I did have to use some skills and a bit of macguyvering. My dog hurt her leg at the park. She was running and went down with a yelp then wouldn’t get up or walk. I called the vet and splinted her as best I could using a stick, a pair of mittens, and my shoelace. I realized only afterwards it would’ve made more sense to splint the front of her leg instead of the back, given the normal ROM. But hey, I was in a field and working on the fly. 

Doggo is okay, but sore. Vet thinks she may have torn her ACL, but that it’s unlikely to impact her athleticism given she’s half border collie and it would take multiple amputations to slow her down. 




Wednesday, 31 October 2018

A Nice Pause

I decided to take a short break from my blog to avoid filling the place with baby stuff. That’s what Facebook is for. 

In summary, Smallest will be six weeks old on Thursday. He’s growing well after we had a rough start. He ended up in NICU for several days followed by several days of phototherapy. But now he’s a pretty standard young infant; meetings milestones. Has a bit of an old-man-going-bald look going on, like my oldest did, but I still find him cute. My co-residents were beyond sweet and got him an awesome shirt which I am looking forward to doing a photo shoot in when he’s big enough. 

Miss M is now two years old, and Miss C is eight. The years are moving on much faster than I ever thought they might.  

I’ve been starting to explore my options for after residency, in light of the accelerating sense of time. 

The plan has always been to go home. But I don’t know that I can practice at home the way I want to so I’m trying to ascertain how likely it is that I could. We’re looking at another Maritime province as a strong possibility as well, since we have friends and family there. 

Because of my time off, I’ll finish residency in February 2021, so I’ve got plenty of time to decide. And things can change over time, as the last few years have gone a long way to demonstrating. 

The time off is allowing me to get ahead in some of my tasks for residency. My QA project and leadership projects are the two things that I really want to get a head start on. I can probably finish my leadership project and at least lay out the structure and do the background reading and literature search for my QA. 

Im feeling a bit disconnected from the medical world so I really want to get back into it. I may start attending grand rounds and such for a variety of departments just to keep my brain going. I hate stagnation. 

It’s lovely to be home with the small people and my husband, but caring for an infant and toddler is not something I find mentally stimulating. Tiring, yes, but it doesn’t challenge me like a good clinical quandary. 

I’ve been listening to more podcasts and I’m going to try to catch up on my leisure reading now that R is into a bit better routine. 

So far, I’ve succeeded over the course of this leave in making a list of things I want to accomplish in the next five months. Hopefully I’m not creating more than five months worth of goals for myself. 

The plan is to get moving on some of these goals this week. I’ve scheduled time tomorrow to work on my leadership project outline, and I figure that is a good start. 

I’ve spent years working on ways to manage my busy life. Being decidedly less busy at the moment is leaving me feeling rather more directionless than I’m comfortable with.

Probably, I’d be well-served by learning to spend more time relaxing than I’m used to. Focus on some self-care. 

I’ll put that on my schedule and make sure I get to it. 



I had to include at least one photo. This is the awesome gift from my co-residents. R is the fourth baby born to residents of my site and they have all received this same shirt. Our site name is on the back. It’s a bit big for him at the moment. 

Friday, 21 September 2018

I Did a Thing

Yesterday, in the dead hours of the morning, I couldn’t get to sleep because I was contracting. 

And they picked up and up. So around 8:30am, we headed to the hospital and the sibling doula met up with us. After a couple hours of walking to see if the contractions picked up, I was admitted. 

Got an epidural right away which only took two tries this time. The epidural was fantastic.

The kids were basically bored to tears throughout most of the labour, and mostly just chilled out on electronics. Doesn’t surprise me at all. The doula was wonderful about making sure they got up and got their energy out and taking them for meals and washroom breaks and such. She was really fantastic to have; absolutely made a huge difference. It would not have been possible to have had the kids present without her. 

When the time came for pushing, my husband and both older kids were at my side. I tend to push fast, and despite the longer labour, that was true this time as well. After a couple good pushes he was out. His big brother and sister were sobbing with joy. There were many tears and happy shouts from them both. 

The resident who delivered him (who is probably one of my favourite residents ever and I’d consider a friend) was utterly amazing. She showed the kids the placenta and explained the physiology. It was really cool for them to be able to have that experience. 

Baby R was seven pounds even. Unfortunately he has needed some transitional support in the NICU and is currently there on CPAP. He was grunting quite a lot last night and having to work quite hard to breathe. I’m being discharged shortly and my husband and I will be trading off who is here with him. It’s fairly likely he won’t be here any longer than the weekend as he’s doing quite well. He’s just grunting a bit and slightly tachypnoeic without the CPAP. It’s likely because of the gestational diabetes; the risk of respiratory distress are much higher. He was 37+1 so a touch on the earlier side as well, which further increases the risk. He’s been slightly tachycardic in-utero and low movement was an issue within the last week so I do wonder whether he was a bit depressed prenatally as well, but I can’t know that for sure. 

Either way, he’s here now and besides needing a bit of a helping hand, he’s doing well and will hopefully be home soon. 






Monday, 10 September 2018

On Happiness

In the nearly six and a half years I've been writing this blog, there have been many ups and downs. I don't always post the downs because sometimes it's best not to ruminate, but overall I think I've given a fairly decent picture of what my life has been like. There have definitely been some periods of pretty intense stress, but overall things have been moving in the right direction this entire time, and I am extraordinarily fortunate.

Being off work at the moment has allowed me a bit more time for reflection than is my norm, and I was surprised the other day at how peaceful my life feels right now.

I hear no end of people telling me how stressful and busy and difficult my life must be, with nearly-four children while being a medical resident. It's something I hear constantly, and it never ceases to amuse me.

Yes, I am busy. Sometimes the days are very long.

But I love it. 

This year, in particular the last six months or so, probably represents the happiest period in my entire life, and things just get better every day.

Nothing has ever felt so very intrinsically right as practicing medicine. I'm good at this, and I enjoy it. If you have to be away from your kids all day, it may as well be something you love that occupies you.

Beyond just the work aspect, my personal life is going incredibly well too. The long, dark financial tunnel of training is coming to an end. I'm looking at an ROS that's going to pay off more than half my debt. I'll be free of student debt two years after I finish residency, and I'll be back practicing in the Maritimes.

My husband and I are looking at our long term plans, and we are watching our dreams start to unfold in front of us. Buying a house that really suits our wants and needs isn't a pie in the sky, wistful 'someday...' for us now. It's something we're seriously planning for, and we know how and when it's going to happen.

The kids are doing amazing. Our household now compared to our household two years ago is a different place. While we have the joyful chaos one expects of a larger family, it's a functional chaos. Aside from very age-typical behaviours, we're not dealing with anything more severe. For the first school year ever, we made it through the first week without hearing a peep from the school.

The older two have matured so much in the past six months in particular it's almost unbelievable. They've both really taken to heart our talks about the sort of people they want to be. Both of them are polite and helpful (generally; they are still kids after all!) They prefer to talk out their problems instead of act out. It's absolutely amazing how big of a change has come over them, and I am so proud of them for how hard they have worked and I have a lot of hope for this school year.

Miss M, of course, is a toddler with all the attendant naughtiness that comes with being nearly two, but she is still an easy, easy child. Sleeps well, eats well, listens relatively well (for a toddler) and is so enthusiastic about everything. She brings a smile to everyone's face, which helps make the 53rd "No, we don't drink the cat water" that day a little more bearable.

Perhaps its just my overly emotional nature when I'm pregnant, but I'm honestly just so very happy with how my life is going. I love seeing the kids grow and mature. I love the fact that my husband will soon be able to be home full time being the nurturing dad he has always enjoyed being. My work is wonderful, even though I'll be a bit sad to be away from it for the next few months.

I have spent so many years working towards a better future for this family. My husband and I have driven ourselves so far past our limits we've had to redraw the lines of possibility to be able to manage everything. But it feels like the world is opening up before us, and the future we thought was possible is starting to unfurl.

We're standing at the edge of the rest of our lives and the path ahead is bright and shining.

How fortunate we are to have made our way here.

Saturday, 8 September 2018

Sleep and Growth - It's a Pregnancy Post

I'm off work now. I did try to go to work this last week, but basically any time I did anything I started having contractions regularly, so I ended up needing to take last week off anyway.

Because having contractions every 10 minutes when you have a thirty minute commute and a history of precipitous delivery is the setting for a very crazy birth story, and I'd rather not have that happen, thanks much.

I am having contractions almost all night every night right now, but they never get closer than 8-10 minutes and fade away by morning every day, so it's all just prodromal/'false' labour (for those who don't know; 'false' labour does feel very much like the real thing with the exception of the fact that the contractions don't increase in frequency past 5 minutes. It does REALLY hurt, and it does cause some very slow, gradual changes, but it's not active labour.) 

So this necessitated that I stop working early and now I'm really bored.

We're ready for the baby, aside from the fact that he's still nameless. The bassinet is set up, the clothes are washed, hospital bags are packed, car seat base is installed. All the baby equipment that we'd put away after Miss M outgrew it has been washed and readied for use. The school has been advised that the kids may be pulled out randomly, the sitter has been given the information of the backup sitter who will watch Miss M.

Things are ready to go. My induction is still booked for October 5th, and I still strongly doubt I'll make it to 39+2. I had prodromal labour like this with my daughters and C was born spontaneously at 37w and while I was induced at 37w with M, the basically just needed to walk me past some Pitocin to get things started so I doubt I was far off delivering on my own anyway.

As it is, I just need to get to September 21st (37+2). That's the day that I will hit 600 insured hours and will be eligible for my full maternity + parental leave benefits. If I deliver before then, I lose the 17 weeks of maternity leave, but still have the parental leave. While I'm not working right now, I'm actually officially on vacation time (which still counts as insured hours) for this coming week and the following week. My official maternity leave starts on September 24th.

At this point, what it means is that my return to work date will change if I deliver early. If I deliver on or before September 20th, I will have to return to work December 15th. Otherwise I'm not returning to work until April 1st. Aside from the day this week I tried to go to work before I needed to go back home, I've actually been on either vacation or sick time since August 24th so I'm dreadfully bored.

I am a bit concerned about keeping up my knowledge and skills during my time off. I have some reading materials, my LMCC study stuff, lectures, etc. While I'm not *technically* supposed to attend any workplace activities, I have been told in the past residents on mat leave have elected to attend the monthly simulations, so I might do that for my own learning. I also plan to attend conferences and whatnot when the opportunity arises as I want to keep up.

But primarily, this time off is to get to know my new small human and learn to navigate being a family of six, which is somewhat terrifying to consider.

Tuesday, 28 August 2018

Practical Stuff: Loan Repayment Considerations

Here's something a little more practical to consider: loan repayment.

Between six years of student loans and my LOC, I've got a lot of debt, as is pretty typical of a freshly graduated doctor. I'm not planning to disclose actual amounts, just to say that it's a lot.

However, I have a few factors working in my favour:
- Big family
- Short residency (even with my leave, I'll finish in December 2020.)
- My home province's student loan rules

Because I moved from a province which does not do integrated Canada-Provincial Student Loans, I have three separate student loans plus my LOC:
- Home Province Student Loan [HPSL]
- Canada Student Loan (standalone)  [CSL]
- Canada-Ontario Integrated Student Loan [COSL]

My home province student loans have 0% interest throughout repayment. That's for everyone; it's not something I have to apply for, which is convenient. They also don't require medical residents to repay their loans until afterwards. I just have to apply for the residency deferral once, and then repayment will start a year after my (original) residency end date in June 2021.

The CSL/COSL is another matter, but this is where having a big family works in my favour. 

There's something called the RAP (repayment assistance program.) It bases your Canada Student Loan and/or combined Canada-Provincial Student Loan on your family size and income. For a single person, they don't start repaying until they have reached an income level of at least $25k. Doesn't matter much to most residents. 

But for a family of 5+ the income level below which repayment is zero is $67k. At least it was in 2016; I think it's higher now. It goes by income in months prior to application and you reapply every 6 months. The interest is paid for you during this period, it does not accrue.

My husband won't be working anymore after the leave (well, probably. That's a separate post.) so there won't be his income. It'll just be mine, which is below the zero-repayment level. Even with my call stipends, our income will only just edge over the zero-repayment level in late 2019 because of the fact that I'll have several months of reduced income during 2019 due to my maternity leave. 

Anyway, what this all means is: 
- HPSL: don't have to repay until 6 months after residency ends (amount will also be reduced under a debt reduction program)
- CSL/COSL: will start repaying at a veeeeery reduced rate in late 2019, won't have to start repayment in full until after residency. (Plus, I'll have almost all of this forgiven under the Forgiveness Program for rural family physicians.)
- LOC: interest-only repayment during residency and for 12 months after

And of course if I end up doing a PGY-3, these things can be continued. 

This sort of information isn't made easily available to residents because so little of it applies to the majority. Because I'm in a unique situation as a resident with a big family, I've been putting together information on these programs for myself for a long time, to make sure I have my financial bases covered.

I also share this information gladly with others because I think that it's entirely justifiable for us to use programs such as these which are intended to help us get our careers off to a good start. It's not exploiting a loophole or anything unethical; it's just strategic application of poorly-advertised programs for their intended use. 

Starting to wonder if I should put together a guide for parenting medical students. There's so little guidance for people who fall outside the norm. Might be useful. 

Friday, 24 August 2018

Vacation

I am utterly and completely exhausted. 

The last couple of weeks have been fantastic from a learning perspective, but physically I’m just worn out. All the running about during the day wouldn’t be a problem if I weren’t eight months pregnant, but I am and I’ve pretty much reached my limit. After today, I only have four more days of work left before I’m off, though, so that’s good. 

Starting off with my hospitalist block was a really good plan. For one, I got to learn who the specialists in the region are and where to send patients for outpatient stuff. I learned a lot about community supports and how to access them. This is stuff that will help me a lot in the next couple years in my clinic. 

It also gave me quite a lot of independence with managing my patients. It was really fantastic to see patients I admitted turn around and get better and go home. Some of them I’ll even be able to follow in my clinic because my FM supervisor is their family doctor. 

I really enjoyed the hospitalist work, to be honest, and I think it’ll be nice when I go home and get to do that occasionally. I wouldn’t want to do it exclusively, but it would be fun to do it as part of my practice. 

While at times it has been absolutely exhausting keeping up on my work, the learning has been incredible. The fact that my program is small so I work one on one with staff has meant quite a lot more autonomy than I think would be typical in a more hierarchical  program with multiple levels of residents. Once my staff got used to how I work and was comfortable with my level of skill, I had a lot of freedom. Appropriate freedom, of course. Staff were still following along and ensuring that I wasn’t screwing up, but I wasn’t expected to clear every single little thing with my staff. It’s a natural part of the graduated responsibility, but it was nice to have it so seamlessly granted. 

It was nice to be able to just put my brain to use. Clinical thinking is my strong suit, always has been, and I’ve really had the chance to demonstrate that on this rotation. The feedback I got from my staff docs has all been extremely positive and I’m so pleased that my anxiety over this transition appears to have been for nothing. 

Plus, this program was absolutely the best choice for me. The working culture at my site is incredible. People are very collegial and very pleasant to me. The staff are absolutely excited to teach and to help make me into the best doctor I can be. I never feel like a burden as a resident and it feels like all the professionals I’m working with are great at their jobs and that makes my job so much easier.

It is so cool that I actually get paid to do this. 

Residency is amazing. 

As tired as I am, as long as the days have been, this has been an immensely satisfying and worthwhile eight weeks. 

But I’m also really looking forward to my week off next week. 

Friday, 10 August 2018

Revisiting Plans

Currently, my maternity leave is scheduled to start on October 5th - my induction date - with everyone understanding that I'll probably deliver before then.

But I'm increasingly having difficulty with the physical demands, few as they are. It's not so much the walking about, it's the constant up and down throughout the day. The discomfort has become true pain and it's at the point where despite doing my physio exercises I'm spending my off days mostly recovering and basically unable to spend any sort of quality time with my kids.

I want to take a bit of time off before the baby is born so that I can rest and nest a little. I do still need to work my 600 hours before I can start maternity leave, though.

But.

Vacation hours count as worked hours too.

So I'm going to take two weeks of vacation starting September 10th, then start my official maternity leave on September 24th. I will hit 600 hours worked on September 14th (36 weeks and 2 days.)

If the baby is born before I reach 600 hours worked, I will have to use up my vacation and professional leave days to get me to 600 hours, and then I can take parental leave but I lose the maternity leave entitlement (yup, if he's born premature I actually will actually get less leave because of the hours requirement since maternity leave can't start later than the day the baby is born.)

In either case, so long as I don't give birth before September 7th, that will be my last day of work. I plan to return to work April 1st if I do end up with the full leave entitlement, December 15th if I don't. Regardless, I'll have some time off to recover and shouldn't need to return to work after giving birth.

I haven't yet heard back from the program about their feelings regarding my plan, but honestly I'm ready to push to get this if that becomes necessary since it's important to look out for myself. I'm entitled to a whole year and am taking much less, so I doubt they'll make any fuss anyway. My program admin are all very reasonable.

So yeah, I'm down in the final weeks before leave and feeling the need for that time off very much. Not that I don't enjoy work. Residency is absolutely fantastic; I highly recommend it. I'll get to that a bit more in my next post.


Monday, 30 July 2018

Transformative

The last week has been one of a lot of growth for me. 

I’m working with a different staff now and he’s much more hands-off than the one I was with for the three weeks prior. Different, not better or worse.

For the first weeks as I got my feet under me, I absolutely needed the hands-on, frequent checking-in my last staff was doing. By the end of my three weeks with him, I’d gotten quite a bit of reassurance that I was actually doing well. My current staff is a bit old school, and he’s an internist not an FM-hospitalist, so his approach is a bit different. He expects me to hold my own and while he does check in and he’s well aware of how his patients are doing, for the most part I’m expected to be fairly independent with my daily work (though always free to ask questions of course.)

It’s been very good for me from a confidence-building point of view. I’m making sure that I’m comfortable with and can defend my decisions. 

One thing I ran into a lot in med school was near-paralysis from uncertainty. I’d be so worried about doing something wrong that I would hem and haw and delay and double and triple check things I was still pretty sure about. Basically I was always certain I was doing something wrong even when I knew that wasn’t the case. 

I’ve been realizing that the people who’ve been telling me that I’m good at this might have been onto something, and I actually do have a pretty good sense for what to do a lot of the time. 

What I needed was a good run of tough cases that I did well with to kick me in the pants and show me that I do have some useful skills and I’m actually appropriately competent for where I’m at in my training. 

My staff I’ve been working with have been giving me very positive feedback, and it’s helping with the confidence element. Having been able to make a significant difference in management several times has also helped. 

I’m not getting a big head or anything, but I am feeling more sure that I can do this. 

This first month of residency has been an absolute roller coaster. Just scary enough to be incredibly fun, and at the end of that ride I’m sitting here, exhilarated, saying “that was fun! Let’s go around again!”

Monday, 23 July 2018

Haha, nope.

I was thinking my call schedule was pretty decent. And it is; I don’t work past 11pm (except when I do because I’m finishing stuff up) and it averages out to 1:4 in a four week period. 

But I’ve actually worked just a smidge under 200 hours in the last three weeks and my body has gone “hey Kay, you’re an idiot.”

My grand plan was to try to ensure that I have all my hours to be eligible for maternity leave pay (600) done as quickly as possible, earlier in pregnancy so that I could ensure if I deliver a bit early it wouldn’t be a problem.

Issue being, my body *really* disagrees with me working this much while very pregnant. Been run down the last few days but it hit me this evening. 

Only my fourth week into residency and I’m sick. I expect because I’ve exhausted every bit of my reserves of strength. I seem to have some sort of gastro thing going on. For most of today I though I was just really, really tired and that’s why I was a bit queasy and fuzzy-brained, but nope. Sick. 

Currently trying to figure out who to notify that I won’t be at work tomorrow because I am going to take an actual sick day. Since absolutely no one wants a doctor with gastro slowly waddling around the hospital. 

I pushed myself too hard, and I am paying for it. I feel so sore and weak that moving around my house this evening is a challenge. Despite wearing my compression socks and being careful to elevate my legs whenever I can, my legs are oedematous tree trunks and my kids thought it was cool to make dents in my shins by poking them. And they hurt. The hours of intractable cramping in my calves every night probably isn’t helping there. (No, I don’t have a DVT.)

My body isn’t playing by the right rules. I’m supposed to just be able to push through anything and keep going. I’m supposed to be able to just get done what needs to be done and catch up later. That’s why I booked a week of vacation at the end of August; to recover from pushing myself hard through my hospitalist rotation. (Vacation days still count as hours worked for calculating my hours, FYI.)

But dammit, nature, you win. 

I have my meeting on Wednesday about my maternity leave plans, and I’m going to bring up with the admin that I’m just not doing well with the call and I need to back off on my hours. Call is voluntary for me at this point so it’s entirely at my discretion if I choose to continue.

And I think I need to choose not to. 

It’s not like me to elect to do less, but at this point I have to do what I am always telling patients to do: listen to what my body is saying. 

And right now it’s screaming REST.