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.