Urban Wisdom:

I don't usually spend $24 on a T-shirt (in fact, this might be a first), but when I saw this shirt at Urban Outfitters, I just had to buy it. A twist on the old fairy tale ending, it says: LIVE HAPPILY EVER NOW.

I like that. That pretty much sums up my goal and new philosophy for this coming year of being 26.

Speaking of birthdays, stay tuned for "Going Nowhere: A Birthday Journey of Sorts"....Coming to a blog near you.

Day of Birth(s)

After much anticipation, I got my first birthday wish of the year! This morning at 12:50am, I delivered the first baby born in New Haven on July 28, 2005. I take back everything I said about getting tired of deliveries--there is nothing trite about participating in the introduction of a new human to the experience of life. We had two deliveries this morning on my watch: the first was this one, daughter #2 to a couple I met yesterday morning when they had started trying to get this baby out. If the little one ever asks, I'm sure her parents will tell her that she sure took her time coming out, that her grandmothers were waiting outside the room for many hours, that mom was both exhausted and ravenous by the time she finally arrived. This is in complete contrast to the second birth of the morning, which started when I heard a sudden piercing scream echo down the corridor of the labor floor. Initially, I tried to be a good girl and suppress my natural rubbernecking instinct--but then I realized with a start that very soon (if not already) I'm going to be "the doctor in the house", so I'd better start acting as if it's my responsibility to respond immediately to any and all screams of pain. So I dutifully jogged down the hall towards the screams, opened door #1, and saw my intern covered in blood and baby mucus, in the process of delivering the woman on the exam table who was still screaming her head off. I quickly donned some gloves and stepped into the 'field' to help with the process that seemed to be doing just fine without our help. Moments later, baby was out--and then we had some time to find out who and what had just happened! Turns out she started contracting at 2:30am, waited a while to come in, arrived on our floor at 4am, and baby popped out just after 4:15! I've heard the legends of taxicab and kitchen table births; now I can personally attest to the fact that after if you're a woman who's had at least one kid already, don't assume that the next one is going to wait around for you and everyone else to get settled and ready!

Now off to Kansas City for a family medicine conference--I'm having a birthday dinner party at Dulles airport during my 2.5 hour layover later today; all are welcome to join us at the California Pizza Kitchen at 5pm!

The Big Squeezy

I didn't think it could happen. But today, I started to feel it creeping up my neck like a slow growing rash as I sat in the charting room twirling back and forth on the wheely chairs, checking my email, trying to look busy, and waiting for the day to end. I hate to say it, but I just wanted to get out of there and go home. After just one week, the novelty and thundering awe of participating in the birth of a new human onto this planet has become merely...my job. I guess it was inevitable--after all, as soon as the babies come out we medical folk leave almost immediately to go tend to the other mothers-to-be, the other unfinished progress notes, or maybe even lunch. Some people look forward to the last item they will have to do a price check on, others for that last meeting they will have to run; but the fact is, anything that I do on someone else's clock, over and over again, no matter how amazing, will at some point feel either rote or tedious, an obstacle between me and my own time.

Or maybe I'm just annoyed that there was nothing for me to do after about 11am today. My residents couldn't exactly let me go home that early, so I just tried unsuccessfully to be helpful for the subsequent six hours until I was finally released from med student custody. It's bad enough that I have a hard time doing nothing (note: I don't mean "wasting time", the process of doing something but getting nothing important done--I'm great at that--by nothing I'm talking about literally just sitting and breathing, waiting, etc) in my spare time; but I'm paying roughly $200 *a day* to get this so-called education--I damn well better be getting some bang for my buck every day!

Or maybe I'm just ready for the weekend. It has, I admit, been a pretty incredible (and incredibly exhausting) ten days on Labor and Delivery. Today I helped deliver my first set of twins by C-section. "Baby A" was a little girl who shot headfirst out of her mom's belly; "Baby B", a boy, decided to switch things up a bit by sticking his feet out at us through the incision. It was quite a sight--those cute little toes poking out of the open abdomen, followed soon by some tiny fingers, then the kissable tuchas, and finally, with a bit of tugging, his head. It was a tense minute while we waited for our boy "B" to realize he had just been born and give a welcome yelp to the world. But he came to after a vigorous rubdown and some oxygen. I found out afterwards that it probably would have been fine to deliver them vaginally, but as their obstetrician pointed out, the legal ramifications of ever erring on the wrong side of safety are too great, and anyway, she said with a smirk, "now I'll be back home in an hour."

One might think at first that C-section kids have it easy, just getting lifted out gently and set down--delivered, one might even say--on their first hard surface like a UPS package. But I'm not so sure anymore. They're just floating around in their uterine home, dozing carelessly to the lullaby of heartbeats and bowel gurgles, when--WHAM!--a slash of lightning across the dark sky widens into a wide crescent of searing light, and an enormous hand as big as their entire torso reaches down and grips their soft head, dragging them towards--and then through!--the hole in the sky. Instantly, they are transported from the old comforts of womb to the startling sounds and lights of their new life. No wonder it takes C-section babies a bit longer on average to get a grip on life. They had no preparation, no chance to pack an overnight bag, and definitely no role in the drama.

At least with a vaginal delivery the kid senses that something major is happening--when your whole world starts closing in around you and you suddenly feel compelled to shove your nice round skull into a space so tight it gets molded into an oblong egg shape, and you essentially feel like something better give or you're going to implode; you're probably quite thrilled when a pair of hands grab ahold of you and pull you into the open air, releasing the pressure on your baby lungs so that you can suck in your first breath. That's how it was with my third successful delivery yesterday, little Emily, whose mom was the first I've seen since I started last week who had a completely natural, drugless, childbirth. She had contractions, they hurt, she breathed through them, they got worse, she dilated fully, we came in, she started pushing, we saw some hair, she pushed some more, I gently cupped the oncoming head with my hands... and before we could say episiotomy, Emily's whole face popped right out. She had part of her cord wrapped around her neck, so we had to clamp and cut it earlier than usual, but after that I just guided Emily's shoulders out one by one, drawing my hand down her slippery back as she slid out easily into my arms. Emily launched into the Aria of the Newborn right on cue, was soon in her mother's waiting embrace (no incisions to close, epidurals to pull, or other wires 'n gadgets to remove), and when I saw them at 6:30 this morning for a postpartum check, mom and babe were sleeping peacefully in bed together, both, it seemed, happily wiped from their hard journeys.

Not that there's anything wrong with a necessary C/Section--but almost a third of babies are now delivered that way, way more than is truly medically indicated; and I don't think the outcomes are necessarily better. Also, it's really hard to feel like something as profound and special as childbirth is happening when everyone's gloved and gowned under the glare of the sterile OR lights, with mom chatting on the other side of the drape with the anesthesiologist and a sterile paper jumpsuit-clad dad. It feels more like...well, a surgery. Duh, I guess. But I find it strange, and maybe a little sad, that doctors and mothers today so willingly give up the sacred for perceived safety, and sacrifice consciousness for convenience. It is, partly, the era in which we live, this world of fast food and Tivo, of conducting entire businesses with the click of a mouse. Maybe the C-section babies will grow up better adapted to this e-climate, better prepared to spend their lives floating in the ozone-less smog, dozing to the lullaby of refrigerator hums and cell phone rings, better-equipped to deal with the benefits of instant transformation over slow and arduous progress...but inexplicably afraid of thunderstorms.

Contiguous Thoughts

Shelley, an old family friend, came to visit this weekend. I'm the easternmost stop on her crosscountry vacation that started out in Cali where she's been living. Not long into her trip, at a random rest stop along Rte 80, she noticed a Hawaii license plate. Shortly thereafter, some folks from Alaska passed her on the right (those silly Alaskans!)--and at that point, Shelley realized, she had no choice. She had to play the license plate game. By now, she's scored all but two states: Louisiana and South Dakota. Apparently Louisianans don't get out much, and there probably aren't enough people living in SD to spare for travel during the corn season. I was thinking about how difficult it usually is to find those pesky Alaska and Hawaii plates...wouldn't it be neat to start a website where people from A & H (and Puerto Rico) could log in while traveling to let license plate game players all over the contiguous 48 know where they are? And speaking of "the contiguous forty-eight states": is this word ever used for anything besides describing the USA sans Hawaii and Alaska? If so, is it really necessary to have a whole word devoted to such a rarely utilized concept? Why not just say "the continuous 48"? Or, let's start using contiguous more often. It's quite a nice word, really--a bit more highbrow than continuous, so speakers can feel more literate; but still close enough sounding to continuous that your average joe will understand what you're saying even if he doesn't know the word. It's a win-win word.

Hard Day's Night

I have newfound compassion for insomniacs and Arctic inhabitants.

Insomniacs: For the last week, my world has shrunk to the size of the Yale-New Haven hospital Labor & Delivery floor, where I have spent over 14 hours every night scurrying about the sacred and mundane activities of obstetric "night float". Floating is hardly the word I would use to describe the way I walk out of the hospital after each shift; they should call it "night bleary-eye" or "night falling-over-and-walking-into-stationary-objects", if you ask me. I suppose I asked for it by choosing to do the whole follow my calling into medicine thing; but after these first few weeks of my clinical training, a part of me wishes I were the kind of person who felt called to become a chocolate taste-tester or massage school demo subject, or maybe a millionaire if push came to shove.

It's been quite a while since I've had this long a stretch of SSS (Sub-Six hours of Sleep). Not only can I feel my cognitive function slowly draining through my sturdy Dansko clogs as I stand on them hour after hour--my motor coordination has gotten so bad that on Wednesday afternoon, biking to a haircut appointment, I literally ran into a garbage can. Obviously, it was not moving at the time. Luckily, neither I nor my laptop were badly hurt, and the garbage can only suffered minor bruises.

Arctic inhabitants: When I do reemerge from the depths (er, 4th floor) of the hospital wards, at the end of my hard day's night, the sun is inexplicably still shining even more brightly than when I left it, and the air has the energizing feel of anticipated productivity, not to mention the rising heat of these July steambaths we've been having. But I, newly knighted denizon of the dark, am supposed to...go to bed?! Sure, I'm tired as all heck. Sure, I barely have enough coordination left to floss. But, but--it's so bright and happy and summery, and I technically don't have to go back to work until five! Thus far, I've only managed to endure about four hours a day of sweaty late morning sleep, clad in just undies and a face mask under a single sheet and the hum of my window fan. I used to think it would be really neat to live in one of those latitudes where the sun doesn't set for months on end. Now, I can't wait to get to next week, when I'll be lucky enough to return to my previous schedule of waking up with the sun at 5am. I have to hand it to those who devised this clever bit of reverse psychology for my thalamus.

Coming Soon, To A Neurologist's Office Near You: iBrain

I have recently begun saying that I love my iPod so much, I can't wait til the technology is developed to get it implanted behind my ear. After all, there is rarely a moment when I am not either listening to music or generating my own private soundtrack to accompany my inner monologue. But did you ever have the experience of being in such a deep morning sleep that when your radio alarm went off, you heard the radio playing in your dream, and no matter how many volume controls you swiveled or plugs you pulled, the radio continued its incessant blare? ... Well, I have. I imagine that's what it must be like for those who have the musical hallucinations described in this NYTimes article.

Maybe if enough people develop these musical hallucinations in the future, as the doctor in the article speculates, Apple will develop a special neurally implantable version of iTunes. And I'd be able to stop worrying about dropping or losing my iPod. Better yet, maybe they'll develop a surgery for *creating* these musical hallucinations in people who want them... symphoniplasty anyone?

The Search for PET

Even chief residents don't always know everything. Luckily, they have us--their trusty med students-turned-personal librarians, who dutifully look up stuff and report back the next day. Admittedly, this is actually a superb teaching tool for us as well as a time saving mechanism for them.

So, tonight my homework was to look up PET scans and figure out how they work. First I looked on UptoDate, one of the most popular online clinical references used by med students and physicians. I typed in "PET". I received the following results:
- PET scan
- Pet therapy
- Petah Tikva, Hemoglobin
- Petasites hybridus root
- Petechiae
- Peter anomaly
- Pietit mal seizures
- Petrolatum
- Petrosal venous sinus catheterization
- Petroselinum crispum (parsley)

Yes, parsley is apparently classified as a drug now, for its antibacterial and antifungal properties in treating halitosis (bad breath). And Petasites hybridus, aka the perennial shrub butterbur, has been found to be quite effective in preventing migraines. It's crazy to me that this widely used clinical reference has so seamlessly and inconspicuously inserted herbs and other "alternative" therapies into its database, while most of my professors over the last two years acted like I was on crack for asking about the benefits of things like yoga or omega-3 fatty acids in class. But as our dean of students said on the first day of medical school, "50% of what we learn in medical school will be proven wrong within the next 10-15 years--the problem is, we don't know which 50%, so you're going to have to learn all of it."

Also, fyi, Petach Tikva hemoglobin is a rare form of unstable hemoglobin found in two unrelated Iraqi Jewish children. Who knew?

Then, I went to PubMed, a search engine for medical research. Again, I type in PET. This time, the first entry I got was:

Pentaethylene-Terephthalate (PET) Bottles: A New Device for Autoerotic Strangulation of the Penis Causing Serious Injury
Thomas A. Voegeli1  and Peter J. Effert1 
Department of Urology, University of Duesseldorf, Moorenstrasse 5, 40225 Duesseldorf, Germany

Abstract  Strangulation of the penis by application of constricting devices may present a challenge for the treating physician. Depending on the type of constricting material, special equipment is essential for successful removal of the foreign bodies. We report a new form of constricting device, the neck of a Coca Cola bottle made of Pentaethylene-terephthalate (PET). Particular difficulties were encountered upon removal. Technical details of this case are described. Prior literature on the treatment of penile strangulation is discussed. Key Words  penis - strangulation - constriction - autoeroticism

Note to any of you male readers out there--stay away from Coke bottles...

It's A Girl!

On Thursday, July 8th, at approximately 4:13pm, my newest little relative, Ellie Samara Neil, emerged from her warm cocoon inside my cousin Melissa to begin flying solo through this experience we call life. Welcome to the world, Ellie! Her middle and Hebrew names were chosen in remembrance of my Uncle Steve, who died this past Christmas day after a yearlong battle with pancreatic cancer; but Ellie will surely feel connected to her grandpa when she finds out that not only was she named after him--she was actually born on his birthday.

But wait, there's more. I was born on my grandpa's half birthday (me: July 28th, him: Jan 28th) and my baby brother Simon was both named after and born on our common grandpa's half birthday (Simon: June 1, my dad's dad Shimon: Dec 1). I could say that it's just a coincidence, but I think life is more meaninful if you find more meaning in it; so I'd rather think of these star crossings as evidence of the cosmic connection between and among generations of lineages. Like a sandwich, we are the top and bottom pieces of bread--one generation coming, the other departing, but both made from the same batch of dough. Grandchildren are the pinnacle of human organism achievement, the first (and sometimes only, for most of us non-Mozart or da Vinci types) physical proof that your existence will last beyond you. And more importantly, that it can do so without you, as grandchildren represent the first replication of your DNA that does not require your own personal genomic template. And then, on the other hand, grandparents give intimations of the common denominator of human existence; realizing that all the 1st cousins have a common grandpa, and the even larger gaggle of 2nd cousins can trace back to a single set of great-grandparents--it is proof that somewhere back in time are some small number of ultimate grandparents, who begot us all. Kind of fun to think of them all sitting around in rocking chairs knitting little booties for their 7 million progeny in the year 2005, isn't it?

Yes, there's something very special about grandparents and grandchildren.

Who is Mark Ecko?

To be honest, I had no idea until this morning, when I happened upon the article about him in today's New York Times magazine. Turns out this "grown-up New Jersey mall rat" turned clothing designer multi-millionaire grew up in my hometown, the one and only Lakewood, NJ! Awesome.

Caveat Emptor!

Last weekend I went "out East" to the ante-Hamptons for some quality July 4th weekend chillin' with my friend Matthew and his family at their house in Hampton Bays--a less pretentious, and presumably less expensive, way to get out of the NYC summer miasma and relax at a real live beach or under real live trees. On Monday morning, we (and apparently every 17-year-old blonde girl on summer vacation within a 10 mile radius) decided to get our morning sustenance at the corner Dunkin' Donuts. Maybe you already knew this, but I was shocked: they now offer a WHOLE WHEAT donut! Ironic, no? I was almost tempted to get one, and you might be too, so I'm warning you: Don't Be Fooled. A donut in whole-wheat clothing is still a piece of deep fried, artery clogging white bread with lots of empty calories. According to the nutritional information , these so-called whole wheat donuts are even worse than regular donuts because their first ingredient (ingredients are always listed in order of amount in a product) is partially hydrogenated oil! Evil, indeed. I hate it when food companies trick innocent people into thinking they're making a healthy choice that actually leaves them worse off than they would have been with the unhealthy choice.

Circadian Arrhythmia

Woke up late today. And by late I mean 5:25am. Ridiculous. Almost didn't have time to preround on my patient before it was time to present to the chief for real rounds. The problem is, I refuse on principle to rise before the sun. In general, I don't live by many self-imposed irrational rules. The only other one I can think of right now is that I must eat breakfast food as my first meal of the day, whatever time that may be. Of course, I'm the one who defines "breakfast food" for myself, but this is just part of the illogic that goes along with the illogical personal rule. (Incidentally, I will truly get to test this in a few weeks when I start obstetrics night float and have to wake up in the afternoon for my 5:30pm-5:30am shift...I'll keep you posted) Anyway, back to waking up. I've been stirring at around 4am, and then again at 5am, fearful that I'll oversleep--but then I feel obligated to lie in bed until my window lightens enough that I know for sure the sun is up. And then I realize how late it is, jump out of bed, and run around like a chicken with its head cut off to make it to the hospital in time...

Speaking of chickens, I clearly counted them before they had hatched yesterday, with my premature self-congratulations on making through my first surgery unscathed. This morning I was in a rush to get to the 9am hysterectomy and didn't have time to eat or drink much of anything beforehand. Note to self and others: bad idea. But the surgery was supposed to be a quick 'n easy laparoscopy, so no worries. That is, until the surgeon realized that the patient had too many adhesions (things stuck to each other from past surgery or infection) to do it laparoscopically, and *I* realized that I was now committed to spending the next 3+ hours standing on a stool under the hot lights, contorted into some inevitably uncomfortable position while my kidneys grew increasingly sullen with my lack of additional hydration. Ugh.
...
Three and a half hours, multiple ligated arteries, two ovaries and a uterus later, I was still standing on a stool perched under the hot lights, over the patient, in my paper gown and mask, trying to alleviate the incredibly painful cramps that had unfortunately chosen today for their monthly arrival. I had that icky dry taste in my mouth that I usually only get during the latter hours of Yom Kippur after fasting without food and water for a full day. Luckily, the surgeon and my resident were all done and about to suture up the incision, my second successful hysterectomy....when suddenly, without warning, I felt strange. "Am I feeling what I think I'm feeling?" I thought to myself. "Nah, couldn't be--we're almost done!" I responded to myself. Before I could get another word in edgewise with myself, I felt a tap on my shoulder, a whisper in my ear asking if I was feeling ok. Luckily, she didn't wait for my answer. The scrub nurse deftly slipped a wheely stool behind me as she gently shoved me down onto it, and within moments I was leaning over the sterile garbage can while the nurse wiped sterile alcohol pads on the back of my neck to cool me down. Given that I didn't actually have enough of anything in me to throw up immediately, the nurse turned back to her more important conern (that of maintaining sterility) and promptly wheeled me straight out of the OR before I could contaminate a single thing.

It all turned out fine in the end. I didn't technically pass out or vomit, and I certaintly didn't fall to the ground and bump my head on a machine and end up in the ER like one of my classmates did on our very first day three weeks ago; but it still felt demoralizing to be the one who had to get wheeled out on a stool and fed apple juice and crackers while the rest of the team got the job done. Guess there's nothing to do now but chalk this one up to experience and make sure to drink well before surgeries in the future. Of course, therein lies the dilemma--need to hydrate, but if too much hydration, may need to pee. And there are no potty breaks in the operating room. Hmm...maybe I could wear some Depends just in case. Or maybe catheterize myself beforehand and then drink as much water as I want. Riiight.

Womb Is Where the Heart Is

My first surgery was a success!
And the patient was fine, also.

Don't worry--by "my" surgery I didn't actually mean that I *did* the surgery, or anything close to it. All I did was hold some retractors at this angle, some scissors at that angle, and my head and torso at a completely different angle, while the head surgeon (aka the attending) instructed my new boss (aka the chief resident) how to do all the cutting and cautery and suturing and such (aka the actual surgery).

You see, the success had nothing to do with what I *did* do; it had everything to do with what I *didn't* do: I didn't faint, vomit, sneeze into the sterile field, accidentally scratch my nose and have to leave to rescrub, have a bathroom accident, get stuck with a needle, stick anyone with a needle, fall asleep, trip over myself and fall onto the patient, offend the scrub nurses, insult the surgeon, or commit any of the other potentially disastrous yet inevitably common flubs that I've heard about others making in my position as a surgical newbie. Score one for me!

To be honest, I was actually feeling a bit out of sorts at first, as I stood waiting in one corner of the cramped little room while everyone else prepped the instruments and patient. Watching the anesthesiologist soothe our nervous patient with the warm lullaby of a morphine drip, listening to the James Taylor crooning on the OR radio, I felt as though maybe he was working his magic on my nerves as well...maybe a little *too* well, as my head started to float up to the ceiling and my knees got a wee bit wobbly. Luckily, my body decided to cooperate with the situation once I got called into the thick of things, and I retained and maintained a firm grip on the right side of gravity throughout the rest of the procedure.

The operation, a vaginal hysterectomy with oophorectomy, was a bit of a change from the happy prenatal visits I've been doing the last two weeks at the Women's Center. There was no baby in this uterus--just a collection of hardened fibroids creating a whole lotta bleeding and pain for this poor woman with a life history not many would trade her for. On one hand, I was excited about the surgery, it being my first and all, but part of me felt very sad at the thought of the castration (we had to take her ovaries also) that was about to take place. When it came time to remove the uterus, I braced myself for the gore and grossness. But it never came. All that emerged from/as our patient's womb was a small, red, heart-shaped object. It was almost adorable. Turns out our patient had a bicornuate uterus, meaning that as an early embryo way back in her own mother's womb, she didn't complete the fusion of her pre-uterine tubes into one uterus. As a result, she has one cervix attached to a two-humped uterus, and it really did resemble the shape of a traditionally drawn heart .

What to make of the blatant symbolism? Here are a few thoughts on this utero-cardiac connection:
1. Bearing children seems to be a gift of the heart, as ordinary women in love become mothers who discover a love for their children that is deeper and more powerful than anything they have ever felt.
2. Functionally, the uterus is like a second heart--the first one gives us life, and the second gives life to our children.
3. It's interesting that her "heart" was bleeding, causing her so much pain. The attending said that she's had a series of unfortunate tragedies in her life, all of which have no doubt caused her emotional heart much pain. Maybe, in removing her bleeding, wounded heart, we have helped heal a part of her past and given her hope for a brighter future....

Ok, enough mushy theorizing. It's 10pm, way past my bedtime already. I've become an early bird. Time to go catch some worms. Ugh.