the birthday man

11 Apr

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John and I have a not-so-funny running joke: every time we want something any time near the vicinity of our birthday, we’ll spout off, “But, honey, it’s my birth<insert interval of time (week, month, etc.)>”  I think it started when John made the observation that men only get a birth-day, whereas with women it becomes a birth-month or some equivalently decadent ritual.

Fittingly, the expression always sort of turns true with us.  It seems like we’re often ships in the night…to get an entire day spared for celebration with one another, it just doesn’t happen.  Not meant as a complaint.  Life is very good.  But it just gives us an excuse to spread out the birthday without guilt: a dinner out here; a gift of a full-night of sleep there…you get the point.

Today my love is one year older with more jubilance and energy than I ever thought possible.  He’s asleep in preparation for his night shift; I just woke up for my late shift in the pediatric emergency department (my current rotation–it’s awesome!  I got to drain an abscess yesterday!  Very satisfying.).  Unfortunately, I won’t see him today.  So I’m wishing that our daughter pulls out all the stops for him this afternoon.  I think a yogurt run and a playground excursion might be in order:

More tame, but of comparable joy to that experienced during last year’s birthday.

women’s heath conference

10 Apr

This weekend I had the privilege of presenting a poster at the Women’s Health Conference  (hosted by the Journal of Women’s Health) in D.C.  It’s pretty energizing to be surrounded by thousands of academics, listening to passionate talks by experts in their respective fields, and getting to share your own research to the mix.  As I struggled to throw the poster together last week, I became simply in awe of all my classmates, so dedicated to research and discovery, for whom this is all old hat!

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The weekend was made invariably happier because John and Ari were available to join me, and we squeezed in the good times.  Initially, we had hoped to take a little babymoon, kind of sneak away for a night in a hotel or something; we didn’t get our act together, and changing work schedules make planning challenging.  After bedtime hours, I broke out for a few hours with some in-town yayas.  (You’ll never imagine the look of shock and judgment I got from the waiter when I ordered a drink [that I didn't even finish, btw] at 8+ months pregnant.)

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And John and I did get a date.  Tapas and froyo in Clarendon, followed by a walk (well, woddle really) around the Jefferson Memorial amid the cherry blossoms.  It was our last trip before number two!

 

spoof 2014

6 Apr

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Really excited to share these pictures.  I had always wanted to be part of Spoof…imagine a med student version of Saturday Night Live meets Jimmy Kimmel in a piano bar operated by some marriage of Disney and Bollywood.  But my participation was always hindered by something: broken shoulder; clerkships and pregnancy; infant child; some combo of the above.  I know, I know…excuses <sigh>.

Anyway, I was ecstatic when a fellow classmate asked me to take the above pictures to be part of the “Weekend HUPdate.”  Unfortunately, since I had to dodge out after the first two hours of the 3.5-hour production, not sure if these made the final cut, but wanted to wait until after the show to share.  While I wish our life resembles the above, most often it’s some variation of this…

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…which is exactly what I feared when I took my daughter to the matinee of the Spoof production after a…let’s just say dramatic morning and early afternoon.  I had already dragged her into the city literally kicking and screaming earlier that morning, let her get utterly soaked by the cold “spring” rain, broke her heart by not letting her walk the full mile back to the parked car, and pretty much ruined any sense of a real nap.

But with John in Alaska, this was our only opportunity to see the show as well as our girl friend Sally who also has kids and is soon moving across the country for residency.  I brought snacks, sat in the very back, and prepared for quick escapes.

Aurelia pulled it together in a way I didn’t expect.  I need to remind myself that she is so much her father’s daughter: extroverted; playful; distractible; loves music and laughter; feeds off others’ energy.  She could not get enough of all the new people, the costumes and, of course, the music!  At one point, we were sitting on the stairs of the auditorium and she was literally springing to her feet, jumping up and down and clapping to the beat of the Bollywood piece.

Thanks so much to everyone there for being kind and generous to her/us (like our friend Hayley who we miss terribly; she took for her a quick walk while I went to the bathroom by myself and watched a skit undistracted).  And thank you to Jen Olenik for these pictures that so beautifully capture her spirit:

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sick days

28 Mar

It’s kind of great to be in a profession where you’re presence is necessary.  That said, the absence of sick and snow days gets old every now and then.  SO many days this winter I got the following email from Public Safety: “Normal University operations are suspended for <Insert Date> due to weather.  Essential University staff and all Health System physicians and staff are required to report to work.”  At least on my sub-I, when I was driving in at 5am on 12 inches of snow and ice, I was the only one on the roads.

Before this week, I took exactly four hours of sick time during clinics.  I was like 36-37 weeks pregnant with Ari on my peds rotation fighting off some generic bug and clearly looking miserable, and I think my attending was just being kind since it was a day or two before the shelf exam.  The general rule of thumb is that if you have a respiratory infection, you put on a procedure mask, try not to spew bodily secretions on anyone, and suck it up.  I had pneumonia in January, and I only missed the last two hours of my rotation so I could be seen by my PCP.  If you’re actively vomiting, then you’re asked to stay home.

Then this week happened.  I’m in the NICU taking care of mostly frail little premies, and I’ve been slammed with a head cold.  That’s all it is, truly.  But I am dripping in snot and phlegm.  The first day I was politely asked to just go home.  The second day, clearly worse, I kept my distance.  My third day, feeling a bit of renewed energy but have paroxysms of cough every 30-40 seconds or so, I was sent home again, this time with the threat, “If you get one of our kids sick, we will FAIL you.”  I don’t think she was entirely joking.  Nor should she be…jeez, I would fail myself.

So home I am, feeling pretty pathetic and sorry for myself because I’m too miserable to get any meaningful work done (though I’ve ploughed through most of the Hunger Games trilogy while hacking up a lung in the middle of the night) and fretting that I might end up failing a rotation I really enjoyed or, worse of course, giving some little 26-weeker rhinovirus on top of immature lungs (though I hardly stepped foot in the unit and certainly did not touch any babies).

And then there was the drama of waking up with my face caked with blood and my bedside tissue stash similarly saturated red.  I truly love being pregnant (seriously), but blowing pounds of snot through my nostrils apparently exacerbates my daily nosebleeds.

Meanwhile, my partner in crime, love of my life, main squeeze (who shared this bug with me) is far, far away (on a glacier, in fact):

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Come home.  Come home come home come home!!!!!

 

cmv: the fallout

25 Mar

At the beginning of the diagnostic process, it’s common nature to want to order of barrage of tests and studies, to amass as much information as possible and then sift through it all to find that one golden diagnosis that will put all the pieces together.  In med school, we learn to try resist that temptation.  Not only is it incredibly expensive (maybe why health care in the U.S. costs over 2.5 times the amount it does in other developed nations), but it can also muddle more than clarify the means of health care delivery.  It’s why we screen for breast cancer in women without certain predisposing conditions with mammograms rather than MRIs, the latter being the arguably more sensitive study.  Too frequently the MRI will come back with incidental findings or false positives that will require follow-up, often more invasive testing (like a biopsy) and, ultimately, a lot of stress for patient, family, and provider.  When I order a study, I try to remind myself, “What will I do with the results?  And will it change my management?”

As a patient, I allow myself the luxury of not thinking like a care provider, and I’m afraid a become a pretty paranoid individual, going way overboard with diagnostic tests and procedures as a means of reassurance.  In the fall, I was mostly convinced that I wasn’t a carrier of Tay-Sachs, but I asked to be tested so I could really put any sense of worry out of my head…and look what it got me.  You’d think I’d learn, but when we found out our babysitter had parvovirus, I though, might as well get tested for both parvo and CMV, since they’re both ubiquitous infections in the pediatric population.  Chances are, I’d be in the 50-80% of women already exposed to CMV and I could just put the matter to bed.

You already know where this story is going.  My serology testing for parvo confirmed that I was IgG positive, meaning that I had already a previous exposure without any signs of an acute infection, and I am likely immune.  Score!  CMV, not so much.  I had both the presence of IgG and IgM antibodies in my blood.  This result is frustrating.  IgM signals an acute infection, but it can remain positive up to 12 months or more after the initial infection.  It can also spike again during re-exposure or reactivation, although the risks to the fetus in such a scenario are incredibly low.  Unfortunately the presence of IgG doesn’t help us out because, with this particular virus, it can rise quite quickly after the initial exposure.

I was disappointed and concerned with the results but, given the fact that I had a normal anatomy scan at 20 weeks and the fetus was growing appropriately for gestational age, I was able to talk myself down off the ledge.  Even an acute CMV infection does not necessarily mean that the fetus is affected.  If I was infected during the first trimester, the risk of transmission is quite low, but the consequences are great (calcifications on the brain, microcephaly, intrauterine growth restriction are some of the common findings)–my normal 20-week ultrasound is reassuring.  If I was infected late in the pregnancy, the transmission risk is much higher (some estimate as much as 40%), but the possible effects on the fetus are less severe, with many being entirely asymptomatic and hearing loss often being the most significant deficit.  I spoke at some length with one of the neonatologists with whom I’m working who specializes in virology.  She validated my frustrations.  In the end, there is so much we don’t know about CMV and, since there is very little we can do to prevent exposure (though pediatricians and daycare workers are certainly at higher risk) and no proven method of treatment, it’s not standard prenatal testing.  I was happy to let the issue rest for now, though accepting that our second born would need to be tested at birth and followed for a couple years to test of hearing impairment mostly.

The midwives I see are normally very low-key, but they did decide to consult Infectious Disease (ID) with my case, and it was recommended that I be followed by both ID and Maternal-Fetal Medicine (MFM).  It’s likely overkill, but I’m already down this road.  Today I met with MFM and had an ultrasound to check for any findings consistent with congenital CMV.  What a treat!  Not only does our daughter look normal (in a good way!) and healthy and growing appropriately, but the technician also noted that she looked to have a full head of hair, taking after her sister and everyone else on her father’s side!  Estimated current weight is 4 lb 9 oz, more than most of the babies I’m caring for in the NICU–we normally throw up a celebratory sign on the crib or isolette when a baby hits the 4-pound mark!

One of the MFM docs recommended an IgG avidity test, which could give us information about whether my infection is acute or likely from more than four months ago.  I declined.  I’m content with my level of reassurance at this point, and I’m not sure what the results of an avidity test would do to this precarious happy place I’m in currently.  If the tests showed low CMV IgG avidity (indicating likely acute infection), I would worry about the high transmission rate of CMV in the third trimester.  If there was high CMV IgG (meaning the infection was likely over four months ago), I would be concerned about the more concerning potential effects of a first trimester infection.  I’m finally trying to discern ahead of time how I would deal with the results of a given study, and act accordingly.  And, regardless, the results would not change management.

I’ll try to focus instead on this little healthy nugget I have at home, who apparently delights in stacking her Chex cereal on top of her sippy cup.  Fingers crossed she’s spared of this awful cold John and I have been hacking through!  Can it please be Spring?

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match day 2014

24 Mar

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So proud of these ladies and others in the class of 2014 for matching into residency!!!

I remember John’s match six years ago almost to the day, when we found out that we would be moving to Boston and, I have to admit, I got a little anxious about my own match a year from now.  Part of the beautiful thing about this year’s match for the Penn class is that, if it didn’t put longtime long-distance relationships back in the same city again, it at least mostly got loved ones closer together (like, the same coast).  A number of friends engaged to be married to partners many miles away now have official job offers in their partners’ respective cities, for example.  

John and I have done the long distance thing before, for a total of three years apart.  It sucks.  One thing he told me when I was pregnant with Ari was, “Oh, God, it just occurred to me: we can’t ever leave each other now!”  After I questioned him about his motives for wanting to jump ship, he rephrased: “I mean, we can’t do long distance with children in the mix.”  Of course, many parents do and make it work.  But John just left for a week-long trip to Alaska and my heart is noticeably a little less upbeat.  The idea of moving away from him again makes me feel pretty sick.

With a little strategy and a lot of luck, hopefully the odds will be in our favor in a year.  For now, congratulations to the remarkable, hugely inspirational (the emotion of match day allows me to use the sappy, perhaps a little trite-but-no-less-true adjectives) class of 2014!!  You deserve it all!!  It is a privilege to have been part of your class for the majority of my med school career.  xo

 

grumble grumble TORCH complex

17 Mar

At least a couple times during my sub-I, I was taking sign-out from the intern who admitted new patients overnight and, although I listened to the presentation of a patient with the quintessential fever, sore throat, fatigue, and lymphadenopathy, it often took me until the final assessment and differential diagnosis to interrupt the presentation.  At the top of the differential was infectious mononucleosis, caused by Epstein-Barr virus (EBV) 90% of the time but, rarely, also caused by Cytomegalovirus (CMV).  I remember both the intern and I coming to the same realization as soon as the words “likely EBV” were spoken.  Bah!!  Unfortunately, I could not directly care for that patient.

CMV is part of the TORCH complex, a group of diseases that are vertically transmitted from mother to fetus and can cause some significant health issues, birth defects, or even death.  The complex is an acronym of member diseases:

  • Toxoplasmosis
  • Other (helpful, right?  includes Coxsackievirus, Chickenpox, Parvovirus, HIV, Chlamydia, Syphilis, and probably more I’m forgetting)
  • Rubella
  • Cytomegalovirus
  • Herpes Simplex Virus-2

What I learned my first day in the NICU is that over 1/100 healthy full-term infants is also an asymptomatic carrier of CMV.  The proportion of premature or ill infants in the NICU carrying CMV is likely much higher.  So I’ve been potentially endangering my second-born to increased risk of hearing loss, visual impairment, and diminished mental and motor capabilities.  Between this experience and my little genetic scare this fall, I feel like mother of the year.

And then last week I got a call from Ari’s babysitter that she (the babysitter) came down with Parvovirus (see “other” above).  Although she’s maybe one of the most responsible sitters on the planet, unfortunately, by the time you develop symptoms of this infection, you’re no longer contagious; you’re most contagious the 5-10 days beforehand.  Can you see my head hitting the wall repeatedly?  This fetus can’t catch a break.  She’s now at risk of developing severe anemia and fetal hydrops.  Yuck!

So, we talked to a lot of people.  We contacted our PCP and the midwives.  John consulted colleagues and friends, while I sat down with the chief of neonatology.  The fact that we have access to such ridiculously overly qualified resources to help us guide our personal healthcare is a privilege and a fortune that is not lost on us.  We came to the conclusion that, due to the fact that I’m a grown adult woman who has a child in daycare, I’ve likely been exposed to both viruses previous and am hopefully immune at this point.

In the end, I got serology testing late last week to see if I either have an acute infection of either virus or have antibodies demonstrating that I’ve been previously exposed and am no longer at risk of being infected.  Many women in pediatrics who have or plan to have children choose to have these simple (though, like everything, not cheap) blood tests performed because there is simply no avoiding these viruses while working with children.  I probably should have been tested long ago–again, uber responsible parenting and family planning right here.

And now I wait.

Luckily we had some good distraction in the form of Ari’s pop-pop this weekend.  And lots and lots good food and outdoor galavanting.

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