Showing posts with label PracticeBalance. Show all posts
Showing posts with label PracticeBalance. Show all posts

Wednesday, May 24, 2017

Mother's Day?

I'm not even posting this close to Mother's Day, and that's just fitting. My second Mother's Day as an actual mother came and went, and a pattern has begun to emerge... I am realizing that this Hallmark holiday is a bit of a joke among many mothers. I read a funny post in an online moms' group where a woman described her Mother's Day with biting snark. She was "allowed to wake up early" while her husband slept in, enjoyed "a peaceful few hours of cooking brunch items for my family with a toddler attached to my leg" after rounding in the hospital, and then ended her day with a hot shower that was interrupted by her husband asking her to scrub the shower walls with his "fun new electric cleaning brush. So. Blessed." It got me thinking about my own two Mother's Days so far.

Last year, we had a plan to go visit my parents for the weekend. My mother makes a big deal of the holiday and holds an annual pool party, the yearly unveiling of their pool for summer use coinciding with agreeable Arizona weather right around the May date. She had a big event planned, as it was my first Mother's Day, and yet things were strained between us. At 43 and with disposable income plus a new baby, my husband and I had decided we were no longer going to stay in my parents' cramped extra bedroom on their uncomfortably small bed (replete with foot board) in their poorly ventilated home. The nearest bathroom is down the hall next to their master bedroom, and last Christmas my mom caught my husband running to the toilet in his underwear in the middle of the night. "Never again," he had exclaimed with stern eyes. Anyway, this decision to stay on our own had unexpectedly hurt my mother's feelings, given her memories of her own young married years visiting their own parents. Painful conversations had occurred, I had put my foot down, and a plan for alternative accommodation was in place. On the morning of our flight, my husband woke up feeling under the weather. I thought nothing of it and continued packing the car with myriad baby equipment, as this trip was also going to be our 6 month old's first flight. He is the picture of health, lean and muscular with no medical problems except for some recurring hemorrhoids. A week prior, I had talked him into having a band procedure, which I thought might solve the problem. In between schlepping loads, he stumbled, perspiration poured from his face, and all 6'6" of him slumped onto the couch. It took a scary minute to revive him, so we rushed to the ER, and in the harsh fluorescent lights I finally appreciated how pale he was. Hematocrit was 20%, and he was admitted overnight for a blood transfusion. I spent my first Mother's Day bringing him barbecue and magazines in the hospital (as if I don't spend enough time there already) and of course apologizing for suggesting the banding in the first place, in addition to playing single parent to my child. Trip aborted and difficult conversations sure to arise again at the next Arizona visit.

This year, Mother's Day happened when I was in Spain on a long trip... which might sound to some like an idyllic scenario. I understand that many people crave an escape from their work and hectic lives at home, but being long time rock climbers and slow travelers, my husband and I normally plan longer trips abroad where we fully immerse in a micro culture for periods of time. We had chosen the Chulilla area for its long climbing routes on tall limestone walls and its balmy spring temperatures. Only we hadn't gotten much climbing done because traveling with an active, headstrong toddler was turning out to be more difficult than we expected. The first week of our trip involved the rental car keys being thrown into the toilet by someone and then - recurring poop theme - me using said toilet before realizing where the keys were. I will spare you the details of the retrieval procedure. A couple of days later, I made the catastrophic mistake of filling our (unleaded) rental car's gas tank with diesel. WHY is the handle for diesel black and the handle for unleaded green in Europe?? Even though our pickiness and frugality usually keep us from eating out much even on trips, we decided to go out to a Mediterranean buffet in Valencia for Mother's Day. The hours for lunch in Spain are 1-5, while the hours for dinner are 8-midnight. Our normal eating time? 5-6 of course, like every other American family with a child. So lunch it was, and it was busy. We waited forever for a table in a sizeable crowd of Spaniards (we are very tall, so envision this as two giants with a giant baby swimming in a sea of tiny Europeans) on the sidewalk outside the glass doors to the buffet. The hostesses didn't even take our name; they just asked how many were in our party and we stepped back, hoping for the best. Over the course of waiting, baby grew tired and hungry. I read her stern face: What's with this late lunch business, during my naptime? We tried to calm her, but the whining grew louder, and then suddenly they took pity on us. We were seated at a cramped two-seat table near the buffet, knees touching under the table and backs of chairs touching the people behind us, and when I asked for a high chair they gave me some sort of booster seat contraption. I fussed with it for a while and then laughingly realized I had situated her in it just perfectly looking like the picture on the side - the red one with the big "X" over it. She ended up on my lap, and I barely ate anything. Hubs came and went happily many times while I entertained our crazy girl, who proceeded to fling paella and jamon in a several foot radius around our table (luckily no other diners but me became covered in food). Lunch came to a hault when she threw a plate that shattered into many pieces and then leaked through her diaper all over my lap.

A glorious day spent at the gas station after my "oh shit" moment

Like lots of mothers this recent holiday, I just might have posted some cute pictures on social media of my family frolicking on the beach (not on the day shown above), followed by comments about how lucky I am. Given the fact that for years I wasn't sure I was going to ever be one, I really do feel grateful to hear that faint little voice say, "Mama". But the sunny travel photos don't necessarily reflect the un-glamorous reality of motherhood that happens every day, with or without a dedicated holiday. Next year on Mother's Day, I don't know exactly what I'll be doing but I'm sure I'll be mothering again. And I'm sure that poop will somehow fit into the picture.


Tuesday, April 4, 2017

Redefining Dr. Mom - A Review of the First PMG CME Conference



If you're a mother in medicine and you haven't heard about Physician Moms Group, you might be living under a (social media) rock. PMG, which started in 2014 as a Facebook group for exchanging advice and support between women physicians who are moms or moms to be, has morphed into a community of more than 60,000 women with an influential internet presence. Any group of women that can sell out the entire stock of Instant Pots on Amazon in minutes or lobby to get discounts on coveted clothing or other products has some serious clout! As part of the group's continued evolution, founder Hala Sabry, DO and her best friend Dina Seif, MD recently held their first CME Conference in Las Vegas on April 1st, 2017, entitled Redefining Dr. Mom. And I was lucky enough to be able to attend!

Let me start out by saying that this was by far the most interesting and engaging CME activity that I have ever witnessed. There is the tendency at such events to plop down in the back row, pour yourself a large cup of coffee, and whip out your phone to scroll email or social media. Instead, this conference was chock full of useful and relevant information, presented in a dynamic and interactive format. Presentations ranged in topic from recognition and prevention of burnout, to financial planning strategies, to nonclinical paths in medicine. To top it off, there was a female physician entrepreneur panel moderated by ZDogg MD (Hala's friend and local Las Vegan)!

ZDogg in the house!

When I looked around at the other attendees, I was struck by the diversity of women in the room. I saw many ethnicities, shapes, and ages. Some women wore jeans while others were clad in suits. Some had bouffants, others had beach hair. There were bare faces and full makeup. Yet we were all physician mothers, present to discuss what might be lacking in our careers and learn what might enhance our current work-life balance. Each excellent presenter shared a personal experience as part of her talk that represented a watershed moment in her journey, something that had led her to question or change her presumed path in medicine.

Another common thread throughout presentations was the emphasis on identifying core values as a way to assess happiness and drive future direction. The presenters also prompted attendees to think outside of standard paradigms - regarding self-care, business, and leadership or mentoring roles. Included as well were optional organized social events for the two nights surrounding the conference - a spa outing and dinner, plus a dinner and Cirque du Soleil show. Being somewhat of a "local" to Vegas (I travel there frequently in the winter), I also led a small group of PMGers and their families on a hike in the Red Rocks the next morning!

PMG is definitely planning more CMEs for the future, and I would highly recommend attending. Also, if you are not a member and are interested in joining, visit MyPMG.com to supply your own credentials, or have a Facebook friend add you to the closed group.

Wednesday, March 15, 2017

The Request Case

One of the things I really enjoy about being an anesthesiologist is the wide variety of patients that I see. You never know who you're going to have the privilege to care for on a given day. Although my group is large, I will occasionally be assigned to a patient that I personally know. And occasionally, someone I know will request me as their anesthesiologist.

Last month I took care of a friend who requested me for her surgery. It was a very straightforward case, everything went smoothly, and she expressed abundant gratitude at the end of her experience. I was also asked to do anesthesia by a friend for a surgery that, knowing her history, was going to be fairly complicated. That one gave me pause, but I did it and everything turned out well.

Gizabeth recently wrote about being a doctor to her friend, and I'll bet that some of you have also taken care of friends (or have become friends with some of your patients). I would venture to say that being an anesthesiologist or surgeon to a friend adds an even further layer of complexity because there is an immediate "life and death" aspect to what we do. However, either fortunately or unfortunately, patients don't usually appreciate this.

On the "pro" side, patients can feel a great sense of empowerment in choosing their own anesthesiologist. A good attitude and sense of empowerment going into surgery can translate to less stress on the patient and better overall recovery. During my residency, I had a scary brain surgery. At first, I thought it would be awkward to personally know my surgeon and anesthesiologist, but out of convenience and timeliness, I chose to have the surgery at my own institution. I was able to choose my anesthesiologist - who at the time was one of my supervisors! In the end, I felt great comfort in personally knowing my healthcare team.

On the "con" side, there is a phenomenon in our specialty called VIP syndrome. Taking care of a VIP subconsciously makes people pause and do things slightly differently than they would normally do, rendering the whole process vulnerable to errors. What if your friend suffers an adverse event under your care? And are your decisions objective enough in the situation?

What do you think? Would you and/or do you take care of friends? How about family members? Let us know your experiences with requests for care by friends, acquaintances, or family.

Friday, January 27, 2017

Witness the Sickness

I am so sick. Like miserable, no energy, hacking cough, congestion, achy muscles type of sick. Who knows what it is, but does it really matter? At work the other day I desperately had one of the X-ray techs do an AP on me. No pneumonia. That would have been too easy. How did I get this? From my 14 month old daycare attending daughter. Only she's moved on and is back to her normal, playful self.

The same thing happened around Christmas, but my husband was the innocent victim. She brought something home that knocked him down with a viral malaise that turned into a raging sinus infection. The babe got better in a few days; he lingered on with "man cold" for a couple weeks. We all know how painful that is for everyone!

I hear that what my household is experiencing is a thing. People tell me, "I've never been as sick as I was my first winter with a child in daycare." I hear, "Every time they change classrooms you'll get deathly ill." I have also heard, "It gets better once they turn two." Please God, let this be the case.

So Mothers in Medicine, my question is, what are your strategies for dealing with this? Is there any preventative magic I should be invoking? Because I don't know that I can go through something like this (two plus weeks of feeling like utter crap) again. We all know how hard it is to take care of our patients (and our children) when we are the sick ones, and we as a profession are the absolute worst at staying home and nursing ourselves back to health! What do you all do?

Monday, January 9, 2017

I Want To Hear Your Voice

I had a dream when you were only six months old that your first words were the complete sentence, "You can't tell me what to do!" You babbled so early and so prolifically that I figured you'd be talking by the time you turned one year. But now here we are two months past that, and I'm still in the dark. At least you've started pointing, but many times I still don't know what you want.

Why are other babies your age using words when you're not? Aren't you the child of a doctor and a lawyer who speak to you constantly in both English and Baby-ese? Who read you books every night? I Google the milestones, and you're definitely lagging in the language department. Have I done all the right things? What did I miss? Is this how it's going to be, you giving the overachiever but unsure parent in me an anxiety attack at every developmental step? I know comparison is futile, but I still fall prey to it sometimes. It's going to be a long parenthood if I don't learn how to stop now.

My thoughts of worry really are just fleeting; all I want is to hear your voice. Your real voice. Not just "mamama", "dadada" and "uh oh". As your mother, I keenly know your cry and your coo, but I want to know what you sound like when you express yourself with words. The lilt in your voice when you're delighted. How the words come out when you're angry. The tones you release when you're sad. I want to talk to you, to hear your thoughts and feelings and desires. Right now all I can do is wonder, but I'll bet it's going to be a beautiful voice.

Tuesday, July 26, 2016

The Buffer Zone

It's July, the time of year when new interns and residents begin their training programs. It's our busiest time at my academic hospital, where all of the anesthesiology attendings pitch in and teach the newcomers. When I'm teaching in the OR, I always ask a simple question: Why do we care about the patient's blood pressure? They usually get it right - adequate blood pressure ensures good blood flow to the brain and other vital organs. Then I sketch this diagram:



Remember the Circle of Willis from medical school? Along with redundant vasculature, our brains possess an elaborate sensor system that autoregulates cerebral blood flow in a sort of "buffer zone". (This curve may also look familiar to you as the representation of how a buffer acts to regulate the pH of an acidic or basic solution.)

Autoregulation is an evolutionary survival mechanism that is meant to ensure adequate perfusion of the brain at a wide range of blood pressures. But at the extreme ends of measurement, autoregulation breaks down. I love how analagous this is to living life. We proceed through our busy days, oftentimes like a pinball falling through a pinball machine, while stressors are flung at us like flags and obstacles in the vertical maze. Too much or too little input leaves us in dangerously unhealthy territory. The next thing we know, we're fighting a virus... or worse.

How can we stay in our own buffer zones? I try to reprioritize self-care. I take some extra vitamin C, drink warm fluids, sit in an epsom salt bath, write in my journal... Make sure I'm nourishing my body with nutrient-dense foods. Say no to extra responsibilities when I can. Sleep as much as possible!

What are the steps you take when you feel you're falling off your autoregulation curve?

Monday, April 11, 2016

The Return From Maternity Leave: Rusty or Rested?

This article on KevinMD was published a week or so before the end of my maternity leave. As I read it, steam emanated from my ears. How dare the author insinuate that physicians lose their technical skills from taking time off equivalent to more than a mere weekend? What about those who must take prolonged time off for sick leave? And what about maternity leave? Are all physician moms, by the sheer reasoning that they had babies, now deemed incompetent?

It goes without saying that we physicians are humans who need adequate time to heal physically in order to perform well mentally. We all need vacations (longer than a weekend) to help stave off burnout, and we all become sick from time to time. During my training and career as an anesthesiologist, I have taken significant periods of time off for vacation, maternity, and sick leave, and yet I've never had a problem integrating back into the basic flow of my job. In fact, on my first day back to work after three months of maternity leave, I had a patient go into anaphylactic shock in the OR - a very rare and deadly event. End tidal CO2 dropped from 37 to 10 and blood pressure was 50/30, but once I identified it I knew exactly what to do. I counteracted the reaction and saved his life with the fortunate and timely assistance of a couple of colleagues who I immediately called into the room (having extra hands is obviously essential in these kinds of situations).

I recently posed this question of competence to physician moms in an online discussion group. Most respondents agreed with me but cited other issues they had returning to work. Some had to regain their prowess with the EMR, others stated that they had a little trouble multitasking, but all felt confident in their abilities to do their required work tasks. I would say that the hardest part for me has been transitioning each day from Mom to MD and back to Mom again. Preparations the night before a workday seem endless, and morning routines take longer than they used to. Picking up my daughter from childcare after work increases the commute time and anxiety depending on how late my OR day has become. I have yet to be the last parent to pick up their child at night, but I'm sure there will be a day like that sometime. Evenings go by so quickly, and I feel I have barely seen my daughter before bedtime comes. Add in being a part-time physician, and suddenly I feel what some moms warned me about: not enough at work, not enough at home.

So Mothers In Medicine, I ask you: how did you feel returning to work after maternity leave? Rusty or rested? Share your experiences here.

Thursday, March 24, 2016

The Most Intimate of Jobs

A random Saturday earlier this month marked the first time I provided sedation anesthesia for patients in the same IVF clinic where I was a patient for 3 years. It was surreal and a little emotional driving up the hill to the clinic and thinking about the many times I went there as a patient myself. All the shots, the blood draws, the ultrasounds, the procedures... Also all the letdown and disappointment that was flanked before and after by hope and excitement. I now have a beautiful baby girl to show for my time as an IVF patient!

A friend of mine who is also in the medical field said to me, "I bet it took a lot of courage to do that. Creepy and scary". While I instead had viewed the experience with gratitude and excitement at the ability to give back to a group of people who had given so much to me, I can understand what she meant. As physicians, we are faced with daily reminders of unpleasant things. Things that have happened possibly to us or to our loved ones, or things that are at the very least reminders of our own mortality.

I think these reminders are a gift, one that doesn't come with many other lines of work in this world. They keep us appreciative of what we have, what we've been through. Has anyone else had an experience like this in their practice? Share your thoughts with us.

Sunday, February 14, 2016

Linea Nigra

I'd learned of it in medical school but never thought I'd have one. I looked for it all throughout my pregnancy, staring down along the midline of my gravid belly. Some telltale signs were there - the nausea, shortness of breath, tender breasts, swollen feet... But I never developed a huge, round, glorious belly that announced the joy of impending birth. Even with the twisting movement of a fetus anxious to emerge, it was hard to believe that this was all real. After years of wanting, of shots and procedures and waiting, it was finally here. But would she come out ok? What would she look like?

Then one day she arrived and they placed her on my belly, now saggy from where she was growing. She was beautiful, and I was immediately in love. Nothing else mattered. The nurse came into the room and announced, "It's time to mash on that uterus, shrink it back down!" It was then that I saw it: a faint, fine, dark line running from my belly button to my pelvis.

It's the tattoo of motherhood, one I never wish to erase, but I know they usually fade after birth. For this year, it's a gift to me from my daughter. A most perfect Valentine.

Monday, January 25, 2016

The Birth Plan

I was 37 weeks pregnant and had just completed a busy Monday in the OR, my last scheduled shift before maternity leave. While relaxing in front of the TV that night, I found my fetal kick count to be significantly lower than normal. I spoke with the on-call OB team, and after going back and forth, we decided it was best if I go to the hospital for further monitoring. I threw on my slippers and jacket (was already in pajamas) and said, "See you in an hour or so," to my husband. I never made it home that night, and six days later I brought my baby girl home from the hospital!

The fetal non-stress test showed that she was ironically doing well, but my blood pressures and urine sample showed that I had developed preeclampsia. My leg swelling was increasing over those last few weeks, but things just got real. My husband dutifully showed up with my pre-packed bag and birth plan. Yes, I had a birth plan - but not the long, detailed essay that some women present to eye-rolling hospital staff, replete with all sorts of unrealistic demands involving birthing balls, hot tubs, candles and music. As an anesthesia resident on the obstetric service, we used to joke that those women with the most detailed and rigid birth plans would inevitably be the women who ended up with "emergency" epidurals at 3 AM, or worse in the OR for a crash C-section.

Instead, what I provided was a one-page sheet with an outline of my complicated medical history and a few important preferences for my care. Because I have adrenal insufficiency and am steroid-dependent, it included a regimen for stress-dose steroids from my endocrinologist. I made it clear that I desired an epidural and that I was ok with all monitoring and testing deemed necessary. I listed a few if-then decision statements regarding vaginal birth vs. C-section. For instance, if I had a vaginal delivery I wanted immediate skin-to-skin contact and delayed cord clamping... if baby is stable.

The feedback I got from nursing and on-call staff about my birth plan was good; they seemed appreciative of the precise and explicit set of preferences that could be passed on through numerous shift changes. I will say, however, that even with my minimal birth plan as a "good luck charm", things still didn't go the way we had originally hoped. And yet, once my daughter was born, none of that mattered one bit. Meconium was present on delivery so she was handed off for resuscitation instead of immediately placed on my chest as I had hoped, we couldn't do delayed cord clamping, etc. But she was healthy! I was lucky to have a smooth albeit slow induction with no complications and a quick period of active labor (only 45 minutes of pushing). We didn't have to go to the OR. I only needed two stitches post-delivery. Again, she was alive and she was healthy! After experiencing a pregnancy loss, I admit that a fear had persisted deep inside me even into the late months of gestation that I would lose her without getting to see her face.

Nothing went exactly as expected, and yet everything turned out fine. Nothing went exactly as expected, and yet everything turned out fine. This is my new mantra, and it would be a good one for all pregnant women to adopt. Because in the instances of labor and childbirth, resistance and rigidity pose potential risks to both mother and baby.

Have you had an experience with a birth plan, either yours or a patient's?

Wednesday, November 18, 2015

Thankful For That Creepy Wiggle

Every year, there is always so much to be thankful for. As physicians, I don't think this idea is usually lost on us; we see patients suffering with difficult health challenges or even life-and-death situations on a daily basis. But what is sticking out this year as the thing I'm most grateful for?

Fetal movement. Yes, that weird sensation inside of my own body. My first child is due December 11, right between Thanksgiving and Christmas - the time that we most contemplate gratitude. This is not my first pregnancy, but I have never gotten far enough in the process to experience fetal movement before. I started feeling the movements around 20 weeks gestation, which began as little "pat pats" in my low abdomen that were easily confused with gas bubbles. They have now transformed into squirmy, distinctive wiggles several times throughout the day.

Overall, I have had a pretty easy pregnancy. My early nausea was fairly mild, I was able to continue with moderate exercise and work throughout my first and second trimester, and I have had no major complications as of yet. My tall stature has blessed me with a long torso within which baby can stretch, and I haven't been confined to maternity clothes. However, in my third trimester I have developed severe leg swelling that has significantly limited my activity (and my work, which usually involves being on my feet most of the day). It is very uncomfortable with constant itching and pain throughout my legs. To keep my mind off of it, I have been trying to focus on the good things... like the consistent blessing of fetal movement, a reminder of why I am going through all of this.

Many have described the sensation of fetal movement as "creepy", "surprising", "uncomfortable", etc. Expectant parents jokingly refer to their growing fetus as a "parasite". To me, the squirmy turns of my belly, the head-butting of my cervix and the kicking of my diaphragm are welcome reminders every day (every hour, really) of how hard I've tried to become a mother: the months of IVF cycles, shots, staying home instead of traveling, rearranging work schedules, waiting, hoping... And about how after all this time, it's finally going to happen!

Monday, October 19, 2015

Hormones and shots and procedures, oh my! What is it like to undergo IVF?

People are having children later in life, whether the reason is pursuit of career aspirations, travel, or riding the asymptotic curve to financial security. This truth is never more evident than in the field of medicine, where more and more women are taking the long road of training to become physicians. Some of us (like me) even choose this training as a second career, rendering us older from the start. You've heard saying such as "40 is the new 30", etc., but the reality is that a woman is born with all of her eggs and those eggs age with her. She may follow a perfectly healthy lifestyle and appear younger than her real age in many ways, but her eggs are as old as she is.

As eggs age, their quality declines in the form of DNA damage, which negatively effects their ability to make a healthy embryo that will grow into a healthy baby. By the age of 40, the percentage of eggs that have DNA damage incompatible with healthy embryo formation is approximately 75%! On top of this immutable fact, aging brings the possibility of medical issues that can affect fertility in both a mother and a father. The chance of a naturally-occurring pregnancy during any given monthly cycle of a 40 year old woman is approximately 5-10%, and due to the DNA damage I already mentioned, the chance of a live birth resulting from that pregnancy is even lower. It is truly a miracle in my opinion that women over 40 have spontaneously-conceived, healthy pregnancies.

Enter in vitro fertilization (IVF). IVF is a long and detailed process, requiring lots of resources, money, time, and patience. The first stage of a typical cycle involves, ironically, taking oral contraceptives to reset the hormone milieu and force all eggs into a senescent, follicular stage. The second stage involves stimulating the ovarian follicles with daily doses of a hormone cocktail. It is usually some combination of FSH, LH or an LH inhibitor depending on timing, and possibly GH. There is quite a bit of monitoring at this stage, including almost daily ultrasounds and blood draws to evaluate the growth and maturation of the eggs. The third stage is egg retrieval, in which all fluid-filled cysts within a certain size distribution are aspirated for the contained egg. The eggs are then fertilized with the intended sperm (by various methods depending on the presence or absence of male-factor infertility) and are allowed to grow for 3-5 days into multi-celled embryos. The last stage is embryo transfer, in which selected embryos are injected back into the uterus for implantation. This may occur using the aforementioned, freshly grown embryos approximately 5-6 days after the transfer, or the embryos can be frozen for testing and/or later transfer. Once an embryo transfer occurs, it's up to fate (and continued hormonal supplementation)... after the dreaded "two-week wait", it's time for a pregnancy test!

As you can imagine, the process is not for the faint of heart, nor is it for the person with no flexible time and no extra money. I had to do IVF to get pregnant, and these are my experiences.

Time: If a fresh embryo transfer is planned, all of the steps mentioned above take approximately 6-7 weeks to complete (not including the two-week wait). If the embryos are intended to be tested or frozen, the first three stages themselves take 5-6 weeks. After the egg retrieval, the ovaries must rest and the enlarged follicles must resorb over time. This is achieved by having a period and going back on oral contraceptives for at least 3 weeks. Then the uterine lining is augmented with estrogen supplementation for another 3 weeks prior to the embryo transfer. During this time, other testing may take place for the patient (such as a hysterosalpingogram, hysteroscopy, or endometrial biopsy) and/or for the embryos (such as preimplantation genetic screening for aneuploidy or diagnosis of genetic diseases).

Not only does each pregnancy attempt take a significant portion of a year (during which time a woman's eggs undergo further aging), but each cycle also requires quite a few appointments for monitoring, lab draws, procedures, etc. Although I sometimes had to apologetically make my schedule requests after my practice group's time deadline, I was lucky to have enough vacation time built into my yearly clinical commitment that I could take as much time off as I needed. Not everyone would need to take the entire day off for an hour-long morning appointment, but as an anesthesiologist I found that it was the only way to make things work. A physician who sees patients in a clinic might be able to shift her clinic hours back a bit to make morning appointments - which occur every other day and at times every day during the stimulation phase of a cycle. And at my fertility clinic, the egg retrievals were conveniently performed on the weekends.

Money: With some exceptions, IVF is commonly not covered under health insurance in the United States. That said, I found that certain ultrasounds, lab tests, and medications would occasionally be covered by my insurance based on the fact that they were recognized as appropriate interventions for my preexisting infertility diagnosis. Prices for IVF vary slightly depending on the part of the country where the fertility clinic is located, the medications prescribed, etc. A typical cycle including the stimulation period, monitoring ultrasounds, and the egg retrieval procedure runs $12,000 on average, not including medications (another $3000 - $5000). A frozen transfer at a later date is approximately $3000 - $5000. Preimplantation genetic testing of embryos adds approximately $5000 - $8000 to any particular cycle. A portion of these costs can be offset using "batching" techniques or multi-cycle discounts, tax deductions (in some cases), and an FSA; however, IVF in its many forms is undoubtedly going to present some financial stress for any patient.

"Heart": Egg retrievals are performed across the country using different modes of anesthesia. At the IVF clinic I used, it was treated as a moderate IV sedation procedure with fentanyl and midazolam; however, there are some clinics that do deeper sedation or even general anesthesia. An embryo transfer, regardless of whether it is fresh or frozen, is usually done with oral diazepam, and the patient does not need to be NPO. Prior to either of these procedures, an IVF patient can expect to have many transvaginal ultrasounds, which can be uncomfortable for some women. There are other diagnostic procedures that may figure into an infertility workup or IVF journey treatment plan as well, such as hysteroscopies, biopsies, hysterosalpingograms, etc. In addition to these procedures, the patient must receive daily injections of hormones during the follicle stimulation phase and sometimes additional daily shots after implantation. Most of these shots are subQ, but some of them are IM. I must admit that I myself am somewhat squeamish when it comes to being a patient, but I found the invasive nature of IVF to be tolerable. The mental aspect of the uncertainty, the waiting, the rescheduling of life so that appointments and cycles can be completed, etc. was much more difficult. But if you are a person who does poorly with procedures, this may be an important factor in your IVF decision path.

Speaking of decisions, IVF can take a toll on personal relationships - friendships, family bonds, and romantic relationships. This usually presents in the form of differences in opinion on direction of care, number of IVF attempts, or ethical issues with genetic testing/embryo selection/possibility of multiple gestation/etc. Going through IVF can also impact your feelings about yourself; many women complain of feeling unwomanly, and I was not immune to this myself. It is difficult to accept that you need assistance achieving something that is so basic to human life as reproduction. I dealt with this through therapy, quiet time/meditation, and journaling, but everyone differs in terms of what works for them to manage such stress. I recommend to every woman undergoing IVF that she at least attempt to get therapy for herself, if not couples therapy for her and her partner.

IVF is a physically and mentally involved endeavor. Copious time, financial allocation, and mental fortitude are required. But for many patients with complex infertility issues, it is their only path to genetic parenthood (as it was mine). I'm 32 weeks pregnant now and I am very happy with the path I took to get here. As a "success story" with a little girl on the way, it was all worth it!

Tuesday, August 25, 2015

Pregnant in the OR: Potential Hazards

Regardless of your position, occupational hazards exist when working in the operating room. Normally these things aren't given too much thought, but when my choices suddenly affected another developing life, it caused me to pause and contemplate these hazards on a deeper level. Unfortunately, studies on pregnant healthcare workers (and other occupations) are difficult to interpret due to the fact that they predominantly consist of retrospective cohort data rife with selection and recall bias or animal studies of direct exposure to substances. Nevertheless, here is a list of some things to consider when working pregnant in the operating room or hospital setting:

Anesthetic Gases. While every effort is made to avoid elective surgery during pregnancy, even pregnant women need to have general anesthesia under urgent circumstances; there is no evidence that gases administered at concentrations appropriate for general anesthesia cause fetal harm. Thus, sub-anesthetic levels that would be passively inhaled in an occupational capacity should theoretically be safe as well. That being said, it is generally recommended that pregnant women in the OR avoid inhalation of the gases when possible. We facilitate this by using ventilator circuits with scrubbing systems and taking care to turn off anesthetic gases if the circuit is open to air for a period of time (such as between mask ventilation and intubation). This is mostly routine practice regardless of pregnancy status.

Methylmethacrylate. MMA is a common ingredient in cement mixtures for joint prosthetics. When mixed, it forms a strong scent which dissipates over a number of minutes as the mixture cures. Studies, which have mainly occurred in animal models, reveal mixed results in terms of impact on fetal development. As a pregnant provider, your choices are to not work on cases using MMA, ask the scrub mixing the cement to use a vacuum device to remove the fumes, or temporarily leave the room during the mixing process. In one human study, MMA was not found above a 0.5 ppm level in breast milk of surgeons who utilized vacuum mixing devices. At our institution, the use of these devices is mixed amongst surgery personnel, but local suction can also be easily employed. If I am in a joint room and my patient is stable, I elect to step into the adjacent substerile core (which has a window to the operating room) for a few brief minutes while the mixing occurs. However, I did have a recent case where the patient was very unstable and I could not leave the room or easily turn the case over to another provider temporarily. After that experience, the scheduler changed me to a different OR.

Radiation. Discussed briefly in my previous Pregnant in the OR post, radiation is commonly used during OR procedures such as orthopedic repairs, gastrointestinal explorations, interventional pain management, interventional radiology, angiography, line placement... I could go on. For radiation, potential harmful effects are directly related to the dose of exposure. The CDC website has a table of radiation doses with corresponding maternal/fetal risks at different gestational ages. At doses higher than 50 rads, risks range from failure of implantation and miscarriage at early stages to growth retardation, mental delay, and increased risk of cancer at later stages. As with general anesthesia, pregnant women themselves must occasionally undergo irradiative procedures, but care is always taken to balance risks with benefits. In addition, protective shielding goes a long way to reduce exposure. Even in an occupational capacity we wear protective lead garments during periods of radiation. Wearing these and standing at least 6 feet away from the beam will decrease the exposure by more than 99%. However, the garments must encircle the body and not just cover the front of the body in apron form. This is especially important for anesthesiologists, who often turn their backs to the OR table to gather drugs or supplies, etc. And during my pregnancy, I have actively avoided assignments that involve continuous use of fluoroscopy (such as cath lab, GI lab, and interventional vascular or radiology).

Infection. It goes without saying that universal precautions need to be followed by everyone, but there are wider implications and possible sequelae if a pregnant woman contracts an infectious disease while working in the OR. Discussing the details of this would be beyond the scope of this article, but the gist is that potentially teratogenic effects of certain microbes and their treatments and/or long-term transmission of viral infections to the fetus such as HIV or HCV are considerations that should provide pause and vigilance when employing personal protection.

Stress. This is the most difficult "hazard" to avoid. Theoretically, emotional and physical stress can cause neuroendocrine and cardiovascular alterations that could affect fetal physiology and hence possible outcomes. Limited studies implicate longer working hours, night shift work, prolonged standing, and physical work as risk factors for preterm birth, SGA infants and miscarriage. It must also be mentioned, especially for trainees, that the financial burden of NOT working during pregnancy can cause significant stress in itself. Some women might choose to take a lighter load or less frequent call shifts during pregnancy, if possible.


I have mitigated many of these hazards during my pregnancy by notifying the schedulers early of my status, so that they could avoid giving me assignments with increased exposure as much as possible. In terms of stress, my job has no call duties, so long and tiring hours have usually not been an issue. Not everyone can be as lucky, but vigilance to self-care postcall and adequate hydration during call can help.

For readers who have been pregnant during hospital or OR duties, did you encounter any other hazards at work? What were your experiences trying to avoid them? Share your thoughts with us here!


References:

Keen RR et al. Occupational Hazards to the Pregnant Orthopaedic Surgeon. J Bone Joint Surg Am. 2011;93:e141(1-5).
Fowler JR and L Culpepper. Working During Pregnancy. UpToDate, 2015.
Radiation and Pregnancy: A Fact Sheet for Clinicians. http://emergency.cdc.gov/radiation/prenatalphysician.asp

Tuesday, July 28, 2015

Intern of the Year

Eight years ago this month, I entered the hospital for the first time with the label "MD". My assignment was a prestigious transitional year internship at a large private/academic hybrid hospital. Amongst my rotations would be Internal Medicine, Surgery, ICU, and some electives.

My internship year was wonderful. I relished in the new freedom of managing patients and writing orders. I thrived on the stress of the endless to-do lists; each time I checked a box on my paper, I got a sense of thrill. The learning curve was so steep, and I became addicted to finding ways to be efficient. I enjoyed my co-interns, the staff, and the attendings. At the end of the year, they voted me Intern of the Year!

Then I started my residency in anesthesiology. I had done no anesthesia rotations during my transitional year and had instead chosen to focus on getting exposure to things that I was likely to not see much in the future. The change was abrupt and was not exactly smooth. Like the swipe of an eraser on a white board, all the positivity and excitement quietly vanished. The sheer volume of material to learn was overwhelming, not to mention the technical parts of the job – placing IV’s, preparing and dosing drugs, mastering the anesthesia monitors and ventilators, patient positioning, and the delicate dance of the patient consent process that is unique to anesthesia. Every day was a great battle to keep wits and stay calm while learning the academic and procedural aspects of the specialty.

As the fall months spread into winter and the days became shorter, a gloom washed over me. Rushing to work in the dark and returning home in the dark… was this what I had signed up for? Were other residents feeling the same way? How did I compare? These questions never really get answered since we don’t work together in the same OR. Come wintertime, performance evaluations from faculty started to trickle in. Some comments were positive, but the negative ones cut deeply into my motivation and self-esteem. But I was the "Intern of the Year"; what was wrong with me?

I continued to struggle with procedures, and my In Training Examination scores were well below average. I suffered from incredible fatigue and knew deep down that something was wrong. It took many months, over half of my residency, to figure out what it was: a pituitary macroademona had taken residence in my sella and was wrapping its tentacles around my optic nerve. I was going blind and didn't even notice! Within a week after my MRI, I was on the OR table being anesthetized by one of my attendings. What followed was a long hospital stay and complications of hyponatremia requiring readmission. After a long period of healing, I returned to residency and finished my training.

A stay in a hospital ICU will change you forever. My achievement record during residency, despite having been crowned Intern of the Year, may have ended up being quite lackluster... but my experience as a patient was a priceless learning experience that I'm grateful to have had. It helps me connect with my scared and vulnerable patients every day, and it is a constant reminder of how lucky I really am. And as an attending, I now thoroughly enjoy the practice of anesthesia.

I'm shortening and simplifying a very long and detailed story, but I write this to inspire all the new interns and residents with their sights set on perfect ITE scores, accolades, votes, and awards. In the end, none of that matters. Your years of training will hold a mix of times of difficulty, times of gratitude and times of great learning. Do your best to navigate these times with balance, and make sure to take care of yourself!

Monday, June 15, 2015

Pregnant in the OR: When to Tell


I was 5 weeks pregnant and working in the spine room. Just as I finished my intubation and secured the airway, I turned to set the ventilator and administer some important medications. The surgery fellow started to position the fluoroscope near the patient's cervical spine, about a foot away from where I was working. "Please don't use the Xray right now; I need to put on a lead shield first," I said. "Yeah, ok... whatever..." he said, as he continued to fine-tune its position. Thirty seconds later he sighed, then started pushing some buttons and eyeing the screen. I looked at him sternly and said, "I'm serious. Don't do it. I'm pregnant."

After coos and congratulations from the fellow, resident, nurse, and scrub tech, I felt a bit awkward. Of course, I myself had just learned of my pregnancy; I hadn't even seen a heartbeat on ultrasound yet! This wasn't the way I expected to tell people my good news, and I really wish I hadn't been forced to do so in that situation. That being said, I really didn't want the radiation exposure at that time. I suffered a miscarriage a few weeks later and then had to engage those same people in some very awkward conversations.

The decision of when disclose a pregnancy in any situation is a highly personal one. Unfortunately, there is a lot of misguided shame surrounding miscarriage in our culture, and thus many expectant moms often wait until their first trimester has passed in order to disclose the good news. But in my line of work, there are clear benefits to telling others earlier rather than later. First, anesthesiology (like surgery and many other specialties for that matter) is a relatively physical practice. Say you're feeling faint during a procedure, battling nausea, needing frequent snacks, or have a constant urge to urinate. People are going to think you're having issues and might worry about your work performance... unless of course they know you are pregnant, in which all of these situations are commonplace and understandable.

In terms of shift scheduling, call assignments and specific work days for any given week are often determined well ahead of time. Usually, requests for days off or vacations are done so about 1-2 months in advance; however, because I work in an academic hospital, the summer poses a major scheduling challenge due to new resident orientation/training. If a baby is due in the summer, special arrangements need to be made so as to not impact the delicate balance of staffing during the transition period for brand new residents. In a private practice situation, far advanced notice might be necessary if the due date is around a major holiday. Therefore, alerting the appropriate vacation/call schedulers to a pregnancy earlier rather than later may affect your entire practice group.

In addition, pregnancy status may impact daily work assignments. At my institution, the schedulers try to avoid giving pregnant women assignments that involve consistent or high doses of radiation, such as what is encountered in the interventional radiology suite or cath lab. (I hope to address this more in a future blog post.) It's difficult to avoid assigments in orthopedic rooms since these cases are so ubiquitous, but you might want to also alert the nurse and scrub of your status so that when they mix the methacrylate joint glue, you can step out to avoid the fumes. And you definitely want your protective lead suit if a fluoroscope is in sight!

Just like disclosing a disability at work, it's a "know when to hold 'em, know when to fold 'em" situation. The right point to fold will be different for each individual. Because my first pregnancy (the one in the story above) ended in miscarriage, I was initially keeping things much quieter with my current pregnancy. However, a similar situation with the fluoroscope still happened again at 7 weeks! I got zapped twice in one day despite my veiled warnings, and after the second time I frustratingly blurted out my news to everyone in the room. Of course they paused, congratulated, and then took things much more seriously in the radiation department. It shouldn't have to be that way, but unfortunately most people are very nonchalant about radiation exposure.

Aside from that incident, I waited until about 10 weeks before I was open about my pregnancy. After I had a couple of ultrasounds under my belt and my IVF docs told me that my miscarriage chance was very low, I notified our anesthesia scheduling partners of my status. They have respectfully given me lower-exposure, lower-stress assignments (like fewer, less physical cases per day with limited fluoro, etc.) As far as other pregnancy symptoms are concerned, I have had my days of nausea and moving slowly, but it hasn't seriously affected my performance at this point.

Has anyone - trainee or practitioner - experienced issues with disclosing a pregnancy? Share your thoughts with us!

Thursday, May 14, 2015

MiM Intro: PracticeBalance

Full disclosure: I am not a mother... yet. But I will hopefully (finally) be one soon!

Like many women in the medical profession, I delayed my plans for starting a family until late in my residency training. I initially worked as a chemical engineer, and I also traveled extensively to rock climb prior to deciding on medicine. In addition to entering the medical field a bit later than average, I frankly wasn't ready to be a mom when I was a medical student. I found the amount of work ahead of me to be exciting but also overwhelming in the face of a potential pregnancy/childbirth/parenting etc.

About half-way through my anesthesiology residency (coinciding with my 35th birthday), my husband and I decided it was time to start trying. Only one thing stood in the way: I hadn't had a period in several months. I had always been irregular, but those irregular intervals had increased during internship to an eventual standstill of menstruation. After ignoring this warning sign for a while, I finally sought the help of a reproductive endocrinologist. This initiated a long journey with many blood draws, tests, and time off which finally revealed that I had a large pituitary tumor causing severe hormonal disregulation. My experiences managing both physical and psychological stresses during medical training prompted me to start my own blog, PracticeBalance.com, in 2011. I continue to write regular posts there about stress management, being a patient, and self-care issues.

After my tumor removal, I have suffered from continued hormone deficiencies, which means that I need to use assisted reproductive techniques to get pregnant. I started following Mothers in Medicine a few years ago, around the same time that we actively began trying to conceive. I work three days per week as a purely clinical anesthesiologist (no research or teaching responsibilities) in a large academic hospital - what I'm hoping will be the perfect setup for balancing a career and motherhood!

So now here I am, currently expecting my first child - three years, one miscarriage, and thousands of dollars later. I hope to bring a perspective to the MiM community about what it's like to be an expectant mom (and then eventually a new mom) while working in the operating room. I could also write about what it's like to be an IVF patient (who happens to be a medical professional), if there is any interest in that. Currently I am experiencing a lot of apocalyptic worry regarding all that could go wrong in my pregnancy - feelings born out of both having had a miscarriage in the past and having work-related experience with all the "bad things" that can happen.

Please let me know what you'd like me to write about by leaving a comment below. I'm excited to be here and look forward to hearing from you!