Anne

When, at your 18 week pregnancy check-up, you are told, “I’m so sorry, but there is no heartbeat,” you have to make a lot of decisions that you never knew you would make.

How will you deliver your baby who has died? And when?  Will you have an amniocentesis?  Do you want an autopsy?  Will you want to see her after she is born?  Will you hold her?  Do you want pictures?  What will you name her?   Will you name her?

My dad called me in the days after the appointment and before the delivery. 

You are still in shock.  Grief has not even set in.  Real grief takes a long time.  What is her name?

We haven’t talked about it.

You have to name her.

My dad knows me and he knows grief.  My brother Mike died at 2 months old.  Deep down, I knew I wanted to name her but I was scared.

When my husband and I had our first child, our son, we spent nine months mulling over names.  We laughed and argued and pondered and teased.  His name was finally settled after he was born.  With our rainbow*, the name selection was a little more serious but just as thoughtful.  We had two names picked before the first trimester was over. 

In contrast, Anne’s name was selected on the interstate as we were on our way to the second appointment with the specialist.  We had just established that we strongly disagreed on method of delivery.  I struggled to broach the subject.  The clock was ticking.  Decisions had to be made.  We had not talked about names at all this pregnancy.

I want to name her.

I don’t.

Silence.  Was it worth it?  All of this conflict when we really needed each other?  In four years of marriage our disagreements had never felt so heavy.

What names have you thought about?

I threw out a couple.  He hated them.

What about Anne?

I love Anne.  Let’s name her Anne.

Anne is my middle name.   Whenever I fill out a form that asks for my middle name now, I think of her.  My name tags, drivers license, and lab coat all bear the letter A.  For Anne.  Anne’s mom.  It makes me happy every time.

On the Still Standing Magazine website, there was recently an article talking about the meaning of the author’s daughter’s name.  With all of the research that went into the names of my other two children, I never thought to look into the meaning of Anne.  I finally did.

Favor.  Grace.  God has favored me.

That she is and that he has.

This grief journey has involved a lot of darkness and tears but there are little joys and blessings along the way as well.  I love Anne.

*Rainbow is a term in the loss community that refers to a child born after a son or daughter who died.  Our Rainbow was born healthy and happy in December 2012.

Pregnancy and Infant Loss Awareness Month

October is Pregnancy and Infant Loss Awareness month.  This is an issue that is dear to my heart.  On January 6, 2012 my daughter Anne was born still.

There are two things that I hope more people can be aware of:

1. That even in 2013 miscarriage and still birth are not uncommon.  1 in 4 women will experience this kind of loss.
2. That this is not something to be brushed aside.  For many, no matter when the loss occurs, this is a son or daughter who is treasured and deeply loved.  The loss is devastating and there is a grief that must be observed.

From awareness, I hope to see the following changes:

1. That the families who experience this kind of loss are better supported.  We were blessed to have a strong support system.  Prior to my own experience, I did not know how to support my friends who suffered similar losses. I wish I could have been a better friend. I do not believe that I am alone in wanting to support those I care about in difficult times.
2. That through awareness there is more support for research.  We had an autopsy, a chromosome analysis and spoke with multiple experts.  To this day we do not know why our daughter died.  Sadly, this is the case for many families.  It is my great hope that there will be more research in this field.

Last year, I participated in the CarlyMarie Project Heal 31 day photo challenge in honor of my daughter.  It was simply amazing.  The process itself was therapeutic.  There were aspects of my own grief that I was able to face and work through.  I shared the process on my Facebook page and was able to connect with a number of amazing friends who had traveled similar paths.  Moreover, 2,000 other people from around the world participated.  Seeing so many stories of love was absolutely incredible.

Project Heal is sponsoring the photo challenge again this year. I will be participating in a few days.  For multiple reasons, I have chosen not to do all 31.  Keep an eye on my blog for updates this month.  For truly beautiful photography and an uplifting perspective on grief, visit CarlyMarie Project Heal.

Day 1 Sunrise

Parenting Expert

I went to bed at 8:30 last night.  I know.  Foolish.  That is how I found myself awake at 2 am, reading the Twitter profiles of people I have never met.  Do you know how many parenting experts there are out there?  Many.  More than I would expect.  Go search “parenting expert” on Twitter and then come back and finish reading this.

It’s not that I don't think it’s possible to be a parenting expert.  I am just astounded that so many individuals have achieved the status.  And here I am, with my doctorate and my pediatric training and my two kids and my kindle full of parenting books and I am definitely not an expert. 

Example 1:

I have spent the past two months trying to get my three-year-old to stay in his bed at bedtime.  Instead he spends two hours needing one more hug and one more drink and one more potty run and one more stuffed animal to cuddle and one more standing in the doorway of the living room looking lost.  Our pediatrician recommended a sticker chart with prizes.  I will admit I am skeptical.  The only sticker chart I remember from childhood was the reading chart in fourth grade.  And I did not care about the stickers or prizes.  I just cared about reading more than Jenny, who lived two blocks away and routinely out-read me.  But I am desperate for a solution so I will try it.  I wonder if Jenny has read more parenting books than I have.

Example 2:

My nine-month-old has taken to shrieking as her preferred form of communication.  Especially when there is food involved.  The three-year-old thinks it is hilarious and copies her.  She thinks he is amazing and echoes back.  And now it is something like a shriek conversation.  They are screaming in unison with every bit of air that can fit in their lungs.  Meanwhile, I use my calm, stern Mom Voice and say “No shrieking,” “No shrieking,” “No shr-,” “Do you need to leave?” “Stop.” “No shrieking.”  Before you know it, I am screaming, “No screaming at the dinner table!” at the dinner table.  It works but I cannot imagine that I am modeling the right behavior.

If you read Malcolm Gladwell’s Outliers, you will recall that it takes 10,000 hours to become an expert at a given activity.  There are 8,765 hours in a year.  If one has a kid who is literally “up all night” for the first year of life, that person could become an expert in about a year and a half.  Although, I might wait and see how he or she does with kid #2’s sleep habits before I listen to any advice.  Alternatively, Gladwell says, it can take ten years to become an expert.  So maybe any parent of a ten-year-old is an expert?  In just the past month, I have had the mother of a nine-year-old and the grandmother of an 11-year-old request prescriptions for prn sedatives for their children.  My gut reaction is that there may be exceptions to that rule. 

There is a writer named Eric Barker, who blogs here, and points out that these 10,000 hours or ten years leading to expertise must involve actual dedicated practice.  In fact, some studies suggest that after ten years some experts may see their skills worsen.  Experts need “countless drills” to improve mastery.  I am not exactly sure what parenting drills would look like.  As a physician, I have practiced suturing on pig feet bought at the grocery store.  I have rehearsed physician-patient interaction with paid actors.  I have resuscitated plastic mannequins time and time again.  I wonder what a third-party would think of my Mom Voice.  A plastic mannequin would certainly prove even more steadfast than my three year old in response to my verbal commands, although the "picking up and placing in bed" strategy would probably be very effective.

I guess seven years from now I will be an expert, too.  I will either be very good or even worse than I am now.  Just in time to start parenting teenagers.  Either way, I will be sure to add Parenting Expert to my Twitter profile.

Spotting measles

There is a sort of game I like to play at work.  Based only on what the triage nurse writes as the chief complaint, I try to guess the final diagnosis. The game is especially fun when the chief complaint is something like "Eats shirts,” but that is a story for another time.  A few weeks ago, a little girl came into the Emergency Department.  The triage note read, "Fever, drooling, mouth sores."  I narrowed my guess to two common viral illnesses.  A good history and exam and the diagnosis would be in the bag. 

My resident saw the patient first.  He came out of the room and described to me a previously healthy, unvaccinated girl with fever, drooling and mouth sores.  Suddenly everything changed. Sure, this child was still most likely to have a common virus, but now I had to consider a list of diseases that I almost never seriously entertain.  Diseases I have never seen because we live in the post vaccine era.

We live in the post vaccine era.  Isn't that amazing?  Vaccines have so changed the landscape of modern medicine that they have earned their own era.  We often talk about how vaccines mean that children are protected against death and morbidity from diseases like tetanus, polio and diphtheria.  While this is true, vaccines have also revolutionized the way that doctors manage infection.  Because of vaccines, I can view fever as nothing more than the normal response of a healthy immune system.  I can confidently tell more parents after a simple, painless examination that their child has an illness he can fight off on his own.  No irradiating him with x-rays or cat scans, no painful blood draws, no tubes shoved into orifices.  It is a great time to be a pediatrician.

As a physician who has only ever known medicine in the post vaccine era, there are some drawbacks.  The most valuable teaching in medical school and residency came from patients and the experienced physicians instructing me.  This is what pneumonia sounds like.  This is what a surgical abdomen feels like.  This is what leukemia looks like.  This.  Right here.  Don't forget this.  Even the best textbook pales in comparison to the real thing.  My knowledge of these vaccine-preventable infections is exclusively from textbooks.

So on the night that I see this little girl with fever and drooling and oral lesions, things go a little differently than usual.  I still think she has a common virus.  But could it be epiglottitis?  I don't know; I've never seen it.  It is probably best to get an x-ray to be on the safe side.  And maybe some labs.  And if we are drawing blood, we better try for an IV.  Could it be measles?  I don't know; I've never seen it.  My resident and I pore over pictures of Koplik's spots.  The textbook says they should have a blue or gray hue, and I don't think that hers do.  It is hard to be confident.  The ramifications of being wrong play out in the back of my mind.

I discharge her.  In my note, I document no cough, no coryza, no conjunctivitis, no rash... no evidence of measles.  Because, according to articles like this US Measles Cases in 2013 May Be Worst in 17 Years, that is a real concern and there may come a day when I no longer have the privilege of saying, "I've never seen that." 

The Patient Needs A Doctor

July always makes me think of my intern year. Every July, my Facebook feed is peppered with commentary on the newness of the interns, the naivete of the medical students, and the challenges of advancement to senior roles.

I look back on my intern year fondly. It was hard. And exhausting. But there is such an incredible feeling of satisfaction not only in accomplishing something that is difficult but also in knowing that you are improving. My husband and I were newlyweds. He was a surgical intern and we supported each other up the learning curve of hospital life. Post-call, over dinners of take-out and three dollar wine, we shared our experiences.

One evening my husband told me about rounding with his attending the morning after an especially busy call night. While making their way down the hall, seeing each newly admitted patient, the attending surgeon paused at the room of a patient who was not on the team list. The man looked terrible -- roughly 60 years old, jaundiced and somnolent. As my husband frantically shuffled through notes and lists wondering how he had forgotten an admission, the attending introduced himself and did a brief exam. Upon exiting the patient's room, he asked the team to add the patient to the list. My husband was certain that he had not forgotten any of the night's admissions and consults. "Sir," he asked, confused. "Is this our patient? I don't remember admitting him."

"This man needs a doctor," the attending responded simply and continued with rounds.**

That night, we laughed at the statement and attributed it to the quirkiness of a dear mentor. The year progressed and the phrase stuck with us. It came in handy as we retold the frustrations and challenges of new services, perceived injustices, and work left undone by other services or other residents. "Oh!" the listener would interject lightheartedly. "You're saying the patient needed a doctor!"

Later in our training, our use of the phrase reflected a more seasoned perspective. While supervising admissions, teaching and managing the very sick, we would also find ourselves caring for people who might traditionally be admitted to different services or were, perhaps, admitted for conservative reasons. As interns we might have complained but as seniors we would merely shrug and say, "I guess the patient needed a doctor." (Of note, this is easier when you are not the one doing the grunt work of an intern.)

I work in the pediatric emergency department now. There is a lot of discussion both during my shifts and in the global medical community about misuse of emergency services by patients. I hear the comments regularly.

"My parents would never have brought me to the ER for that."
"Didn't they call their PCP? It's the middle of the day."
"It's 2 am. This couldn't wait until the morning?"

On Twitter, other blogs and in medical journals, there is discussion as to how we can encourage proper home triage. I used to ask the patients themselves but have stopped unless it seems useful to my clinical decision making. The answers are always the same. The pediatrician's schedule was full. The parents could not take time off from work. They did not have a car. It seemed like it was getting worse. Someone was hurting. Someone was worried.

In all of these situations, whether expressed out of frustration or resignation, the statement "This patient needs a doctor" repaints the picture. What was once an injustice becomes a call to duty. Sometimes our job is not fair. Politics, fatigue, electronic medical records, work hours and someone else's bad day can all compete to cloud our outlook. While many of these things do need improvement, it helps to remember that at the bottom of this, there is a patient who needs a doctor.


**For my mom and others not in the medical field, a patient does not get admitted to the hospital without a specific doctor agreeing to care for him or her. The patient in this story was admitted to another hospital service but the surgeon identified him as potentially in need of surgical care.

There's an app for that

I joined Twitter two years ago when my 22 year old sister told me I was too young to act like a technology-ignorant, old fuddyduddy. What she did not tell me was the wealth of information that can be accessed by engaging through social media. I learn from and talk to all kinds of interesting people regularly. If you are not on Twitter, you should try it. If you think it is a waste of time filled only with the vapid musings of the famously famous, you are doing it wrong. The biggest celebrities that I follow are Atul Gawande and Wendy Sue Swanson. Neither is very likely to be featured on TMZ tonight but if I ever meet either in person, I am very likely to be starstruck.

If you would like to read more about why health care professionals should be on Twitter, Brittany Chan wrote a nice piece on the topic here.

I want to share with you the content of a cool Twitter conversation (twittersation?) I had a few weeks ago.

It started with a tweet by Joel Topf about using the iPhone flash to look in someone’s throat. Cell phones have so permeated our lives that a physician’s iPhone is apt to be more readily available than traditional tools. No to mention, the LED flash is brighter than the standard otoscope lightbulb.

The tangential conversation that followed highlights what can happen when you combine the iPhone LED flash, human ingenuity and a strong interest in looking in throats and ears.

1. The Remotoscope 

http://pediatricdevicesatlanta.org/remotoscope

Emily Hahn shared this one. It is an attachment for the iPhone that lets you video the tympanic membrane (ear drum). I want one. The ability to show parents what their child's ear looks like would be incredible. I spend a lot of time describing the tympanic membrane but I do not know what picture my words are painting in the imagination of the parent. I hope it is a close approximation of what I see. An actual video that we can both look at and discuss would advance the conversation immensely. Hopefully it would allow the parent to have a deeper understanding of ear infections. Maybe it would lead to fewer tympanostomies (aka ear tubes).

In the hands of a medical student or resident, it would lend itself to specific teaching and targeted feedback. It took me a long time to figure out that my biggest obstacle to visualizing the ear drum was proper positioning of the child. My findings were always double checked with a senior physician's exam, but it was difficult for my instructors to glean what I had actually seen. It is even more difficult to teach the difference between infected and not infected when the learner has not gotten a good look.

The Remotoscope is currently being studied at Emory and Georgia Tech and is in the clinical study stage of development. One of the questions they are considering is whether this tool could be used by parents at home and spare a trip to the doctor.

Here is a video demonstrating its use:

2. How to look at your larynx with your iPhone 

There was some commentary on the quality of the videos of tonsils obtained with an iPhone. Michael Katz shared Dr. Helgi’s photo, acquired with an iPhone.

https://twitter.com/traumagasdoc/status/285846804745056256

For those of you who may be unfamiliar, the structure in the center is the epiglottis (protective flap over the airway) leading into the trachea (tube that connects the throat to the lungs). It is located past the tonsils. Pretty impressive shot. How does one get this pic? According to Dr. Helgi, like this:

https://twitter.com/traumagasdoc/status/285854316588331009

Now, I will be honest. One of my favorite resources at work is the Quat Wipe. I use them on my stethoscope, ID, phone, keyboard, etc. I have not reviewed any of the evidence but I like to think they are significantly stronger than Clorox wipes and have near-magical properties. I have a lot of faith in them. But not enough to put my phone in my or anyone else's mouth. I will not be trying this anytime soon.

However, when the folks in Georgia are ready to share their Remotoscope with the rest of us, call me. Or email. Or tweet… It is all on my iPhone, which is nearly always in my hand.

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To learn more about the people mentioned in this post, click on their names. They are all physicians that I follow on twitter. They all tweet about medicine as well as non-medical topics that they find interesting. Check out their Twitter profiles and click the follow button!

To read more about the remotoscope, go here:
http://gatech.edu/newsroom/release.html?nid=155181
http://pediatricdevicesatlanta.org/remotoscope

Guest Post at Still Standing Magazine

Today I am writing over at Still Standing Magazine.

Still Standing is an online publication that is focused on "inspiration and hope, in the face of loss and infertility." The magazine has been a source of peace and healing for me over the past year and I am incredibly honored to have my writing posted there.

 In January 2012, our daughter Anne was born still after eighteen weeks of pregnancy. Her death broke our hearts but with her short life, she has taught us more about love and grief and parenting than we could have ever thought possible.  This guest post, My Anne Pants, is just a piece of her story.