Archive | March, 2014

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!!!!!

 

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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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a timely read

15 Mar

A beautiful, thoughtful piece written by a fellow mother in med school and a future neonatologist: 

Sometimes I wish I had chosen to continue the pregnancy for purely selfish reasons. Had we not aborted, our son’s birth would have been noted, his death would have been marked, and our deep and long-lasting grief would have been acknowledged and validated. Instead, we chose to give our baby what we felt was the most humane, comfortable, and loving end-of-life experience we felt we could facilitate, a cause that on its face is championed even in the most introductory ethics discussions among new medical students.

Because of the choice we made to end his life, our son never got the chance to gaze up at his parents, to see who it was that had been talking and singing to him all along. He never got the chance to fall asleep in our arms, bundled and cozy, pink lips and fuzzy hair like a duckling, smelling of milk and baby, the very best smell in the world. Neither, however, did he have to suffocate to death at birth, his small body gasping to fill his woefully hypoplastic lungs. He did not have to feel pain shooting throughout his abdomen, grossly distended with urinary ascites. He did not have to experience one minute away from the warmth and love of my body. We chose, instead, for him to be born straight into peace.

While in the NICU this month, I absolutely appreciate the validity of this choice.  And I respect and admire the love and bravery of Ms. Danziger, for making this excruciating parenting decision, for surviving this entire endeavor and continuing to mother in the face of profound grief, for sharing this piece of her story.

the nicu

11 Mar

I’m in the neonatal intensive care unit this month.  It’s a foreign nation and language.  With TFLs, TPNs, and HFOVs.  Our patients are of ELBW and suffer from BPD and AOP, with notable A&Bs.  I can’t really tell you what all that means.  But it’s for this reason that the rotation comes highly recommended by pediatric residents–gives some exposure to this world before being thrown in with more responsibility as a resident.

It’s totally surreal caring for sweet infants who were conceived more recently than our little nugget still in utero.  (I got some good advice to wait to do this rotation until several weeks after viability.)  For the most part, these peanuts are going to be fine.  One of the patients I’m following is now a couple days old, but was originally due weeks after our girl.  The parents were at the bedside today, the mother fighting back tears.  My incredibly lovely (and hilarious and thoughtful) attending approached her.  “So many hormone fluctuations and lack of sleep!  Of course you need to cry!  But look at how strong your girl is.  We’ll give her some light [phototherapy] and we’ll let her grow, and then we’ll send her home with you, and you’re both going to be fine.”

Speaking of growing strong:

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helen

9 Mar

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It’s a pretty awesome thing to know a great-grandparent.  As the youngest (by a long shot) of four children, I only “knew” one mine for about a year before she passed away at the age of 97.  Of course I don’t really remember her, but as a kid I treasured the few pictures of us together, and I just thought it was cool that she at least knew I existed, that I was newest member of the family tree she created.

Her daughter was my grandmother Helen, or Mimi as we called her.  She surpassed her mother’s longevity, celebrated her 99th birthday this January, then passed away two month into her 100th year of life, on March 7, 2014.  She suffered from pneumonia last month and never fully recovered.  Per her wishes, she continued supportive care but had no invasive procedures.  In the days surrounding her death, I was told that she was made quite comfortable.  Although she had had similar spells in recent past and bounced back, she had otherwise led an incredibly healthy 90+ years; her life was saturated with activity, art, music, education, literature, and love.

Mimi lived in Florida, hundreds of miles from family, and none of us were able to get down there in time.  She was surrounded by friends and the community in which she lived for the last decade.  She couldn’t speak, but many of us got to talk to her as we listened to her heavy breath sounds over the telephone in her last days.  I spoke with her about two hours before she died: told her I loved her, chatted about school (she had graduated from Penn!), and revealed the name we are thinking of for her newest great-granddaughter.  That evening, John and I toasted her over a good scotch, her drink of choice.

My sister, after seeing Mimi in January for her 99th, remarked that she didn’t think it would be her last time seeing her.  My impression of her during our visit in November was different, not necessarily because she looked particularly more sick or frail.  I just had this nagging feeling that Mimi would be fine until she wasn’t (which could be any time), and then she would go quickly.  I’m thankful that she did.

And I’m especially thankful that Aurelia and Helen got a chance to know each other, albeit for too brief a time.