Sunday, December 31, 2006

Lessons Learned This Holiday Season

  1. It is not enough to bring your toothbrush and medications in your carryon; you should also bring your passport. Because even if you are not flying through, say, Denver, it may happen that of all the flights going out of your airport the Saturday before Christmas, yours could be the one that is cancelled for “maintenance.” (Now, to me, “maintenance” implies routine things like changing oil or rotating tires. Things you would never do on one of the busiest travel days of the year. Couldn’t they just admit that the flight was cancelled because the PLANE BROKE?) On such a busy day, there will be no extra seats on any of the rest of the flights that day, unless you are willing to fly via a complicated connection THROUGH ANOTHER COUNTRY. Hence the need for passports (which TrophyHusband was able to drive home and retrieve in time).
  2. You might also want to bring a few changes of clothes in your carryon. Because even if you are checked into a flight three hours early, it may happen that none of your luggage makes it on the plane with you.
  3. Don’t pack a suitcase for each person; mix it up a bit. This way, when all of the bags eventually show up except yours (which does not arrive until the night before you are leaving to go back home), you will still have something to wear.
  4. My mother really needs to update her wardrobe. Since I had no clothes to wear, I had to borrow hers. She is somewhat shorter and wider than I am, so I couldn’t comfortably wear her things the whole trip. And when I braved the mall wearing her clothes and asked the sales clerk where I might find jeans, she looked me up and down and sniffed, “Well, you wouldn’t want the Juniors department,” and took me to a rack of Mom Jeans. I couldn’t decide whether to slap her or spontaneously combust from embarrassment, so I just slunk away. (I did find an awesome outfit, in the Juniors department, so there, judgmental salesgirl.)
  5. It is truly is better to give than receive. You become acutely aware of this when your gifts are stuck in your lost suitcase and you have to unwrap others’ gifts and then say, “Thanks! I hope my gift to you isn’t being sold on a corner in another country!”
  6. My husband is a trophy and a mensch. OK, I already knew this one, but he proved it over again. My family has a tradition of giving most gifts as “stocking stuffers,” which creates an absurdly huge stack of gifts to unwrap Christmas morning, but is pretty cool because you never know who gave what; it’s quite freeing. But many of the gifts were stuck in my suitcase (see #5). Then my brother (whose awesome girlfriend recently broke up with him, probably with good reason) announced that he had bought no stocking stuffers at all. I thought it was going to be like Whoville, only without the singing. But my husband, despite being Jewish and finding this whole Christmas thing incomprehensible, had gone out on the sly and bought a heap of cute and thoughtful gifts, and the pile of loot was not appreciably smaller than usual. (HellBoy, when he saw all the presents, said, “It’s Hannukah morning!” which pleased my husband greatly.)
  7. If you are very tired and have just eaten a big Christmas dinner, do not lie down with the child while putting him to bed. Because it may happen that you wake up the next morning with fuzzy teeth, and your parents and their guests will be very perplexed as to why the hell you never came back to the table.
Happy New Year, everyone.

Monday, December 18, 2006

If You Don't Think Studying Is Hard, You're Doing It Wrong

A disclaimer: I never said I had a fun or easy way to study, or even a particularly original one. I only said that it worked (for me).

When I decided I was going to try to get into medical school, I’d had thirteen years of grade school, three years of college, and two years of grad school. But the vast majority of this time was spent in classes in the arts, and the art I perfected was that of doing just enough to get an A- in anything. (The trick to that, if you’re interested, is: read the assigned material closely enough to get the gist of the ideas, show up to most of the classes (in particular the first three and the last three), write a paper that is slightly longer than the minimum assigned length, and string together coherent sentences for the midterm and final. So few people (no matter how fancy the school) manage to do all of those things that they’ll feel guilty marking you down much for simple crappiness (and believe me, I was guilty of much crappiness). There were a few classes that I got really into, but it seemed like even when I flayed myself open for a class, the T.A. wouldn’t care for my take on the subject and would give me an A- anyway.)

So let’s say I was a tad unprepared for premed classes. I had a heavy load of them, too, since I pretty much hadn’t done anything in college that counted as a science course, with the exception of Physics for Phreaks (where all I remember doing is going on a field trip to walk through a noise-canceling room while some poor grad student babbled about waves). I crammed into a two-semester period almost every required premed course, including labs. I read the books and got the gist; I showed up for class; and when I sat down for my first test—a physics quiz—I wasn’t too worried.

My attitude was rudely adjusted when the quiz came back with a big red “59” written in the top right corner. Thanks to the curve (a lovely device not often used in liberal arts courses), it worked out to something like a C, but holy shit—a 59??? I had blown 41 percent of the questions?? This wasn’t going to get me into med school. And I’d already quit my job.

OK, so it was firmly established that I was no Feynmann. I needed to get serious. Here’s the method I followed:
  • Realize that how painful something is to study is directly proportional to how much you need to study it.
  • Go to every class—and stay awake.
  • Read all of the material, painstakingly slowly, at least three times over.
  • The “gist” is useless; memorization is what counts.
  • After you think you’ve memorized something, try writing it all down on a blank sheet of paper. Hmm, maybe not as well memorized as you thought?
  • When you quiz yourself, which should be often, make sure you get all of the answers right three times in a row.
  • Beware the mnemonic. Mnemonics only work in very specific circumstances. For instance, “NAVY” is a handy mnemonic for remembering the order in which one encounters the important structures in the groin: Nerve, Artery, Vein, Ying-Yang. Most mnemonics, no matter how clever or bawdy, just inspire one to invention. Does that I in “PILES of POOP” stand for Ischemic? Infectious? Iatrogenic? Ipsilateral? Italian? Who the hell knows? I found that making up a memorable saying works much better. For instance, if you drink enough alcohol to affect your liver, there is a tell-tale pattern to the increase in the liver enzymes: the AST, aka the SGOT, is usually twice as high as the ALT, aka the SGPT. I remember this by saying “You AST for it, you SGOT it.” (I know it’s stupid. But it works—I remember not only the pattern, but that AST=SGOT.) Corny tricks like the ones for remembering someone’s name (you know, picturing Mr. Heinz as a giant ketchup bottle, for example) work well also.
  • You will never be hip again. Obviously.
  • Get enough sleep. Cramming all night the day before a test does not work for science classes.
  • Study similar things in proximity to each other. Calculus and physics go well together, for instance.
  • If studying something is making you fall asleep, take a power nap.
  • I said power nap. Do not let yourself sleep longer than 20 minutes.
  • Colorful highlighters and tabs and note cards are festive and helpful—up to a point. Past that point, they become time-sucking OCD rituals.
Hey, like I said, it’s not fun. But it worked for me. Despite my pathetic start, I went on to get the highest grade of anyone in that physics class, and I got an A+ average in my premed courses. I realize now that if I had used these kind of techniques in my liberal arts courses, I probably would have rocked them, too. Even when I worked hard, I neglected ever really to learn the material by heart.

In a few years I’m going to have to take my recertification test, so I’ll be hauling out these methods pretty soon. For now, I confess that I’m often getting by on the gist.

Sunday, December 10, 2006

Cold-Weather Running for Maggots

  • It’s not too cold. From my sitemeter stats, I know that none of you are running where you risk hypothermia from venturing outdoors, provided you are properly attired and do not have a lung disorder. (If you have exercise/cold induced asthma, as I do, your tolerance for extreme cold may be less. Using an inhaler before running helps.)
  • Go synthetic. No cotton, ever, on any part of your body, when running in the cold. When you sweat, cotton becomes soggy, and when it becomes soggy, it becomes cold. This is all right while you’re running, but if you stop and walk you’re toast. Iced toast. Ditto for goosedown. (Wool is ok, if you can stand it.)
  • Layers. In general, the more, the better; you can always pull things off and tie them around your waist. A polyester turtleneck, a fleece, and a breathable-fabric windbreaker works well. (Non-breathable windbreakers will leave you too wet.) A windbreaker that covers your butt is nice. Two layers is pretty much the max on your legs, or you’ll be waddling. None of these items needs to be running-specific, and they’re usually cheaper if they’re not. I like Campmor for good, reasonably-priced stuff.
  • Coverage. There are synthetic clothing options for covering up every bit of you, and how far you want to go depends on your cold tolerance. You will likely be sorry if you don’t use a headband or hat and a good neck gaiter (the tall, thin ones are very flexible) at the very least; a balaclava works for some, but isn’t very flexible. Goggles or glasses help keep your eyes from tearing, but wire-frame glasses will transmit the cold. (Using anti-fog spray on your glasses is a good idea.) Gloves are a must, and tucking your hands into your sleeves adds warmth. I’ve never been able to tolerate a face mask; I just use a neck gaiter and keep turning it as it gets too wet from my breath.
  • Snot. Your nose will run. Bring tissue, or make sure your gloves are soft and absorbent.
  • Reflect. It’s dark in the morning and dark in the night, and you’d be surprised how hard it is for cars and bikes to see you. Make sure you’ve got reflective stuff above and below. I have a nerdy reflective vest.
  • Know which way the wind blows. Always run with the wind on your way out and against it on the way back.
  • You can run in the snow. Running on packed snow or unshoveled sidewalks isn’t too hard, but you will need to go more slowly. Since you’re going for time, not distance, this shouldn’t matter much.
  • You cannot run on ice. You will fall and break your wrist.

Thursday, November 30, 2006

Beam Me Up

The light box thing came. It’s pretty funky. I got the desk lamp version, partly because it was listed on the sheet my doctor gave me and partly because I thought I might be able to pass it off as, you know, a desk lamp.

Not a chance. This thing looks like it was left behind after an alien visitation. Everyone who’s stopped by my office has skidded to a stop and said, “WHAT is THAT???!!”

Though when I confess it’s a light box, they all say, “Ooooohhhh ... I want one!” So I guess there are more dorks out there than I suspected.

I’ve only had it for two days, which is a little early to expect results. It definitely feels different than a regular lamp. It doesn’t seem all that bright—until you switch it off, at which point the room seems to have been dunked in essence of gloom. So after spending the recommended half hour with it beaming on my face like a Gro-Light on a happy pot plant, I move it way over to the corner of my desk and point it down. I don’t know if this will cause a mania-inducing overdose, but a little hypomania wouldn’t be such a bad thing. This has been a really tough month. I don’t feel depressed, exactly; no hopelessness/helplessness/inability to imagine a better future, etc. I just feel melancholy. And yes, that’s normal, but it’s no fun, and it’s affecting other people. I’m avoiding posting, because I can only think of gloomy topics. I’m like a sullen, disaffected teenager. I seem to see only the sad facets of every situation. For instance, one of my students has a deformed thumb. So what, right? It obviously hasn’t harmed her success in the world thus far. But every time I see her, I find myself mesmerized by it, hardly able to focus on anything else. I’m afraid to comment on others’ blogs, for fear of focusing on the deformed thumb.*

Before I sign off, I do have one piece of happy news. One of my colleagues has been going through infertility treatment for a looong time (during which five different women in the office got pregnant, two in an “oops” manner). She underwent multiple interventions, including seven IVFs. Then she thought that she must be going into early menopause, because she hadn’t had her period in a while. You know where this is going … she’s fifteen weeks pregnant now. So how’d it happen? Did she “just relax”? Nope. She and her husband had a fight, followed by makeup sex, and ta-da! Her RE was like, “You got pregnant by having sex? Eww!” So now I have an irritating story to tell people who are trying. “Just have a fight with your partner! You’ll be pregnant in no time! I know this person …”

*Not to imply that anyone else has deformed thumbs, or deformed blogs.

Monday, November 20, 2006

Rage, Rage Against the Dying of the Light

I went in for my quarterly tune-up with my psychiatrist recently. I think he’s a little bored of me; he hasn’t had to tweak anything for ages. This time, though, when he asked the usual questions about how things were going, I answered, “Fine, I guess, though of course it’s always especially hard after the time change in the fall.”

He perked right up.

“Why does that bother you?” he asked.

“Well, because it gets dark so early,” I answered.

Which is how I found out that it’s not entirely normal to dread the autumnal equinox and to count down the days until the light starts to grow again. I’d never understood how anyone can say fall is their favorite season. I’m used to my mood taking a swan dive in the fall, reaching its nadir about the end of December. It always creeps back up, but the prospect of the weeks and weeks of darkness stretching out ahead of me is tough.

So now I’ve got a light therapy lamp coming in the mail. I will set it up on my desk at work. I am going to look like a complete dork. Rather, I will be revealed to be a complete dork. But, I hope, a cheerful dork.

Thursday, November 16, 2006

Scurvy of the Soul

Medical school is full of “That’s how that works?!!” moments. One I remember especially clearly was when I learned about scurvy:
Scurvy is a disease caused by a dietary deficiency of vitamin C (ascorbic acid). The disease has occurred with regular frequency throughout human history and prehistory in populations lacking fresh foods … Deficiency of the vitamin causes a breakdown in the binding function of these tissues, producing a series of characteristic signs and symptoms: weakness, lethargy, irritability, anemia, purple spongy gums which bleed freely, loosening teeth, the reopening of healed scars … and hemorrhaging in the mucous membranes and skin. In severe cases the mortality rate is high.
Up until then, I’d believed that scars were stronger than regular skin. When in fact they're weaker. Maybe this was something most everybody else knew, but it really shook me up. The mantra “What doesn’t kill you makes you stronger” is so satisfying. “What doesn’t kill you leaves a scar that may weaken and rupture again if stressed” is kind of scary.

I got to thinking about this recently when I was doing a computer search to see if a paper I’d had published recently was showing up yet. Only one other person with my last name is published in the medical literature, so it was quickest to type in just my last name to look for my papers.

But it turns out that they’ve been slowly working backward in time to put medical articles into the citation system. Which is why the last time I entered my name into PubMed, two articles written by my father appeared.

My father was a statistician who collaborated with medical researchers, so it’s not surprising that he had some papers published under his name. But he died when I was five, and all I knew about his job is that it had something to do with computers. Seeing his name pop up without warning like that was painful; a reminder that he’s not here, and of how much he has missed. I had never even thought about the fact that we could have talked about my work.

People often say that you never get over a loved one’s death. When I was much younger, I hated to hear this. I spent a long time trying to convince myself that my father’s death didn’t really have an effect on me. It happened when I was so young, after all. But things did sneak up on me. When I was driving down a street one day I caught sight of a little girl learning to ride a bicycle, her father running behind her, his hand on the back of her seat. Suddenly I was so upset I had to pull over to the side of the road. Then I remembered that my father had just started teaching me how to ride a bike the summer he died. After he was gone I had to do it myself: there was a big pothole in our driveway, and if I climbed on the bike at the top of it and rolled down, there was just enough momentum to get me started. I did it over and over again until I had it.

Once glimpsed, the knowledge that a person who loves you and takes care of you can disappear in an instant never goes away. It can teach you to appreciate people, but it also makes you very wary.

The truth about what happens when something wounds you is that first there is pain and bleeding. Then you start to heal, and a scar forms. A scar is vastly better than nothing; at least the acute pain goes away, and you don’t bleed to death. But it’s never the same as it was.

I think that human interaction is like vitamin C for the soul: get too little, and your psychic wounds can reopen.

I guess that’s why I keep blogging.

Wednesday, November 08, 2006

I Didn't Mean Right NOW

I got a call from the Medical Examiner's office that one of my patients was found dead. It was the woman I saw the other week, the one who couldn't stop drinking, the one I called a drink-yourself-to-a-miserable-death alcoholic. The cause of death was clearly alcohol-related. She was found by her daughter, who had stopped by with her newborn baby. I didn't even know she had a daughter.

I spoke with the daughter on the phone. She talked about how the alcohol was the only thing that mattered to her mother; she only ever called her daughter to scream at her. The daughter seemed incredibly nice.

I haven't got anything profound to say about this. I'm just trying to imagine what it must be like to care more about getting drunk than about your daughter, or your brand-new grandchild, or your own life.

Tuesday, October 31, 2006

Ghouls and Ghost Stories

Yes, I backdated my post to October. Suzan-Lori Parks may have been able to write a play a day for a year, but I know I’m not up to writing even a decent post a day for a month, so I don’t want to imply that I’m doing so by posting on November 1st.

Yesterday I supervised the residents for outpatient office hours. I mostly enjoy this part of my job; it’s a perfect opportunity to teach the art of medicine. There are all kinds of techniques for giving patients what they need and want AND being efficient. Sitting down when talking to them, asking “What else?” and “What else?” and “What else?” until they can’t think of anything more, asking “What questions do you have?” at the end of the visit instead of “Do you have any questions?” Explaining that something “isn’t dangerous” rather than saying “it’s not serious.” Oh, I’ve got tons of cute tricks up my sleeve.

Yesterday got a little out of control, however. We saw 17 patients between 2 and 5 pm, and most of these patients were not 10 minute visit types. A couple of them were very appropriate for Halloween, and haunted my thoughts all night. (Some details altered to shield identities.)

One was a patient I’ve been following for a couple of years; she got put on the resident schedule because I was out of town last week. This patient is truly horrifying. She’s an alcoholic, but not a flunked-a-couple-CAGE-questions alcoholic; no, she’s an old-school, drink-yourself-to-a-miserable-death alcoholic. She used to have a real job and a real life, but has lost it all. She has developed almost every sequela of alcoholism there is—heart damage, liver damage, brain damage, nerve damage—but most frightening is that she keeps falling down and damaging her flesh and bones. She drags herself into my office about every two months for follow-up from a visit to the ER with another horrifying injury. She fell flat on her face and smashed her nose in. She fell and bit through her lip, almost severing the whole bottom lip off. She’s broken both arms several times. She’s so malnourished at this point that she can’t heal properly. She’s a trembling, emaciated, misshapen wraith. And she’s always furious. Furious that she’s in pain all the time (and that I won’t give her narcotics, though she usually has plenty left over from the ER and the orthopedic surgeons). Furious that everyone is “shitty” to her. Furious that she has no life. And especially furious that everyone keeps “implying” that her problems are due to drinking, because she DOESN’T HAVE A PROBLEM, GODDAMMIT. She cries and shakes and fills the room with the fumes of whatever she had to steady her nerves that morning and licks her scarred lips with her cracked, swollen, vitamin-deficient tongue. And begs for sleeping pills.

My poor resident was terrified. I ended up doing most of the talking, because at least I’m used to her. There’s really not much to say; I just agree and express sympathy about the fact that her life is hell, and then decline to write prescriptions for mind-altering substances, explaining that I’m concerned they could make her fall even more often. I’m not sure why she keeps coming back. I don’t know how to help her. So that was the only lesson I could give the resident: sometimes there’s nothing you can do.

The second frightening patient seemed only perplexing at first. He was a new patient, a mild-mannered elderly man. He spoke only Albanian, so everything had to be said through the phone interpreter, and even the interpreter seemed to have difficulty figuring out what he was saying. He came with a “case worker” who knew absolutely nothing about him (and definitely didn’t speak Albanian). He presented with papers from prison stating that he had some medical problems and some psychiatric problems. He’d been released several months ago, and had been able to fill his regular meds, but not his psych ones.

The resident came out of the room and explained all this to me. “Someone has to know the story,” I said. “Talk to the case worker and find a number we can call.” She seemed skeptical, but returned to the room.

Turns out that this patient had been in prison for 25 years after becoming psychotic and strangling his mother. He’d been treated in prison with monthly injections of antipsychotic meds, which apparently worked well enough that he was released to a halfway house. Off his meds. The pharmacy hadn’t filled the prescription for the injection because they didn’t carry it.

We slowly and carefully went back in the room and got on the phone with the Albanian translator again, determined that the patient was not interested in harming anyone at present, and explained that we would be starting him on some new pills that he must take every day. (We also got him an appointment with psychiatry, but in our institution that takes a month or so.)

The last scary patient was frightening in what she had rather than who she was. She’s a sweet little white-haired 85-year-old woman who was recently admitted for a possible stroke. As they often do, the neurologists had sent a test for syphilis as part of her workup. The initial test came back positive, but they assumed it was a false positive, and discharged her with instructions to follow up with me and get the results of the confirmatory test.

Of course, the second test was positive too.

The resident was panicked. “How am I supposed to tell her?” he asked. “Her daughter is in the room!”

So I went in with him. First I asked if the patient understood why she was there.

“For the test results,” she said.

“And do you know what the tests were for?”


So I politely asked the daughter to step out for a minute, then dropped the bomb.

She sat for a moment, her eyes narrowing. Finally she said, “That brings back some bad memories. That no-good son of a bitch. My mother told me I shouldn’t marry him!”

Turns out her husband had cheated on her some forty years ago, and she found out because he’d given her syphilis. She’d been treated, but she didn’t remember how, since she was allergic to penicillin.

“That’s why I kicked him out,” she said. “He’s dead now, and it’s a good thing, because if he weren’t I’d throttle him myself. I thought this was over and done with.”

By the time I got home last night, HellBoy had already gone out trick-or-treating and come home—he’d had enough after just one house. He was having a good time sitting on the stoop with his dad greeting all the other kids.

I didn’t stay out there long. I’d had enough of ghouls and ghost stories for the day.

Wednesday, October 18, 2006

Are You On Drugs or Something?

In response to my prior post, some people have requested specifics about the medications.

My first was sertraline (Z*l*ft), an SSRI. Started at 25mg daily, then 50, and eventually 100. Worked great. Felt like myself again, except that I didn’t get depressed and I was no longer afraid of spiders. (I still had some trouble talking on the phone—another phobia of mine—but it was a lot better.) Side effects were entirely manageable, not unlike having had an extra cup of coffee … with the exception of that one pesky thing. Libido wasn’t so much the issue. I could open negotiations, I just had a hard time sealing the deal. I enjoyed casting, but I didn’t reel one in very often. I could crank the starter, but the engine didn’t always turn over. The water got hot, but the pot wouldn’t boil. I could paddle the surfboard, but it was hard to catch a wave. I had a nice time mountain climbing, but had to turn back before the summit. If I were Cracklin’ Rosie, even Neil Diamond might have run out of time.

What’s that? Get to the point? I couldn’t, that’s the point.

It didn’t matter too much at first, because I was busy and single. But then I met my future husband, and I began to long for what I was missing. I’d never been a zero-to-60 in four seconds kind of girl to begin with, and we didn’t have that much free time. So, as I described previously, I stopped. But being happy in the sack doesn’t make up for being clinically depressed, as it turns out.

The next medication I went on was buproprion (W*llb*trin), 150mg twice a day. It’s in a completely different class than sertraline. Worked great for the depression, and practically no side effects. Its one drawback is that it doesn’t have any effect on anxiety; SSRIs are really the only ones available that work for that. So spiders started to freak me out again, and it got harder to start conversations with people I didn’t know. But overall a good choice.

Enter infertility treatment. Much stress, much anxiety, not much sleep. Then a new job on top of that. I started to feel as if I was overloading the buproprion. I got a new psychiatrist finally (I had been seeing my PCP, who was great, but not, obviously, a specialist in tweaking these meds). And he said, you know, the sexual side effects of SSRIs are dose-related, and you were taking a relatively high dose. How about we leave you on the buproprion, but add a whiff of sertraline back?

Simple but brilliant. I added 25mg of sertraline, with no appreciable effect on my sex life but a definite dampening of the anxiety.

I was, naturally, worried about what to do if I ever did manage to get pregnant. When I broached the subject with my husband, I was relieved to find he had a strong opinion that it was much riskier to go off meds during such a stressful time than to expose a baby to medication that has not been shown to do any real harm. We decided that since the real issue was depression, once/if I actually got pregnant, I’d taper off the sertraline, just to decrease any possible risk. In fact, I upped the sertraline to 50mg during the worst of the IVF treatment and left it there until we’d seen a heartbeat, then tapered off. I continued buproprion during pregnancy and restarted 25mg of sertraline once the baby was born. (Buproprion does get into breastmilk, but again we decided that the benefits clearly outweighed the risks.)

I find it interesting that a lot of people are afraid to try antidepressants, not because they might not work, but because they might. If you start and find out that you feel like a completely different person, what then? Are you stuck forever? It’s hard to explain why this doesn’t really make sense, because you won’t truly understand unless you try it. What I tell my patients is that if the antidepressants work, you will feel—normal. Not a different person, just yourself, the person that you can remember being, though perhaps long ago. As testament to this, most people who are on antidepressants for a long time eventually get to a point where they feel like the meds aren’t working, because they feel utterly normal. And a lot of people can eventually go off while continuing to hold on to their normal self. The reason I can’t is that it is very likely that if I were not to continue antidepressants for the rest of my life, I could expect the episodes of depression to come more frequently and become more intense. Some people have episodes every once in a blue moon and can use antidepressants as needed, but my last depression came with so little warning and so little provocation that I don’t want to risk it.

And as long as I can make the sale, catch some fish, start the car, boil some water, catch a wave, and get to the top of the mountain, I’m good.

Wednesday, October 11, 2006

The MICU: How I Know Antidepressants Work

A student recently asked me, “When did you get to the point where you weren’t scared about seeing patients?”

That’s an easy one.

By the time a medical trainee gets to the point of making independent decisions about a patient and has the power to carry out these decisions—the first year of residency, or internship year—they have been through four years of medical school training (generally two years in the classroom and two years in a clinical setting). Most interns are reasonably well equipped to assess a patient and make initial management decisions. This is not to say that they are not absolutely terrified. The first month of internship is a heady time, but an anxious one. The first time a nurse pages you in the middle of the night demanding that you assess a patient in trouble, your heart starts to beat like a cornered stoat. I’ll never forget my first such call, that a patient was having “rigors.” As I descended the stairs to her floor, I went over the causes of rigors. Fever? Medication reaction? When I got to the room, however, I realized that the patient was not having rigors; she was simply shaking. I examined her and talked to her, but nothing obvious emerged as a cause. Finally she made the confession that unlocked the mystery: she had panhandled for change in the cafeteria, then called her connection to come to her room, and the two of them had smoked crack in the bathroom.

That explained the shaking, but what to do about it? This is how raw I was: I actually pulled out my little intern’s pocket guide, called something like “How Not to Make A Complete Ass of Yourself on the Medicine Floors,” and tried to look up what to do when your patient has smoked crack in the hospital.

Over the months, as the call nights add up and your experience grows, the initial white-knuckle terror fades, but a sick patient can still give you a little frisson of fear. What if I can’t figure out what’s wrong? What if I do something stupid and kill her?

Then you become a second-year resident and are placed in charge of the MICU (the Medical Intensive Care Unit, pronounced “Mick You”). This is the place for the sickest of the sick. If you train in a large tertiary-care hospital, as I did, it’s the place for the sickest of the sickest of the sickest of the sick, from miles around. And I do mean in charge. Sure, there’s an attending and a fellow who are technically your superiors. But they don’t spend the night. When dinnertime rolls around and your team is on call, everyone drains out of the unit like tepid bathwater and you are left In Charge.

(I should note here that I trained several years ago, when fellows NEVER spent the night in the MICU. They’d paid their dues, now you pay yours, page them if you need them and they might step out of the movie theater to tell you “Sounds like you’re doing all the right things! See you tomorrow!” These days I have reason to believe that this is less common. I dearly hope this is true, in case I ever end up in intensive care.)

Twenty-four beds, stocked with the most amazingly ill people you’ve ever seen in your life. People who shouldn’t be alive. People who really aren’t alive as that term is conventionally understood. People who have been on machines for months, who are yellow, bloated to the point of splitting, and have mold eating away at their noses and ears. Twenty-four beds, two raw interns, and you. (Also a handful of the baddest of the bad-asses, the ICU nurses. In some ways they are the ones In Charge, and the good ones will save your sorry know-nothing ass, but you do not know yet which ones are the good ones and which ones simply enjoy watching helpless doctors squirm. Not to mention the fact that there are many, many brand-new nurses—if you think doctoring can burn a person out, try nursing.)

Adding to my stress was the fact that when I started my second-year rotation in the MICU, I was slogging through the tar pit of a fairly bad depression, one which had come upon me with almost no warning. Some background: episodes of depression since childhood, some worse than others, always lasting months, usually but not always precipitated by a stressful event. Finally started on antidepressants during my last year of medical school while I was not in fact depressed, just not great and trying to extricate myself from a bad relationship. Worked brilliantly, stayed on them through internship year “just in case”and was truly happy that year. Then started going out with my running partner, and given the fact that the pills made getting to my own private Idaho a near-impossibility, I decided to go off of them. Without telling my boyfriend. My sex life improved, and I felt fine! Hey, I don’t need those silly pills! They’re for wusses! Until the morning I woke up and felt like I couldn’t, well, anything. I managed to hide it for a week or two until I couldn’t anymore. At which point my boyfriend made me promise never to go off my meds again without warning him first. (He was absolutely awesome about the whole thing, further cementing my belief that he was My Mensch.) So I got to my doctor, got some slightly different pills, and started on them just as I started in the MICU.

It’s hard for a normal person to stay sane on an ICU rotation. You’re on call every third night, for starters. This means: Arriving early Monday morning, working all day, staying up all or most of the night admitting or managing people who are trying their best to die, working all the next day, and finally going home about 35 hours later. Then you collapse into sleep, wake up, and come in for your one “normal” day. Go home, collapse into sleep, wake up, and come in for your next call day. I counted one week: I worked 108 hours, exactly one of them spent sleeping.

So the situation is tough. In a way, going into it depressed didn’t seem inappropriate. But it did make it harder. And by far the hardest part was getting the calls after everyone had gone home telling me that a patient was being helicoptered in from an outside hospital. This patient was coming to ME. Of all the people in the whole tri-state area, I was supposed to save them. As I got the information, I literally could feel cold sweat trickling down my sides from my armpits. Up till then, I’d thought that was just a figure of speech.

There were two kinds of patients choppered in. The first kind were outrageously well, but something in their test results had freaked out the other hospital so much that they thought the person was about to die. These people were kind of like the full-term infants brought to the NICU for observation: the contrast between them and the truly critically ill folks was surreal. They were also more annoying in some ways, because they could talk and demand sandwiches and want to know why they were there.

The second kind, well. These were the ones that warranted my sweat. They were so sick, so unstable, that it was hard to know where to start first. I once put a central line in a patient’s femoral vein that, when the patient began to develop a blood pressure again, turned out to be in the femoral artery. (And I left it in, because a good arterial line is hard to get.) But the scariest thing of all was: although I could (and was expected to) call the fellow to discuss the case, if I didn’t know what was important enough to tell her—if I didn’t recognize the important physical sign, the critical lab result—I could easily miss something and kill the patient.

After a few weeks of this, a pattern started to emerge. Hey, I’ve admitted scores of sick patients, and I haven’t killed any of them. Some died, sure—the mortality rate was something like 50% overall—but the ones who could be saved, were (along with a few who probably shouldn’t have been). And I got very, very good at looking at a patient and knowing whether they were Sick or Not Sick. It is very hard to kill a Not Sick patient, and there are a limited number of ways to fix a Sick one.

And about three weeks in, I was strolling through the unit one evening humming a little tune.

“You’re in a good mood tonight!” the intern said.

“Yes, I am,” I said. And then I stopped in my tracks. I’m in a good mood. I’m on call in the MICU and I’m IN A GOOD MOOD.

Shit, those drugs work.

I never stopped them again.

And once I left the MICU, I never panicked about any patient ever again, because I’d seen Sick, and the vast majority of patients are Not Sick. As for the rare Sick ones, there are medications that can keep a lump of hamburger alive for a few hours—long enough to get them to … the MICU.

Sunday, October 08, 2006

I Would Miss My Water If My Well Ran Dry

A quick word on water.

In my earlier post on the subject, I may not have made it clear that I love water. When I want a non-caffeinated, nonalcoholic beverage, it is my drink of choice. I drink it before and after running. I drink it with lunch. I drink it first thing in the morning upon arising (granted, I need it at that time to swallow my pills, but it tastes good too). Until HellBoy was old enough to snatch at it, I drank it whenever nursing. And it's what I keep in HB's sippy cup.

Please, if you are thirsty, by all means drink water. If you are thirsty, you need it, and it's far better for you than anything else you'll find in the cooler at the 7-11.

My only objection to water is that people keep spreading the myth that you should drink more of it than you're thirsty for.

So drink up! (If you're thirsty.)

Thursday, September 21, 2006

How I Found A TrophyHusband, Part 3

Looking, looking for the sign that my running partner was thinking the same things about me that I was thinking about him ...

He asked me out to a movie—aha! A date!

Except he asked another friend along. Maybe not.

He asked if I would give him a ride home from a Halloween party—maybe we would make out in the car!

Except he slept the whole way home and hopped out at his place with a sleepy "Bye!" Maybe not.

Meanwhile, I was becoming more and more certain that this was something I really wanted to happen. He started an ICU rotation, which meant he was on call every third night, which meant he couldn't run on my every other day schedule. And for the first time in my life, I CHANGED MY SCHEDULE. I guess I had it bad.

Then one day I rang his doorbell to pick him up for our run, and instead of coming down, he buzzed me up. When I got into his apartment, I found him on the phone. He gestured that he'd be just a minute, so I wandered around trying to pretend I wasn't listening. Which of course I was, and what I was hearing sounded kind of odd.

"Just give me a call before you come to pick that stuff up," he was saying. "I don't think I have anything at your place I want, but if you see anything, I guess bring it over."

After he'd hung up, I gave up all pretense of not having listened in and said, "What was that all about?"

"Oh," he said, as he locked his door and we headed down the stairs, "Ex-girlfriend." And then (VERY uncharacteristically) clammed up.

I pondered this as we ran down the street toward the park. What ex-girlfriend could this possibly be? As far as I knew, he hadn't really had a girlfriend since we'd started residency, now nearly a year and a half ago.

Finally I couldn't stand it. "Um, how 'ex'?" I asked.

"Two weeks."

At first I thought I'd heard him wrong, but it's pretty hard to confuse the phrase "two weeks" with anything else.

Two weeks? Two weeks??!! He'd broken up with someone two weeks ago? But ... but ... we'd been running together and hanging out for months, and I had heard not a word about any girlfriend!

"How long were you, er, dating?"

"Four months."

Four months? Four months??!! But we'd been telling each other practically everything! Why on earth would he have hidden the fact that he was seeing someone from me?

Of course. He hadn't wanted me to know because he wanted in my pants. But now that they'd broken up, he could tell me. This was my sign.

I didn't press him on it that day, but eventually I found out that she was an undergraduate, and that they'd met when he went into the bar where she waited tables. She was five years younger than he was. Do the math: eleven years younger than me. Oy. But anyway, it was over, and all systems were go from my perspective.

The fateful day, I was post-call from my rotation, and I'd had only 2 or 3 hours of sleep. We'd agreed to go for a run after work (it was his one good day), but he got held up. Now, ordinarily I'd have just gone on my own. But this day, I waited. And waited. And waited. He kept calling me with updates every half hour or so; one of his patients was unstable and the unit was so busy he couldn't sign them out. The hours passed. Finally on his last call, he said, "It's pretty late—wanna just go get some dinner?"

Would I? I scampered over to his place (he lived closer to restaurants) with my whiskers aquiver. I was in the post-call buzz—there's something about sleep deprivation and hard work followed by freedom that makes everything seem a little brighter and happier. I got to his place, and he met me with a grin. "Let's go to the place around the corner," he said, and pulled a bottle of wine out of his coat pocket.

Well, all right.

So we sat in this little hole-in-the-wall place—a takeout joint, really, with just one tiny table—and drank wine and talked and talked and talked and drank and drank and drank. There was one moment when I got a little doubtful again when a friend of his showed up and he invited her to join us—??—but she sat for a few minutes and headed off again. It was pretty late by the time we lurched out of there and back around the corner to his place.

We paused at his stoop. We were joking about something, and he put his hands on my shoulders and gave me a fake neck rub. And I said the cheesiest come-on I have ever uttered:

"Do you give good backrubs?" Giggle. In my defense, I was now operating on no sleep and half a bottle of wine, but still.

"Oh, I give great backrubs .... want one?"

So up the stairs we went. I did redeem myself somewhat with what I said next, as he keyed the door:

"Am I really going to get a backrub?"

"Nope," he said.

"OK," I said, and went in.

[This is where we fade tastefully out for a few hours. I will say that I did get the backrub after all.]

The days following were heady, giddy times, where we marveled at what was happening, told each other the things we hadn't been able to say before ... including, from him, the statement that he'd had NO designs on me.

What the..? How?

That's right, he claimed that he'd had no ulterior motives for not mentioning his girlfriend, it just hadn't come up. And after all, I'd made it so very clear that we were Just Friends that he hadn't given the possibility of Us a thought. He'd been astounded that I suddenly jumped his bones. Very very happy once he'd gotten over the shock, but shocked nonetheless.

And he sticks to that story to this very day.

Tuesday, September 12, 2006

How I Found A TrophyHusband, Part 2

First, a side note: my new running partner (let’s call him RP) had, in general, quite good taste in clothes … for a doctor. He did like to take some sartorial risks—hence the red jeans.

Our first run together could have been a disaster, because I was so full of my bad self after finishing my marathon that I went much farther and faster than I'm really capable of. I took RP on an eight-mile-plus loop and paced myself so poorly that I had to stop multiple times to keep trying to work out a painful stitch in my side. He was entirely good-natured about it, just mentioning that it was a bit farther than he'd expected. He didn't mock me for having to stop, either. I was sure after this that he’d decide I wasn’t worth the trouble, but he hung in there, and we settled into a much more comfortable 40-45 minute routine, every other day. Which is a lot of time to spend with someone you’re not dating, when you think about it. Especially if you spend it sweaty and nearly naked.

One of the first things I learned about him was, the man can talk. And talk. And talk. He was like a human ipod; I could bring up a theme and he could just expound on it for the next forty minutes. I didn’t have to say a thing if I didn’t feel like it. Maybe that sounds unappealing, but you have to understand that I adore being able to be silent with someone. I just don’t always want to talk, even if I’m happy to have company. And it wasn’t that he wouldn’t let me get a word in edgewise; I was simply free to hop in and out of the current of conversation as I wished.

So I learned a lot about him. I learned that despite having gone straight through college and medical school, he’d done a lot of interesting things—cycled halfway across the country, climbed mountains in Bolivia—and that he’d desperately wanted to take time off, but his mother had put up such a fuss that he decided it wasn’t worth the fight. I heard about his crazy family and his wild times at college. He adored movies, and could quote verbatim dialogue from something he’d seen once ten years before.

Still, he was one hyper, anxious dude. And he hated being an intern. As in, would probably have quit if he didn’t have so many student loans. I also learned that he was kind of a ho. He’d had a long-term girlfriend in college, but aside from that, he’d never gone out with anyone longer than a few months. And he’d gone out with a lot of women. A lot.

I started joking with friends that if I got desperate, I could obviously hook up with my running partner. Not as a serious thing, god no.

Then something interesting happened: internship year ended, and we became residents. The life of a resident is very different from that of an intern: you’re the one running the show instead of shoveling the coal. And RP seemed utterly transformed.

Thus it was revealed to me that the person I’d been working with—Intern RP—was almost nothing like the real RP. The real RP was charming, funny, warmhearted, cheerful, open-minded, generous, loyal—a mensch. He was also exceedingly smart, and tremendously fun to be around.

So we started hanging out. Movies, brunch, beers. Being stupid, I took a little while to understand what was happening. The first time I had an inkling I was out on a date with someone else, feeling bored and awkward, when I thought, I wonder what RP’s up to? I’d sure rather be hanging out with him … hmmm.

Suddenly I started to feel a little awkward with him. After all, I’d been pretty clear about the boundaries of our relationship, and I couldn’t blame him if he’d ruled me out. Then there was that classic not wanting to mess up a good friendship dilemma.

So I looked for clues that he might be thinking about me the same way I was thinking about him. And couldn’t seem to find any.

Had I blown it?

To be concluded.

Wednesday, September 06, 2006

How I Found A TrophyHusband, Part 1

When I Certainly Didn’t Deserve One and Didn’t Know Where to Look

I arrived at my residency program finally unencumbered by the messy relationship I’d been mucking around in for the previous, oh, seven years, and I was happy to be single. I was also happy to be starting residency. I was happy to be on antidepressants at last when I’d needed them for years. I was happy, happy, happy.

Which is not to say that I wasn’t looking.

In fact, I made up some guidelines for who I was looking for. I don’t remember them all, but I know they included:
  • No more than five years older or younger than me
  • Preferably not in the medical field
  • Smart(er than me)
Why these rules? I have no idea. I was pretty stupid when it came to relationships (see: Messy seven years). I knew this, and I guess I thought rules would help. But of course, being stupid, I made stupid rules.

The first time I remember talking to TH was at a party early in internship year. It was a dumb “Eighties” party—practically designed to make me feel my age, since I was having sex in the eighties, while these kids were still trading Pokemon cards—and he was wearing tight red jeans. Despite this, I thought he was pretty cute. I definitely have a type—the Jewish intellectual—and he fit the bill. He was also talkative (important since I’m not), funny, and had a cute butt. In addition, he had appealing crow’s feet and had lost enough hair to make me think he was closer in age to me than the rest of the interns.

I was six or seven years older than the people who’d gone straight through college and residency. I didn’t mind this per se, but I felt like it changed my prospects as far as romantic relationships went. Mostly in that I wasn’t so interested in people who’d had little life experience. (Hence the five-year rule, I guess.) So I flirted a bit with this apparently worldly-wise guy, until something he said made me realize that he must look a lot older than he was. When I finally asked him his age, I was alarmed to discover that he was seven years younger than I was. (Later I found out that it was actually six years; the party occurred in between our birthdays.) And I thought, well, rule him out!

Which turned out to be a good call, because when I eventually worked with him, I discovered that he was the most anxious, compulsive, unhappy, and insecure intern in our whole class. He was a mess. It wasn’t even clear that he was particularly smart, he was so lacking in self-confidence. When I would “run the list” of eligible guys in our program with my friends, I always rejected him out of hand.

So the year wore on. I was pretty busy, but I managed to go on a few dates. (Nothing worth describing.) I was horny, but really, I was still very happy. I was running, I loved my residency, I loved my new city, I loved my apartment. I had left my ex with the realization that I would truly rather be alone than be with the wrong person, and I was enjoying being alone.

Then one day toward the end of internship year, Mr. Tight Red Pants approached me.

“I keep seeing you running near my apartment,” he said.

“Yeah, I was training for a marathon,” I said.

“I’m looking for a running partner. Would you be interested?” he asked.

I stared at him for a few moments, trying to decide if this was a come-on. But he seemed genuine. And I could use a running partner—the person I’d trained for the marathon with had developed a hip fracture.

So I said yes. But I made it clear (very clear, according to him) that this was a Running Relationship Only.

What a stupid bitch I was.

To be continued.

Monday, August 28, 2006

More Medical Myths

More medical myths I wish I could put down forever:
  1. Drinking lots of water is good for you. NOT TRUE. (Yes, this is a repeat from my last medical myths post, but it seems to be the one people are most skeptical about, so I think it bears repeating. I'm not lying, y'all.) This myth probably started because of a misunderstood study long ago that the average amount of water a person uses for the business of existing for 24 hours is equal to about 8 eight-ounce glasses of water. The misunderstanding is that this is not EXTRA water; it's the water that already exists in all the foods and beverages (including caffeinated ones!) a person takes in during the day. Thirst is actually a wonderful mechanism for telling you how much water you need. Extra water does not benefit you. It doesn't help constipation, it doesn't help your skin, it doesn't benefit your kidneys (unless you have kidney stones), it doesn't help you exercise. Perhaps it helps some people avoid eating and drinking a lot of fattening junk, but this is questionable. What it DOES do is make you pee constantly, and in some instances can actually kill you. The water myth is reprinted in every issue of every health and beauty magazine published, so I have little hope of it dying.

  2. Bedrest prevents preterm births. NOT TRUE. I know that it seems to make sense—it must help to "rest," right? And if you stand up, the baby might just fall out!—but studies have shown that it's useless. So why does nearly every OB in the country keep recommending it? Well, think about it. What if they didn't recommend it, and a baby is born prematurely? Yeah, they could be sued, but also, they'd feel awful. If they prescribe bedrest and the baby is born prematurely anyway, everybody says, "well, at least they did everything they could." And what you'll often hear is, "it may not help, but it can't hurt"—a saying that really lights my fuse. In fact, it can be harmful—scratch that: it almost always IS harmful. Maybe only slightly harmful, in that the mother becomes physically deconditioned and has a harder time with delivery and postpartum recovery, and in that the mother gets put out of work earlier than she may have wanted, but sometimes very harmful. I'll give you an illustrative anecdote: a woman who works in my institution as a secretary has preterm labor at twenty-some weeks, and was put on strict bedrest. Weeks and weeks. She nearly went crazy, but even worse, she developed a blood clot from inactivity. So she had to go on blood thinners to prevent her from dying from a blood clot to her lungs. And then had a terrible GI bleed from being on blood thinners and had to have a transfusion. So bedrest almost killed her TWICE. But did she even think about suing the doctors who prescribed bedrest? Of course not, because she believed that she had to do all of this for the baby's sake, and the baby was born healthy.

    I think the bedrest myth is also harmful in that it adds to the fear that women of childbearing age might be a liability in the workforce. There's a doctor in my institution who is on her third month of bedrest, and the burden on her department is substantial. I wouldn't be surprised if they hesitate to hire the next 30-year-old woman who applies for a position. But god forbid a pregnant woman has any problems and DOESN'T go on bedrest. Oh, the guilt! I had preterm contractions (rather than true preterm labor, in which there are cervical changes), which has not really been shown to predict early delivery, but there are plenty of women who are guilted into bedrest for even this condition, and people tried it on me—"Don't you realize that your baby is more important than your job?" (Part of the whole infuriating pregnant-woman-as-vessel thing.) I was fortunate to have a super-smart OB who is also my good friend, so I had someone backing me up in refusing to be put to pasture, but few women are this lucky.

    I think that the biggest obstacle to making people stop putting women on bedrest is that almost nothing has been shown to be effective in the long term to prevent threatened preterm delivery, and until there's something that CAN be done, it's very hard to get people to stop doing things that don't work. (There was a recent meta-analysis that old-fashioned progesterone might be helpful—keep your fingers crossed.)

  3. Taking lots of vitamins is good for you. NOT TRUE. Taking a regular multivitamin probably isn't a bad idea, but in most studies, high doses of vitamins have been shown to be either useless or harmful. (The studies that show possible benefits get lots of press; the later ones debunking them, very little.) Fat-soluble vitamins (A, D, and E) can build up in your tissues, causing hypervitaminosis. Water-soluble vitamins (the B vitamins and C) are generally excreted by your body if they're not needed, though they'll turn your pee nearly fluorescent. Folate (vitamin B9) helps prevent neural tube defects in embryos, but it's added to all grain products these days, so deficiency is much more rare than it used to be.

  4. Refined sugar is worse for you than honey. NOT TRUE. Sweet things in excess are bad for you, whether their sweetness comes from refined sugar, raw sugar, honey, fruit, high-fructose corn syrup, or whatever else is invented next. (I'm reserving judgment on artificial sweeteners for now, but kicking the sweet habit altogether is probably better than relying on these.) What do I mean by "in excess"? I can't describe it, but I know it when I see it. Or eat it.

  5. If something is herbal/all natural, it's safe. NOT TRUE. For all its faults, the FDA does do a fairly good job of ensuring that drugs that enter the marketplace are reasonably safe and effective. But the FDA is powerless over "nutritional supplements" and herbal medications. It's not that herbal remedies are necessarily useless; several prescription medications have been developed from herbs, in fact. It's that they are almost entirely unregulated. There is no guarantee that what is printed on the side of a bottle of, say, milk thistle is a true representation of what lies within, and plenty of evidence that it is often a gross misrepresentation. There are some real rip-offs out there. And some herbs are powerful poisons.

    Somehow people started believing that doctors can't be trusted when we warn against natural remedies because we're biased against them. I'm not sure why we would be; we recommend plenty of things that don't require a prescription: a good diet, exercise, good sleep habits, quitting smoking. All of these things are all-natural and patient-initiated. And we'd love it if someone found a miracle cure for, well, anything, regardless of whether it required a prescription. I don't mind if a patient wants to try something herbal (in fact, I'll admit it, I'm happy if they get a placebo effect), as long as it's reasonably safe and not expensive. I just don't want my patients shelling out lots of money for anything that is useless and/or harmful.

(I know I'm coming off as anti-granola, and honestly, I'm not; I'm probably crunchier than most people think.) (Though granola can have a surprisingly high sugar and saturated fat content ...)

Any more myths you'd like to have debunked?

Thursday, August 24, 2006

Running Q & A

Culled from the maggot files:

Q: I heard that you have to get expensive shoes fitted by a running professional or else you’ll end up with an injury.

A: This is only true if you are a fancy-schmancy, very high-mileage runner (in which case you don’t need this whole Q&A section, so why are you even here?). Most of you beginning to intermediate runners without significant orthopedic problems just need to make sure that your shoes:
1. fit you well (usually you’ll require a half-size larger than you wear in regular shoes)
2. are cushy
3. are intended for running
4. feel good when you run rather than when you walk (yes, you must run around when trying them on, preferably not on carpet. Yes, this feels idiotic)
It’s best to go to a real running store if you can, but you don’t need to break the bank. (Unless you’re the type of person who is more likely to actually do something if you’ve dropped a big chunk of change into it, in which case, go ahead, knock yourself out.)

Q: Do I really have to wear a sports bra?

A: Yes, unless you’re a man (and don’t have man-boobs). Yes yes yes. Please get those things under control. Even the Itty-Bitty Titty Committee members will bounce when running. As for the well-endowed, the bounteous provides this product plug: “Big-boobed runners: I got one word for y’all: Enell.”

Q: My knee/hip/foot hurts. Can I still run?

A: My rule of thumb is, if the running is either too painful to do OR seems to be making something WORSE, then no, and you might want to see an orthopedist. Otherwise, yes.

Q: My underwear scrunches up into my ass when I'm trying to run.

A: Gotta go commando. No panties for running. They either scrunch, wad, or give you VPL in your running tights.

Q: Why do my shins hurt?

A: Probably from shin splints, a poorly understood but usually temporary and nondangerous condition often seen when increasing mileage. If it’s not too bad, just stop increasing mileage for awhile, make sure your shoes are supportive, and ice your shins after running.

Q: Will running (especially on pavement) give me arthritis or otherwise damage my knees or hips in the long run?

A: No. This is a perennial favorite warning from smug couch potatoes – “you’re just going to ruin your knees!” There has been a lot of research in this area, and even among elite high-mileage runners, the opposite appears to be true. (The biggest risk factor for developing arthritis? Obesity.) It’s hard to link to studies since they’re mostly not open source, but here are a few choice quotes:
... [I]t appears that long-distance running does not increase the risk of osteoarthritis of the knees and hips for healthy people who have no other counterindications for this kind of physical activity. Long-distance running might even have a protective effect against joint degeneration.

The presence of radiographic hip [arthritis] and the progression of radiographic knee [arthritis] was similar for older runners and nonrunners. Lumbar spine bone mineral density remained higher in runners.

Older persons who engage in vigorous running and other aerobic activities have lower mortality and slower development of disability than do members of the general population.

… [O]ur observations suggest that a lifetime of long distance running at mileage levels comparable to those of recreational runners today is not associated with premature osteoarthrosis in the joints of the lower extremities.

498 long-distance runners aged 50 to 72 years were compared with 365 community control subjects to examine associations of repetitive, long-term physical impact (running) with musculoskeletal disability ... Runners had less physical disability than age-matched control subjects and maintained more functional capacity … Runners sought medical services less often, but one third of the visits that they did make were for running-related injuries. … Runners demonstrated better cardiovascular fitness and weighed less. … Musculoskeletal disability appeared to develop with age at a lower rate in runners … than in community control subjects ... These data suggest positive effects of systematic aerobic running activity upon functional aspects of musculoskeletal aging.
Q: Isn’t it bad to exercise where there are a lot of cars and air pollution?

A: If you have a choice, it’s best to run where you’re not taking bong hits from the tailpipe of a diesel bus. And if you have asthma, you may have more trouble on days when the ozone level is high. But overall, it’s still a lot healthier to run in a city than not to run at all. There’s not a lot of research in this area, however.

Q: When can I start running faster/farther than an arthritic sloth?

A: Patience, grasshopper. I mean, maggot. Running slowly is fantastic for your health; running faster adds very little to this. Almost everyone errs on the side of increasing too quickly, and then you're in trouble. If you must have numbers: once you're spending your whole 30 minutes running, wait a couple of weeks, and then you can start going EITHER 10% farther per week (not per run) or 3% faster per run (I can't do that math without hurting my brain, but if you're a numbers junkie, I suppose you won't mind).

Monday, August 21, 2006

Just Peeve

A weekend on call—64 straight hours of being at the mercy of any Nervous Nellie, Suspicious Sam, or Crotchety Carrie who insists on speaking to The Doctor—often leaves me feeling a bit … peevish.

So it was today that I got to musing on a few of my pet peeves.

I’m a live-and-let-live kind of person in general. Really. I notice when something is done wrong, but I don’t get worked up over it. Ok, sure, it bugs me when someone says “for you and I,” and I wish I could get people to believe that they don’t need to drink so much water. But as long as the only person who suffers the consequence of a mistake is the person who makes the mistake, I don’t much care.

It certainly distresses me when someone does something wrong that affects others. Littering, for example, or talking in a movie theater. But to really peeve me, a mistake has to not only mess things up for the rest of us, it has to require real energy on the part of the person making the error. Strenuous misguided labor that results in making things worse for others just chaps my ass. For instance:

Women standing up to pee. This is a silly practice. You really can’t catch anything from resting your thighs on a toilet seat. And it’s hard to do; it requires balance, strength, and concentration to avoid peeing on your own shoes. But why should I care if someone wants to get a mini quad workout in the restroom? Because it messes things up for the rest of us. Women can’t pee without splattering. Not necessarily a lot, but enough to baptize the toilet seat with a few stray droplets and cause an unpleasant splashing sensation for the next person who tries to sit down. This creates a moist domino effect: the next person is more likely to avoid sitting in the future, causing further splatter, and so on. Please, if it skeeves you out to rest your delicate thighs on a public toilet seat, either take some paper towels in with you to clean up after yourself when you’re finished (and remember, don’t flush them—just tuck them in the tampon box), or get one of these.

Using a car’s side mirrors as extra rear-view mirrors. The mirrors on the sides of the car are meant to reveal what’s in your blind spots. If you adjust them to show the back of your car, you are wasting your time, but worse, you are making it more likely that you will not be able to see the rest of us, and you may hit us. These are some good descriptions of how to properly position the side mirrors.

Installing Jacuzzi tubs in every frickin’ rehab and new construction in the country. Jacuzzis are stupid. I know of hardly anyone who actually uses theirs more than once a year. Jacuzzis are noisy, they take forever to fill, they use up all the hot water in the house, and they’re hard to clean. They take up a lot of space and cost a lot of money as well. But who do Jacuzzis really hurt? Well, anyone who wants to have a new bathroom with a real bathtub; it takes a lot of money to tear one out. But the Jacuzzi craze really hurts everyone, because they take twice the amount of hot water to fill one compared to a real bathtub, and they have motors. The amount of energy wasted on these dumb contraptions is outrageous.

What am I forgetting? Where have you noticed people striving mightily to do something completely idiotic and harmful? (Mentioning Hummers is too easy—that’s shooting ducks in a barrel. Dead ducks.)

Tuesday, August 15, 2006

A Fool for a Patient

This is a combination stupid patient story/stupid doctor story.

It’s a good thing I don’t believe in divine retribution for selfishness, because if I did, I’d never take a personal day again. Yesterday I woke up with, in addition to a lingering (though lower) fever and progressive rash, an unbelievably bad headache. TrophyHusband wrangled HellBoy while I lay in bed with a washcloth on my eyes and an icepack on my head. I finally somehow got myself up and into work, where I had to see patients in the morning. I got through each visit trying to move as little as possible (“You say you’ve got a gigantic wound on your foot with things crawling out of it? OK, I believe you — no need to take a look!”) Finally one of my partners noticed that my rash was creeping up my neck and down to my feet and that I looked like I was about to die. She took the rest of my patients for me and sent me home. I took my migraine med, but it didn't work, and I pondered whether to go to the ER just to get SOMETHING to make the pain stop. When I lay still, it felt like there were big shards of plate glass sticking into the top of my head; when I moved, it felt like someone was whacking the shards with a broomstick.

When TH got home and found me taking nap #4 on the living room floor, he said, "Um, you have meningitis, you dope." (He didn't really call me a dope, but it was in his tone.) And I was like, oh, right — fever, rash, blinding headache, and I CAN'T BEND MY NECK, duh.

It seemed pretty clear from the history that this was a viral meningitis, not bacterial, so I didn't want to go wait at the ER for a spinal tap to be told the same thing, but he did consult with an ID colleague to double-check that he didn’t need to hogtie me and drag me there. Then I doped myself up with every pain-reducing, nausea-relieving, and consciousness-altering (legal) medicine in the house and fell into a blessed sleep. Today the pain is MUCH better, and I can stand to look at a computer screen without shrieking "The light! The light! Make it stop!" But I still can’t look left without a stabbing pain in my eyeballs. Too bad I’m not a Republican.

Saturday, August 12, 2006

The Verdict: Not Guilty

Wow, there are some mighty guilty folks out there. Reading the comments on my last post really helped, and I think I am developing a mantra collection:
  • My first reaction: Good grief, you people should not be feeling so guilty! Which led me to: hmmm … maybe I shouldn’t either? So I like Ozma’s “compassion” mantra.
  • Reading about all these ridiculous things others feel guilty about makes me realize that there are a lot of things I could feel guilty about, but don’t. Daycare, for instance. I know that this is the best choice for us, and I don’t sweat it … so maybe another mantra I can use when I’m feeling guilt-ridden is “It’s no different from daycare!”
  • I realize I have a fear that if I’m not feeling guilty, then I’m being a bitch (as Orange brought up). New mantra: “Embrace your inner Bitch.” (Not that feeling guilty is the opposite of being a bitch. But it’s hard to imagine a guilty bitch.) (Though Orange, I think you should feel guilty about misspelling “wracked.”)
  • A mantra that is a paraphrase of what Artemis said: “I’ve been wearing guilt like underwear, and it’s time to go commando!”
  • Virginia’s mantra (“At least I'm not Bush, At least I'm not Bush”), while certainly true and quite funny, is almost too extreme for the circumstances. Perhaps “At least I’m not Britney”?
  • NotMisery’s point that feeling guilty is a choice speaks to me. I’m all about making conscious choices to feel a certain way: I choose to be happy rather than sad (when I’m on the right meds, that is); I choose to be cheerful rather than bitter; I choose to be grateful rather than whiny (usually). I can certainly try choosing to not feel guilty. (I’m having trouble coming up with the opposite of guilty again, though. Innocent? No. Bitchy? Sort of. Well-meaning? Wishy-washy. Peaceful? Eh.)
  • I like Ariella’s question, "What does this guilt really MEAN?" I think in some circumstances that could work as a mantra.
  • Kungfukitten’s wand-waving and ass-shaking, though not a mantra, is a cheering mental image.
And so far, it’s working. I spent the first part of this past week visiting my parents. We got back Thursday, but I had scheduled Friday off from work as well. I had a brief thought that perhaps I should go in anyway, but armed with my new mantras, I resisted. Instead, I dropped HellBoy off at daycare, then went back home, ate ice cream for breakfast, gave myself a pedicure, read some blogs, ate peanut butter and ice cream for lunch, cleaned out my car, washed the shower curtain (I know those last two sound like chores, but they thrilled me), went out and had second lunch at a café, then bought myself new running shoes. Then I went to another café and read more blogs, while my in-laws picked HellBoy up from daycare. When I got home, I had them take him off to the park while I went out in the glorious weather and broke in my new shoes. All with nary a guilty twinge. Not bad, eh?

Today I came down with a virus that’s been going around — high fever and a weird rash — but I refuse to believe that this is punishment for my self-centered, guilt-free day. (I am deeply grateful that I was raised as a heathen rather than Catholic or Jewish or Southern Baptist.)

Thursday, August 03, 2006

Guilty or Not Guilty?

I lived much of my life relatively guilt-free. I don't mean remorseless; I mean free of unproductive self-flagellation about choices I've made. I sort of assumed it was a combination of nurture and nature; my mother was never a guilt-tripper, and I was naturally fairly obedient to my super ego. I felt bad if I did something wrong, sure, but if I'd made the best of whatever situation I faced, I didn't beat myself up over things.

Then I gave birth. The instant HellBoy was laid across my stomach, looking bluish and stunned, a tidal wave of guilt crashed over my head. I wasn't good enough at giving birth; it had taken too long; I might have hurt my baby!

The guilty feelings continued sloshing around for weeks. I was starving him because I insisted on breastfeeding; I was going to roll over on him in my sleep because I selfishly wanted him in the bed with me; and on and on. Gradually, thank heavens, the tide receded a bit, and I was able to gain some perspective. But I never went back to my blessed pre-baby guilt-free state.

Lately I've been suffering from it a LOT. I feel guilty about going running when my son wants me to play with him. I feel guilty about NOT running when I've blogged about how frickin' important it is. I feel guilty about blogging instead of working. I feel guilty about not blogging. I feel guilty about snapping at my husband when I'm too tired to see straight. I feel guilty about driving to work and polluting the environment. I feel guilty about air conditioning. I feel guilty about not wanting to hear about the conflict in the Middle East. I feel guilty about saying it's not too hot to run and then watching the thermometer go into the triple digits.

It's as if all my years of not feeling guilty left me peculiarly impaired for handling it now.

I need some sort of method for dealing with this before it drives me crazy. A mantra or something.

What do you feel guilty about? And how do you handle it?

Wednesday, August 02, 2006

Query Awards

From today’s Keyword Analysis, brought to you by the Commission for Lazy Blogging:

Easiest query to answer:

5 things mates needed for a good marriage

1. A good husband
2. A good husband
3. A good husband

4. A good husband
A good husband

Most masochistic query:

i just started running i am so sore is it ok to keep running

Answer: Heh heh heh. Yes. (But SLOWLY.)

Most rhetorical query:

toddler sleep problems

Answer: Ha ha ha.

Query displaying the most hopeless optimism:

typical routine three month baby

Answer: HA HA HA.

Query that most stumped me on initial viewing:

and one thing i chose to admit, is that your momma momma momma should let me babysit

Answer: A dumb Morningwood song. The correct wording is “and one thing I chose to admit, is that your momma momma momma SHOULDN’T let me babysit.”

Most jittery query:

running away from ritalin dr. knowitall

Answer: Are you SURE you don't need that Ritalin?

Slackingest query:

good doctors excuses

Answer: Go with back pain! They like totally can’t prove you don’t have it!

Best query:

killing maggots on goats

Answer: You have MAGGOTS on your GOATS?

Worst query:

maggots in bra

Answer: AAAGH! (On further research, there is apparently an internet “joke” going around with a disgusting photoshopped picture. Don’t go looking. It’s FAKE. What is the matter with people?)

Sunday, July 30, 2006

A Weighty Issue

I cannot describe how pleased I am that so many of you are heeding my call to wedge yourselves into your running bras and get out on the pavement.

But I am dismayed to see how many of you immediately started talking about your weight—that you wanted to lose some, that you did lose some, that you weren't losing any.

If you go back to my original post, you will see that never once do I mention weight loss as a reason to run.

Whaaa--? I hear some of you thinking. Why would I do something so unpleasant if I'm not going to get skinny?

Sigh. OK. I will tell you why you should later. But first let me tackle the topic of getting fat.

You probably already know that the country is experiencing an obesity epidemic. The majority of adults in the U.S. are above a healthy body weight. This in turn has caused an epidemic of Type 2 diabetes. And diabetes is the number one cause of 1) blindness 2) amputations and 3) kidney failure requiring dialysis. How great would it be if we could avoid all that? So doctors are desperate to find a way to get people to lose weight. Fat people are also desperate to lose weight, because even as everyone has gotten fatter, discrimination against fat people has not decreased at all.

So if everyone's on the same side, what gives? Why is everyone getting so big?

It's tempting to say that it's the fault of the fast food chains. And they do play a role, but I would argue a small one. The problem is multifactorial. There are several important differences between the U.S. now and forty years ago (or the U.S. and some other countries where people have not yet started to expand). First, people no longer have to move. Most people can now do their jobs by lifting only their fingers; correspondence, chatting, ordering, everything can be done by computer. (Being a physician is one of the few professions where we must keep moving — from room to room, down the hospital hall, to the front desk.) Second, people and jobs have moved away from the city centers, so almost everyone commutes by sliding their padded butt into a carseat and driving to a parking lot next to their job. People don't even expend the energy to shift their own car gears anymore. Third, food is now available everywhere, at any time of day or night. Not just at fast-food joints; everyone has a vending machine no farther than an elevator ride away from their desk, a 24-hour convenience store (with a parking lot) on the corner down the street from their house, and a huge refrigerator stocked with goodies.

Humans are genetically programmed to eat when we can and rest when we can, because we evolved during a time when if you passed up a meal or a rest stop, you were that much closer to being the weak one who got left on the rock to distract the saber-tooth tiger. (This programming is not uniform; some of us are jittery and jumpy and more easily distracted and tend to stay naturally slim. It was probably an advantage to a tribe as a whole to have a few people like this, so as to be able to alert the calm ones to danger and to run really fast if need be.) It probably didn't happen often that anyone got fat back then, but even if a tribe were so lucky, the consequences of this—premature death—were not, evolutionarily speaking, undesirable; these folks had already had their offspring, who cares if they lived to be 90? It's not just humans who are like this, either. I used to feel really sorry for birds in cages, because flying seems like such a wonderful thing, and they're being prevented from doing it. Then I learned that when birds live in a place where there are no predators on the ground, they give up flying. They get fat and lazy and waddle around, just like humans.

So when you pass up running and instead pull your car into the 7-11 for a Slurpee, you are simply heeding your DNA. That's right, it's not your fault. So quit feeling guilty; it's unproductive. But do realize that you are not in the environment your DNA thinks you are, and it's now up to you to adapt yourself.

It's been shown over and over again that if you put people into a controlled environment, calories in minus calories out equals weight gained or lost. No one is immune from this law of physics. What can't (yet) be measured, though, is just how hungry a person gets when they take in less than they put out, or how unpleasant a person feels when expending calories. You may suffer more when trying to lose weight than I would, I can't deny that.

Which brings me to the running thing. Simply running will not cause you to get skinny. Running more and eating less will. The running part is simple; the eating less, harder. But I'll give you a rough idea of what has been shown to be helpful (and in fact, I follow most of the rules myself):
  1. Eat breakfast. People who put off eating until late in the day tend to be fatter.
  2. Avoid simple sugars. This includes, but is not limited to, soda, juice (yes, even 100% fruit juice), candy, cakes, pies, chips, and white starchy foods. Simple sugars go down easy, then shoot your blood glucose up, which shoots your insulin up, which makes your blood glucose plummet, which makes you hungry. Hello, vicious cycle!
  3. Make it a rule to stay away from the vending machines, the corner store, and the coworker offering donuts. Fast and easy snacks result in fast and easy pounds.
  4. Don't keep bad food you can't resist in your house. What's that? You need to keep stuff around for your kids? Why on earth would you want your kids eating crap either?
  5. Get enough sleep. Sleep-deprived people tend to get fatter; it's not known why.
  6. EXERCISE. Exercise alone doesn't guarantee weight loss, but it does seem to prevent weight gain. Over the years, I have watched everyone I know slowly, slowly expanding, with the exception of those who get regular exercise.
But please do not run for the weight. Run because a fat runner is much healthier than a skinny couch potato. Run because it makes you strong. Run because it makes you happy in your own body, whether it's lumpy or flat, tall or short, square or round. Run because you'll live longer (and no, you won't wish you were dead, ha ha). Run because when you're out there running (as slowly as you can stand to, remember), you will have the experience of being alive in the world with your body doing what it was designed to do.

Wednesday, July 26, 2006

Watching Golf?

I'm thinking I should compile some of the responses on my last post to give to my students and residents so they can get some perspective on what patients and other clinicians think about the topic.

A couple of things I wanted to to clarify:
  • Orange did not, in fact, spontaneously accuse me of having a stick up my ass. She simply agreed with me when I asked whether I did.
  • Although I address my patients in a formal way, I don't think my manner with them is formal. I welcome—no, encourage—their input, laugh and joke with them, pat their shoulders. A few of them routinely hug me, and a couple have kissed me. (One kissed me on the lips once. An experience I hope is never repeated.) And despite my byline, I have never actually uttered the words "That's Doctor Mama to you," except in jest.
I haven't been on the blogosphere much lately because things are fraying a bit around the edges here. One of my colleagues called me this weekend to report that she was having weakness in her hand and leg, and her rheumatologist thought she should be admitted to the hospital, but what did I think? When I told her to get her butt to the hospital stat, she said, "But who's going to take care of the baby?" "Er, where's your husband?" I asked. "Downstairs watching golf on TV."

I ended up meeting her at the hospital and staying with her the first few hours. She's doing okay, but she has a pretty scary condition, and a lot on her plate. Her husband is being a father finally (with the help of his mother), but I'm not sure it will last once she gets home. She's talking about changing jobs to decrease the stress in her life. I wish she'd change husbands instead. I've been filling in for her as much as I can at the office; one of my mothers-in-law is staying with us, so TrophyHusband has help at home ... and I'm terribly, terribly grateful that this is pretty much the extent of what I have to grumble about.

Wednesday, July 19, 2006

You Can Call Me Doctor If You Want

Orange recently asked me if I ever tell my patients to call me by my first name. The answer is no, never. I don't call them by their first names, either. I call everyone "Ms." or "Mr.," unless they really insist, in which case I avoid saying their name at all. This is the only area of life in which I'm like this; for instance, the only adults I didn't call by first name when I was a child were my teachers, and I find it weird and hilarious when kids call me Ms. DoctorMama (or worse, Mrs. TrophyHusband).

I just feel that if I'm going to be poking and prodding folks in their most intimate places, I better make sure that they know I respect them first. (I do let a couple of old men get away with calling me Miss Firstname, but I still call them Mr. Thrombosis and Mr. Bad-Hip.) I especially dislike it when high SES white people call me by my first name; I feel like saying, Listen, you really don't want me to be your friend, you want me to be your doctor, so let's not muddy the waters, all right? I don't much like it when doctors I don't know personally call me by first name either. It's especially obvious to me when this happens because there are two ways to pronounce my first name, and people who don't know me usually pick the wrong one. Makes me feel like I'm being examined by a telephone solicitor. (I run into trouble with our pediatrician because she's a nurse practitioner; it feels absurd to call her Nurse, but double-standard-ish to call her by her first name.)

Orange says I've got a stick up my ass, but she also calls it "quaintly elegant" and "traditional." What do you think? Are you on a first-name basis with your doctor? Do you think it affects your relationship either way?